Associated soft tissue injury of fracture of the body of talus

Low-Energy Hawkins Type III Talar Neck Fracture-Dislocation With Neurovascular and Tendon Entrapment in a Pediatric Patient

Several serious complications can occur after talar neck fractures. However, these fractures are extremely rare in children. We present a pediatric low-energy Hawkins type III fracture-dislocation that had excessive displacement accompanied by neurovascular and tendon entrapment. A 9-year-old male patient referred to our hospital 5 hours after jumping off a swing in a children's playground. An excessively displaced talar neck fracture-dislocation was observed at the initial evaluation. The patient underwent urgent surgery. The tibialis posterior flexor digitorum longus tendons, posterior tibial artery, and tibial nerve were entrapped at the fracture site. The talar neck fracture was reduced using open reduction. The neurovascular structures and tendons were removed from the fracture site. The fracture was fixed using two 4.5-mm cannulated screws. The patient was able to bear full weight at 10 weeks postoperatively. At 6 months, the patient was able to walk unassisted with full ankle range of motion. However, at 2 years, his American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score had decreased to 72 points, and we observed avascular necrosis in the talar head. In conclusion, talar fractures are rare but can lead to serious complications. In the pediatric population, even low-energy trauma, such as had occurred in our patient, can result in severe displaced fracture-dislocations. After severe displaced fracture-dislocations, important soft tissue structures can become entrapped between fracture fragments, and surgeons should be aware of this situation when considering using closed reduction.

Plate Fixation of Talus Fractures: Where, When, and How?

Talus fractures are rare orthopedic injuries. Surgical fixation is challenging for treating surgeons. The clear majority of fractures require operative treatment. The indication and use of plates in fixation of talus fractures are reviewed. Specific applications including fractures of the lateral process, posterior fractures, extreme comminution, bone grafting, and spring plating to hold key segments are reviewed in this article.

Fractures of the Talus: State of the Art

Talus fractures occur rarely but are often associated with complications and functional limitations. Urgent reduction of associated dislocations is recommended with open reduction and internal fixation of displaced fractures when adjacent soft tissue injury permits. Delayed definitive fixation may reduce the risks of wound complications and infections. Restoration of articular and axial alignment is necessary to optimize ankle and hindfoot function. Despite this, posttraumatic arthrosis occurs frequently after talar neck and body fractures, especially with comminution of the talar body. Osteonecrosis is reported in up to half of talar neck fractures, although many of these injuries will revascularize without collapse of the talar dome. Initial fracture displacement and presence of open fractures increase the risk of osteonecrosis. Talar process fractures may be subtle and easily missed on plain radiographs. Advanced imaging will provide detail to facilitate treatment planning.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis?

BACKGROUND

Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes.

METHODS

The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%).

RESULTS

One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01).

CONCLUSIONS

Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis.

Surgical treatment of talar body fractures

BACKGROUND

Fractures of the body of the talus are uncommon and poorly described. The purposes of the present study were to characterize these fractures, to describe one treatment approach, and to evaluate the clinical, radiographic, and functional outcomes of operative treatment.

METHODS

Fifty-six patients with fifty-seven talar body fractures who had been treated operatively during a sixty-seven-month period at a level-1 trauma center were identified with use of a database. Twenty-three patients had a concomitant talar neck fracture. Eleven of the fifty-seven fractures were open. All patients underwent open reduction and internal fixation. Complications, secondary procedures, and the ability to return to work were evaluated at a minimum of one year. The radiographic presence of osteonecrosis and posttraumatic arthritis was ascertained. Foot Function Index and Musculoskeletal Function Assessment questionnaires were completed.

RESULTS

Thirty-eight patients were evaluated after an average duration of follow-up of thirty-three months. Early complications occurred in eight patients. Ten of the twenty-six patients who had a complete set of radiographs had development of osteonecrosis of the talar body. Five of these ten patients experienced collapse of the talar dome at a mean of 10.2 months after surgery. All patients with a history of both an open fracture and osteonecrosis experienced collapse. Seventeen of twenty-six patients had posttraumatic arthritis of the tibiotalar joint, and nine of twenty-six had posttraumatic arthritis of the subtalar joint. Fractures of both the talar body and neck led to development of advanced arthritis more frequently than did fractures of the talar body only (p = 0.04). All patients with open fractures had end-stage posttraumatic arthritis (p = 0.053). Twenty-three (88%) of twenty-six patients had radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Worse outcomes were noted in association with comminuted and open fractures. Osteonecrosis and posttraumatic arthritis adversely affected outcome scores.

CONCLUSIONS

Open reduction and internal fixation of talar body fractures may restore congruity of the adjacent joints. However, early complications are not infrequent, and most patients have development of radiographic evidence of osteonecrosis and/or posttraumatic arthritis. Associated talar neck fractures and open fractures more commonly result in osteonecrosis or advanced arthritis. Worse functional outcomes are seen in association with advanced posttraumatic arthritis and osteonecrosis that progresses to collapse. It is important to counsel patients regarding these devastating injuries and their poor prognosis and potential complications.

Combined talar body and tibial plafond fracture: a case report

We report a case of a crush fracture of the body of the talus associated with an anterior tibial plafond fracture. This injury is a rare variant of talar body fracture which merits special attention. The bony injury in this type of fracture is associated with multiple loose fragments involving both weightbearing surfaces of the ankle joint. After appropriate imaging to allow preoperative planning, we utilized a two-incision approach which was necessary to achieve adequate exposure and fixation. We used basic fracture management principles to deal with a previously undocumented fracture pattern.