TALUS FRACTURES

PRESENTER - Dr SELIM ALI AHMED

PGT-1(Orthopaedics)

MODERATOR- Dr MANASJYOTI DAS

Assistant professor,
Department of orthopaedics, TMCH
 CONTENTS
 INTRODUCTION
 ANATOMY
 CLASSICATIONS
 MECHANISM OF INJURY
 CLINICAL FEATURES
 DIAGNOSIS
 TREATMENT
 COMPLICATIONS
 INTRODUCTION

 The heel bone of horse was used as dice and was called Taxillus. This Word evolved into Talus.
 In 1919, Anderson published a series of foot injuries sustained by aviators in World War I which he
called Aviator's Astralaqus.
 He emphasized that the mechanism of injury was excessive dorsiflexion of the foot as pressure was
applied to the rudder bar.

In 1970, Hawkins developed a classification of talus fractures, which provided guidelines for
treatment as well as the prognosis of different fracture types.

Later on, Canale and Kelly,1978 Expanded the HAWKINS classification system and introduced type IV.
 OSSEOUS ANATOMY OF
TALUS

 TALUS is second largest tarsal bone

 It acts as a connecting link between the foot and the leg
 It is unique as 60% of its surface is articular ,it has ligamentous
and capsular attachments but no muscular attachments.
 Because of the large amount of articular surface and the lack of
any musculotendinous attachment, the talus is left with a tenuous
blood supply.
PARTS OF TALUS

 HEAD
 NECK
 BODY
 LATERAL PROCESS
 POSTERIOR PROCESS
 MEDIAL PROCESS
 HEAD OF TALUS

 Anterior articular surface is

large ,oval and convex articulating
with navicular bone.
 The spring ligament inferiorly, the
sustentaculum tali
posteroinferiorly, and the deltoid
ligament medially.
NECK OF TALUS

 Constricted portion of bone between the body and

the oval head.
 Directed forward ,medially ,downward
 It deviates medially 15 to 25 degree with the
body.
 Relatively thin diameter which makes it weaker
and hence more vulnerable area to fracture.
BODY OF TALUS

 5 SURFACES-
 SUPERIOR SURFACE
 INFERIOR SURFACE
 MEDIAL SURFACE
 LATERAL SURFACE
 POSTERIOR SURFACE
 LATERAL PROCESS

 Wedge shape
 Articulates
Inferomedially-posterior calcaneal facet
Superolaterally-lateral malleolus
POSTERIOR PROCESS

 It has medial and lateral tubercle

 FLEXOR HALLUCIS LONGUS passes in between.
 Lateral tubercle-posterior talofibular ligament
 Medial tubercle-deltoid ligament
 Os trigonum-seen in 50% Foot,develops from
separate ossification centre just posterior to
lateral tubercle.
 VASCULAR ANATOMY OF
TALUS
 Main supply comes from the dorsalis pedis,
deltoid branches, and artery of the tarsal
sinus and tarsal canal. Together they form a
rich anastomotic network that provides the
potential for healing despite significant
injury and displacement.
 It receives blood supply through capsular
and ligamentous attachments
 Talus is supplied by
A. Anterior tibial artery - Dorsalis pedis
artery
B. posterior tibial artery - artery of tarsal
canal
-deltoid artery
VASCULAR ANATOMY OF
TALUS
 Head and Neck –supplied by Dorsalis
Pedis artery and peroneal artery
 Body
-Medial 1/3 – Deltoid artery
-Middle 1/3 - Artery of Tarsal Canal
- Lateral 1/3 – Anastomotic sling
between arteries of tarsal canal
and
sinus tarsi
 Posterior tubercle
-Branches of posterior tibial artery
TALUS FRACTURE

 Anatomical classification of talus fracture

1. Talar neck fracture
2. Talar body fracture
3. Talar head fracture
4. Lateral process fracture
5. Posterior process fracture
AO/OTA CLASSIFICATION OF TALUS
FRACTURE
HAWKIN CLASSIFICATION
FOR TALAR NECK FRACTURE
 Type I : Nondisplaced AVN

TYPE I 0-25%
 Type II : Displaced with Subtalar
TYPE II 25-50%
Subluxation
 Type III : Associated with Subtalar and Ankle TYPE III 50-75%

subluxation
TYPE IV 75-100%
 Type IV : Associated with Subtalar, Ankle and
Talo-NavicuIar subluxation
HAWKIN CLASSIFICATION
 SNEPPEN CLASSIFIED
BASED ON
ANATOMICAL LOCATION FOR
TALAR BODY FRACTURE

 • I- trans-chondral dome fractures;

• II- shear fractures;
• III- posterior tubercle fractures;
• IV- lateral process fractures; and
• V- crush fractures
TALAR NECK FRACTURES

 Most common type of talar fractures

MECHANISM OF INJURY
 Forced hyper-dorsiflexion of the ankle and
impingement of the taller neck on the distal
anterior tibia.
 Axial compression to dorsiflexed foot
causes talar neck fracture
TALAR BODY FRACTURE

 The fracture line is proximal to Lateral process of

Talus
 Incidence of AVN is same in Neck and Body
fracture,
but Post-traumatic arthritis is more with Body
fracture.

 MECHANISM OF INJURY
 Axial compression of Talus between Tibial
Plafond and Calcaneum.
 Occurs due to fall from height or Motor vehicle
TALUS HEAD FRACTURE

 Incidence- 5 to 10 % of talar injuries

Mechanism of injury-
Fall from height, with Foot in plantar flexion and
longitudinal compression force along the long
axis of the forefoot
 Talo-Calcaneo-Navicular joint disruption
 Shortening of the medial column
 Loss of the Medial longitudinal arch
LATERAL PROCESS OF TALUS
FRACTURE

 SNOWBOARDER'S FRACTURE
 MISDIAGNOSED OFTEN ANKLE SPRAIN

 MECHANISM OF INJURY-
Axial loading, dorsiflexion , external rotation and eversion
of foot.
 V SIGN- it is the contour of lateral process on lateral view of
X-ray
 V sign positive- any disruption in contour of V indicating
fracture lateral process
POSTERIOR PROCESS OF TALUS
FRACTURE
 Posterior process of Talus has Medial and
Lateral tubercles with Flexor hallucis longus
passing in the groove
 Medial tubercle - Deltoid Ligament
 Lateral tubercle-posterior talofibular
ligament
 MECHANISM OF INJURY
- Medial tubercle of Posterior process fracture
due to Forceful eversion of the ankle
- Lateral tubercle of Posterior process fracture
due to Forceful inversion of the ankle
CLINICAL FEATURES

 Patients presents with h/o trauma Followed by c/o Pain and swelling of
the hind foot
 Restriction of movements of the ankle
 O/E-Tenderness over Talus and Subtalar joint
-Restriction of Ankle and Subtalar movements
 Tenting is a dangerous sign.
 Pulse should be checked and compare with those in the
opposite foot.
 DIAGNOSIS

 X-RAY
[Link] VIEW
[Link] VIEW
[Link] MORTISE VIEW
[Link] VIEW
-For better visualization of neck of Talus.
A view of the talar neck achieved by placing
the foot plantigrade on
the x ray film and angling the beam at 75 degrees
top the perpendicular.
[Link]’S VIEW
 DIAGNOSIS

 CT SCAN- give excellent visualization of

the congruity of the subtalar
joint and provide superior details of fracture.
 small but significant fractures of
the inferior aspect of the talus,
are better appreciated on CT scans
compared to plain x-ray films alone.
 MRI SCAN- may be done to identify the soft tissue
injury
NON OPERATIVE TREATMENT OF
THE FRACTURES TALUS :
TREATMENT:
TALAR NECK FRACTURE
TALAR BODY FRACTURE
LATERAL PROCESS OF TALUS
FRACTURE
TYPE I TYPE II TYPE III
SIMPLE COMMINUTED CHIP
POSTERIOR PROCESS OF TALUS
FRACTURE

TREATMENT

NON DISPLACED - Conservative

DISPLACED- ORIF with Herbert screw fixation
TALUS HEAD FRACTURE
TREATMENT

 NON DISPLACED FRACURE- Conservatively with non

weightbearing short leg cast

 DISPLACED/LARGER FRAGMENT/INSTABILITY OF TALONAVICULAR

JOINT- ORIF is done
 TREATMENT OF FRACTURE
TALUS BODY
 PROBLEMS FACED WITH TALOCALCANEAL FUSION
 DECREASE IN HEIGHT AND THE RIGIDITY OF ANKLE JOINT
 BLAIR SUGGESTED ALTERNATIVE PROCEDURE
TIBIOTALAR ARTHRODESIS
PROCEDURE-sliding graft from anterior surface of tibia is inserted
into the remnant of head and neck of the talus in an attempt
to obtain fusion around the area

TALOCALCANEAL FUSION
TIBIOTALAR
ARTHRODESIS
BLAIR TIBIOTALAR
ARTHRODESIS

BLAIR FUSION
A, Approach to the ankle.

B, Excision of body of talus.

C, Sliding bone graft.

D, Graft in final position

 TREATMENT

ADVANTAGES OF TIBIO TALAR ARTHRODESIS OVER CALACANEOTIBIAL

FUSION

 Position of foot is unchanged

 Weight bearing thrust is placed on more or less normal undisturbed joint tissue.
 No shortening
 After surgery- still slight flexion and extension of the foot on leg ,
 the two subtalar facets and talonavicular joint is possible.
 No posterior displacement of navicular
 TREATMENT
EXTERNAL FIXATION

 External Fixation Limited roles.

 Multiple injured patient with
talar neck fracture in whom definitive
surgery will be delayed.
 Temporary measure to stabilize reduced joints
COMPLICATION

 OSTEONECROSIS
 Delayed union and Non-union
 MALUNION
 POST-TRAUMATIC ARTHRITIS
 INFECTION AND SKIN NECROSIS
 COMPLICATION
 OSTEONECROSIS
 HAWKINS SIGN- Subchondral osteopenia in the
talus at 6-8 weeks tends to indicate talar viability .
However, the presence of this sign does not rule out
osteonecrosis and it’s absence also not diagnostics for
osteonecrosis
 MRI is the most sensitive test to detect AVN and detect
as early as 3 weeks after the injury.

 Treatment
 Patellar tendon bearing orthosis
 Primary triple arthrodesis
 Total talectomy with tibio-calcaneal fusion
 COMPLICATION
 MALUNION(incidence is 28-32%)
 Dorsal displacement of the distal fragment and varus malunion are
common.
 Results in limitation of the dorsiflexion and painful gait.
 Treatment- corrective osteotomy of neck

 POST-TRAUMATIC ARTHRITIS
 Incidence is 46-69%
 Subtalar joint most commonly involved.
 Due to osteonecrosis, cartilage damage,stiffness and
mal-alignment of the joint occurs.
 Treatment —Local analgesic infiltration,
COMPLICATION
 TALONAVICULARARTHRITIS IN DISPLACED FRACTURE
Conservatively managed with longitudinal arch support shoe
If conservative fails then talonavicular arthrodesis relieves symptoms

 NONUNION- UNCOMMON

 MALUINION - TALONAVICULAR JOINT SUBLUXATION

COMPLICATION

 INFECTION AND SKIN NECROSIS

 Treatment is extremely challenging.
 Avascular body of the talus acts as
large sequestrum.
 Surgical debridement including
talectomy
may be required as treatment.
 COMPLICATION

 DELAYED UNION AND NON

UNION
o Delayed and non union are rare
complications of talar fracture
o Delayed union is refer as lack of
radiographic heeling for 6 months
o Incidence of non union is between 0%
to 4%
o Treatment-ORIF with Bone graft
BIBILOGRAPHY

 ROCKWOOD AND GREEN’S FRACTURE IN ADULT

THANK YOU