What Is Talus Fractures?/Talus Fractures of the body are rare and serious injuries, frequently seen as an associated injury in long bone fractures and in polytraumatized patients. The high variability of talar fractures and their relatively low incidence together with the high percentage of concomitant injuries makes the treatment of these injuries a challenge to the surgeon. They constitute <1% of all fractures and 13%–23% of talus fractures.[rx],[rx] These fractures are seen following high-velocity injuries and are therefore associated with considerable soft tissue damage. In addition fractures of the talar body are difficult to identify adequately due to the overhang of the tibial plafond anteriorly and posteriorly and are often missed.3rx]
The talus ranks as the second-largest tarsal bone with unique anatomic features and serves an important role in mobility of the foot and ankle as it is the osseous link between the leg and the foot. The anatomy of the talus is quite complex with three separate articulations with distinct features including the subtalar joint with its three faces. The talus divides into a head, neck, and body. Not surprisingly the covering of approximately two-thirds of the surface is articular cartilage, and there are few muscle or tendon attachments.[rx]
The convex talar head is covered with hyaline cartilage articulating with the navicular at the anterior/distal aspect linking the ankle and midfoot. The talar head also articulates with the calcaneus via the anterior facet at its inferior margin (anterior portion of the subtalar joint). The talar body articulates with the calcaneus inferiorly using the middle (anteromedial) and posterior (posterolateral) facets. The posterior facet is the larger of the two making up the posterior subtalar joint while the middle facet articulates with the sustentaculum tali (medial process from the calcaneus). Incidentally, it is the middle facets of the subtalar joint which are most commonly involved in the talocalcaneal coalition accounting for 45% of tarsal coalitions. The superior aspect of the body, the talar dome or trochlea, articulates with the tibia at the tibiotalar joint. The neck is the portion of the talus which joins the head and body, without an articular surface or cartilage. The sinus tarsi and tarsal canal lie along the inferior margin of the neck.[rx]
The posterior process of the body is composed of the medial and lateral tubercles. The flexor hallucis longus tendon runs between these two tubercles. A Stieda process is an anatomic variant defined as elongation of the lateral tubercle. The os trigonum is another normal variant due to the non-fusion of the lateral tubercle ossification center. Both of these normal variants can be involved in pathology ranging from fracture to os trigonum syndrome.[rx]
The lateral process extends from the lateral aspect of the body of the talus. This process articulates with the fibula superiorly and forms the anterolateral portion of the posterior facet of the posterior subtalar joint. Fracture of the lateral process has been termed “snowboarder’s fracture” and is commonly missed on initial radiographs. Evaluation of the lateral process of the talus is best on AP radiographs of the ankle.[rx][rx]
Vascular supply to the talus arises from three arteries: posterior tibial, dorsalis pedis and perforating peroneal arteries. The blood supply is predominately extraosseous because of the extensive articular cartilage coverage and is therefore easily disrupted in the setting of displaced fractures or dislocation leading to avascular necrosis or osteonecrosis.rx[rx][rx]
The talar vascular supply and its lack of muscular attachments predispose it to a significant injury in the setting of trauma. Since a considerable proportion of the surface of the bone has a cartilage covering, the surface area accessible to vascular supply is limited. Additionally, since talar fractures correlate with high-energy injuries, associated musculoskeletal and vascular injuries may be associated. Not surprisingly, displaced fractures and dislocations have a higher incidence of subsequent osteonecrosis. Due to these considerations, talar fractures may be associated with significant morbidity and long-term disability if not appropriately managed.
Causes of Talus Fractures
Fractures of the head and neck are associated with high energy trauma, as may be seen with motor vehicle collisions or fall from significant height. While MVC or falls can also cause the traumatic injury of the body of the talus, osteochondral injuries and fractures of the lateral process can result from by sports injuries (snowboarding, inversion, or eversion).
- Primary Cause – Trauma.
- Berndt and Harty through cadaveric studies showed that the OLT was likely a result of trauma.
- Transchondral fracture of talar dome.
- Medial lesions were created when the posteromedial talar dome impacted the tibial articular surface during combined plantarflexion, inversion and external rotation.
- Lateral Lesions generated when the anterolateral talar dome impacted the fibula during inversion and dorsiflexion.
- Other causes.
- Ischemic necrosis.
- Embolic phenomenon.
- Ossification defects.
- Predisposing factors.
- Endocrine disorders.
- Peripheral vascular disease.
- Genetic predisposition?
- 10-25% bilateral lesions.
Symptoms of Talus Fractures
- Sudden pain in the heel and inability to bear weight on that foot
- Swelling in the heel area
- Bruising of the heel and ankle
- Generalized pain in the heel area that usually develops slowly (over several days to weeks)
- Swelling in the heel area
- Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
- Significant swelling, which may occur along the length of the leg or may be more localized.
- Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
- Bruising that develops soon after the injury.
- Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
- Change in the appearance of the ankle—it will look different from the other ankle.
- Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.
Diagnosis of Talus Fractures
After reviewing your symptoms and medical history, your doctor will do a careful examination. During the exam, he or she will:
- Examine your foot and ankle carefully to see if there are any cuts from the injury.
- Check to see if you can move your toes, and can feel things on the bottom of your foot. In some cases, nerves may be injured at the same time that the bone is broken.
- Check your pulse at key points of the foot to be sure that there is good blood supply to the foot and toes.
- Check to see that pressure from fluids is not building up in the muscles of the leg, a condition called compartment syndrome. Compartment syndrome can result in loss of sensation and function, and requires emergency surgery once it is diagnosed.
- Determine if you have any other injuries by examining the rest of your injured foot, as well as your legs, pelvis and spine.
History invariably involves trauma to the ankle. Physical examination typically reveals swelling and hematoma involving the ankle. The dynamic examination may reveal a limited range of motion at the tibiotalar, subtalar, and midtarsal joints. Patients may be unable to bear weight.
Talar head fractures lead to dorsal midfoot pain, swelling and focal tenderness over the talar head, and pain with motion at the midtarsal joint.[rx] Because lateral process fractures are often radiographically occult on initial presentation, the clinical evaluation may find persistent lateral ankle pain following forced dorsiflexion and inversion injuries to the foot.[rx] Patients diagnosed with lateral ankle pain not responding to conservative measures should be evaluated for lateral process fracture. The nutcracker sign has been described for fractures of the posterior process, with a positive sign consisting of pain and crepitation with forced plantar flexion of the ankle. Tenderness over the Achilles tendon insertion and posterior to the talus may also be seen with these fractures. Pain with movement of the hallux may be elicited due to the motion of the flexor hallucis longus tendon in the adjacent groove.[rx] Fractures of other portions of the talus do not have specific localizing signs.
No laboratory examination is involved in the diagnosis of these fractures. The initial radiographic evaluation includes anteroposterior (AP), mortise, and lateral views of the ankle and AP, oblique, and lateral views of the foot. A Canale radiographic view may also be obtained to evaluate for talar neck fractures, which are often oblique to the sagittal plane of the foot. This specialized view is used less commonly with the wide availability of CT but may be used intraoperatively. The Harris radiographic view, an additional nonstandard image, of the calcaneus permits better visualization of the posterior and middle portions of the subtalar joint. Multiplanar computed tomography (CT) serves several roles: to aid surgical planning, to further evaluate for a clinically suspected radiographically-occult talar fracture, to evaluate displacement, and to detect additional fractures.[rx][rx][rx][rx]
Talar fractures are divided based on the involvement of the head, neck, or body, with further subdivisions of patterns in the body. Different classification schemes for these sections are used to describe fracture patterns and guide management.
Talar head fractures occur at the articular surface of the talonavicular joint and may have associated subluxation or dislocation of the talus and fractures of adjacent bones. No classification scheme exists to describe this fracture, though the two patterns described for the head are crush injury to the articular surface with significant comminution and shear fractures. Talar head fractures are best visualized on foot radiographs.
The commonly accepted posterior margin of the talar neck is delineated by the lateral talar process and the talar dome cartilage. A fracture occurring anterior or inferior to these structures is considered a talar neck fracture. Conversely, a fracture posterior or superior to these structures is considered to involve the talar body.[rx] The proposed mechanism of talar neck injuries results from forced dorsiflexion of the talus against the anterior tibia. The subtalar ligamentous injury commonly precedes the fracture. There may be associated with subtalar, tibiotalar, or talonavicular joint subluxation or dislocation. Talar neck fractures may be isolated, though the majority do extend to either the body or head. However, an articular extension to the subtalar, talonavicular, or tibiotalar joints is not typical. The modified Hawkins-Canale classification is used to describe these fractures and has its basis in associated joint malalignment.
The modified Hawkins-Canale Type I fractures are nondisplaced and may involve disruption of the vascular supply which enters the dorsolateral neck and travels to the body, but with preservation of the remaining sources of talar neck vascular. Nondisplaced fractures can be challenging to detect on standard radiographs. Type I injuries have the best prognosis and lowest risk of osteonecrosis. Type II fractures have displacement with associated subluxation or dislocation of the subtalar joint, medial more often than lateral. The tibiotalar and talonavicular joints remain in proper alignment. Open fractures may be seen with complete dislocation. With Type II fractures, at least two sources of arterial supply are disrupted, including supply to the dorsolateral neck and inferiorly to the roof of the sinus tarsi and tarsal canal (artery of the tarsal canal). The third vascular source which also supplies the medial talar body may also be injured (deltoid and calcaneal branches), though this is less likely than with Type III and IV fractures. Type III fractures have displacement with subluxation or dislocation of the subtalar and tibiotalar joints. The talonavicular joint remains in normal alignment. This pattern of malalignment may further injure the posterior tibial neurovascular bundle.
Additionally, all three major arterial sources to the talus are commonly injured resulting in a high risk of osteonecrosis. Type IV fractures demonstrate dislocation or subluxation of the subtalar, tibiotalar, and talonavicular joints. In addition to the vascular disruption seen in Type III injuries, disruption of blood supply to the head and neck fragments may be seen with this injury.
Talar body fractures include fractures of the talar dome, lateral and posterior processes, and the body proper. The anatomic boundary separating the talar neck and the head is described above. The Sneppen classification is used to describe these fractures.
Fractures of the talar dome (Sneppen A) are typically due to an impaction injury and may injure the articular cartilage or subchondral bone. Injuries to these structures, similar to other joints in the appendicular skeleton, have been termed osteochondral defects, a lesion with its particular classification system describing the stability of the fracture fragment which will not be discussed in this article. Compression fractures of the talar dome are often radiographically occult, with one estimate of false-negative radiographs reported at 31%.[rx] Osteochondral defects of the lateral dome are often shallow and occur after dorsiflexion and inversion injuries. Osteochondral defects of the medial dome are deeper and likely occur secondary to plantar flexion and inversion.
Fractures of the talar body proper may involve the tibiotalar joint, talocalcaneal joint, or both. Coronal (Sneppen B) and sagittal (Sneppen C) shear fractures of the body result from axial loading of a dorsiflexed foot. Comminuted crush injuries (Sneppen F) are due to high-energy impact and are frequently open fractures.
Fractures of the posterior process (Sneppen D) involves the lateral tubercle more often than the medial tubercle. These fractures are secondary to forced plantarflexion or direct impact on the posterior ankle, which causes compression of the posterior process between the tibia and the calcaneus.
Lateral process fractures (Sneppen E) are often radiographically occult initially and occur with axial loading, forced dorsiflexion, and external rotation or eversion of the foot.[rx] This fracture has been termed “snowboarder’s fracture” due to its high association with participants in this activity.[rx] As with other talar fractures, there is also an association with motor vehicle collisions and falls. Lateral process fractures are also further classified using the Hawkins criteria: Type I (simple), Type II (comminuted), and Type III (chip or avulsion).
Treatment of Talus Fractures
Nondisplaced talar head fractures receive conservative treatment.
Initial Treatment Includes
- Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
ICE and elevation – It help for prevention swelling, edema
Splinting – Bulky Jones type splints are commonly applied.
Weight-bearing by others person or cratch – All patients who are candidates for outpatient treatment are non-weight bearing at discharge.
- Rest, compression, and elevation (RICE) – Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
- Immobilization – Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weight-bearing. For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.
- Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your ankle fracture look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and phalanges movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
- Taping the hand – as a type of soft splint, with the pinky and phalanges, taped together to help in healing correction of the dislocated bone, which may be done with anesthesia.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
The following medications may be considered doctor to relieve acute and immediate pain
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
- Muscle Relaxants – These medications provide relief from associated muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
- Calcium & vitamin D3 – to improve bone health and healing fracture.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
- Dietary supplement -to remove general weakness & improved health
Displaced talar head fractures require surgery to reduce the malalignment of the talonavicular joint to reduce the incidence of osteoarthrosis and osteonecrosis.
- Type I neck fractures may are candidates for nonoperative treatment. However, even subtle displacement of a talar neck fracture may necessitate open reduction and internal fixation (ORIF), highlighting the role of CT in the evaluation of these fractures.
- Type II neck fractures require surgical reduction and fixation.
- Type III and
- IV neck fractures may be initially treated with a closed reduction in the emergency department to relieve skin tension and lessen soft-tissue injury with subsequent definitive surgical management (ORIF).
Talar body fractures may be treated conservatively if nondisplaced. However, the majority of body fractures are displaced and require operative management to restore fragment and joint alignment. Posterior process fractures are treated nonoperatively, though excision of the fracture fragment may be necessary if pain persists despite appropriate conservative management.[rx][rx] Nondisplaced lateral process fractures are treated conservatively. ORIF is necessary if fracture fragments are either displaced greater than 2 mm or are larger than 1 cm in size.[rx] Severely comminuted fractures and those fractures associated with articular injury may require excision of the fracture fragments. It has been suggested that, in general, Hawkins Type I fractures should be treated with ORIF, Type II fractures with excision, and Type III fractures with immobilization and non-weight bearing status.[rx]
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