Updated: 8/18/2020

Talar Neck Fractures

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Introduction
  • Epidemiology
    • most common fracture of talus ( 50%)
  • Mechanism
    • a high-energy injury
    • is forced dorsiflexion with axial load
  • Associated conditions
    • ipsilateral lower extremity fractures common
Anatomy
  • Articulation 
    • inferior surface articulates with posterior facet of calcaneus
    • talar head articulates with
      • navicular bone
      • sustenaculum tali
    • lateral process articulates with
      • posterior facet of calcaneus
      • lateral malleolus of fibula
    • posterior process consist of medial and lateral tubercles separated by groove for FHL
  • Blood supply
    • talar neck supplied by three sources 
      • posterior tibial artery
        • via artery of tarsal canal (dominant supply)
          • supplies majority of talar body
        • deltoid branch of posterior tibial artery
          • supplies medial portion of talar body
          • may be only remaining blood supply with a displaced fracture 
      • anterior tibial artery
        • supplies head and neck
      • perforating peroneal artery via artery of tarsal sinus
        • supplies head and neck
Classification

Hawkins Classification 
Type Description AVN Images
Hawkins I
Nondisplaced
0-13% AVN
Hawkins II Subtalar dislocation 20-50%
Hawkins III
Subtalar and tibiotalar dislocation
20-100%
Hawkins IV
Subtalar, tibiotalar, and talonavicular dislocation
70-100%
 
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
      • Canale view
        • best view to demonstrate talar neck fractures
        • technique is maximum equinus, 15 degrees pronated, xray 75 degrees cephalad from horizontal 
  • CT scan 
    • best study to determine degree of displacement, comminution and articular congruity
    • CT scan also will assess for ipsilateral foot injuries (up to 89% incidence) 
Treatment
  • Nonoperative 
    • emergent reduction in ER
      • indications
        • all cases require emergent closed reduction in ER
    • short leg cast for 8-12 weeks (NWB for first 6 weeks)
      • indications
        • nondisplaced fractures (Hawkins I)
      • CT to confirm nondisplaced without articular stepoff
  • Operative
    • open reduction and internal fixation
      • indications
        • all displaced fractures (Hawkins II-IV) 
      • techniques
        • extruded talus should be replaced and treated with ORIF 
      • complications  
        • post-traumatic arthritis
        • mal-union
        • non-union
        • infection
        • wound dehiscence
Techniques
  • ORIF
    • approach
      • two approaches recommended
        • visualize medial and lateral neck to assess reduction
        • typical areas of comminution are dorsal and medial
      • anteromedial
        • between tibialis anterior and posterior tibialis
        • preserve soft tissue attachments, especially deep deltoid ligament (blood supply)
        • medial malleolar osteotomy to preserve deltoid ligament
      •  anterolateral 
        • between tibia and fibula proximally, in line with 4th ray
        • elevate extensor digitorum brevis and remove debris from subtalar joint
    • technique
      • anatomic reduction essential
      • variety of implants used including mini and small fragment screws, cannulated screws and mini fragment plates
      • medial and lateral lag screws may be used in simple fracture patterns 
      • consider mini fragment plates in comminuted fractures to buttress against varus collapse   
    • postoperative
      • non-weight-bearing for 10-12 weeks
Complications
  • Osteonecrosis
    • 31% overall (including all subtypes)
    • radiographs
      • hawkins sign 
        • subchondral lucency best seen on mortise Xray at 6-8 weeks   
        • indicates intact vascularity with resorption of subchondral bone 
      • associated with talar neck comminution and open fractures
  • Posttraumatic arthritis
    • subtalar arthritis (50%) is the most common complication    
    • tibiotalar arthritis (33%)
  • Varus malunion (25-30%) 
    • can be prevented by anatomic reduction 
    • treatment includes medial opening wedge osteotomy of talar neck 
    • leads to  
      • decreased subtalar eversion
        • decreased motion with locked midfoot and hindfoot
      • weight bearing on the lateral border of the foot
 

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Questions (23)
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(SBQ12FA.67) A 35-year-old male fell and sustained an open talar neck fracture. He underwent operative fixation of his fracture. He presents at 2 months after surgery. He denies any constitutional symptoms and his pain is well controlled. On exam, his wounds are well healed with no erythema. Imaging is shown in Figure A. What can the patient be told about his condition? Tested Concept

QID: 3874
FIGURES:
1

Hawkins sign is positive. The likelihood of developing osteonecrosis is high

10%

(226/2283)

2

Hawkins sign is positive. The likelihood of developing osteonecrosis is low

77%

(1764/2283)

3

Hawkins sign is negative. The likelihood of developing osteonecrosis is high

6%

(133/2283)

4

Hawkins sign is negative. The likelihood of developing osteonecrosis is low

4%

(95/2283)

5

He has developed chondrolysis

2%

(43/2283)

L 2 B

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(SBQ12TR.12) A 25-year-old male sustained an isolated injury to his right foot after a fall from height. On examination, he has moderate swelling and pain over the dorsum of the foot. The overlying skin is intact. Radiographs of the foot are seen in Figures A and B. A CT scan image is seen Figures C. When consenting the patient for open reduction and internal fixation of this injury, what would you document as the most common complication? Tested Concept

QID: 3927
FIGURES:
1

Symptomatic implants

2%

(149/6348)

2

Subtalar arthritis

80%

(5051/6348)

3

Tibiotalar arthritis

4%

(285/6348)

4

Malunion

11%

(686/6348)

5

Wound dehiscence

2%

(146/6348)

L 2 A

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(OBQ12.91) 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? Tested Concept

QID: 4451
FIGURES:
1

Reimplantation of the talar body followed by cast immobilization

1%

(44/5369)

2

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

18%

(949/5369)

3

Talar body allograft with internal fixation to native talar head

1%

(53/5369)

4

Fragment removal, antibiotic spacer placement and external fixation

2%

(102/5369)

5

Reduction of native talar body and ORIF of talar neck fracture

78%

(4183/5369)

L 2 B

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(OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot supination and diminished subtalar motion compared with the contralateral side. Which of the following is an option for reconstruction of this patient's deformity? Tested Concept

QID: 3601
FIGURES:
1

Total ankle arthroplasty

1%

(17/2984)

2

Lateral calcaneus closing wedge osteotomy

24%

(726/2984)

3

Calcaneal neck opening wedge osteotomy

7%

(206/2984)

4

Talar neck opening medial wedge osteotomy

55%

(1653/2984)

5

Triple arthrodesis

12%

(370/2984)

L 3 B

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(OBQ09.207) Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? Tested Concept

QID: 3020
1

Tibiotalar dorsiflexion

10%

(95/931)

2

Tibiotalar plantarflexion

1%

(10/931)

3

Subtalar eversion

67%

(623/931)

4

Subtalar inversion

19%

(180/931)

5

Internal rotation

2%

(16/931)

L 3 C

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(OBQ08.234) A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. What is the next most appropriate course of action? Tested Concept

QID: 620
1

Injection of bone cement into the talus to prevent further avascular necrosis

2%

(21/1245)

2

Ankle fusion

1%

(11/1245)

3

Subtalar fusion

1%

(17/1245)

4

Ankle arthroscopy to address this osteochondral lesion

4%

(45/1245)

5

Continued observation as the vascularity to the talus is intact

92%

(1145/1245)

L 1 C

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(OBQ05.95) A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body? Tested Concept

QID: 981
FIGURES:
1

Medial malleolus

4%

(57/1438)

2

Deltoid ligament

72%

(1042/1438)

3

Anterior talofibular ligament

9%

(135/1438)

4

Lateral malleolus

2%

(25/1438)

5

Calcaneonavicular ligament

12%

(174/1438)

L 2 C

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(OBQ04.173) A 30-year-old male undergoes successful surgical fixation of a displaced talar neck fracture. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved? Tested Concept

QID: 1278
1

Tibiotalar and/or subtalar arthritis

58%

(792/1368)

2

Loss of forefoot supination

1%

(15/1368)

3

Osteonecrosis

38%

(519/1368)

4

Nonunion

3%

(36/1368)

5

Infection

0%

(1/1368)

L 4 C

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(OBQ04.145) A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. A post-reduction radiograph is seen in Figure C. Which of the following is the most appropriate treatment at this time? Tested Concept

QID: 1250
FIGURES:
1

Definitive closed treatment

5%

(103/2126)

2

Addition of percutaneous pins

7%

(139/2126)

3

Open reduction and internal fixation

86%

(1832/2126)

4

Tibiotalocalcaneal arthrodesis

1%

(13/2126)

5

Primary subtalar arthrodesis

2%

(35/2126)

L 1 B

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(OBQ04.126) A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. Which of the following radiographic features is a good prognostic factor for this injury? Tested Concept

QID: 1231
FIGURES:
1

Talar dome subchondral lucency

77%

(483/629)

2

Talar dome subchondral sclerosis

15%

(93/629)

3

Diffuse osteopenia

0%

(3/629)

4

Associated medial malleolus fracture

4%

(26/629)

5

Talar lateral process fracture

3%

(21/629)

L 1 B

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(OBQ04.44) A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms? Tested Concept

QID: 105
FIGURES:
1

Combined varus and plantar malunion

26%

(563/2174)

2

Isolated varus malunion

15%

(331/2174)

3

Isolated valgus malunion

3%

(57/2174)

4

Isolated dorsal malunion

49%

(1066/2174)

5

Isolated plantar malunion

6%

(140/2174)

L 4 C

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