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Journal of the American Academy of Orthopaedic Surgeons114

Major fractures and dislocations ofthe talus and peritalar joints areuncommon. However, fractures ofthe talus rank second in frequency(after calcaneal fractures) of alltarsal bone injuries. The incidenceof fractures of the talus ranges from0.1% to 0.85% of all fractures.1

Talus fractures most commonlyoccur when a person falls from aheight or sustains some other typeof forced dorsiflexion injury to thefoot or ankle. The anatomic config-uration of the injury is importantbecause of both the function of thetalus and its relationship to the ten-uous blood supply. The classifica-

tion of these fractures is based ontheir anatomic location within thetalus (i.e., head, body, or neck). Eachtype has unique features that affectboth diagnosis and treatment.

Anatomy

The talus is the second largest tarsalbone, with more than one half of itssurface covered by articular cartilage.The superior aspect of the body iswidest anteriorly and therefore fitsmore securely within the ankle mor-tise when it is in dorsiflexion. Thearticular medial wall is straight,

while the lateral articular wallcurves posteriorly, such that theymeet at the posterior tubercle. Theneck of the talus is oriented mediallyapproximately 10 to 44 degrees withreference to the axis of the body ofthe talus and is the most vulnerablearea of the bone after injury. In thesagittal plane, the neck deviatesplantarward between 5 and 50 de-grees.

The talus has no muscle or tendi-nous attachments and is supportedsolely by the joint capsules, liga-ments, and synovial tissues. Liga-ments that provide stability andallow motion bind the talus to thetibia, fibula, calcaneus, and navicu-lar. The tendon of the flexor hallu-cis longus lies within a groove onthe posterior talar tubercle and isheld by a retinacular ligament. Thespring (calcaneonavicular) ligamentlies inferior to the talar head andacts like a sling to suspend the head.

Inferiorly, the posterior, middle,and anterior facets correspond tothe articular facets of the calcaneus.Between the posterior and middle

Dr. Fortin is Attending Orthopaedic Surgeon,William Beaumont Hospital, Royal Oak, Mich.Dr. Balazsy is Fellow, Department of Ortho-paedic Surgery, William Beaumont Hospital.

Reprint requests: Dr. Fortin, Suite 100, 30575North Woodward Avenue, Royal Oak, MI48073-6941.

Copyright 2001 by the American Academy ofOrthopaedic Surgeons.

Abstract

Fractures of the talus are uncommon. The relative infrequency of these injuriesin part accounts for the lack of useful and objective data to guide treatment.The integrity of the talus is critical to normal function of the ankle, subtalar,and transverse tarsal joints. Injuries to the head, neck, or body of the talus caninterfere with normal coupled motion of these joints and result in permanentpain, loss of motion, and deformity. Outcomes vary widely and are related tothe degree of initial fracture displacement. Nondisplaced fractures have a favor-able outcome in most cases. Failure to recognize fracture displacement (evenwhen minimal) can lead to undertreatment and poor outcomes. The accuracy ofclosed reduction of displaced talar neck fractures can be very difficult to assess.Operative treatment should, therefore, be considered for all displaced fractures.Osteonecrosis and malunion are common complications, and prompt and accu-rate reduction minimizes their incidence and severity. The use of titaniumscrews for fixation permits magnetic resonance imaging, which may allow earlier assessment of osteonecrosis; however, further investigation is necessaryto determine the clinical utility of this information. Unrecognized medial talarneck comminution can lead to varus malunion and a supination deformity withdecreased range of motion of the subtalar joint. Combined anteromedial andanterolateral exposure of talar neck fractures can help ensure anatomic reduc-tion. Posttraumatic hindfoot arthrosis has been reported to occur in more than90% of patients with displaced talus fractures. Salvage can be difficult andoften necessitates extended arthrodesis procedures.

J Am Acad Orthop Surg 2001;9:114-127

Talus Fractures: Evaluation and Treatment

Paul T. Fortin, MD, and Jeffrey E. Balazsy, MD


Vol 9, No 2, March/April 2001 115

facets is a transverse groove, which,with a similar groove on the dor-sum of the calcaneus, forms thedorsal canal that exits laterally into acone-shaped space, the tarsal sinus.The tarsal canal is located just belowand behind the tip of the medialmalleolus. These two anatomic re-gions form a funnel: the tarsal sinusis the cone, and the tarsal canal is thetube. Because blood vessels reachthe talus through the surroundingsoft tissues, injury resulting in cap-sular disruption may be complicatedby vascular compromise of the talus.

Blood Supply

Wildenauer was the first to correct-ly describe in detail the blood sup-ply to the talus. His findings wereconfirmed by Haliburton et al2

through gross dissection and micro-scopic studies on cadaver limbs. In1970, Mulfinger and Trueta3 pro-vided the most complete descrip-tion of the intraosseous and extra-osseous arterial circulation.

Only two fifths of the talus canbe perforated by vessels; the otherthree fifths is covered by cartilage.The extraosseous blood supply ofthe talus comes from three mainarteries and their branches (Fig. 1).These arteries, in order of signifi-cance, are the posterior tibial, theanterior tibial, and the perforatingperoneal arteries. In addition, theartery of the tarsal canal (a branchof the posterior tibial artery) andthe artery of the tarsal sinus (abranch of the perforating peronealartery) are two discrete vessels thatform an anastomotic sling inferiorto the talus from which branchesarise and enter the talar neck area.

The main supply to the talus isthrough the artery of the tarsalcanal, which gives off an additionalbranch that penetrates the deltoidligament and supplies the medialtalar wall. The main artery givesbranches to the inferior talar neck,

thereby supplying most of the talarbody. Therefore, most of the talarbody is supplied by branches of theartery of the tarsal canal. The headand neck are supplied by the dor-salis pedis artery and the artery ofthe tarsal sinus. The posterior partof the talus is supplied by branchesof the posterior tibial artery via cal-caneal branches that enter throughthe posterior tubercle.

Extensive intraosseous anasto-moses are present throughout thetalus and are responsible for the sur-vival of the talus in severe injuries.Preservation of at least one of thethree major extraosseous sources canpotentially allow adequate circula-tion via anastomotic channels. Ini-tial fracture displacement, timing ofreduction, and soft-tissue handlingat the time of surgery are all factorsthat can potentially affect the integ-rity of the talar blood supply.

Fractures of the TalarHead

Fractures of the talar head are rareand often difficult to visualize onroutine radiographs. It is not un-

common, therefore, for fractures ofthe talar head to go unrecognized.Coltart,4 in his review of 228 talarinjuries, reported only a 5% inci-dence of talar head fracture. Mostof these injuries were secondary toflying accidents. Kenwright andTaylor5 reviewed 58 talar injuriesand found a 3% incidence of talarhead injury, whereas Pennal6 re-ported a 10% incidence among allfracture-dislocations involving thetalus.

According to Coltart,4 the mech-anism of injury consists of theapplication of a sudden dorsiflexionforce on a fully plantar-flexed foot,which thereby imparts a compres-sive force through the talar head.Another mechanism is thought tobe hyperdorsiflexion, resulting incompression of the talar headagainst the anterior tibial edge. Im-paction fractures of the talar headcan also occur in association withsubtalar dislocations. Patients usu-ally give a history of a fall and com-plain of pain in the talonavicularjoint region. Swelling and ecchy-mosis may be present, along withpain on palpation of the talonavicu-lar joint. Depending on the size

Anteroposterior view Inferosuperior view

Perforating peroneal artery

Anterior lateralmalleolar artery

Artery of tarsal sinus

Artery of tarsal sinusDorsalis pedis artery

Posterior tarsal artery

Posterior tibial artery

Deltoid artery

Deltoid artery

Artery of tarsal canal

Artery of tarsal canal

Lateral tarsal artery

Medial tarsal artery

Figure 1 Blood supply to the talus.

Talus Fractures


and degree of displacement of thefracture fragment, routine radio-graphs may not identify the frac-ture; therefore, computed tomogra-phy (CT) may be needed to definethe extent of the injury.

Initial treatment of nondisplacedfractures and those involving avery small amount of articular sur-face includes immobilization in ashort leg cast for 6 weeks, as wellas rest, ice, and elevation. If thefragment causes instability of thetalonavicular joint or is displaced,causing articular incongruency,open reduction and internal fixa-tion should be considered. Typi-cally, a medial approach to thetalonavicular joint is used, carefullyavoiding the posterior tibial tendi-nous attachment to the navicular.Dissection must also proceed cau-tiously over the anterior aspect ofthe talar head to avoid disruptionof the blood supply to the head.Small-fragment subchondral can-cellous lag screws or bioabsorbablepins can be utilized to fix the headfracture. With more severe impac-tion injuries, bone grafting is occa-sionally necessary to maintain thearticular reduction.

Postoperatively, weight bearingis not allowed for 6 to 8 weeks.Early range-of-motion exercises canbe initiated if the fixation is stableand the patient is reliable. Rapidhealing usually ensues with a lowincidence of osteonecrosis becauseof the abundant blood supply to thetalar head. The prognosis is good aslong as severe comminution is notpresent and anatomic reduction isobtained.

Not uncommonly, these injuriesgo unrecognized, which leads toloss of medial-column support andtalonavicular joint instability. Smallnonunited head fragments that aresymptomatic and cause limitationof joint range of motion can be ex-cised. Nonunions involving a largerportion of the articular surfaceshould be treated on the basis of theoverall integrity of the joint surface.Severe posttraumatic arthrosis maynecessitate talonavicular joint ar-throdesis. Due to the coupled mo-tion of the hindfoot joints, fusion ofthe talonavicular joint essentiallyeliminates motion at the subtalarand calcaneocuboid joints andshould be considered a salvage pro-cedure.

Fractures of the Talar Neck

Talar neck fractures account forapproximately 50% of all talar frac-tures. In 1919, Anderson reported18 cases of fracture-dislocation ofthe talus and coined the term �avia-tor�s astragalus.� He was the first toemphasize that forced dorsiflexionof the foot was the predominantmechanism of injury.

Fractures occur when the narrowneck of the talus, with its less densetrabecular bone, strikes the strongeranterior tibial crest. As forces pro-gress, disruption occurs through theinterosseous talocalcaneal ligamentand the ligamentous complex of theposterior ankle and subtalar joints,leading to eventual subluxation ordislocation of the body from thesubtalar and tibiotalar articulations(Fig. 2). With forced supination ofthe hindfoot, the neck can encounterthe medial malleolus, leading tomedial neck comminution and rota-tory displacement of the head.

In the laboratory, it is difficult toproduce talar neck fractures withforced dorsiflexion alone. Petersonet al7 experimentally produced thesefractures only after eliminating ankle

A B C

Figure 2 A, Preoperative lateral radiograph shows a displaced fracture of the talar neck. B, Canale view demonstrates anteromedial andanterolateral lag-screw placement. C, Postoperative lateral radiograph shows reduction of the talar neck and subtalar joint.



joint motion by vertical compressionthrough the calcaneus, forcing thetalus against the anterior tibia. Theyfelt that these forces could be repro-duced in an extended leg if the tri-ceps surae was contracted.

In a study by Hawkins,8 15 of 57patients (26%) had associated frac-tures of the medial malleolus. Canaleand Kelly9 found that 11 of 71 pa-tients (15%) with fractures of the talarneck had associated fractures of themedial and lateral malleoli (10 and 1,respectively). This level of incidenceof malleolar fractures supports theconcept that in addition to dorsiflex-ion, rotational forces contribute todisplacement of a talar neck fracture.

Displaced talar neck fracturesoften occur as a result of high-energyinjuries. Hawkins8 reported that64% of patients had other fractures,and 21% had open fractures.

ClassificationHawkins,8 in his classic paper,

described a classification systemthat could be correlated with prog-nosis. He classified fractures intogroups I to III. In 1978, Canale andKelly9 reported on the long-termresults in their series of talus frac-tures. They referred to the three dif-ferent Hawkins groups as �types�and included a type IV not previ-ously described. The terms �group�

and �type� have since been used in-terchangeably in the literature.10

The classification for fractures of theneck of the talus is based on theradiographic appearance at the timeof injury (Fig. 3).

Type I fractures of the neck of thetalus are nondisplaced. Any dis-placement is significant and pre-cludes classification as a type I frac-ture. The fracture line enters thesubtalar joint between the middleand posterior facets. The talus re-mains anatomically positioned with-in the ankle and subtalar joints.Theoretically, only one of the threemajor blood supply sources is dis-rupted�the one entering throughthe anterolateral portion of the neck.True type I fractures may be difficultto see on conventional radiographs,and CT or magnetic resonance (MR)imaging may be necessary for con-firmation. Fractures with clear dis-placement of even 1 to 2 mm shouldbe considered type II fracturesrather than type I.

Type II fractures combine a frac-ture of the talar neck with subluxa-tion or dislocation of the subtalarjoint. In 10 of the 24 cases reportedby Hawkins,8 the posterior facet ofthe body of the talus was dislocatedposteriorly; in most of the remain-ing cases there was a medial subta-lar joint dislocation, with the foot

and calcaneus displaced medially.Two of the main sources of bloodsupply to the talus are injured�thevessels entering the neck and pro-ceeding proximally to the body andthe vessels entering the foramina inthe sinus tarsi and tarsal canal. Thethird source of blood supply, enter-ing through the foramina on the me-dial surface of the body, is usuallyspared, but can be injured.

Type III injuries are character-ized by a fracture of the neck withdisplacement of the body of thetalus from the subtalar and anklejoints. Hawkins8 identified 27 ofthese fractures and found that thebody of the talus extruded posteri-orly and medially and was locatedbetween the posterior surface ofthe tibia and the Achilles tendon,where it can compress adjacent tib-ial neurovascular structures. Thebody of the talus may rotate withinthe ankle mortise; however, thehead of the talus remains alignedwith the navicular. All three sourcesof blood supply to the talus areusually disrupted with this injury.Over half of type III injuries areopen, and many have associatedneurovascular and/or skin com-promise.

In type IV injuries, the fracture ofthe talar neck is associated with dis-location of the body from the ankle

Figure 3 Classification of talar neck fractures.8,9

Type I Type II Type III Type IV

Talus Fractures


and subtalar joints with additionaldislocation or subluxation of thehead of the talus from the talona-vicular joint. In the series of Canaleand Kelly,9 3 of 71 talar fractures(4%) were type IV injuries, all ofwhich had unsatisfactory results.

Clinical and RadiologicEvaluation

Patients with talar neck fracturespresent with significant swelling ofthe hindfoot and midfoot. Grossdeformity may be present, depend-ing on the displacement of the frac-ture and any associated subtalarand ankle joint subluxation or dis-location.

A history of a fall from a heightor a forced loading injury (e.g., amotor-vehicle collision) may beelicited. A talus fracture may beonly part of the total spectrum ofthe patient�s injuries, and a generaltrauma survey should be includedin each patient�s evaluation. Particu-lar attention should also be directedto the thoracolumbar spine, becausespine fractures have been found inassociation with talar neck andbody fractures. Focused evaluationof the involved foot should includean assessment of the neurovascularstatus as well as the integrity of theskin over the fracture site. Dis-placed talar neck fractures oftenlead to significant stretching of thedorsal soft tissues. Prompt reduc-tion is mandatory to avoid skin ne-crosis. With fracture-dislocations,posterior displacement of the bodyleads to bowstringing of the flexortendons and neurovascular bundle.Patients can present with flexion ofthe toes and tibial nerve dysesthe-sias. As many as 50% of type IIIHawkins fractures present as openinjuries, with a subsequent infec-tion rate as high as 38%.11 Hence,an open fracture must be treatedwith urgency.

Radiographic evaluation consistsinitially of anteroposterior (AP), lat-eral, and oblique views of the foot

and ankle. This allows classificationof the fracture and an assessment ofassociated injuries. The specialoblique view of the talar neck de-scribed by Canale and Kelly9 (Fig. 4)provides the best evaluation of talarneck angulation and shortening,which is not appreciable on routineradiographs. This view should beobtained to assess initial displace-ment of all talar neck fractures beforeembarking on an operative reduction.Computed tomography is invaluablefor preoperatively assessing talarbody injuries with regard to fracturepattern, degree of comminution, andthe presence of loose fragments inthe sinus tarsi. The typical CT proto-col involves 2-mm-thick sections inthe axial and semicoronal planeswith sagittal reconstructions.

TreatmentThe goal of treatment of talar

neck fractures is anatomic reduction,which requires attention to properrotation, length, and angulation ofthe neck. Biomechanical studies oncadavers have shown why preciselyreducing talar neck fractures leadsto better outcomes. In one cadavericstudy, displacements by as little as 2mm were found to alter the contactcharacteristics of the subtalar joint,with dorsal and medial or varus dis-placement causing the greatestchange. The weight-bearing loadpathway changed, and contact stresswas decreased in the anterior andmiddle facets but was more local-ized in the posterior facet.12 Inanother study, varus alignment wascreated by removing a mediallybased wedge of bone from the talarneck. This resulted in inability toevert the hindfoot, and the alteredfoot position was characterized byinternal rotation of the calcaneus,heel varus, and forefoot adduction.13

The altered hindfoot mechanics witha talar neck fracture may be one fac-tor that leads to subtalar posttrau-matic arthrosis. For these reasons,open reduction and internal fixation

is recommended for displaced frac-tures.

Type I FracturesTruly nondisplaced fractures of

the talar neck can be treated success-fully by cast immobilization. Caremust be taken to obtain appropriateradiographs, including a Canaleview, to ensure that there is no dis-placement or malrotation. A cast isapplied, and weight bearing is notallowed for 6 to 8 weeks or untilosseous trabeculation is seen onfollow-up radiographs. Nonopera-tive treatment necessitates frequentradiographic follow-up to makecertain that the fracture does notdisplace during treatment.

Type II FracturesInitial management of displaced

talar neck fractures should involveprompt reduction to minimize soft-tissue compromise. This can often beperformed in the emergency room.However, repeated forceful reduc-tion attempts should be avoided.The foot is plantar-flexed, bringingthe head in line with the body. Theheel can then be manipulated intoeither inversion or eversion, depend-ing on whether the subtalar compo-nent of the displacement is medial orlateral.

Figure 4 Radiographic positioning for theoblique view of the talar neck, as describedby Canale and Kelly.9

75°

15°



Anatomic reduction of this frac-ture is difficult to obtain by closedmeans. Rotational alignment of thetalar neck is very difficult to judgeon plain radiographs. Even mini-mal residual displacement can ad-versely affect subtalar joint mechan-ics and is therefore unacceptable.12

Even if closed reduction is success-ful in obtaining an anatomic reduc-tion, immobilization in significantplantar-flexion is typically necessaryto maintain position. For these rea-sons, operative treatment of all typeII fractures has been recommended.10

Numerous surgical approacheshave been described for talar neckfractures. The medial approachallows easy access to the talar neckand is commonly used. An incisionjust medial to the tibialis anteriorstarting at the navicular tuberosityexposes the neck and can be ex-tended proximally to facilitate fixa-tion of a malleolar fracture or toperform a malleolar osteotomy.Surgical exposure can contribute tocirculatory compromise of the talus.Care must be taken to avoid strip-ping of the dorsal neck vessels andto preserve the deltoid branchesentering at the level of the deep del-toid ligament.

The disadvantage of the medialapproach is that the exposure is lessextensile than that which can beachieved along the lateral aspect ofthe neck. This limited exposuremakes judging rotation and medialneck shortening difficult. Medialneck comminution or impaction canbe underestimated; if either condi-tion is present, compression-screwfixation of the medial neck will resultin shortening and varus malalign-ment. In these circumstances, a sep-arate lateral exposure allows a moreaccurate assessment of reduction andbetter fixation.

The anterolateral approach lateralto the common extensor digitorumlongus�peroneus tertius tendonsheath provides exposure to thestronger lateral talar neck. A wide-

enough skin bridge must exist be-tween the two incisions, and strip-ping of the dorsal talar neck mustbe avoided.

Once the fracture has been re-duced, it is provisionally stabilizedwith Kirschner wires. Two screws(one medial and one lateral) are in-serted from a point just off the artic-ular surface of the head and directedposteriorly into the body (Fig. 2, B).Lag screws can be used unless thereis significant neck comminutionthat would result in neck shorten-ing or malalignment when the frac-ture is compressed. Bone graft isoccasionally necessary to make upfor large impaction defects of themedial talar neck (Fig. 5, A).

Another alternative for screwplacement is the posterolateralapproach described by Trillat etal.14 An incision is made lateral tothe heel cord in the interval be-tween the flexor hallucis longus

and peroneal muscles (Fig. 5, B).This allows safe access to the entireposterior talar process. Care mustbe taken during exposure to avoidinjury to the peroneal artery and itsbranches. Most commonly, theposterolateral exposure is used incombination with an initial antero-medial or anterolateral approachfor provisional fracture reductionand stabilization with Kirschnerwires under image intensification.The patient is then positionedprone or on one side, and a postero-lateral approach is used for place-ment of cannulated screws for finalfracture fixation. Alternatively, ifanatomic reduction can be accom-plished with closed manipulation,posterior-to-anterior screw fixationcan be used through a single poste-rior approach.

Posterior-to-anterior screw place-ment provides superior mechanicalstrength compared with insertion

Lateral view

Superior view

Figure 5 A, Placement of bone graft into an impaction defect in the medial talar neck. B, Posterolateral exposure of the talus as described by Trillat et al.14

B

Peroneus brevis and longus

Flexorhallucislongus

Posteriortalus

Screwplacement

Tricepssurae

A

Talus Fractures


from anterior to posterior.15 San-ders10 has suggested that screwscan be placed on either side of theflexor hallucis groove and directedanteromedially. On the basis oftheir findings in a cadaveric study,Ebraheim et al16 suggested that thebest point of insertion for anterior-to-posterior screws is the lateraltubercle of the posterior process.

Pitfalls of posterior-to-anteriorscrew fixation include penetration ofthe subtalar joint or lateral trochlearsurface, injury to the flexor hallucislongus tendon, and restriction ofankle plantar-flexion due to screw-head impingement. These potentialproblems can be minimized byplacement of smaller-diameter coun-tersunk screws directed along thetalar axis.

Several types of screws have beenused, including solid-core stainlesssteel small-fragment lag screws.Cannulated screws offer the poten-tial advantage of easier insertion.Titanium screws have the advantageof compatibility with MR imaging,allowing early assessment of osteo-necrosis.17

Bioabsorbable implants haveseveral theoretical advantages, butexperience is limited with thesedevices. They are not easily visibleon radiographs, resorb over time,and can be placed through articularsurfaces. These are most often usedin fractures of the talar body butmay be helpful as supplementalfixation of talar neck fractures.10,18

Screws placed from the talarhead into the body may interferewith talonavicular joint function ifthe screw head is prominent andnear the joint. This often necessi-tates countersinking the screw head.Headless lag screws have beenshown to have mechanical proper-ties comparable to those of small-fragment compression screws.19

They have the theoretical advantageof not interfering with talonavicularjoint function when placed throughthe talar head.

The timing of operative treat-ment of type II fractures remainscontroversial. There are no data tosuggest that emergent treatment oftype II fractures improves outcome,but most would agree that theyshould be treated with all possibleexpediency.

Type III FracturesType III fractures, which are

characterized by displacement ofthe talar body from the ankle andsubtalar joints, pose a treatmentchallenge. Urgent open reductionis mandated to relieve compressionfrom the displaced body on theneurovascular bundle and skinmedially and to minimize the oc-currence of osteonecrosis. Many ofthese injuries have an associatedmedial malleolar fracture, whichfacilitates exposure. When themalleolus is intact, medial malleo-lar osteotomy is often required toallow repositioning of the talarbody. Careful attention to the softtissues around the deltoid ligamentand medial surface of the talus isnecessary, as these may contain theonly remaining intact blood sup-ply. A femoral distractor or exter-nal fixator may be applied for dis-traction of the calcaneus from thetibia to help extricate the bodyfragment. A percutaneous pin maybe placed in the talus to toggle thebody back into its anatomic posi-tion. Fracture stabilization can becarried out as described for type IIfractures.

Because nearly half of these frac-tures are open, meticulous irriga-tion and debridement is mandatedon an urgent basis. Open type IIIinjuries are devastating and typi-cally associated with significantlong-term functional impairment.20

In cases of severe open injury withextrusion of the talar body, a di-lemma exists as to whether to saveand reinsert the talar body or todiscard it.10 Marsh et al11 reportedon the largest series of open severe

talus injuries. In 12 of 18 cases, thetalus was totally or partially ex-truded through the wound. Deepinfection developed in 38% of thepatients despite contemporary openfracture management. The occur-rence of deep infection was themajor factor contributing to poorresults. There was a 71% failurerate in patients in whom an infec-tion developed. In cases of contam-inated wounds when the talar bodyis totally extruded and completelydevoid of soft-tissue attachment,consideration should be given todiscarding the body fragment andplanning a staged reconstruction.

Type IV FracturesType IV injuries are treated in a

manner similar to type III injuries,with urgent open reduction and in-ternal fixation. The talar body andhead fragments are reduced andrigidly fixed. Stability of the talo-navicular joint is then assessed; if itis unstable, consideration should begiven to pinning the talonavicularjoint. The significance of this injuryis that osteonecrosis of both thetalar body and the head fragment ispossible.10 As with type III injuries,urgent treatment is of paramountimportance.

Postoperative CareProvided stable fixation has been

achieved, early range of motion isbegun once the wounds are healed.With comminuted fractures andthose with significant instability ofthe ankle, subtalar, or talonavicularjoint, consideration should be givento cast immobilization until provi-sional healing has taken place (4 to6 weeks). Weight bearing is de-layed until there is convincing evi-dence of healing, which may takeseveral months.

ComplicationsThe reports of the incidence of

complications vary widely (Table 1).There is, however, a consistent



trend for the incidence of complica-tions to increase with the Hawkinsstage.

Fractures of the Talar Body

Talar body fractures occur less fre-quently than fractures of the talarneck.13 Because fractures of thetalar body involve both the anklejoint and the posterior facet of thesubtalar joint, accurate reconstruc-tion of a congruent articular surfaceis required.

Evaluation and ClassificationIt is sometimes difficult to differ-

entiate vertical fractures of the talarbody from talar neck fractures.Inokuchi et al21 suggest that thediagnosis can be accurately pre-dicted on the basis of the locationof the inferior fracture line in rela-tion to the lateral process. Frac-tures in which the inferior fractureline propagates in front of the lateralprocess are considered talar neckfractures. Fractures in which theinferior fracture line propagatesbehind the lateral process involvethe posterior facet of the subtalarjoint and are therefore consideredtalar body fractures.

Plain radiographs often underes-timate the extent of articular injury.Computed tomography is neces-sary to define the fracture pattern,amount of comminution, and extentof joint involvement.

Talar body fractures have beenclassified by Sneppen et al22 on thebasis of anatomic location, as follows:type A, transchondral or osteochon-dral; type B, coronal shear; type C,sagittal shear; type D, posteriortubercle; type E, lateral process; andtype F, crush fractures. Boyd andKnight23 also proposed a classifica-tion system for shearing injuries ofthe talar body. In their classificationsystem, body fractures are differenti-ated according to associated disloca-tion of the subtalar or talocrural joint.As with talar neck fractures, talarbody fractures with associated dislo-cation have a higher incidence ofosteonecrosis. In the simplest sense,talar body fractures can be dividedinto three groups: group I are prop-er or cleavage fractures (horizontal,sagittal, shear, or coronal); group II,talar process or tubercle fractures;and group III, compression or im-paction fractures (Fig. 6).

Treatment of Talar Process andTubercle Fractures

The extent of joint involvementand the degree of comminutionshould be considered when treatingfractures of the talar process ortubercle. These injuries are oftenmissed or neglected; this can lead tosignificant disability, because suchfractures can involve a substantialportion of the ankle and subtalararticular surface. In general, non-displaced process or tubercle frac-tures can be treated with castingand maintenance of non-weight-bearing status. For displaced frac-tures with significant articular in-volvement, consideration should begiven to operative fixation (Fig. 7).Not uncommonly, however, theextent of comminution precludesoperative fixation, and fragmentscan only be either excised or man-aged nonoperatively (Fig. 8).

Treatment of Cleavage andCompression Fractures

Displaced cleavage and crushfractures of the talar body are opti-mally treated with anatomic reduc-tion and internal fixation. Becausethese fractures occur beneath theankle, a mortise, medial, or lateralmalleolar osteotomy is often neces-sary to gain exposure to the frac-ture.16 Once the fracture has beenexposed, temporary Kirschner-wirefixation is used before final fracturestabilization with screws. Bioab-

Table 1Complications Following Talar Neck Fractures*

Fracture DegenerativeType Osteonecrosis Joint Disease Malunion

Type I 0%-13% 0%-30% 0%-10%Type II 20%-50% 40%-90% 0%-25%Type III/IV 8%-100% 70%-100% 18%-27%

* Range of cited incidence values in references 1, 4, 5, 6, 8, 9, 11, 23, 25, and 26.

Figure 6 Talar body fractures. Group I are fractures of the body proper or cleavage frac-tures (horizontal, sagittal [shown], shear, or coronal). Group II are talar process or tuberclefractures (lateral talar-process fracture shown). Group III are compression or impactionfractures of the articular surface of the body.

Group I Group II Group III

Talus Fractures


sorbable pins or subarticular screwscan be helpful (Fig. 9). Severe inju-ries with significant impaction ofthe cancellous bone of the talus mayrequire bone grafting (Fig. 10).

Results

Differences in treatment methodsamong reported series and thesmall numbers of patients make itdifficult to make valid inferencesregarding the outcome of talus frac-tures. Contemporary managementwith open reduction and internalfixation of all displaced fractureshas led to improved clinical results.Canale and Kelly9 reported only59% good or excellent results in aseries of 71 fractures followed foran average of 12.7 years. More thanhalf of the patients with type II frac-tures in that series were treatedwith closed reduction and casting.Many of these fractures were com-plicated by varus malalignmentand subsequent arthrosis. Low etal24 reported good or excellent re-sults in 18 of 22 patients who un-derwent open reduction and inter-nal fixation for displaced talar neck

fractures. Other authors have re-ported comparable clinical results,as well as diminished osteonecrosisand arthrosis, with operative treat-ment of all displaced fractures.25,26

Complications and Salvage

Osteonecrosis, malunion, and ar-throsis are the most commonly re-ported complications after talus

Figure 7 Preoperative CT scan (A) and lateral radiograph (B) showing a displaced posteromedial talar tubercle fracture (arrows). C, Radiograph obtained after lag-screw fixation.

A B C

A B

Figure 8 Plain radiograph (A) and CT scan (B) demonstrate a comminuted lateral talar-process fracture (arrow), which was subsequently treated by excision of fragments.



fracture. Nonunion occurs infre-quently.

OsteonecrosisOsteonecrosis is a frequent com-

plication of talar neck and body frac-tures and dislocations. Hawkins8

reported no osteonecrosis in 6 type Ifractures, whereas Canale and Kelly9

reported a 13% incidence in 15 type Ifractures. Hawkins reported a 42%incidence in 24 type II fractures and a91% incidence in 27 type III fractures.

Osteonecrosis is not always easilyrecognized. Hawkins8 stated that

the time to recognize its presence iswithin 6 to 8 weeks; however, it mayfirst be observed on radiographs atany time from 4 weeks to 6 monthsafter fracture-dislocation. It usuallypresents as relative opacity of theinvolved bone caused by osteopeniaof the neighboring bones of the footsecondary to disuse and cessation ofweight bearing.

The Hawkins sign (evidence ofpreserved vascularity of the talus) isseen 6 to 8 weeks after the injury. Itconsists of patchy subchondralosteopenia on the AP and mortise

views of the ankle and is useful asan objective prognostic sign. Thepresence of the Hawkins sign is areliable indicator that osteonecrosisis unlikely. The absence of the Haw-kins sign, however, is not as reliablein predicting the development ofosteonecrosis.9 A film of the normalside, taken at the same exposure,should be available for comparison.

Magnetic resonance imaging isvery sensitive for detecting osteone-crosis and estimating the amount oftalar involvement. Adipocyte via-bility produces strong T1-weightedimages. With avascularity of bone,death of marrow adipocytes occursearly.27 This alters the appearanceof fat signals on the T1-weightedimage. It does not appear that MRimaging is helpful in assessing os-teonecrosis until at least 3 weeksafter the time of injury, and false-negative MR images have beenreported.16,28 The role of MR imag-ing in the follow-up of both nonop-eratively and operatively treatedtalus fractures has yet to be deter-mined.

Initial treatment for osteonecrosisis conservative. It is important tonote that a talus fracture can healdespite the development of osteo-necrosis. The main determinant forprogressing the patient�s weight-bearing status on the injured extrem-ity is the presence of fracture heal-ing. Once radiographic evidence ofhealing has been demonstrated, thepatient may be allowed to bearweight.

It may take up to 36 months forrevascularization of the talus tooccur; therefore, prolongation ofnon-weight-bearing status until therisk of collapse no longer exists isnot practical. There is no definiteevidence to suggest that weightbearing on an avascular talus willcontribute to collapse. Hawkins8

stated that collapse of the talusoccurred despite maintenance ofenforced non-weight-bearing statusfor several years.

A B

C D

Figure 9 A, AP radiograph of a talar body fracture. B, CT reconstruction shows the talarneck component of the fracture (arrows). Postoperative AP (C) and lateral (D) radio-graphs. Medial malleolar osteotomy was required for fracture exposure. Headless subar-ticular screws were used for fracture fixation.

Talus Fractures


Patients with pain and evidence ofosteonecrosis may be offered an off-loading orthosis, such as a patellartendon�bearing brace, which maylimit symptoms. However, thesetypes of orthotic devices have notbeen shown to prevent collapse of thetalar dome in the presence of osteo-necrosis. It should be noted thatosteonecrosis of the talus is not al-ways symptomatic, and patients mayfunction quite satisfactorily withoutdiscomfort despite having radio-graphic findings of osteonecrosis.Surgical salvage is indicated only forpatients with intractable symptomsafter nonoperative treatment.

Operative treatment of osteone-crosis after a talus fracture dependson the location and extent of necro-sis and the degree of accompanyingarthrosis of the ankle and subtalarjoints. Patchy osteonecrosis withisolated involvement of one joint isapproached differently than totalbody necrosis and collapse. In casesof limited osteonecrosis with ar-throsis, arthrodesis of the involvedjoint is an effective means of elimi-nating pain. It is important thatany dead bone adjacent to the fu-sion interface be removed to ensuresuccessful union. Bone graft is nec-essary to fill any defect created byremoval of the necrotic bone. Incases of isolated lateral dome in-volvement, the fibula can be usedas a strut graft.

Operative salvage in cases oftotal body osteonecrosis and col-lapse is a challenge. Talectomyalone has been used in such caseswith only minimal success.8,9 Haw-kins8 reported on 6 patients evalu-ated an average of 6 years aftertalectomy. All patients had prob-lems related to pain or shorteningof the limb. To address some of the problems with talectomy alone,a Blair-type fusion has been sug-gested.10 This involves resection ofthe necrotic talar body fragmentand fusion of the talar head to theanterior distal tibia. This has the

A B

C D

Figure 10 AP (A) and lateral (B) plain radiographs show an impacted talar-body frac-ture. Axial CT image (C) and sagittal CT reconstruction (D). AP (E) and lateral (F) radio-graphs obtained after operative fixation. The medial malleolar fracture facilitated expo-sure to the talar body. The impacted articular segment was elevated and bone-grafted.

E F



potential advantages of limiting theamount of limb shortening andpreserving some hindfoot motion.This technique can result in a pain-less plantigrade foot, but potentialproblems include high rates of non-union at the tibiotalar junction andlate collapse.10

Alternatively, the defect createdby removal of the talar body can bespanned with tricortical graft be-tween the distal tibia and the calca-neus in conjunction with fusion ofthe talar head and anterior distaltibia. This preserves limb lengthand limits the risk of late collapsebetween the tibia and the calcaneus(Fig. 11). Another option that hasbeen recently reported is to leavethe necrotic talar body in place andspan from the tibia to the calcaneuswith bone graft. Kitaoka et al29

reported union in 13 of 16 patientstreated with this technique.

Nonunion and MalunionNonunion is the least frequent

complication of talar neck fracture.In a review of the world literatureup to 1985,30 the reported incidencewas 2.5%. The differentiation of anonunion from a delayed union issomewhat arbitrary. Consolidationacross the site of a type III talarneck fracture may take as long as 8months.30 Treatment of nonunionis dependent on the presence of co-existing problems, such as arthro-sis, osteonecrosis, and infection,and is injury-specific. Considera-tion should be given to arthrodesiswhen nonunion is associated withadvanced hindfoot arthrosis.

Malunion after inaccurate reduc-tion of talar neck fractures has areported incidence as high as 32%,with varus malunion occurring mostfrequently.9,10 It is difficult to assessthe accuracy of reduction on plain

radiographs; therefore, malunion isprobably more common than re-ported. Canale and Kelly9 foundthat varus malunion occurred mostfrequently in Hawkins type II frac-tures that had been treated in aclosed manner. Type III fractureswere more likely to be treated oper-atively, and the incidence of mal-union was less in this group. Theauthors stressed the importance ofobtaining adequate radiographs,particularly the specialized obliqueview that allows assessment of neckalignment.

Because treatment of talar neckmalunion is difficult, preventing thiscomplication is important. It hasbeen recommended that minimallydisplaced fractures of the talar neckcan be treated with casting,8,9 butacceptable amounts of displacementhave been variably defined. Canaleand Kelly9 suggested that 5 mm of

Figure 11 AP (A) and lateral (B) plain radiographs demonstrate osteonecrosis of the entire talar body. C, Lateral postoperative radio-graph shows tibiocalcaneal arthrodesis with intramedullary nail fixation. The necrotic talar body was removed.

A B C

Talus Fractures


displacement and 5 degrees of angu-lation or varus are acceptable. San-georzan et al12 studied the effect ofmalalignment of the talar neck onthe contact characteristics of the sub-talar joint. Displacement by 2 mmresulted in changes in the subtalarcontact characteristics. These smalldisplacements are likely critical andcan lead to altered subtalar jointmechanics and arthrosis. Therefore,displaced fractures should be accu-rately reduced and internally fixed.With any medial comminution, atwo-incision approach may providethe best chance for accurate fracturereduction.

Patients with varus malunionwalk with the foot internally rotatedand often complain of excessiveweight bearing on the lateral borderof the foot. Initial management con-sists of footwear modification anduse of inserts intended to cushionthe lateral overload.

Surgical treatment of talar neckmalunion is dependent on the statusof the ankle, subtalar, and talonavic-ular joints. Long-standing varusmalunion with significant arthrosisand loss of hindfoot motion can besalvaged with arthrodesis to obtaina plantigrade foot. At the time ofarthrodesis, the malpositioning ofthe foot should be corrected. Pa-tients with varus malunion typicallyhave a shortened medial column ofthe foot. Correction of the deformityinvolves lengthening of the medialcolumn or shortening of the lateralcolumn of the foot in conjunctionwith derotation of the forefoot.Occasionally, joint function is pre-served, and correction of the varusdeformity with talar neck osteotomyis possible. Monroe and Manoli31

reported a successful outcome aftertalar neck osteotomy and insertionof a tricortical bone graft to restoremedial neck length.

Dorsal malunion can occur whenthe body is not properly derotatedduring reduction and the headfragment remains dorsal to the

body. This can lead to sympto-matic impingement of the dorsalsurface of the talus on the distaltibia and restriction of ankle dorsi-flexion. In the absence of signifi-cant arthrosis, resection of the dor-sal prominence of the talar neckmay relieve symptoms.

Skin Necrosis and InfectionDeep infection and skin slough

are probably the most dreaded com-plications of severe talar fractures.Displaced fractures can lead to ex-cessive tension on the dorsal skinand subsequent necrosis. Extensivesoft-tissue loss can increase thechance of infection and often neces-sitates flap coverage. Prompt re-duction will help minimize thispotentially disastrous complication(Fig. 12). Acute, deep infection, suchas septic arthritis, should be treatedaggressively with serial debride-ment and attempted wound closureor coverage and prolonged antibi-otic therapy.20 Chronic deep infec-tion with bone involvement typicallyrequires removal of the infectedbone and hardware. Antibiotic-

impregnated bone-cement spacerscan be used to fill large defects, andstaged reconstruction can be consid-ered after the infection has been erad-icated.

Posttraumatic ArthrosisSubtalar and tibiotalar arthrosis

with limited range of motion is afrequent residuum of severe talarinjuries. Arthrosis can result fromarticular damage at the time of in-jury or from abnormal joint me-chanics, as is seen with talar neckmalunion. The exact incidence ofarthrosis for each fracture type isunknown. In a study of displacedtalar neck fractures, Sanders10 re-ported that the incidence of arthro-sis varied from 47% to over 90%.Arthrosis is often not symptomaticand is, therefore, probably morecommon than has been reported. Aswith osteonecrosis, the presence ofarthrosis does not preclude a satis-factory outcome.

Arthrodesis may be consideredfor symptomatic arthritic joints ifbracing and lifestyle modificationdo not provide sufficient relief. It is

A B

Figure 12 A, AP plain radiograph shows a Hawkins type III fracture. B, Injury was leftunreduced for 48 hours, which resulted in full-thickness skin loss that necessitated free-vascularized-flap and skin-graft coverage.



important not to underestimate thepossibility of osteonecrosis in pa-tients with arthritis subsequent totalar injuries. The presence of focalosteonecrosis may not be apparenton plain radiographs, and conven-tional arthrodesis techniques mayfail if large areas of necrotic boneare not appropriately treated withbone grafting.

Summary

Talus fractures often present ascomplex injuries. Optimal diagno-sis and management require a thor-ough understanding of the osseousanatomy and the vascular supplyof the talus. Fractures with signifi-cant displacement or associateddislocation require urgent reduc-

tion to afford the best outcome.Using a combination of antero-medial and anterolateral incisionsfor fracture exposure facilitatesanatomic reduction. Severe talarinjuries with significant initial dis-placement remain problematic, andeven aggressive management doesnot always lead to a satisfactoryoutcome.

References

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differentiation between neck and bodyfractures. Foot Ankle Int 1996;17:748-750.

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