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Talar Neck Fractures

Topic updated on 11/08/15 1:56pm
Introduction
  • Epidemiology
    • most common fracture of talus ( 50%)
  • Mechanism
    • a high-energy injury
    • is forced dorsiflexion with axial load
  • Associated conditions
    • ipsilateral lower extremity fractures common
Anatomy
  • Articulation 
    • inferior surface articulates with posterior facet of calcaneus
    • talar head articulates with
      • navicular bone
      • sustenaculum tali
    • lateral process articulates with
      • posterior facet of calcaneus
      • lateral malleolus of fibula
    • posterior process consist of medial and lateral tubercles separated by groove for FHL
  • Blood supply
    • talar neck supplied by three sources 
      • posterior tibial artery
        • via artery of tarsal canal (dominant supply)
          • supplies majority of talar body
        • deltoid branch of posterior tibial artery
          • supplies medial portion of talar body
          • may be only remaining blood supply with a displaced fracture 
      • anterior tibial artery
        • supplies head and neck
      • perforating peroneal artery via artery of tarsal sinus
        • supplies head and neck
Classification

Hawkins Classification
Type Description AVN Images
Hawkins I
Nondisplaced
0-13% AVN
Hawkins II Subtalar dislocation 20-50%
Hawkins III
Subtalar and tibiotalar dislocation
20-100%
Hawkins IV
Subtalar, tibiotalar, and talonavicular dislocation
70-100%
 
Imaging
  • Radiographs
    • recommended views
      • AP and lateral
      • Canale View
        • optimal view of talar neck
        • technique is maximum equinus, 15 degrees pronated, Xray 75 degrees cephalad from horizontal 
  • CT scan 
    • best study to determine degree of displacement, comminution and articular congruity
    • CT scan also will assess for ipsilateral foot injuries (up to 89% incidence) 
Treatment
  • Nonoperative 
    • emergent reduction in ER
      • indications
        • all cases require emergent closed reduction in ER
    • short leg cast for 8-12 weeks (NWB for first 6 weeks)
      • indications
        • nondisplaced fractures (Hawkins I)
      • CT to confirm nondisplaced without articular stepoff
  • Operative
    • open reduction and internal fixation
      • indications
        • all displaced fractures (Hawkins II-IV) 
      • techniques
        • extruded talus should be replaced and treated with ORIF 
      • complications  
        • post-traumatic arthritis
        • mal-union
        • non-union
        • infection
        • wound dehiscence
Techniques
  • ORIF
    • approach
      • two approaches recommended
        • visualize medial and lateral neck to assess reduction
        • typical areas of comminution are dorsal and medial
      • anteromedial
        • between tibialis anterior and posterior tibialis
        • preserve soft tissue attachments, especially deep deltoid ligament 
      •  anterolateral 
        • between tibia and fibula proximally, in line with 4th ray
        • elevate extensor digitorum brevis and remove debris from subtalar joint
    • technique
      • anatomic reduction essential
      • variety of implants used including mini and small fragment screws, cannulated screws and mini fragment plates
      • medial and lateral lag screws may be used in simple fracture patterns 
      • consider mini fragment plates in comminuted fractures to buttress against varus collapse   
    • postoperative
      • non-weight-bearing for 10-12 weeks
Complications
  • Osteonecrosis
    • radiographs
      • hawkins sign 
        • subchondral lucency best seen on mortise Xray at 6-8 weeks
        • indicates intact vascularity with resorption of subchondral bone 
      • associated with talar neck comminution and open fractures
  • Posttraumatic arthritis
    • subtalar arthritis (50%)
      • most common complication 
    • tibiotalar arthritis (33%)
  • Varus malunion (25-30%)
    • can be prevented by anatomic reduction
    • treatment includes medial opening wedge osteotomy of talar neck 
    • leads to  
      • decreased subtalar eversion
        • decreased motion with locked midfoot and hindfoot
      • weight bearing on the lateral border of the foot

 

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Qbank (11 Questions)

TAG
(OBQ12.91) A 35-year old male is involved in a fall from height and present with the isolated injury shown in Figures A and B. The body of the talus is extruded medially through a large linear open wound. Along with irrigation and debridement, what is the most appropriate definitive management of this injury? Topic Review Topic
FIGURES: A   B        

1. Reimplantation of the talar body followed by cast immobilization
2. Reduction of talar body, fracture fixation with smooth Steinman pins, and spanning fixator placement
3. Talar body allograft with internal fixation to native talar head
4. Fragment removal, antibiotic spacer placement and external fixation
5. Reduction of native talar body and ORIF of talar neck fracture

PREFERRED RESPONSE ▶
TAG
(OBQ11.178) A 25-year-old man presents one year after undergoing open reduction and internal fixation of the fracture seen in Figure A. Current radiographs demonstrate a united fracture with no evidence of ostenecrosis, subtalar or tibiotalar arthritis. Physical exam is notable for ambulation on the lateral border of the right foot with hindfoot varus, midfoot supination and diminished subtalar motion compared with the contralateral side. Which of the following is an option for reconstruction of this patient's deformity? Topic Review Topic
FIGURES: A          

1. Total ankle arthroplasty
2. Lateral calcaneus closing wedge osteotomy
3. Calcaneal neck opening wedge osteotomy
4. Talar neck opening medial wedge osteotomy
5. Triple arthrodesis

PREFERRED RESPONSE ▶
TAG
(OBQ09.207) Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion? Topic Review Topic

1. Tibiotalar dorsiflexion
2. Tibiotalar plantarflexion
3. Subtalar eversion
4. Subtalar inversion
5. Internal rotation

PREFERRED RESPONSE ▶
TAG
(OBQ08.234) A 30-year-old patient underwent open reduction internal fixation of a talar neck fracture 8 weeks ago. His current radiographs demonstrate a subchondral radiolucency of the dome of the talus. What is the next most appropriate course of action? Topic Review Topic

1. Injection of bone cement into the talus to prevent further avascular necrosis
2. Ankle fusion
3. Subtalar fusion
4. Ankle arthroscopy to address this osteochondral lesion
5. Continued observation as the vascularity to the talus is intact

PREFERRED RESPONSE ▶
TAG
(OBQ05.95) A 29-year-old male sustains the isolated lower extremity injury shown in Figure A. During open reduction, what structure must be kept intact in order to protect the remaining blood supply to the talar body? Topic Review Topic
FIGURES: A          

1. Medial malleolus
2. Deltoid ligament
3. Anterior talofibular ligament
4. Lateral malleolus
5. Calcaneonavicular ligament

PREFERRED RESPONSE ▶
TAG
(OBQ04.44) A 34-year-old female is involved in a motorcycle crash. She sustains a talus fracture with associated dislocation of the subtalar joint and maintained congruence of the tibiotalar and talonavicular joints as shown in Figure A. The fracture has healed and she now has symptomatic impingement of the dorsal surface of the talus on the distal tibia and restriction of ankle dorsiflexion. What is the most likely deformity causing these symptoms? Topic Review Topic
FIGURES: A          

1. Combined varus and plantar malunion
2. Isolated varus malunion
3. Isolated valgus malunion
4. Isolated dorsal malunion
5. Isolated plantar malunion

PREFERRED RESPONSE ▶
TAG
(OBQ04.126) A 30-year-old male sustains the injury shown in figure A and undergoes successful open reduction and internal fixation. Which of the following radiographic features is a good prognostic factor for this injury? Topic Review Topic
FIGURES: A          

1. Talar dome subchondral lucency
2. Talar dome subchondral sclerosis
3. Diffuse osteopenia
4. Associated medial malleolus fracture
5. Talar lateral process fracture

PREFERRED RESPONSE ▶
TAG
(OBQ04.145) A 47-year-old male sustains the closed injury seen in Figures A and B after failing to land a motorcycle jump. A post-reduction radiograph is seen in Figure C. What is the most appropriate treatment at this time? Topic Review Topic
FIGURES: A   B   C      

1. Definitive closed treatment
2. Addition of percutaneous pins
3. Open reduction and internal fixation
4. Tibiotalocalcaneal arthrodesis
5. Primary subtalar arthrodesis

PREFERRED RESPONSE ▶
TAG
(OBQ04.173) A 30-year-old male undergoes successful surgical fixation of a displaced talar neck fracture. Which of the following is the most likely long-term complication even after anatomic reduction and stable fixation is achieved? Topic Review Topic

1. Tibiotalar and/or subtalar arthritis
2. Loss of forefoot supination
3. Osteonecrosis
4. Nonunion
5. Infection

PREFERRED RESPONSE ▶
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HPI - Fell from the stairs.
poll Best treatment
10/31/2013
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