Talus fracture and dislocations

Calcaneal fractures
Review of Orthopaedic Trauma
R2 / v.s "
2009/09/15
natomy-parts
Head-articulate with navicular
Neck-nonarticular
Body-articulate with tibia and
calcaneus
No muscular or tendinous
attachment
lood supply
traosseous supply
Posterior tibial a. tarsal canal a.
Anterior tibial a. sinus tarsi a
Peroneal a. sinus tarsi a.
Intraosseous supply
Talar head
Talar body
-anastomosis between tarsal canal a. and tarsal
sinus a.
Talar head fracture
5~10 oI all talus Iracture
Mechanism: aial loading with the ankle in plantar Ileion,
against the distal tibia with ankle in dorsiIleion
Associated injuries: Metatarsal Iracture midIoot instability
Treatment
Nondisplaced F: Most, short leg cast and no weightbearing Ior 8~12
weeks
isplaced F: 50ecison ; ~50ORIF / talonavicular art
hrodesis
Complications: arthritis, osteonecrosis(10), osteochondral
Iracture
Talar neck fracture
Aviators astragalus
High energy injury, hyperdorsiIleion
15~20 open Iracture
Associated with malleloar Iracture(25 oI cases),
medial malleolus is more common
High risk oI soIt tissue injury and compartment
syndrome
Radiography: Ioot and ankle series; Canale view
(ma. plantar Ileion with 15
o
oI pronation with the beam directed 75
o
cephalad)
Classification-Hawkins classification
nondisplaced
isplaced
Subtalar subluation
Ankle dislocation
(Talar body dislocation)
Talonavicular
dislocation
Treatment
Hawkins type I
4~6 weeks oI no weightbearing in a short leg cast walking
cast Ior 1~2 months
Joint stiIIness or late Iracture displacement: Percutaneous
Iiation
Treatment
Hawkins type II
Orthopaedic emergency: traction and plantar Ileion by
manipulation anatomic reduction(50) treated as type I
(5mm displacement with angulation oI 5
o
or less)
Open reduction: screw placed across the neck Iracture
Anteromedial: most common, greatest risk oI injury the artery and
tarsal canal.
Anterolateral: least vascular risk
Posteromedial: high incidence oI painIul sequelae
Avoid malalignment: varus deIormity oI talar neck
pproach
Treatment
Hawkins type III
Similar to type II
SoIt tissue problems are more
Irequent; poorer
ORIF and Skeletal traction
through the calcaenus
Open Iracture (~ type III)
:talar body ecision Iollowed
By primary tibiocalcaneal or Blair-
type arthrodesis
Hawkins type IV
Rare injury
As type II

highway T.
lair-type arthrodesis
Complication
Skin necrosis and inIection: dorsal skin envelope, delay
reduction, osteomyelitis (type III) ecision oI inIected bone
elayed union or nonunion
elayed union: 10, tenuous blood supply weightbearing s
houlder be limited until bridging callus
Nonunion: rare, reduced with immediate internal Iiaion,
Iailed to unite Ior 1 year: ORIF and bone graIting
Malunion
closed manipulation without internal Iiation Varus m
alunion , subtalar arthritis (type II, 50)
proper X-ray studies: identiIying malalignment (aIter manipulation
or ORIF )
Complication
Posttraumatic arthritis
Subtalar joint(50), tibiotalar joint(33), both(25)
Time oI injury, osteonecrosis with late segmental collapse,
malunion or prolonged immobilization
Local injection, conservative treatment, arthrodesis
Osteonecrosis
Hawkins sign: Its presence signiIies that osteonecrosis will not occur ;
its absence does not indicate that osteonecrosis will deIinitely occur
Weightbearing is delayed indeIinitely
OIIloading in a patellar tendon-bearing brace up to 36 ms
A late segmental collapse: tibiocalcaneal Iusion, Blair Iusion,
ModiIed Blair Iusion (maintaining the head and neck)
Hawkins sign
Revascularization and atrophic
change in the body oI the talus
at 6~8 weeks
subchondral luceny in the
dome oI the talus on A.P view
Good prognostic sign
MRI or nuclear medicine
Talar body fracture
Superior articular surIace or the trochlear region
Much poorer prognosis than talar neck Iractures
Surgery in all but those with minimal displacement
Medial surgical approach with a malleolar osteotomy
Lateral approach : less risk oI vascular compromise
Incidence oI osteonecrosis : 50, not related to
Iracture type
Talar process fracture
--lateral process fractures
amination
Mimic those oI a lateral ankle sprain
Inversion injury
X-ray: demonstrate subtle or no obvious Iinding
Treatment (on the size oI Iragment, displacement and comminution)
Nondisplaced Iracture: short leg cast (nonweightbearing) Ior 4 weeks and
more 2 weeks (weightbearing)
isplaced Iracture without comminution: ORIF with small Iragment
Iiation or a Herbert screw
Comminuted Iracture: addressed with ecision and early subtalar motion
with no weightbearing
Complication
Healed displaced Iragment can rise to subtalar arthritis ecision su
btalar arthrodesis
Talar process fracture
--posterior process fracture (Shepherds fracture)
iagnosis
Pain: Vague ,nonspeciIic and local to the posterior ankle, aggravated
by Iorced equinus oI the ankle
Hallu motion may reproduce the painIul syndrome
(Ileor hallucis longus through the groove)
Mechanism oI injury
HyperdorsiIleion and/or inversion tightening oI the post.
taloIibular ligament avulsion oI lateral tubercle
Forced plantar Ileion: compression oI lateral tubercle
Stress Iractures
Lead to Iailure oI the lateral ossicle to unite
Talar process fracture
--posterior process fracture (Shepherds fracture)
Radiography
Lateral ankle view
Acute Iracture oI the trigonal processroughed edge~ v.s
discontinuity oI the os trigonum smooth edge~
Treatment
Nonweightbearing cast Ior 4 weeks walking cast Ior 2 w
eeks
Symptoms lasting over 6 months indicate nonunion
cision through a posterolateral approach (between Ileor
hallucis longus and peroneals)
Osteochondral defects of the talus
6.5 oI all ankle sprain, 55 medial, 45 lateral
iagnosis: An ankle sprain, sensation oI a Ioreign body
Radiography: A lateral lesion is usually Ilatter and more waIer
-like as opposed to a medial lesion, which is deep and cup
shaped
MRI: overlying cartilage separation and dissociation oI the
Iragment
Classification
Berndt and Harty classiIication
1. Small area oI compressed subchondral
bone
2. Partially detached
3. Completely detached, Iragment in the
crater
4. Completely detached, loose within the
joint
Ferkel MR classiIication
Treatment (based on erndt and Harty classification)
Stage I and II and medial stage III
Cast immobilization Ior 6~12 weeks
II symptoms persist Ior 4~6 ms surgery
Stage IV and lateral stage III
Small lesions: surgical ecision and drilling base
Larger lesions(~1/3 articular surIace): ORIF,
medial (malleolar osteotomy) or lateral arthrotomies;
nonweightbearing with aggressive ROM eercise Ior
8~12 weeks
Osteochondral defects of talus
--chronic lesions
Persistent symptoms aIter appropriate conservative T
Activity related: pain, locking, swelling
Ankle stiIIness and arthritis
MRI: assess stability (the presence or absence oI Iibrous
attachment or Iluid in the base oI the Iragment)
Treatment: as stage IV and lateral stage III
islocation involving the talus
Subtalar dislocation
Medial dislocation(85)
--immediate closed reduction under general anesthesia
--open reduction and calcaneal traction pin
Lateral dislocation (15)
Complications
--skin necrosis, stiIIness, subtalar osteochondral deIects,
recurrent subtalar instability and arthritis
--rarely, osteonecrosis oI the talar body occurs
islocation involving the talus
Total talar dislocation
A rare injury, most open
Reduction aIter irrigation and debridement
Contamination with complete talar etrusion: primary tibio-
calcaneal arthrodesis
Calcaneal fracture
natomy
Largest, most irregularly shaped bone in Ioot
Large calcellous bone and multiple processes
Achilles tendon posteriorly and plantar Iascia inIeriorly : tuberosity
Posterior Iacet: talar lateral process and body
Middle Iacet: Sustentacular Iragment (Ileor hallucis longus pass)
Anterior process: cuboid
Calcaneal fracture
60 oI Ioot Iractures involve the calcaneal Iracture,
2 oI all Iracture
ClassiIication
sse-Lopresti
--traarticular(25) v.s intraarticular(75) Iracture
Sanders
--CT classiIication oI intraticular calcaneal Iracture
Associated injuries
A Iall Irom a height or highenergy mechanisms
10 lumbar spine Iracture(L1); 10 oI calcaneal Iracture
are bilateral
1.Sustentacular
2.Medial
3.Central
4.lateral
1
1
ntraarticular fracture
(joint depression and tongue type)
Mechanism injury
Aial loading
Lateral process oI talus primary Iracture line secondary Ir
acture line
iagnosis
Tenderness, tremendous swelling at the heel, ecchymosis,
tarsal tunnel distribution
Radiography
Shortening and widening oI the calcaneus with varus
orientation oI the tuberosity
Loss oI Bohlers and Gissanes angles
Radiography
Broden`s view showing the depressed
posterior Iacet
varus position oI the tuberosity

ntraarticular fracture
Joint-depression type, in which the
primary Iracture line eited the bone
close to the subtalar joint
tongue-type, in which the primary
Iracture line eited the bone posteriorly
ntraarticular fracture
CT scan
Assess involvement oI the posterior Iacet and the etent oI comminution
and calcaneocuboid joint
Typical shorting ,widening, varus and medial displacement oI the heel
two Iracture lines in the lateral and mid (Type IIAB) Iacet
comminuted intraarticular Iracture ,sander type IV
ntraarticular fracture
SoIt tissue management
Swelling: Operative intervention is best perIormed within 12
hours or 1~2 weeks aIter
Tendons incarcerated: Ileor hallucis longus, peroneus longus
Compartment syndrome
-- compartment pressure monitoring and Iascitomy
--wrinkle test: swelling has subsided
ntraarticular fracture
--Treatment
Nondisplaced articular Iractures
Bulky (Bobert-jones) dressing: active subtalar ROM, prohibit
weightbearing walking 8~12 wks later
isplaced intraarticular Iracture with large Iragment
ORIF with soIt tissue allow
Lateral etensile approach: make Iull-thickness soIt tissue Ilaps
and avoid the sural nerve
Medial approach: visualization oI sustentaculum tali (articular
reduction), subcortical cancellous screws
Correct morphology and restore height & width
Skeletal traction via a steinmann pin in the tuberosity
Lateral buttress plating with Iiation
ntraarticular fracture
--Treatment
isplaced intraarticular Iracture with severe
comminution
Increasing intraarticualr comminution leads to less
satisIactory results
ORIF primary arthrodesis
Restoring the heel width and height
ntraarticular fracture
--complications
SoIt tissue breakdown: lateral etensile approach, the ape oI
incision as long as 4 weeks Irom injury
Local inIection: early debridement and antibiotics
Subtalar arthrosis: UCBL type orthotic devices arthrodesis
Anterior ankle impingement: non-reduction and talus settles,
bone block distraction arthrodesis
lateral impingement: Iibula on the peroneal tendon lateral w
all eostectomy
Cutaneous neuromas: sural nerve (lateral approach)resection a
nd burying oI the nerve into the peroneal m. belly
ntraarticular fracture
--results
The results are disappointing even in the best oI hands
ven with anatomic restoration oI the posterior Iacet,
subtalar stiIIness continues to be troublesome
The most predictable outcome is restoration oI heel
height and width
traarticular fracture
--avulsion fractures of a process of the calcaneus
Anterior process Iractures oI the calcaneus
Plantar Ileion and inversion
OIten conIused with lateral ankle sprains, but tenderness is
more distal over the sinus tarsi
Treatment
Small bony Iragment: short leg casting Ior 4~6 weeks with
weightbearing as tolerated
Large bony Iragment, a displaced Iragment, involving a
portion oI the calcaneocuboid articular surIace: ORIF
traarticular fracture
--avulsion fractures of a process of the calcaneus
Tuberosity Iractures oI calcaneus
Avulsion oI bony Iragment when the Achilles tendon is loaded
The articulation oI posterior Iacet becomes involved
Treatment
Nondisplaced or minimally displaced: immobilization in
equinus Ior 3 weeks
isplaced: ORIF to restore the integrity oI Achilles tendon
Failure to repair the injury may lead to plantar Ileion
weakness