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Management of talus fracture

Dr.Mohana RaoOrtopaedic Surgeon

Hospital Pulau PinangTrauma Symposium

8/5/10Foot and Ankle Symposium, Kangar

The Truth

Even very experienced surgeons would have treated a few in their lifetime

But, it is important to treat well

Introduction

The issue of blood supply?

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

Tib. post and the medial contribution

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

Conservative very specific indication

Most times require surgical

Remember that this is a weight bearing bone

Articulates with many other bones

Management

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

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

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

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

General rule of thumb

Conservative treatment for

Extraarticular fractures

Undisplaced fractures (1-2 mm)

Fragments less than 0.5cm

Patient is too unwell

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

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

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

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

Double dorsal incision

Anteromedial and anterolateral

Screw fixation Type I

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Type 3 Talar body fracture

More common than talar head

7% - 38%

High energy trauma

Fracture line behind the lateral tubercle

Why the big hype

Involve the subtalar and ankle joint

See the lateral tubercle

Fixation

2 incisions

Disengage all the fragments

Clear the subtalar joint

Hold with temporary k-wires

Screw

Non compressive

or

Arthroscopic assisted

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Lateral process fracture

About 25% of the talus fracture

Commonly wrongly termed s avulsion of the fibula

Missed

Snowboarders fracture

Recognize this?

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 fracturesBERNDT and HARTY

Type I: Subchondral depression without break in

the cartilage.

Type II: Fractured partially detached osteochondral

fragment.

Type Ill: Totally detached but nondisplacedosteochondral

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 Br52:160-167, 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 LaingbThehindfoot: Calcaneal and talar fractures and dislocationsPart 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 talarfractures Injury, Int. J. Care Injured (2004) 35, S-B23S-B35,

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