The document provides information on a seminar about fracture talus. It begins with an introduction discussing the complexity of talus anatomy and variability in fracture patterns. It then covers the history of talus fractures dating back to Roman times and key publications. The remainder summarizes talus anatomy, blood supply, fracture classifications including Hawkins classification of talus neck fractures, clinical presentation, diagnosis, and treatment options for different fracture types including complications like AVN.
2. Introduction
īļThe complexity of anatomy , physiological role of talus
in functioning of lower extremity and variability of
fracture pattern often complicates the outcomes of
talus fracture
īļTo gain full confidence in the treatment , orthopaedic
surgeon should have thorough knowledge of osseous
anatomy and vascular supply and modern method of
fixation .
īļSurgeon should be prepared to deal with complications
which often occur.
3. HISTORY
ī Roman Times- The heel bone of horse was used
as dice and was called Taxillus. This Word evolved
into Talus
ī Year 1500-Talus Fracture was first described by
Egyptians .
ī Year 1608 âFabricius Von Hilden -Reported
fracture dislocation resulting in Talectomy.
4. HISTORY
ī Year 1882- SHEPARD- Described fracture of
lateral tubercle in English literature.
ī Year 1919-Anderson â reported the first series
of talar neck fractures in World War I pilots and
coined the term Aviators Astragalus.
ī YEAR 1943- BLAIR described talectomy of the
Talus body with tibial slide fusion to the head
and neck of talus.
5. HISTORY
ī Year 1970- Hawkins â presented
classification of neck of talus fracture based
on pattern of injury and disruption of blood
supply .
ī He determined the risk of osteonecrosis to
talar dome
6. HISTORY
ī§ YEAR 1978- Canale and Kelly Expanded the
HAWKINS classification system and introduced
type 4 .
ī§ Canale â pioneered specific radiographic techniques for
talus
8. ANATOMY
īSecond largest tarsal bone.
īOssification â from one
centre which appear in 6th
month of intrauterine life
ī60 % is covered with
articular cartilage
9. ANATOMY
ī PARTS OF TALUS
1. HEAD
2. NECK
3. BODY
4. LATERAL PROCESS
5. POSTERIOR PROCESS PROCESS
10. ANATOMY
BODY OF TALUS
ī 5 surfaces:-
ī 1. superior surface
ī 2. Inferior surface
ī 3.medial surface
ī 4. lateral surface
ī 5.posterior surface
12. ANATOMY
ī Body of talus
ī Medial surface:-
ī articular surface for medial
malleolus
13. AnatomyâĻ
ī Body Of Talus
Inferior surface:-
ī§ Posterior and middle
articulating surfaces.
ī§ SULCUS talli
14. ANATOMYâĻ
ī NECK OF TALUS
ī Constricted potion of bone between
the body and the oval head .
ī Directed forward , medial word ,
downward
ī Angle of medial deviation is 15 to 20
degree in adults
ī Plantar deviation is 24 degree
approx
ī Neck body angle is 150 degree in
adults
ī Relatively thin diameter makes it
weaker area and hence more
vulnerable to fractures
15. ANATOMYâĻ
ī HEAD OF TALUS
ī Anterior articular surface is large , oval and convex articulating
with navicular bone
ī Inferior surface have two facets medial and lateral for articulation
with calcaneum
16. ANATOMY
ī TARSAL CANAL
ī Formed of sulcus of inferior
surface of talus and superior
sulcus of calcaneum
ī Contents- artery of tarsal
canal and talocalcaneal
interosseous ligament
TARSAL
CANAL
17. ANATOMY
ī Posterior process has a medial and lateral tubercle
separated by a groove for the flexor hallucis longus
tendon
31. FRACTURE TALUS
ANATOMICAL CLASSIFICATION OF TALUS
FRACTURE :-
ī 1. Talar neck fracture
ī 2. Talar body fracture
ī 3. Talar head fracture
ī 4. Lateral process fracture
ī 5. Posterior process fracture
32. CLINICAL PRESENTATION
ī Talus fractures frequently occur in a young, active, and
mobile population
ī History of high velocity injury present
âĸ Clinically :-
īŧIntense pain , unable to move ankle,
īŧGross edema and echymosis usually present
īŧWhen there is subluxation or dislocation the normal
contours of ankle and hind foot are distorted
īŧOpen injury may occur if there is significant distortment
34. RADIOGRAPHIC XRAYS
ī CANALE AND KELLY
VIEW
īview of the talar neck
achieved by internal rotation
of the foot by placing the foot
plantigrade on an x-ray film
and angling the beam at 75
degrees to the perpendicular
ī Gives best view of talus neck
ī Useful intraoperatively to
check alignment of neck
35. DIAGNOSISâĻ
ī CT SCAN
īgive excellent visualization of
the congruity of the subtalar
joint and provide superior
details of fracture.
īsmall but significant fractures of
the inferior aspect of the talus,
are better appreciated on CT
scans compared to plain xray
films alone.
37. FRACTURE NECK OF TALUS
ī§ Constitue 30 % of talus fractures.
ī§ MECHANISM OF INJURY
ī§ Forced hyperdorsiflexion of the ankle and
impingement of the taller neck on the distal
anterior tibia .
ī§ Axial load to plantar foot causes talar neck
fracture
38. HAWKIN CLASSIFICATION
OF TALAR NECK FRACTURE
ī Hawkins 1970 - talar neck fractures into three type
ī Canale and Kelly added type IV
ī Based on displacement of body of talus.
ī Useful to perdict long term outcome and development
of avn of talar body
39. HAWKINS TYPE 1
ī Undisplaced fracture
of talar neck.
ī Here medial blood
supply is still assured
40. HAWKINS TYPE 2
ī Displaced fracture of the talar neck with subtalar dislocation or
subluxation.
ī The medial blood supply may be preserved.
41. HAWKINS TYPE 3
ī Displaced fracture of the talar neck with dislocation or
subluxation of the talar body from both the tibiotalar and
subtalar joints.
ī All medial blood supply to the body is disrupted
42. HAWKINS TYPE 4
ī Displaced fracture of the
talar neck with
dislocation or
subluxation of the
talonavicular , tibiotalar ,
and subtalar joints.
ī Worst prognosis because
of avn of the body and
often of the head
fragment
43. TREATMENT
ī Goals of treatment:
1. Early anatomic reduction of the neck fracture
2. Reduction of dislocated joints
3. Stable fixation
4. Avoidance of complications
44. Treatment Options
īHawkins type 1 fracture
ī Nonoperative Management
īConsidered for fractures in which there is no
displacement of the fracture line and no
incongruity of the subtalar joint.
īSHOULD BE CONFIRMED WITH CT SCAN IF
DOUBTFULL
45. Treatment OptionsâĻTYPE 1
ī Non operative management
īTreated with below knee non weight
bearing cast with ankle in slight
equinus for 1 month
īCast should be removed and short leg
walking cast is applied for 2 more
months until Clinical and x-ray signs
of healing appears.
īOnce secure union is achieved active
range of motion and progressive
weight bearing as tolerated is started.
46. TREATMENT TYPE 1
ī OPERATIVE HAWKINS TYPE 1
ī Hawkins I
Operative-
Percutaneous screw fixation
47. TREATMENT
ī HAWKINS TYPE 2
ī NON OPERATIVE
īAchieving closed reduction is very difficult.
īShould be only attempted if surgery is delayed.
48. TREATMENT
ī HAWKINS TYPE 2 CLOSED REDUCTION
ī firstly, adequate analgesia and sedation
ī technique involves bringing the foot, including the talar head, to the
residual talar body fragment
ī requires the talar body to be reduced within the ankle mortise
ī the knee is flexed and the foot is flexed plantar ward. This relaxes the
gastrocsoleus complex and brings the talar head fragment into proper
relation to the body
ī At that point, any varus or valgus malalignment can be corrected as well
ī reduction is achieved, excessive dorsiflexion will cause a redisplacement
of the head fragment, and therefore radiographs to confirm reduction
should be performed with the foot in a comfortable position of equinus.
51. TREATMENT
ī HAWKINS TYPE 3 AND 4
ī Most authors agree that group III and IV cannot be
reduced and held by closed attempts
âĸ Almost all require surgical stabilization.
ī Most patients require additional surgery for relief
of complications resulting from the initial injury
52. SURGICAL OPTIONS
ī TYPE 3 & TYPE 4
ī SCREW FIXATION
īANTERIOR TO POSTEROR
īPOSTERIOR TO ANTERIOR
âĸ DIRECT PLATE FIXATION
53. Treatment
Screw fixation
Advantages Disadvantages
Anterior-to-posterior
screw fixation1
1. Direct visualization of
fracture reduction
1.Difficult to insert
perpendicular to fracture
line
2. Avoidance of articular
cartilage damage
2.Less strong compared to
posterior-to-anterior screws
and plate fixation
3. Use of compression
screws where indicated
3.Inappropriate use of
compression may cause
malalignment , especially
varus
54. Treatment
Screw fixation
Advantages Disadvantages
Posterior-to-anterior
screw fixation
Stronger fixation
compared with anterior
screw fixation
Indirect visualization of
reduction; may require
change in positioning
Easily inserted
perpendicular to fracture
line
Some cartilage damage to
posterior talus.
May cause less soft tissue
disruption
Risk of iatrogenic nerve
damage
56. TREATMENT
ī External Fixation
Limited roles:
ī Multiply injured patient
with talar neck fracture in
whom definitive surgery will be
delayed.
ī Temporary measure to
stabilize reduced joints
58. AVN OF TALUS
ī Most common complication of talar neck fracture.
ī Extent of involvement of talar body by osteonecrosis is
directly related to degree of vascular disruption
59. AVN: Incidence after Talus Fracture
ī Hawkins (1970)
I 0%
II 42%
III 91%
ī Canale(1972):
ī I: 15 %
ī II: 50 %
ī III: 85 %
ī IV: 100 %
Behrens (1988):
Overall 25 %
60. HAWKINâS SIGN
ī§ Osteonecrosis is identified
based on AP radiograph
between 6 and 8 weeks
ī§ Subchondral lucency is
indicative of relative osteopenia
secondary to bony resorption
and an intact blood supply
ī§ Progresses from medial to
lateral due to vascular re-
establishing from medial side of
dome through deltoid ligament
ī§ Indicative of diffuse osteopenia
with vascular congestion
suggests continuity of blood
supply
61. AVN: Diagnosis
ī Technetium bone scan and
MRI are used to evaluate
osteonecrosis and also
condition of articular
cartilage in MRI
Osteonecrosis of talar body
after 6 months of fracture
64. ī Degenerative arthrosis of
tibio-talar joint secondary to
Hawkinâs III talar neck
fracture
Degenerative arthrosis
65. TALAR BODY FRACTURE
ī DEFINITION-fractures of the talar body are intra-
articular injuries in which the articular surfaces of the
tibiotalar and the subtalar joints are involved.
ī RADIOGRAPHIC âLATERAL XRAY VIEWS
fractures extending into or posterior to the lateral process
of the talus are defined as talar body fractures, whereas
fractures anterior to the lateral process are defined as
talar neck fractures.
66. TALAR BODY FRACTURE
ī MECHANISM OF INJURY
ī AXIAL COMPRESSION OF THE TALUS BETWEEN
TIBIAL PLAFOND AND THE CALCANEUS
ī USUALLY SEEN IN MOTOR VEHICLE ACCIDENTS
AND FALLS FROM HEIGHT
67. TALUS BODY FRACTURE
ī CLASSIFICATION
ī SNEPPEN ET AL CLASSIFIED BASED ON ANATOMICAL
LOCATION
ī I- transchondral dome fractures;
ī II- shear fractures;
ī III- posterior tubercle fractures;
ī IV- lateral process fractures; and
ī V- crush fractures
68. TALAR BODY FRACTURES
ī MULLER AO/OTA
CLASSIFICATION
ī fracture are grouped
according to increasing
severity with increasing
treatment difficulty and
worst prognosis
ī C1- osteochondral
injuries with ankle
joint involvement
C 1
70. TALAR BODY FRACTURES
ī MULLER AO/OTA
CLASSIFICATION
ī C3- ankle and subtalar
joint involvement
c3
71. TALAR BODY FRACTURE
ī TREATMENT
ī OPERATIVE
ī SURGICAL APPROACH â ANTEROMEDIAL
APPROACH WITH MEDIAL MALLEOLUS
OSTEOTOMY
ī .
72. TALAR BODY FRACTURE
ī SURGICAL ORIF- As surface for fixation is always
articular, fixation is done by headless compression
screw or bioabsorbable pins
73. TALAR BODY FRACTURE
TREATMENT
ī COMMINUTED FRACTURES OF BODY
īDifficult to treat
īAccurate replacement of fragments is near
impossible
īLong term results- bad
ī§ IN SUCH CASES TALECTOMY ALONG WITH
CALCANEOTIBIAL FUSION IS PREFFERRED.
īŧGIVES PATIENT PAINLESS AND STABLE WALKING
FOOT
75. TALAR BODY FRACTURE
ī PROBLEMS FACED WITH TALOCALCANEAL FUSION
ī DECREASE IN HEIGHT AND THE RIGIDITY OF ANKLE
JOINT
ī BLAIR SUGGESTED ALTERNATIVE PROCEDURE-
ī TIBIOTALAR ARTHRODESIS
76. TALAR BODY FRACTURE
ī TIBIOTALAR
ARTHRODESIS
ī PROCEDURE-sliding graft
from anterior surface of
tibia is inserted into the
remnant of head and neck
of the talus in an attempt to
obtain fusion around the
area
77. TALAR BODY FRACTURE
ī ADVANTAGES OF TIBIO TALAR ARTHRODESIS OVER
CALACANEOTIBIAL FUSION
īPosition of foot is unchanged
ī Weight bearing thrust is placed on more or less normal
undisturbed joint tissue.
īNo shortening
īAfter surgery- still slight flexion and extention of the foot
on leg , the two subtalar facets and talonavicular joint is
possible.
79. Talus head fracture
ī Incidence- 5 to 10 % of talar injuries
ī Mechanism of injury-
īaxially directed loading and compression of
talar head
īDorsal compression fracture of anterior tibial
plafond
âĸ injuries to calcaneocuboid and subtalar joint
are common with these injuries
80. TREATMENT
TALAR HEAD FRACTURE
ī PRINCIPLES
īMaintainance of alignment of dorsomedial arch of foot.
īPrevention of talonavicular joint incongruity and instability
īReduction of displaced talar head fragment
81. TREATMENT
TALAR HEAD FRACTURE
ī Fracture without displacement
ī Well molded short leg cast for 6 weeks
īWeight bearing is started at 6 weeks
82. TREATMENT
TALAR HEAD FRACTURE
ī Displaced fractures and those associated with joint
subluxation or dislocation
ī ORIF
īSmall comminuted segments can be excised
īLarger fragments are reduced with screws ranging from
2.0 to 3.5 mm
83. TALAR HEAD FRACTURE
COMPLICATIONS AND PROGNOSIS
ī TALONAVICULAR ARTHRITIS IN DISPLACED
FRACTURE
īConservatively managed with longitudianal arch support
shoe
īIf conservative fails then talonavicular arthrodesis releives
symptoms
ī NONUNION- UNCOMMON
ī§ MALUINION - TALONAVICULAR JOINT SUBLUXATION
84. FRACTURE OF LATERAL PROCESS OF TALUS
ī Snowboarderâs fractureâ
ī MISDIAGNOSED OFTEN-
ANKLE SPRAIN
ī MECHANISM OF INJURY-
Axial loading, dorsiflexion ,
external rotation and eversion of
foot
85. FRACTURE OF LATERAL PROCESS OF TALUS
ī RADIOGRAPHIC XRAYS
ī VON KNOCH ET AL
described v sign
ī V SiGN- it is the contour of
lateral process over lateral
view xrays
ī V sign positive- any
disruption in contour of V
indicating fracture lateral
processs
Negative V sign
87. FRACTURE OF LATERAL PROCESS OF
TALUS - treatment
ī Type I fractures can be treated in a non weight-bearing
cast for 6 weeks, unless they are displaced or involve a
significant portion of the talar side of the posterior facet,
in which case they should be treated by ORIF.
ī Type II fractures benefit from dÊbridement of frature
fragments
ī Type III fractures- treated conservatively with cast
application
ī If non union occurs the debridement of fragments is
advised
88. POSTERIOR PROCESS FRACTURES
ī These include the medial and lateral
tubercle fractures
ī Fracture occurs in a severe ankle
inversion injury where posterior
talofibular ligament avulses the
lateral tubercle
ī Undisplaced fracture treated with a
short leg cast for 4 weeks
ī Displaced fracture treated with
primary excision of small fragments
or ORIF when entire posterior
process is fractured
89. REFERENCES
ī Rockwood and Greenâs Fractures in Adults; 7th
Edition; Volume 2
ī Watson â Jones fractures and Joint injuries, 7th
Edition
ī Campbellâs Operative orthopaedics; 11th Edition;
Volume 4
ī Grays Anatomy for students
As in world war 1 flying accidents were common âĻanderson was consulting surgeonâĻ..he coined the term aviators astralguslll
Superior surfaceâĻpresents a smooth trochlear surface which articulates with lower end of tibiaâĻtrochlea is broader in front than behind, convex before back ward, slightly concave from side to sideâĻinfront it is continuouas with suoerior surface of neck of talus
Inferior surface presents with two articular surfaces , the posterior and middle calcaneal surfaces which articulates with corresponding foramen over the calcaneum, separated by a deep groove called sulcus talli..in the articulated foot this it lies above similar groove upon upper surface of calcaneum and forms with it a canal (sinus tarsi )
EXTRAOSSEOUS ARTERIES INCLUDE ANTERIR TIBIAL OR DORSALIS PEDIS ARTERY WHICH IS SMALLER TERMINAL BRANCH OF POPLITEAL ARTERY AND POSTERIOR TIBIAL ARTERY WHICH IS LARGER TERMINAL BRANCH OF POPLITEAL ARTERY AND PEROFORATING PERONEAL ARTERY BRANCH OF POSTERIOR TIBIAL ARTEY
THESE ARTEIES ANASTOMOSE TO FORM SLING AROUND THE TALUS WHIS IS SOURCE OF INTERAOSSEOUS BLOOD SUPPLY OF TALLUS
THESE ARTERIES SUPPLY THE HEAD AND NECK OF TALUS
POSTERIOR TUBERCLE IS DIRECTLY SUPPLIED BY POSTERIOR TUBERCLE ARTERY
ARTERY OF THE TARSAL CANAL WHICH BRANCHES AROUND 1 CM PROXIAMAL TO MEDIAL AND LATERAL PLANTAR ARTERIES IS THE MAJOR SUPPLIER OF HEAD BODY OF TALUS
DELTOID ARTERY WHICH IS THE BRANCH OF ARTERY OF TARSAL CANAL IT DIRECTLY SUPPLIES THE BLOOD TO MEDIAL HALF OF TALAR BODY
SINUS TARSI ARTERY -- THIS ARTERY IS FORMED BY ANASTOMOSIS BETWEEN BRANCHES OF POTERIOR TIBIAL ARTERY TIBIAL ARTERY AND PERFORATING PERONEAL ARTERIES IN THE TARSAL CANALâĻ.THIS ARTERY SUPPLIES LATERAL ONE 8TH OF TARSAL BODY
THIS IS THE CORONAL SECTION OF TALUSâĻâĻ.NOW THEAD IS SUPPLIED FROM TWO SOURCES âĻ.MEDIAL SUPERIOR HALF IS SUPPLIED BY DORSALIS PEDIS ARTERY BRANCHESâĻâĻ.INFERIOR HALF IS SUPPLIED DIRECTLY FROM ARTERY OF TARSAL SINUS
BODY OF TALUS IS SUPPLIED BY ANASTOMOTIC ARTERY OF TARSAL CANALâĻ.
THE DELTOID BRANCHES WHICH SUPPLIES THE BODY ON ITS MEDIAL SURFACE ,,,IT SUPPLIES MEDIAL ONE THIRD OF BODY OF TALUS
This view is particularly useful intraoperatively to assess the reconstruction of a talar neck fracture with associated medial combination and to confirm that varus misalignment has been avoided
Anterolateral approach is usuallyy applied for treatment of talus fracture
Anteromedial approach is used along with anterolateral approach in order to expose talar neck
Anteromedial approach combined with medial malleolar osteotomy helps the better exposure of talar body.
AS THERE IS ENOUGH COMENSATORY MOVEMENT WHICH DEVELOPS IN PATIENTS MIDTARSAL JOINT âĻ.ENABLING HIM TO WALK WITH SLIGHT LIMP
Four years after tibiocalcaneal fusion by compression arthrodesis and autogenous iliac bone grafting. B, Sixteen
years after fusion, degenerative changes at midtarsal joints are present but patient is active with mild symptoms
RESULTS OF BLAIR FUSION A- TYPE 3 FRACTURE DISLOCATION
2ND XRAY IS IMMEDIATELY AFTER BLAIR FUSION
3RD XRAY IS AFTER FUSION AT 3 MONTHS