5/7/2010

The Truth

Management of talus fracture

Even very experienced surgeons would have

treated a few in their lifetime
But, it is important to treat well

Dr.Mohana Rao
Ortopaedic Surgeon
Hospital Pulau Pinang
Trauma Symposium
8/5/10
Foot and Ankle Symposium, Kangar

Introduction

Tib. post and the medial contribution

The issue of blood supply?

Blood supply is rich, but 70% covered by
hyaline cartilage and no muscular
attachments.

Sinus tarsi and tarsal canal artery

anastomosis

Post and medial anastomotic network

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Dorsal neck network

To make it simpler
Dorsalis pedis
Tibialis posterior
Peroneal branches
All the above anastomose
Medial side has very important supply to the
body

Management

Management

Conservative very specific indication

Most times require surgical
Remember that this is a weight bearing bone
Articulates with many other bones

Probably the AO principles can be applied to

strictly
Anatomical reduction,
Stable internal fixation,
Preservation of the blood supply, and
Early active pain-free motion

Fracture of the talus

Can be looked at through different angles:

Many classifications
Some are difficult to remember
Hawkins classification is popular and only
applies to the neck of talus fracture

Fracture of the talus

Can be central or peripheral
Anatomically divided to head, neck, body,
dome and the processes and to be complete,
cartilage damage.

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My Technique

Open or closed
Soft tissue condition
Associated injuries
Presence of dislocation or subluxation
Presence of other limb or life threatening
conditions
Central or peripheral
CT scan all hindfoot and midfoot fractures

Timing of surgery
Delayed fracture fixation may not increase the
occurance of AVN.
Use this study to benefit you
Delay till wrinkle sign is visible

General rule of thumb

Conservative treatment for
Extraarticular fractures
Undisplaced fractures (1-2 mm)
Fragments less than 0.5cm
Patient is too unwell

Pearl

External fixator is your friend

Open fracture risk of osteomyelitis is high
Poor soft tissue condition, use your friend
Distract, plantigrade foot
Rest the foot
Wrinkle sign

Fracture of the talus

Have a high index of suspicion
Pain around the ankle, fracture line may not
be visible
May not always be the neck fracture

Fracture of the head

Very rare
Not well documented
Maybe less than 10%
Cause long term
disability
Disturbance in gait
Subtalar pain
Medial column collapse
Associated injuries

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Fracture of the head

Fracture of the head

Fracture of the head

Fixation

Direct incision
Anteromedial incision
Reconstruct lateral column
Use ext fixator for distraction if need be
Locking plate is useful
KIV bone graft
Fluoroscopy is a must

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Neck of talus fracture

Hawkins classification in 1970
Canale and Kelly added a type 4

Treatment
Type 1 Conservative
All the rest with ORIF
Percutaneous fixation has been described
after manipulation.
Technique is not very reproducible
Many authors prefer open reduction

Hawkins LG: Fractures of the

neck of the talus. J Bone Joint
Surg Am 52:991-1002, 1970

Incision

Once again, many described

I have used a single midline incision
Not anymore
Use a double incision
Very versatile
Able to visualize both ends of fracture

Screw fixation

Double dorsal incision

Anteromedial and anterolateral

Type I

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Type 3

Talar body fracture

Why the big hype

More common than talar head

7% - 38%
High energy trauma
Fracture line behind the lateral tubercle

See the lateral tubercle

Involve the subtalar and ankle joint

Fixation

Arthroscopic assisted

2 incisions
Disengage all the fragments
Clear the subtalar joint
Hold with temporary k-wires
Screw
Non compressive
or

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Lateral process fracture

Recognize this?

About 25% of the talus

fracture
Commonly wrongly
termed s avulsion of the
fibula
Missed
Snowboarders fracture

The wonder of CT
Really not an overcall

Treatment

Small can be left alone

Otherwise screw fixation
If not fixed, cause subfibular impingement
Chronic ankle pain

Posterior process fracture

Postero lateral process is larger

Obviously posteromedial is smaller
FHL runs inbetween
Commonly missed
Chronic ankle pain

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Posteromedial process fracture

CT scan

Posterolateral fracture not reduced

causing subtalar instability

Osteochondral fractures
BERNDT and HARTY
Type I: Subchondral depression without break in
the cartilage.
Type II: Fractured partially detached
osteochondral
fragment.
Type Ill: Totally detached but nondisplaced
osteochondral
fragment.
Type IV: Displaced osteochondral fragment

Subtalar dislocation

Foot will appear funny

Must be reduced
Back slab often unstable
K wire if necessary

Referances
Mulfinger GL, Trueta J: The blood supply of the talus. J Bone Joint Surg Br
52:160-167, 1970
Haliburton RA, Sullivan CR, Kelly PJ: The extra-osseous and intra-osseous
blood supply of the talus. J Bone Joint Surg Am 40:1115-1120, 1958
Lindvall E, Haidukewych G, Dispasquale T, et al: Open reduction and stable
fixation of isolated, displaced talar neck and body fractures. J Bone Joint
Surg Am 86:2229-2234, 2004
Pennal GF: Fractures of the talus. Clin Orthop Relat Res 30:53-63, 1963
Canale ST, Kelly FB Jr: Fractures of the neck of the talus. J Bone Joint Surg
Am 60:143-156, 1978
Coltart WD: "Aviator's astragalus." J Bone Joint Surg Br 34:546-566, 1952
John S. Early, Management of fractures of the talus: body and head region.
Foot Ankle Clin N Am 9 (2004) 709 722

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Referances
John S. Early, Management of fractures of the talus: body
and head region. Foot Ankle Clin N Am 9 (2004) 709 722
Donald J Mcbridea, C. Ramamurthya, Patrick LaingbThe
hindfoot: Calcaneal and talar fractures and dislocations
Part II: Fracture and dislocations of the talus, Current
Orthopaedics (2005) 19, 101107
Central talar fracturestherapeutic considerations,
Patrick Cronier, Abdelhafid Talha, Philippe Massin Injury,
Int. J. Care Injured (2004) 35, S-B10S-B22
Dan-Henrik Boack, Sebastian Manegold Peripheral talar
fractures Injury, Int. J. Care Injured (2004) 35, S-B23SB35,

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