Review Question - QID 4451

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Talar Neck Fractures Treatment Operative QID: 4451 (OBQ12.91)

QID 4451 (Type "4451" in App Search)

A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. The body of the talus is extruded medially through a large linear open wound. Along with irrigation and debridement, what is the most appropriate definitive management of this injury?

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Reimplantation of the talar body followed by cast immobilization

51/5994

Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement

18%

1087/5994

Talar body allograft with internal fixation to native talar head

61/5994

Fragment removal, antibiotic spacer placement and external fixation

108/5994

Reduction of native talar body and ORIF of talar neck fracture

77%

4645/5994

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The patient is presenting with a displaced talar neck fracture with extrusion of the talar body. Reimplantation of the talar body and ORIF of the talar neck fracture is the most appropriate treatment.

Talar extrusions are rare injuries and are caused by high energy mechanisms. Complete dislocation without a concomitant fracture is extremely rare. The talus is prone to dislocation as there are no muscular attachments. These injuries need to be treated with anatomic reduction and internal fixation to prevent avascular necrosis and post-traumatic arthritis.

Smith et al. investigated the clinical results and functional outcome after reimplantation of the extruded talus. They concluded that salvage and reimplantation of the talus is a relatively safe procedure with only 2 of the 27 patients developing an infection. No association was found between outcome and associated talar fracture.

Van Opstal et al. reported on two cases of talar extrusions following high energy injuries and reviewed the associated literature. Both cases were treated with wound I&D, reduction and external fixation. After 1 year they had pain free ROM with no signs of AVN or arthritis. Review of the literature showed that anterolateral dislocations are more common than anteromedial. Total talar dislocation is thought to be the endpoint of maximum pronation or supination injuries.

Figures A and B show an extruded talar body in the setting of a Hawkins III talar neck fracture. Illustration A shows a clinical photo of an extruded talus.

Incorrect Answers:
Answer 1: Displaced talar neck fractures should not be treated in a cast, especially open fractures
Answer 2: Definitive treatment of this injury is most effectively accomplished with formal ORIF. Steinman pin fixation is not adequate, even in the presence of an external fixator.
Answer 3: There is no data supporting removal of fragment and use of allograft overuse of native talar body
Answer 4: There is no data supporting removal of the fragment. The associated references support retaining the fragment.