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Updated: Dec 18 2023

Talar Neck Fractures

Images
https://upload.orthobullets.com/topic/1048/images/weatherford_120510_00001-2_moved.jpg
https://upload.orthobullets.com/topic/1048/images/r talar neck.jpg
https://upload.orthobullets.com/topic/1048/images/talar neck fx dislocation lateral.jpg
https://upload.orthobullets.com/topic/1048/images/hawkins 4.jpg
  • 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
      • 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 risk
      • Hawkins I
      • Nondisplaced
      • 0-13%
      • 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
          • 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
          • indicates intact vascularity with resorption of subchondral bone
        • increased risk with increasing degree of initial fracture displacement
        • 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%)
      • Posttraumatic arthritis may necessitate fusion surgery
    • 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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