Summary Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures. Diagnosis is made radiographically with foot radiographs but CT scan is often needed for full characterization of the fracture. Treatment is generally nonoperative with immobilization for minimally displaced injuries and surgical reduction and fixation for displaced and intra-articular fractures. Epidemiology Incidence rare less than 1% of all fractures second most common tarsal fractures after calcaneus fxs Anatomic location talar body fractures account for 13-23% of talus fractures lateral process fractures account for 10.4% of talus fractures talar head fracture least common talus fracture Etiology Mechanism talar body injuries often result from high energy trauma, with the hindfoot either in supination or pronation lateral process of talus injuries result from forced dorsiflexion, axial loading, and inversion with external rotation often seen in snowboarders Anatomy 3D Anatomy of talus Talus has no muscular or tendinous attachments Articulation there are 5 articulating surfaces seventy percent of the talus is covered by cartilage 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 this forms the lateral margin of the talofibular joint posterior process consist of medial and lateral tubercle separated by groove for FHL Blood supply because of limited soft tissue attachments, the talus has a direct extra-osseous blood supply sources include posterior tibial artery via artery of tarsal canal (most important and main supply) supplies most of talar body via calcaneal braches supplies posterior talus anterior tibial artery supplies head and neck perforating peroneal arteries via artery of tarsal sinus supplies head and neck deltoid artery (located in deep segment of deltoid ligament) supplies body may be only remaining blood supply with a talar neck fracture Classification Anatomic classification Anatomic classification Lateral process fracture Type 1 Fractures do not involved the articular surface Type 2 Fractures involve the subtalar and talofibular joint Type 3 Fractures have comminution Posterior process Posteromedial tubercle Avulsion of the posterior talotibial ligament or posterior deltoid ligament Posterolateral tubercle Avulsion of the posterior talofibular ligament Talar head fracture Talar body fracture Physical Exam Symptoms pain lateral process fractures often misdiagnosed as ankle sprains Physical exam provocative tests pain aggravated by FHL flexion or extension may be found with a posterolateral tubercle fractures Imaging Radiographs recommended views AP and lateral lateral process fractures may be viewed on AP radiographs Canale View optimal view of talar neck technique maximum equinus 15 degrees pronated Xray 75 degrees cephalad from horizontal careful not to mistake os trigonum (present in up to 50%) for fracture may be falsely negative in talar lateral process fx CT scan indicated when suspicion is high and radiographs are negative best study for posterior process fx, lateral process fx, and posteromedial process fx helpful to determine degree of displacement, comminution, and articular congruity MRI can be used to confirm diagnosis when radiographs are negative Treatment Nonoperative SLC for 6 weeks indications nondisplaced (< 2mm) lateral process fractures nondisplaced (< 2mm) posterior process fractures nondisplaced (< 2mm) talar head fractures nondisplaced (< 2mm) talar body fractures technique cast molded to support longitudinal arch Operative ORIF/Kirshner wire Fixation indications displaced (> 2mm) lateral process fractures displaced (> 2mm) talar head fractures displaced (> 2mm) talar body fractures medial, lateral or posterior malleolar osteotomies may be necessary displaced (> 2mm) posteromedial process fractures may require osteotomies of posterior or medial malleoli to adequately reduce the fragments fragment excision indications comminuted lateral process fractures comminuted posterior process fractures nonunions of posterior process fractures Technique ORIF/Kirshner Wires approaches lateral approach for lateral process fractures incision over tarsal sinus, reflect EDB distally posteromedial approach for medial tubercle of posterior process fracture or for entire posterior process fracture that has displaced medially between FDL and neurovascular bundle posterolateral approach for lateral tubercle of posterior process fractures between peroneal tendons and Achilles tendon (protect sural nerve) beware when dissecting medial to FHL tendon (neurovascular bundle lies there) combined lateral and medial approach required for talar body fractures with more than 2 mm of displacement Fragment excisions incompetence of the lateral talocalcaneal ligament is expected with excision of a 1 cm fragment this is biomechanically tolerated and does not lead to ankle or subtalar joint instability Complications AVN Hawkins sign (lucency) indicates revascularization lack of Hawkins sign with sclerosis is indicative of AVN Talonavicular arthritis posttraumatic arthritis is common in all of these fractures this can be treated with an arthrodesis of the talonavicular joint Malunion Chronic pain from symptomatic nonunion may have pain up to 2 years after treatment Subtalar arthritis found in 45% of patients with lateral process fractures, treated either non-operatively or operatively anatomic reduction of the articular surface can decrease incidence Prognosis Lateral process injuries have a favorable outcomes with prompt diagnosis and immediate treatment