Reduction and Fixation of Talar Fractures
David Thordarson
Fractures of the neck of the talus account for approximately 50% of significant injuries to the talus. They are commonly caused by high-energy trauma such as motor vehicle or motorcycle accidents or falls from a height (1). Although it has been theorized that hyper-dorsiflexion of the ankle with abutment of the neck of the talus against the anterior lip of the tibia causes this fracture, it has been found in the laboratory to be caused by axial loading of the ankle in the neutral position while compressing the calcaneus against the overlying talus and tibia. As talar neck fractures usually result from high-energy trauma, they occur more frequently in young adults. They occur more often in men than women (3:1) and most frequently in the third decade of life. Many have associated injuries of the musculoskeletal system. Approximately 20% to 30% of patients have associated medial malleolar fractures, especially in Hawkins type III fractures. It is not unusual for patients with severe lower extremity injuries to have an overlooked talus fracture.
INDICATIONS AND CONTRAINDICATIONS
Fractures of the talus are relatively uncommon fractures of the foot, but they have potentially serious complications. Because of the severe disability after nonoperative treatment of a displaced fracture, there are few contraindications for operative treatment of talar neck and body fractures. Since the fracture is usually associated with high-energy trauma, a patient occasionally is too unstable to undergo any operative treatment upon presentation to the hospital. After the patient’s condition has stabilized, he or she should be treated in an urgent fashion to minimize the risk of complications, including especially skin necrosis and avascular necrosis of the talar body. Any displaced fracture of the neck or body of the talus requires open reduction and internal fixation (ORIF) (2,3). A common treatment goal is urgent anatomic reduction to restore congruity to the ankle and subtalar joints and to reduce the risk of avascular necrosis by preserving the remaining blood supply (4).
Although these fractures occur relatively infrequently, the consequences may be disastrous; thus, it is important for surgeons who manage patients with acute trauma to be knowledgeable of treatment. This chapter focuses on talar neck fractures but does discuss talar body fractures, which require a slightly more extensive intraarticular exposure, usually via a malleolar osteotomy.
PREOPERATIVE PLANNING
Operative management of these patients should be performed as soon as possible. Physical examination frequently reveals severe swelling of the foot that is usually progressive for the first 24 hours or longer. Fracture displacement can be masked by this swelling, making palpation of
fracture dislocations difficult or impossible. The neurovascular structures are generally spared from serious injury. Soft tissue damage can be extensive with a significant incidence of open fractures. Compartment syndrome of the foot sometimes occurs.
fracture dislocations difficult or impossible. The neurovascular structures are generally spared from serious injury. Soft tissue damage can be extensive with a significant incidence of open fractures. Compartment syndrome of the foot sometimes occurs.
 FIGURE 28.1 A: With a cassette placed beneath the foot, the ankle is placed in maximum plantarflexion; the foot is pronated 15°, and the radiograph beam is angled cephalad in a 75° angle relative to the cassette to obtain the modified Canale anteroposterior radiograph of the neck of talus. B: Canale view of the talus was obtained intraoperatively. This view can be useful in demonstrating the adequacy of fracture reduction and fixation placement. |
Radiographic evaluation includes anteroposterior, lateral, and oblique radiographs of the foot and anteroposterior view of the ankle. These views allow the fracture to be characterized by displacement, comminution, and incongruity of the subtalar, ankle, and/or talonavicular joints. Varus and valgus displacement of the talar neck can be difficult to demonstrate on a routine anteroposterior radiograph. Canale described a modified anteroposterior radiograph (Fig. 28.1) that can be particularly beneficial in the intraoperative assessment of reduction (5).
Treatment of fractures of the neck of the talus is predicated on their classification (Table 28.1 and Fig. 28.2) (6).
In patients with fractures of the body of the talus, a preoperative computed tomography (CT) scan in the sagittal and coronal planes can be helpful in defining the fracture anatomy and the degree of comminution. In patients with clearly defined fractures of the talar neck or body based on plain radiography, the CT scan is generally unnecessary and may delay urgent operative treatment of these fractures.
The common treatment goal of all fractures of the neck and body of the talus is urgent anatomic reduction with rigid internal fixation. In patients with a Hawkins type II fracture with subluxated or dislocated subtalar joint, an attempt at closed reduction in the emergency room with traction and
plantarflexion is warranted. If anatomic or near-anatomic reduction of the fracture is achieved, the patient can be splinted in plantarflexion and taken to surgery in a semi-elective fashion since little remaining tension on the blood supply of the talar body will persist. Open reduction and internal fixation should be performed even if an anatomic closed reduction of a Hawkins II fracture has been achieved, as it avoids the inevitable equinus contracture that develops after a prolonged period of casting in plantarflexion (7,8). In Hawkins type III fractures with a dislocated body of the talus, closed reduction is usually unsuccessful and may further traumatize articular cartilage and soft tissue. These cases are surgical emergencies, as the dislocated body of the talus can lead to skin necrosis and disrupts any potential remaining blood supply through the deltoid branches.
plantarflexion is warranted. If anatomic or near-anatomic reduction of the fracture is achieved, the patient can be splinted in plantarflexion and taken to surgery in a semi-elective fashion since little remaining tension on the blood supply of the talar body will persist. Open reduction and internal fixation should be performed even if an anatomic closed reduction of a Hawkins II fracture has been achieved, as it avoids the inevitable equinus contracture that develops after a prolonged period of casting in plantarflexion (7,8). In Hawkins type III fractures with a dislocated body of the talus, closed reduction is usually unsuccessful and may further traumatize articular cartilage and soft tissue. These cases are surgical emergencies, as the dislocated body of the talus can lead to skin necrosis and disrupts any potential remaining blood supply through the deltoid branches.
TABLE 28.1 Hawkins Classification of Fractures of the Neck of the Talus | |||||||||
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 FIGURE 28.2 Hawkins classification. A: Medial-view diagram of a Hawkins I fracture, which is a nondisplaced fracture of the neck of the talus that has a congruent ankle and subtalar joint. B: Lateral radiograph of Hawkins I fracture. Note the nondisplaced vertical fracture of the anterior body of the talus. |
 FIGURE 28.2 (Continued) C: Medial view of a Hawkins II fracture demonstrates displacement of the fracture at the neck of the talus and subluxation of the subtalar joint. Notice that the ankle joint is congruent. D: Lateral radiograph demonstrating Hawkins II fracture with dislocated posterior facet of subtalar joint but congruent ankle joint. E: Medial view of a Hawkins III fracture demonstrates complete dislocation of the body of the talus posteromedially with disruption of the ankle and subtalar joints. F: AP radiographic views of Hawkins III fracture with dislocation of the body of the talus posteriorly and medially clearly evident here. |
 FIGURE 28.2 (Continued) G: Medial view of the foot shows a Hawkins IV fracture with dislocation of the ankle, subtalar, and talonavicular joints. H: Lateral radiograph demonstrating Hawkins IV fracture with obvious incongruity of talonavicular, ankle, and subtalar joint. |
SURGICAL TECHNIQUES
Technique 1: Fracture Without Dislocation of the Talar Body
The patient is placed in a supine position, with a bump under the ipsilateral hip to orient the foot perpendicular to the floor. A thigh tourniquet is used and the leg is prepped and draped about the knee. Intraoperative fluoroscopy will be necessary with either a full size C-arm or a mini fluoroscopy unit (Fig. 28.3), depending on the availability and the surgeon preference.
A combined anteromedial and anterolateral approach to the neck of the talus should be used (Figs. 28.4 and 28.5). The anteromedial approach is made from the anterior aspect of the medial malleolus to the dorsal aspect of the navicular tuberosity (Fig. 28.6).
The dissection is carried down to the bone, just dorsal to the posterior tibial tendon. Disruption of the deltoid ligament should be avoided as it will violate some of the blood supply to the body of the talus. The fracture can be visualized and subsequently reduced through this incision. Dissection of soft tissues at the level of talar neck dorsally and plantarward should be avoided such that no further damage to the blood supply occurs.
An anterolateral hindfoot incision is made that allows for exposure of the lateral aspect of the talar neck to confirm the accuracy of reduction and to provide another site for hardware placement (Fig. 28.7). Because of limited exposure medially, the fracture may be malreduced with only an anteromedial incision. The second incision also permits removal of any osteochondral fragments from the subtalar joint. Fracture comminution is frequently present on the medial neck of the talus; thus visualizing the lateral aspect of the talar neck can provide a more accurate assessment of the adequacy of reduction since there is less frequently laterally based comminution.
The anterolateral hindfoot incision is made from the anterior aspect of the lateral malleolus toward the base of the fourth metatarsal. The extensor digitorum longus and peroneus tertius tendons are retracted. The extensor digitorum brevis muscle is retracted dorsally.
If osseous fragments are evident in the subtalar joint preoperatively, they should be located and removed, possibly with the aid of a lamina spreader in the sinus tarsi. The subtalar joint can be probed blindly and irrigated to remove any articular debris that may not have been evident on preoperative radiographs.
The fracture is reduced under direct visualization through the medial and lateral incisions. The surgeon must beware of comminution of the medial neck of the talus because it can lead to a varus malreduction of the neck of the talus that subsequently leads to a rigid, supinated foot. The fracture may have a gap on the lateral neck when the medial side has been provisionally fixed in a shortened manner (Fig. 28.8).Related posts:
Hallux Metatarsophalangeal Interposition Arthroplasty (Modified Keller Procedure)
Realignment of Lesser Toe Deformities
Tarsometatarsal Arthrodesis
Calcific Insertional Tendinopathy and Calcaneal Prominence Resection
Compartment Releases of the Foot
Autologous Osteochondral Transfer for Talar Defects: Mosaicplasty
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