Your SlideShare is downloading. ×
0
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Talar fractures2
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Talar fractures2

3,631

Published on

0 Comments
5 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
3,631
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
321
Comments
0
Likes
5
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Fracture Talus Dr.Jayant Sharma. M.S, DNB, MNAMS CONSULTANT ORTHOPADICS AND SPORTS MEDICINE. www.drjayantsharma.com
  • 2. TALUS  IInd most common tarsal fracture  60% coverage by articular cartilage  no tendon / muscle attachments Tenuous blood supply  90% of motion of foot / ankle  Body, neck, head, lat. and post. processes
  • 3. Blood supply  Branches from post. and ant. tibial arteries,  Perforating peroneal arteries  Anastomoses in sinus tarsi and tarsal canal  inferior sling  Capsular and ligamentous supply
  • 4. Fractures  Head  Neck – 50%  Body ± Dislocation  Lat process  Post Tab
  • 5. Issues  How to diagnose  Reduction  Lat process and post tub  Osteochondral fracture  Vascular complication  Avascular necrosis
  • 6. HOW TO DIAGNOSE?  X-ray – AP / Mortice (enlocated / assoc #)  - Lateral (#, subtalar joint)  - Neck view (Canale & Kelly)  CT – comminution, alignment, subluxation
  • 7. Talar neck fracture  Mechanism – hyperdorsiflexion or direct axial load e.g MVA, fall from height, “aviators astragalus”  Posterior capsule ruptures , talar neck impacts on distal tibia , vertical fracture.  Foot subluxes forwards > talar body in equinus. Or  Pushed postero-medially out of mortice sits between medial malleolus and tendo Achilles.
  • 8. Talar neck fracture  Osteonecrosis depends on degree of displacement.  Undisplaced disrupt intra-osseous branches of sinus tarsi / tarsal canal arteries but major sling remains intact.  If Displaced above -- disrupt dorsalis pedis branches to neck.
  • 9. Talar neck fracture Classification  Hawkins’ classification (1970)  I – undisplaced vertical fracture  II – displaced fracture and dislocated S.T. jt.  III – above + dislocated ankle joint  IV – above + dislocated talo-navicular joint (Canale & Kelly, Khazim & Salo) Associated fractures - 64% (Hawkins, Lorentzen) Medial malleolus. 19-28% Calcaneum. 10% Metatarsal fractures. Distal tibio-fibular joint diastasis.
  • 10. Talar neck fracture Treatment  Best results with prompt, accurate anatomical reduction & maintenance  Type I – absolutely no displacement / ST incongruency  BK cast 6 -12 weeks (NWB 6 weeks)
  • 11. Talar neck fracture Treatment  Type II – prompt closed reduction, traction, plantarflexion,  correct varus /valgus  Xray – in equinus  BK cast in equinus (6weeks), cast for up to 3 months & 2 weekly  Internal fixation (antegrade fixation)
  • 12. Type II Talar neck Fracture Treatment  Avoid multiple attempts at closed reduction.  Open reduction -  Antero-medial or antero-lateral approach  Cannulated screws (4.5/ 6.5 mm) (titanium)retrograde or antegrade– beware penetration talo-navicular joint NWB cast 6- 12 weeks
  • 13. Talar neck fracture  Treatment  Type III – 25% open  Closed – prompt reduction, closed reduction often impossible  ?Arthroscopic assisted reduction Open reduction – postero-medial or anteromedial approach  Leave deltoid ligament fibres intact  Osteotomise / fractured medial malleolus
  • 14.  Internal fixation –  cannulated compression screws (avoid comminuted medial neck)  Delayed primary closure at 5-7 days  BK cast NWB 3 months Treatment
  • 15. Treatment  Type IV – manage as for III, and reduce talo-navicular joint(usually heals in cast)  Prognosis related to displacement of body Talar Neck Fracture
  • 16. Fractures neck with subtalar dislocation and post dislocation of Talus Emergency Immediate Reduction 1942 – Boyd & Knight – Red and ST Arthrodesis 1957 - Bohler – Open reduction If close Red fails- 1959 - Allgower – open red and lag screw 1962 - Watson Jones –open reduction If close Red fails 1963 - Mc Keever Red and Triple Arthrodesis
  • 17. Posterior displacement of body needs open reduction
  • 18. Points to remember ORIF may not be easy. Be prepared to do medial Malleolus Osteotomy – use of Calcaneal pin Save Talus – Be prepared to face AVN
  • 19. Talar neck fracture – Complications  Skin Necrosis and Infection  Prompt reduction, debride the open wounds and leave open.  Persisting infection > radical debridement of body.  Best results from excision of sequestered talus and tibio-calcaneal fusion.
  • 20. Talar neck fracture Malunion  Varus – lateral weight bearing Subtalar joint stress secondary arthritis (osteotomy and bone graft)  – Dorsal displacement of head -- reduced dorsiflexion, pain (excise dorsal talar beak) Delayed Union / Non-union  Delayed union common, but Non-union rare (0-4%)  Poor blood supply, limited periosteum on neck  No healing at 12 months > Cortico-cancellous bone graft
  • 21. Blair Fusion-- Advantages Position of foot unchanged Backward displacement not required Foot & Ankle relationship not disturbed Limb not shortened Preserves some Sub- Talar Motion
  • 22. Talar neck fracture Complications- Osteonecrosis  Degree varies with injury, but still need early, accurate reduction to reduce its secondary effects.  Type I : 0-13%  Type II : 20-50 %  Type III : 83-100%
  • 23.  X-ray – increased radio- density talar body  Later – collapse of subchondral bone, reduced joint space, fragmentation of body  MRI clearly defines presence and extent of involvement. Talar neck fracture - Osteonecrosis
  • 24. Talar neck fracture - Osteonecrosis  “Hawkins’ sign” – high sensivity, moderate specificity.  At 6-8 weeks, disuse atrophy because NWB.  AP X-ray- subchondral atrophy in dome, implying vascularity
  • 25. Talar neck fracture - Osteonecrosis  Primary goal is union, which still occurs, therefore continue NWB, even if no Hawkins sign.  Once united, still need up to 3 years before revascularisation /PTB brace/NWB If dome collapse and pain, identify joint/s involved and arthrodese. Usually tibiotalocalcaneal fusion.
  • 26. Talar body fracture  20% talar fractures  Classification - Sneppen (1977)  I - Osteochondral dome fracture  II – Coronal, sagittal, horizontal Shear fractures  III – Posterior process fractures  IV – Lateral process fractures  V – Crush fractures
  • 27.  1% talar fractures  Mechanism:  – dorsiflexion / inversion anterolateral lesion  – plantarflexion / inversion posteromedial lesion  Often not visible on Xray > persistent pain weeks after “sprain” +/- locking  Bone Scan - sensitive, but not specific  MRI – identification and classification Osteochondral Dome Fracture
  • 28.  - Classification  Anderson (1989)  I – subchondral trabecular compression  II – incomplete separation of fragment  IIa – subchondral cyst  III – fragment not attached, but remains in  normal position  IV – displaced fragment loose within joint  Pritsch arthroscopic grading of cartilage condition (firm, soft, frayed) Osteochondral Dome Fracture
  • 29. Osteochondral Dome Fracture Treatment  Incidental finding at ORIF > remove or fix  Incidental finding on Xray > observe  Symptomatic – Stage I / II - BK cast 6 - 12 weeks NWB – If still symptomatic > soft > leave NWB or drill cartilage frayed > debride & curette – If >1 cm and subchondral bone fix with absorbable pin
  • 30. Osteochondral Dome Fracture  -Treatment  Stage III – prolonged NWB versus early surgery  - Arthroscopy > debride fragment & curette underlying bed  Stage IV – remove loose body, if bed covered by fibrocartilage > leave, if frayed debride to bleeding subchondral bone / mosaicplasty  Results - 50% have pain on activity  (Pettine & Morrey, Angermann & Jensen)
  • 31. Shear Fractures of Body  Fracture line extends into dome, or into subtalar joint.  MVA, fall from height. Generally poor long-term results. Higher risk of osteonecrosis.  AP / lateral / mortice / CT  Undisplaced -- BK cast until radiol signs of healing  Thordarson (2001) > 1mm+ displacement -- ORIF via medial malleolar osteotomy  Complications > osteonecrosis – NWB up to 2 years, arthritis 75%
  • 32. Lateral Process Fracture Snowboarder’s Fracture 25% talar fractures  May extend into subtalar joint (bigger fragments)  Mechanism – dorsiflexion and inversion.  AP / mortice / CT  Undisplaced – BK cast NWB 6 weeks  Displaced >2mm / 1cm fragment > ORIF  Prognosis – often present with nonunion or arthritis months after injury. Best results with undisplaced fracture or accurat reduction. May need late excision of non-united fragments or subtalar fusion
  • 33. Posterior Process Fracture. Lateral tubercle fracture  – Mechanism : inversion or compression (extreme equinus)  – DDx: os trigonum  – Xray : lateral, Bone Scan  – Treatment : undisplaced – BK cast 4-6 weeks  – Persistent pain and stiffness – excise non-united  fragment
  • 34. Posterior Process Fracture Medial tubercle fracture  – Rare, pronation in dorsiflexion (athletes)  – Present late with medial pain and swelling  – Xray : lateral, avulsed medial fragment on AP  – Undisplaced : BK cast 6 weeks  – Displaced : ORIF especially if ST joint involved.  – Non-union : persistent pain > excise fragments
  • 35. Crush fracture  Uncommon, high complication rate.  Usually significant displacement, and subluxed subtalar / ankle joints  C. T  Treatment : anatomical reduction via anteromedial arthrotomy +/- osteotomy medial malleolus, pins / screws for large articular fragments. Bone graft / substitute.  If stable fixation, early ROM post-op  Complications : osteonecrosis, arthritis, malunion
  • 36. Fractured Head of Talus  Uncommon.  Usually involves talo- navicular joint.  Mechanism : compression of head, plantarflexed foot.  Xray : AP / lateral / oblique – check navicular and calcaneo-cuboid joint.
  • 37. Fractured Head of Talus - Treatment  Undisplaced : BK cast NWB 6 - 12 weeks, then medial arch support 3-6 months  Displaced : anatomical reduction via anteromedial approach. Excise comminuted fragments.  Complications : persisting subluxation and arthritis. Talo-navicular pain may improve with firm longitudinal arch support.  If fails, then arthrodesis talonavicular joint or entire midfoot (test with local anaes. injections)
  • 38. Association with Fracture calcanceum Talus may be subluxated or fractured along with fracture calcanceum - a very rare injury.  Total Talectomy  Tibio Calcaneal Fusion
  • 39. Points to Remember  Earlier the reduction the better are the chances of success  Subtalar subluxation and dislocation should not be missed  Deforming force is the key to reduction  Do not hesitate to put calcaneal pin  Immobilisation for longer period  Appreciate the jeopardised blood supply the foot Treat As Emergency
  • 40.  Recognise the Collapse of talus  BLAIR fusion is the Best.  Tibio calcaneal fusion to be undertaken as a last resort  Rare fractures to be kept in mind

×