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David Sanders MD, MSc, FRCSC London Health Sciences Centre University of Western Ontario London, Ontario, Canada Created March 2004; Revised August 2006.

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Presentation on theme: "David Sanders MD, MSc, FRCSC London Health Sciences Centre University of Western Ontario London, Ontario, Canada Created March 2004; Revised August 2006."— Presentation transcript:

1 David Sanders MD, MSc, FRCSC London Health Sciences Centre University of Western Ontario London, Ontario, Canada Created March 2004; Revised August 2006 Revised May 2011 Fractures of the Talus and Subtalar Dislocations

2 Outline: Talar Neck Fractures Anatomy Incidence Imaging Classification Management Complications Talar body, head and process fractures Subtalar dislocations Classification Management Outcomes

3 Surface 60% cartilage No muscular insertions Anatomy

4 Blood Supply 4 primary arterial sources: Artery of tarsal canal Artery of tarsal sinus Dorsal neck vessels Deltoid branches mediallateral Inferior view of talus, showing vascular anastomosis

5 Vascularity Artery of tarsal canal supplies majority of talar body Side ViewTop View Deltoid Branches Posterior tubercle vessels Artery of Tarsal Sinus Artery of Tarsal Canal Superior Neck Vessels Artery of Tarsal Sinus Artery of Tarsal Canal Posterior tubercle vessels

6 Talus ORIF Technique Vascularity

7 Incidence 2 % of all fractures 6-8% of foot fractures High complication rates avascular necrosis post-traumatic arthritis malunion

8 Mechanism of Injury Hyperdorsiflexion of the foot on the leg Neck of talus impinges against anterior distal tibia, causing neck fracture If force continues: talar body dislocates posteromedial often around deltoid ligament

9 Injury Mechanism Previously called “aviator’s astragalus” Usually due to motor vehicle accident or falls from height Approximately 50 % of patients have multiple traumatic injuries

10 Biomechanics Theoretical shear force across talar neck: 1200 N during active motion [Swanson 1992] Fracture fixation must withstand this force to permit active motion in the postoperative phase

11 Imaging Complex 3-D structure Multiple plain film orientations: AP, Lateral, Broden, & mortise views demonstrates joint congruity of ankle and subtalar joint Canale view for longitudinal alignment: approximately 15° IR to get calcaneous out of view Canale View

12 Slight ankle plantarflexion with knee bent to rest foot on the table 15 degree pronation Xray Tube 15 degree from vertical Canale View

13 CT Scan Most useful assessment tool for surgical planning Confirms displacement Demonstrates subtalar joint reduction, comminution, osteochondral fractures/debris

14 MRI Scan Primary role in talus injuries is to assess complications, especially avascular necrosis May be poor quality if extensive hardware present Zone of osteonecrosis following distribution of Artery of Tarsal Canal

15 Talar Neck Fractures: Classification Hawkins, 1970 Predictive of AVN rate Widely used

16 Talus ORIF Technique Hawkins Classification Hawkins, LR, JBJS, 52A: 991, 1970 I)Nondisplaced <10% II)Subtalar Displacement <40% III)Subtalar & TC ~90% IV)*Pantalar 100% *Canale, ST, JBJS, 60A: 143, 1978

17 Hawkins 1 Type I: undisplaced AVN rate 0 – 13 % Uncommon as most talar neck fractures are displaced

18 Hawkins 2 Displaced fracture with subtalar subluxation / dislocation A)fracture line enters subtalar joint B) subtalar joint intact AVN 20 – 50 % Most common type

19 Hawkins 3 Subtalar and ankle joint dislocated Talar body extrudes, usually around deltoid ligament Commonly open fractures, reduction very difficult Closed: plantar flex foot & flex knee Open: joy sticks AVN 83 – 100 %

20 Hawkins 4 Added to classification by Canale, 1974 Incorporates talonavicular subluxation Rare variant Complex talar neck fractures which otherwise do not fit classification are included as Type 4 injuries

21 Classification: Comminution: An important additional predictor of results, especially regarding prognosis re: Malunion Subtalar joint arthritis Included in AO-OTA classification as a modifier

22 Goals of Management Immediate reduction of dislocated joints Vascularity Cutaneous tension Vascular compromise Anatomic fracture reduction Stable fixation Facilitate union Avoid complications

23 Talus ORIF Technique Definitive Treatment Prompt anatomic operative reduction “die is cast” with injury Use “joy stick” K-wires for reduction Articular bone affects ROM (V, Sup, PF) Maintenance of reduction with HW Screws (A  P, P  A), countersink Plates (2.0 mini condylar or T) Dual incisions Do not dissect capsular attachments Maintain as much soft tissue attachments

24 Treatment of Talar Neck Fractures Emergent reduction of dislocated joints Stable internal fixation Debridement of subtalar joint Maintain as much soft tissue/vascular attachments Choice of fixation and approach depends upon personality of fracture

25 Treatment of Talar Neck Fractures Post operative rehabilitation: Sample protocol: Initial immobilization, 2-6 weeks depending upon soft tissue injury and patient factors, to prevent contractures and facilitate healing Non weight-bearing, Range of Motion therapy until 3 months or fracture union

26 Hawkins I Fracture Options: Non Operative & Non- Weight-Bearing Cast for 4-6 weeks followed by removable brace and motion OR: Percutaneous screw fixation and early motion

27 Hawkins II, III, and IV Fractures: Results dependent upon development of complications Osteonecrosis Malunion Arthritis

28 Case Example 29 yo male ATV rollover Isolated injury LLE

29 These injury films are tough to interpret, but close review demonstrates the dislocated talar body with some comminution.

30 Diagnosis “Hawkins’ 3” talar neck fracture Associated comminution, probably involving medial column and subtalar joint

31 Controversies for this Case: Surgical timing Closed reduction Surgical approach Fixation

32 Surgical Timing In general: emergent reduction of dislocated joints Allow life threatening injuries to take priority and resuscitate adequately first

33 Closed Reduction? May be very useful, particularly if other life threatening injuries preclude definitive surgery Difficult in Hawkins’ 3 and 4 injuries

34 Closed Reduction Technique: Adequate sedation Flex knee to relax gastrocs Traction on plantar flexed forefoot to realign head with body Varus/valgus correction as necessary Direct pressure on talar body Adjunct: traction pin, general anesthetic, etc Avoid repetitive reduction attempts in order to avoid skin compromise or tearing

35 Closed Reduction Example

36 External Fixation Limited roles: Multiply injured patient with talar neck fracture in whom definitive surgery will be delayed Temporizing measure to stabilize reduced joints Construct bridges tibia – calcaneus – midfoot

37 Surgical Approaches: Options 1 incision techniques: Anteromedial or Anterolateral Problem: difficult to visualize the entire talar neck and subtalar joint without significant soft tissue stripping and devascularization Problem: usual medial comminution inhibits accurate read of fracture reduction

38 Surgical Approaches: Options 2 incision technique: (generally preferred) Anteromedial and lateral/anterolateral Problem: 2 skin incisions, close together Benefit: excellent fracture visualization at critical sites of reduction and subtalar joint with less stripping

39 1 st Approach: Anteromedial Medial to TibAnt Make incision more posterior for talar body fractures to facilitate medial malleolar osteotomy

40 1 st Approach: Anteromedial Provides view of neck alignment and medial comminution Extend incision distally to talonavicular joint – hardware is placed distal to proximal and needs to be well countersunk to avoid impingement

41 2 nd Approach: Lateral Tip of Fibula directly anterior Mobilize EDB as sleeve Protect sinus tarsi contents

42 2 nd Approach: Lateral Visualizes Anterolateral alignment and subtalar joint Facilitates Placement of “Shoulder Screw” or lateral plate

43 2 incisions: Skin bridge Narrow skin bridge but generally well tolerated Talus fractures generally have less soft tissue problems compared to plafond or calcaneus fractures

44 Fixation Options Stable Fixation to allow early motion is the goal 1200 N stress across talar neck during early motion (Swanson JBJS 1992) That is a lot of force! 2 A to P screws only resists about 1 kN of stress so need more fixation

45 Surgical Tactics: Fixation Anterior Partial threaded screws Fully threaded screws Mini-fragment plates (2.0, 2.4 mm) Posterior Lag screws Implant selection depends upon injury, degree of comminution, bone quality

46 Posterior to Anterior Fixation: Screw fixation stronger from posterior than from anteromedial (T Bray) Screws perpendicular to fracture site 2 PA screws in compression are able to withstand the theoretical shear force of active motion Avoid excessive posterior capsular stripping Creates potentially 3 incisions (posterior, medial, lateral) 90°

47 Anterior Screw Fixation: Screw fixation alone is acceptable for non-comminuted fractures, but consider adding a plate if there is comminution. Easy to insert under direct visualization This example: displaced type 2: 4 A- P screws including medial “buttress” fully threaded cortical screws and lateral “shoulder” screws

48 Anterior Screw Fixation: This example: 4.0 mm partially threaded compression screws through non-comminuted columns Mini-fragment (2.4 mm) screws for osteochondral fragments Consider Titanium for MRI

49 Plate Fixation: Very useful in comminuted fractures: 2.0 or 2.4 mm plates Easiest to apply to lateral cortex – impinge on medial side

50 Talus ORIF Technique Hawkins 3

51 Talus ORIF Technique

52 Complications AVN Malunion Nonunion Arthritis

53 Talus ORIF Technique Results Chateau, Indy, 2002 JOT 23 pts, 20 mo F/U Dual, mini fragment “Low” rate AVN Elgafy, Foot Ankle fx Arthritis: Ankle 25%, Subtalar 53% AVN 16% Harborview, 2002 OTA 60 fx, 30 mo F/U w/in 24 hr (40 pts)/ Dual 91% Worse results with: Comminution Open Osteonecrosis 39% (II)  56% to collapse 64% (III)  67% to collapse

54 AVN: Incidence after Talus Fracture Canale (1972): I: 15 % II: 50 % III: 85 % IV: 100 % Behrens (1988): Overall 25 % Ebraheim/Stephen (2001): Overall 20 %

55 Talus ORIF Technique AVASCULAR NECROSIS Rates with Hawkins Class AVN does not = poor result ? MRI-probably not prognostic ? Does early ORIF minimize AVN

56 AVN: Diagnosis Hawkins’ Sign: Xray finding 6-8 weeks post injury Presence of subchondral lucency implies revascularization

57 AVN: Imaging Plain radiographs: sclerosis common, decreases with revascularization MRI: very sensitive to decreased vascularity

58 Talus ORIF Technique Hawkins 3

59 Talus ORIF Technique 1 year follow-up |Osteonecrosis without collapse

60 Bilateral Injuries Fixed at 72 hours

61 2 years – Pain, Stiffness, Limp Hawkins III Hawkins II

62 AVN Treatment: Precollapse: Modified WB PTB cast Compliance difficult Efficacy unknown Postcollapse: Observation “Blair fusion” is one option if symptomatic

63 Malunion: Incidence Common: up to 40% Most often Varus

64 Malunion: Diagnosis Varus hindfoot, midfoot supination on clinical exam Dorsal malunion on Xray

65 Malunion Mechanical effects > 3 degrees malunion: decreased subtalar ROM (Daniels TR, JBJS 1996) > 2mm: altered subtalar contact forces (Sangeorzan J Orthop Res 1992)

66 Clinical Effect of Malunion Malunion: More pain Less satisfaction Less ankle motion Worse functional outcome

67 Malunion Rx: Talus osteotomy Calcaneus osteotomy Possible midfoot osteotomy Tendo Achilles Lengthening

68 Talus ORIF Technique Arthrosis (Subtalar) Pain &/or stiffness – 16 (52%) Dx arthrosis – 6 (19%) Subtalar arthrodesis – 3 (10%)

69 Post Traumatic Arthritis Incidence of post- traumatic arthritis %

70 Post-Traumatic Arthritis Most commonly involves Subtalar joint Rx: Arthrodesis

71 Nonunion Uncommon, even with AVN Delayed Union very common Frequently results in late malalignment

72 Talar Body Fractures Treatment strategy and outcomes similar to talar neck fractures Medial or Lateral Malleolar Osteotomy frequently required

73 Medial Malleolar Osteotomy Predrill and pretap malleolus Osteotomy aims just off the medial corner of mortise to facilitate interdigitation Chevron, straight, or stepcut techniques Osteotome to crack cartilage helps avoid mortise malalignment

74 Talar Body + Fibula Fracture Visualize body through the fibula fracture

75 Talar Body Case Example 58 year old female 4 week old fracture Missed initially

76 Case, cont’d Extensive comminution into subtalar joint Poor bone quality

77 Selected Rx: Primary Arthrodesis Tricortical bone graft to reconstitute talar height

78 Osteochondral Injuries Frequently encountered with talus neck and body fractures Require small implants for fixation Excise if unstable and too small to fix

79 Osteochondral Injuries

80 Osteochondral Fragment Repair Large fragment repaired, small fragment excised

81 Talar Head and Process Fractures Treat according to injury Operate when associated with joint subluxation, incongruity, impingement or marked displacement Fragments often too small to fix and require excision

82 Case Example: Talar Head Fracture Talar head injury Subtle on plain x-ray

83 Talar Head Fracture, continued CT demonstrates subtalar injury and subluxation

84 Treatment of Talar Head Fracture Required 2 incisions to debride subtalar joint from lateral approach, and reduce / stabilize fracture from medial side

85 Lateral Process Example Usually require CT scan Often excised due to size of fragments Difficult to achieve union

86 Lateral Talar Process Fractures “Snowboarder’s fracture” Mechanism: may occur from inversion (avulsion injury) or eversion and axial loading (impaction fracture) Often misdiagnosed as “ankle sprain” Best results if treated early, either by immobilization, ORIF or fragment excision If diagnosed late consider fragment excision as attempts to achieve union often fail

87 Talus Fracture AO/ASIF Classification Lateral Process (81-A2.1)

88 Treatment Options Non-operatively for minimally displaced fractures Excision of fragment Isolated mini fragment screws Mini plate fixation

89 Fracture Complications Extend into subtalar joint Accelerated post-traumatic arthritis  pain  stiffness  disability  subsequent surgery for subtalar joint fusion

90 Mini Plate Procedure 1.Lateral approach 2.Subtalar chondral debris removed 3.Impaction elevated if present & filled with allograft if required 4.Preliminary 0.45 Kirschner wire (K-wire) fixation mm “T” plate applied upside down 6.Lag screw fixation - avoiding overcompression with comminution

91 Talar Fracture Isolated Lateral Process

92 Talus Fracture Lateral Process & Talar Neck Marginal Impaction Comminuted Fracture

93 Posterior Talar Process Fracture 2 components: medial and lateral tubercle Groove for FHL tendon separates the two tubercles Differentiate fracture from os trigonum – well corticated, smooth oval or round structure

94 Posterior Talar Process Fractures Medial tubercle fracture: “Cedell’s fracture” Lateral tubercle: “Shepherd’s fracture” Treatment: immobilize or excise or ORIF

95 Treatment Usually associated with Talar Neck Fx Posteromedial Approach behind Neurovascular Bundle Medial Malleolar Osteotomy – usually not effective for exposure or fixation

96 Example – 18 yo “Car Surfer”

97 CT Evaluation

98 Treatment – 3 Incisions

99 Subtalar Dislocations Spectrum of injuries Relatively Innocent Very Disabling

100 Classification Usually based upon direction of dislocation: Medial dislocation: 85 %, low energy Lateral dislocation: 15 %, high energy

101 Other Important Considerations: Open vs Closed High or low energy mechanism Stable or unstable post reduction Reducible by closed means or requiring open reduction Associated impaction injuries All have prognostic significance:

102 Important Distinction: Total talar dislocation, or pan talar dislocation Results from continuation of force causing subtalar dislocation High risk of AVN, usually open, poor prognosis Open pantalar dislocation with skin loss showing Incongruent reduction: Result was AVN and pantalar fusion

103 Management of Subtalar Dislocation Urgent Closed reduction: Adequate sedation Knee flexion Longitudinal foot traction Accentuate, then reverse deformity Successful in up to 90 % of patients

104 Open Reduction: More likely after high energy injury More likely with lateral dislocation Cause: soft tissue interposition (Tib post, FHL, extensor tendons, capsule) bony impaction between the talus and navicular

105 Rehabilitation: Stable injuries: 4 weeks immobilization Physio for mobilization Unstable injuries: Usually don’t require internal fixation once reduction achieved If necessary – external fixation or transarticular wire fixation

106 Outcome of Subtalar Dislocations: Less benign than previously thought Subtalar arthritis: Up to 89 % radiographically Symptomatic in up to 63 % Ankle and midfoot arthritis less common

107 Summary: Talar Neck Fractures Anatomy Incidence Imaging Classification Management Complications Talar body, head and process fractures Subtalar dislocations Classification Management Outcomes

108 Selected References Hawkins LG 1970 Fractures of the neck of the talus. J Bone Joint Surg Am 52(5): Canale ST, Kelly FB, Jr Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 60(2): the two classics on talus fractures. Rates of AVN, classification, etc. Good descriptive papers. Additional Clinical papers: Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J 2000 Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 21(12): Metzger MJ, Levin JS, Clancy JT 1999 Talar neck fractures and rates of avascular necrosis. J Foot Ankle Surg 38(2): Pajenda G, Vecsei V, Reddy B, Heinz T 2000 Treatment of talar neck fractures: clinical results of 50 patients. J Foot Ankle Surg 39(6):

109 Selected References Recent Literature: Sanders DW, Busam M, Hattwick E, Edwards JR, McAndrew MP, Johnson KD. Functional outcomes following displaced talar neck fractures. J Orthop Trauma 2004; 18: Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone Joint Surg 2004; 86-A: Good outcome papers on talar neck Fleuriau Chateau PBFleuriau Chateau PB, Brokaw DS, Jelen BA, Scheid DK, Weber TG. Plate fixation of talar neck fractures: preliminary review of a new technique in twenty-three patients. J Orthop Trauma. 2002;16(4):213-9.Brokaw DSJelen BAScheid DKWeber TG -plate fixation discussed Vallier HA, Nork SE, et al. Surgical treatment of talar body fractures. J Bone Joint Surg 2004; Supp 1: ; and 2003; 85-A: good talar body review and surgical technique Bibbo C, Anderson R, Marsh WH. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases. Foot ankle int 2003: 24: best current info on subtalar dislocations

110 References Cont. Biomechanics Sangeorzan BJ, Wagner UA, et al. Contact characteristics of the subtalar joint: the effect of talar neck misalignment. J Orthop Res 1992; 10(4): Daniels TR, Smith JW, Ross TI. Varus malalignment of the talar neck. Its effect on the position of the foot and on subtalar motion. J Bone Joint Surg Am. 1996; 78: Swanson TV, Bray TJ, Holmes GB Jr. Fractures of the talar neck. A mechanical study of fixation. J Bone Joint Surg Am 1992; 74(4): Attiah M, Sanders DW et al. Comminuted talar neck fractures: a mechanical study of fixation techniques. J Ortho Trauma 2007; 21:

111 Return to Lower Extremity Index OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to


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