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Updated: Jun 18 2024

Talus Fracture (other than neck)

Images - AP - Non displaced Lateral Process f_moved.jpg - Lat - Non displaced Lateral Process f_moved.jpg - Non displaced Lateral Process fx_moved.jpg Scan - Non displaced Lateral Process fx_moved.jpg
  • 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 eversion 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
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