Summary Talar neck fractures are high energy injuries to the hindfoot that are associated with a high incidence of talus avascular necrosis. Diagnosis is made with radiographs of the foot but frequently require CT scan for full characterization. Treatment is emergent reduction of the talus following by internal fixation in an acute or delayed fashion. Epidemiology Incidence common most common fracture of talus ( 50%) Etiology 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 navicular bone sustenaculum tali 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 Navicular bone Sustenaculum tali 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 risk Hawkins I Nondisplaced 0-13% 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) Talus extrusion techniques extruded talus should be replaced and treated with ORIF ~63% of reimplanations do not require secondary procedure low incidence of infection with adequate I&D and antibiotic therapy high incidence of AVN without collapse 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 delayed internal fixation is not associated with avascular necrosis 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
QUESTIONS 1 of 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Previous Next (OBQ20.201) A 35-year-old roofer sustains a fall from height onto his feet. He notes immediate pain and swelling upon his hindfoot, and is unable to bear weight. He is brought to the emergency department by his coworkers, where radiographs are obtained (Figure A). The patient is placed into a well-padded Bulky Jones splint and placed on the surgery schedule for the next day for open reduction and internal fixation. Which of the following is true regarding acute definitive fixation of his injury? QID: 215612 FIGURES: A Type & Select Correct Answer 1 Higher rates of infection 40% (337/844) 2 Higher rates of varus malunion 8% (71/844) 3 Lower rates of osteonecrosis 40% (338/844) 4 Lower rates of subsequent subtalar osteoarthritis 8% (64/844) 5 Lower rates of wound dehiscence 4% (30/844) L 5 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ18FA.64) A 35-year-old male sustains an isolated injury depicted in Figure A after a motor vehicle accident. On examination, there is significant soft tissue swelling without open wounds. A decision is made to delay surgery until soft tissues are stabilized. Which of the following statements are true regarding this injury? QID: 211803 FIGURES: A Type & Select Correct Answer 1 Avascular necrosis is more common following this injury than post-traumatic arthritis 14% (178/1241) 2 Delayed internal fixation of displaced fractures does not increase the risk of avascular necrosis 57% (707/1241) 3 Fracture comminution is associated with a decreased avascular necrosis rate 1% (12/1241) 4 Delayed internal fixation increased the risk of secondary surgical procedures 26% (320/1241) 5 Fracture displacement is not associated with avascular necrosis 2% (21/1241) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ18FA.45) A 27-year-old male is involved in a motor vehicle collision and presents to the ER with the right lower extremity injury shown in Figures A and B. He undergoes immediate closed reduction and the post-reduction CT is shown in Figures C and D. The patient undergoes percutaneous surgical screw fixation of the injury. At 2 years follow-up, he presents with a supination deformity with decreased eversion of the foot at rest. Radiographs reveal no evidence of talus subchondral sclerosis or collapse. Which of the following is the most likely cause of the finding in this patient? QID: 211594 FIGURES: A B C D Type & Select Correct Answer 1 Avascular necrosis 10% (160/1650) 2 Subtalar arthritis 23% (376/1650) 3 Tibiotalar arthritis 1% (21/1650) 4 Varus malunion 64% (1063/1650) 5 Planovalgus 1% (17/1650) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3874 FIGURES: A Type & Select Correct Answer 1 Hawkins sign is positive. The likelihood of developing osteonecrosis is high 10% (284/2883) 2 Hawkins sign is positive. The likelihood of developing osteonecrosis is low 78% (2250/2883) 3 Hawkins sign is negative. The likelihood of developing osteonecrosis is high 5% (156/2883) 4 Hawkins sign is negative. The likelihood of developing osteonecrosis is low 4% (119/2883) 5 He has developed chondrolysis 2% (48/2883) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 3927 FIGURES: A B C Type & Select Correct Answer 1 Symptomatic implants 2% (157/7146) 2 Subtalar arthritis 80% (5715/7146) 3 Tibiotalar arthritis 5% (329/7146) 4 Malunion 10% (742/7146) 5 Wound dehiscence 2% (167/7146) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 4451 FIGURES: A B Type & Select Correct Answer 1 Reimplantation of the talar body followed by cast immobilization 1% (49/5816) 2 Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement 18% (1039/5816) 3 Talar body allograft with internal fixation to native talar head 1% (61/5816) 4 Fragment removal, antibiotic spacer placement and external fixation 2% (106/5816) 5 Reduction of native talar body and ORIF of talar neck fracture 78% (4520/5816) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3601 FIGURES: A Type & Select Correct Answer 1 Total ankle arthroplasty 1% (27/3355) 2 Lateral calcaneus closing wedge osteotomy 25% (827/3355) 3 Calcaneal neck opening wedge osteotomy 7% (237/3355) 4 Talar neck opening medial wedge osteotomy 54% (1823/3355) 5 Triple arthrodesis 13% (429/3355) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.207) Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? QID: 3020 Type & Select Correct Answer 1 Tibiotalar dorsiflexion 10% (138/1351) 2 Tibiotalar plantarflexion 2% (21/1351) 3 Subtalar eversion 67% (903/1351) 4 Subtalar inversion 19% (257/1351) 5 Internal rotation 2% (24/1351) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 620 Type & Select Correct Answer 1 Injection of bone cement into the talus to prevent further avascular necrosis 2% (26/1508) 2 Ankle fusion 1% (17/1508) 3 Subtalar fusion 2% (24/1508) 4 Ankle arthroscopy to address this osteochondral lesion 4% (65/1508) 5 Continued observation as the vascularity to the talus is intact 91% (1368/1508) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 981 FIGURES: A Type & Select Correct Answer 1 Medial malleolus 4% (74/1736) 2 Deltoid ligament 71% (1231/1736) 3 Anterior talofibular ligament 10% (174/1736) 4 Lateral malleolus 2% (38/1736) 5 Calcaneonavicular ligament 12% (213/1736) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 1250 FIGURES: A B C Type & Select Correct Answer 1 Definitive closed treatment 4% (111/2478) 2 Addition of percutaneous pins 7% (167/2478) 3 Open reduction and internal fixation 86% (2133/2478) 4 Tibiotalocalcaneal arthrodesis 1% (22/2478) 5 Primary subtalar arthrodesis 2% (40/2478) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 1278 Type & Select Correct Answer 1 Tibiotalar and/or subtalar arthritis 61% (1070/1751) 2 Loss of forefoot supination 1% (22/1751) 3 Osteonecrosis 34% (594/1751) 4 Nonunion 3% (54/1751) 5 Infection 0% (2/1751) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 1231 FIGURES: A Type & Select Correct Answer 1 Talar dome subchondral lucency 77% (673/878) 2 Talar dome subchondral sclerosis 15% (131/878) 3 Diffuse osteopenia 1% (6/878) 4 Associated medial malleolus fracture 4% (33/878) 5 Talar lateral process fracture 4% (31/878) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 105 FIGURES: A Type & Select Correct Answer 1 Combined varus and plantar malunion 26% (653/2521) 2 Isolated varus malunion 15% (381/2521) 3 Isolated valgus malunion 3% (66/2521) 4 Isolated dorsal malunion 49% (1238/2521) 5 Isolated plantar malunion 7% (164/2521) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (3) Podcasts (1) Orthopaedic Summit Evolving Techniques 2020 Pro: MIS: The Arthroscope Will Get It Perfect - Let Me Show You How - Richard Ferkel, MD Trauma - Talar Neck Fractures B 2/25/2022 610 views 4.0 (4) Orthopaedic Summit Evolving Techniques 2020 Pro: Open Approach: Fix It With Plates Or Screws & Avoid Deformity & Arthritis - Michael Suk, MD Michael Suk Trauma - Talar Neck Fractures B 2/25/2022 895 views 4.2 (4) Orthopaedic Summit Evolving Techniques 2020 Feature Lecture Talus Fractures What I Have Learned & How I Avoid Complications - Bruce J. Sangeorzan, MD Trauma - Talar Neck Fractures B 2/25/2022 1048 views 4.5 (2) Trauma | Talar Neck Fractures Trauma - Talar Neck Fractures Listen Now 20:7 min 1/14/2020 1260 plays 5.0 (5)
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