Ortho-Preferred

Fractures of the Talar Neck


- Radiographic Evaluation:
     - associated injuries:
           - medial malleolus frx (AP view);
           - sustentacular tali frx;
           - metatarsal head frx;
     - its essential to gauge amount of dorsal and medial comminution of talar neck, as well as tendency
           for varus angulation;
     - Hawkins Classification
           - type I talar fractures
           - type II talar fractures
           - type III talar fractures


- Treatment:
      - see: operative treatment
      - closed reduciton attempt after x-rays;
      - emergent ORIF all open/unreducible fxs;
      - attempt reconstruction / avoid arthrodesis;
      - use rigid, interfragmentary compression screws (3.5, 4.0, 6.5 mm)
      - goal of frx treatment with talar neck fractures is to restore neck to its anatomic position and also to check for varus or supination
               malalignment of talar neck;
      - because supination forces in Class II and Class III injuries cause subluxation of the subtalar joint, it is important to ensure that
               subtalar joint has been reduced completely;
               - an increased incidence of fractures of medial malleolus has been reported with type II and III fractures;
      - malunion is avoided by open anatomic reduction & internal fixation.
               - w/ incomplete reduction, varus hindfoot & dorsal displacement are most common;
               - dorsal displacement leads to limited dorsiflexion & may be salvaged by dorsal beak resection.
               - symptomatic varus deformity is likely to require triple arthrodesis.


- Results:
    - infection - rare in closed injuries;
    - avascular necrosis
           Hawkins 1:   0- 13%
           Hawkins 2:  20- 50%
           Hawkins 3:  20-100%
           - problem - precision of dx: Hawkins Sign helpful if present at 6-8 weeks;
    - arthritis - 40-90%
           - related to articular damage, subchondral collapse (from AVN), immobilization, and malunion;
    - non union of talar frx:
           - frx healing is somewhat less of problem than might be expected w/ this injury;
           - delayed union ( > 6 mo after injury) is common, but nonunion is relatively rare;
           - delayed unionn - upto 15%; Non Union rare; both decreased with ORIF;
    - in the report by Elgafy H, et al (2001), 58 patients with 60 talar fractures were retrospectively reviewed;
           - 27 (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body;
           - 48 fractures had operative treatment and 12 had non-operative management;
           - average follow-up period was 30 months (range, 24-65);
           - 32 fractures (53.3%) developed subtalar arthritis (but only 2 patients had subsequent subtalar fusion);
           - 15 fractures (25%) developed ankle arthritis (none of these patients required ankle fusion);
           - fractures of the body of the talus were associated with the highest incidence of DJD of both the subtalar and ankle joints;
           - 10 fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse;
           - avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck;
           - assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then
                   the body fractures;
    - varus malunion:
           - can be difficult to recognize when treating talar neck fractures;
           - may be cause by medial screw compression w/ medial neck comminution;
           - varus position limits subtalar motion;
           - may cause subtalar arthrosis and pain;
    - ref: Outcomes of Talar Neck Fractures: A Systematic Review and Meta-analysis.


- Salvage:
    - Type IV:
          - subtalar, tibiotalar, and talonavicular joint subluxation or dislocation;
          - talar neck fracture w/ dislocation of the head fragment;
          - open type IV fractures are associated w/ high rate of infection (30%), despite aggressive debridement
                   and infection; 
          - salvage treatment:  
                   - consider placement of methylmethacrylate spacer shaped like a talus;
                   - there are documented cases of patients being pain free for several years with this method of treatment



References:

Fractures of the talus: experience of two level 1 trauma centers.  

Treatment of talar neck fractures: clinical results of 50 patients.

Surgical treatment of talus fractures: a retrospective study of 80 cases followed for 1-15 years.

Talar Neck Fractures: Results and Outcomes.

Open Reduction and Stable Fixation of Isolated, Displaced Talar Neck and Body Fractures.

Direction of the oblique medial malleolar osteotomy for exposure of the talus

Management of Talar Neck Fractures



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, May 13, 2016 5:00 am