Fractures of the talus

Posttraumatic Cavovarus Deformity Due to a Varus Malunited Talar Neck Fracture, Treated With Corrective Talar Osteotomy: A Case Report

Although talar fractures are frequent bone injuries, fracture displacements of the talar neck are rare, and they can lead to under-treatment and poor prognosis. Furthermore, maltreatment of the talar fractures leads to complications such as malunion (which is the most common), nonunion, osteonecrosis and hindfoot arthritis, which can cause significant disability. The most common position of the talar neck malunion is the varus malunion. Alternative treatments include open reduction with or without bone grafting, open reduction combined with ankle fusion, talar neck osteotomy and talar neck osteotomy combined with subtalar fusion. However, the outcomes of foot function after corrective arthrodesis are poor. In this paper, we present a patient who underwent an open wedge corrective osteotomy of the talus for a cavovarus deformity developed after a malunion of a comminuted talar neck fracture. The patient walked normally three months postoperatively.

[Fractures of the talar neck and body : An overview]

Fractures to the talar neck and talar body (central talar fractures) are rare injuries but often result in devastating outcomes. It is therefore important to diagnose these injuries early and provide the best possible treatment. The analysis, classification, and surgical planning of central talar fractures should be based on computed tomography (CT) imaging. In the case of dislocated fractures, surgeons must strive for an anatomic reduction and fixation. The approach routes are based on the fracture morphology and must enable adequate reduction of the fracture. This can often only be achieved by two or more approach routes. The outcome correlates with fracture complexity and the quality of the reduction. Complications such as avascular necrosis and posttraumatic osteoarthritis are common and have a negative effect on the results of the treatment.

A comparative study of three different approaches in treatment of talar neck fractures

Purpose

The primary objective of this study was to observe and compare the radiographic and clinical outcomes among three different approaches which are anteromedial, anterolateral and combined approach in patients of talar neck fractures. The secondary objective was to observe various complications.

Material and method

A total of 30 patients underwent open reduction and internal fixation (ORIF) from September 2018 to march 2020 were selected retrospectively. 10 patients were there in each group. Talar neck fractures were classified according to Hawkins classification. All patients underwent ORIF with 4 mm Herbert screws. The follow-up examination included radiological evaluation, clinical and functional outcomes according to American Orthopaedic Foot and Ankle Society hind-foot score (AOFAS).

Results

30 patients were followed up for an average of 20.85 months (range 16-24). The mean time to bony union was 17.25 weeks, 17.35 weeks and 15.92 weeks in groups operated with anteromedial approach, anterolateral approach and combined approach respectively. The mean AOFAS hind-foot score was 76.34, 77.16 and 78.34 at 18th month follow-up in all three groups respectively. In each group, 1 patient had deep wound infection and 2 patients had superficial wound infection. Subtalar arthritis was the most common complication.

Conclusion

There is no significant difference between the three groups in terms of AOFAS hind-foot score, further combined approach provides better visualization of talus fractures and early bony union but it takes longer duration of surgery with increased post-operative complications in comparison with other two groups.

Rare shear-type fracture of the talar head in a thirteen-year-old child — Is this a transitional fracture: A case report and review of the literature

BACKGROUND

Talar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close.

CASE SUMMARY

A thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications.

CONCLUSION

Injuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.

Fractures of the Talus: Current Concepts

Talus fractures continue to represent a challenging and commonly encountered group of injuries. Its near-complete articular cartilage surface, and its role in force transmission between the leg and foot, makes successful treatment of such injuries a mandatory prerequisite to regained function. Familiarity with the complex bony, vascular, and neurologic anatomy is crucial for understanding diagnostic findings, treatment indications, and surgical techniques to maximize the likelihood of anatomic bony union. This review details the structure and function of the talus, a proper diagnostic workup, the treatment algorithm, and post-treatment course in the management of talus fractures.

Measurement of talar morphology in northeast Chinese population based on three-dimensional computed tomography

Morphological data of talus are important for the design of talar prostheses. The talar morphology of Chinese population has been rarely reported. This study adopted a three-dimensional (3D) measurement approach to provide accurate data for the anatomical morphology of talus in Northeast Chinese population and compared it with that of foreigners.One hundred forty-six healthy subjects form Northeast China underwent computed tomography (CT) arthrography. 3D digital talar model was reconstructed and thirteen morphological parameters were measured through Mimics and Magics software. Length and breadth indexes of total talus, trochlea, medial and lateral malleolus articular surface were mainly selected. Statistical analysis was conducted by independent-samples and paired-samples t test through SPSS software.All the indexes were normally distributed. No significant difference between left and right talus was identified in either males or females (P > .05). Most of the indexes showed significant sexual differences except the radian of lateral malleolus articular surface and the posterior breadth of trochlea (P < .05). The talar anatomy of Chinese subjects is different from the published data in other populations.The promising approach adopted in this study addresses some inconvenience with previous conventional methods on cadaver specimens. The geometric parameters of talus in Chinese population differ from those in other populations. The talar measurements and morphology analysis in this study suggest that population characteristics should be taken into account. This study will provide references for the design of talar prostheses in Chinese population.

Management of Talar Body Fractures

Fractures of talar body are uncommon injuries often associated with fractures of other long bones and in polytraumatized patients. The integrity of the talus is essential for the normal function of the ankle, subtalar, and midtarsal joints. The relative infrequency of this injury limits the number of studies available to guide treatment. They occur as a result of high-velocity trauma and are therefore associated with considerable soft tissue damage. Axial compression with supination or pronation is the common mechanism of injury. Great care is necessary for diagnosing and treating these injuries. Clinically, talar body fractures present with soft tissue swelling, hematoma, deformity, and restriction of motion. Associated neurovascular injury of the foot should be carefully examined. The initial evaluation should be done with foot, and ankle radiographs and computed tomography is often done to analyze the extent of the fracture, displacement, intraarticular extension, comminution, and associated fractures. Differentiating talar neck from body fractures is important. Optimal treatment relies on an accurate understanding of the injury and the goals of treatment are the restoration of articular surface and axial alignment. Indications for nonoperative management are seldom indicated and are few as in nonambulatory patients, or in with multiple comorbidities who are not able to tolerate surgery. Splinting, followed by short leg casting for 6 weeks until fracture union should be undertaken. Surgery is indicated in most of the cases, and different approaches have been described. Sometimes, a dual approach with a malleolar osteotomy is necessary for articular restoration. Clinical outcomes depend on the severity of the initial injury and the quality of reduction and internal fixation. The various complications are avascular necrosis, malunion, infections, late osteoarthritis, and ankylosis of subtalar joint.

Surgical management of Hawkins type III talar neck fracture through the approach of medial malleolar osteotomy and mini-plate for fixation

Background

Fractures of the talar neck are relatively uncommon yet current interventions suffer from a high incidence of complications and poor functional outcomes. In the present study, we report a surgical treatment of Hawkins type III talar neck fracture through the approach of medial malleolar osteotomy and mini-plate for fixation and discuss the therapeutic effects after long-term follow-up.

Methods

From January 2010 to January 2015, 21 patients with 22 fractures were treated using this approach within days of sustaining the injury. Clinical and radiographic data were collected during regular post-operative follow-ups. Health-related quality of life factors were evaluated using visual analogue scale (VAS). Functional outcomes were determined according the Hawkins score and the Ankle-Hind foot Scale of the American Orthopedic Foot and Ankle Society (AOFAS). Present of complications such as arthritis, avascular necrosis (AVN), and malunion were evaluated using radiographs and magnetic resonance imaging (MRI). Anatomical parameters of injured and corresponding uninjured talus were measured and compared using digital three-dimensional (3D) computer model.

Results

The mean duration of surgery was 65.6 ± 9.7 min. The average blood loss volume of the patients was 29.1 ± 5.7 ml. All the patients except 1 were followed up 18 to 41 months (average 29.6 months). The average VAS score for these patients was 3.2 ± 1.1, and the mean Hawkins score was 11.4 ± 3.4 at the final follow-up visit. The average AOFAS score was 72.8 ± 17.3. Nine patients outcomes were rated as “excellent”, 4 as “good”, 4 as “fair,” and 4 as “poor”. No malunion, screw loosening, plate breakage, or other internal fixation failures were found at final follow-up. Long-term complications included: 1 case of malunion, 5 cases of complete AVN, 8 cases of partial AVN, 13 cases of talocrural arthritis, 14 cases of subtalar arthritis, and 3 cases of talonavicular arthritis. Secondary surgery was performed in 4 cases. The relevant average anatomical data of injured and uninjured talus show no significant difference.

Conclusions

This surgical treatment we used here resulted in decreased soft tissue trauma, adequate exposure of talar neck, satisfactory performance of daily life activities, and quality of life following surgery and restoration of anatomy of injured talus. However, long-term complications such as arthritis and AVN are still commonly seen.

What’s in a name? Lower extremity fracture eponyms (Part 2)

Eponymous extremity fractures are commonly encountered in the emergency setting. Correct eponym usage allows rapid, succinct communication of complex injuries. We review both common and less frequently encountered extremity fracture eponyms, focusing on imaging features to identify and differentiate these injuries. We focus on plain radiographic findings, with supporting computed tomography (CT) images. For each injury, important radiologic descriptors are discussed which may need to be communicated to clinicians. Aspects of management and follow-up imaging recommendations are included. This is a two-part review: Part 1 focuses on fracture eponyms of the upper extremity, while Part 2 encompasses fracture eponyms of the lower extremity.