1) Talus and calcaneus fractures can result from high-energy injuries like falls or motor vehicle accidents. 2) Hawkins classification is commonly used to describe talus neck fractures, with type I being undisplaced and having the lowest risk of avascular necrosis, while type III and IV involve dislocation and have the highest risk. 3) Treatment depends on fracture type but often involves open reduction and internal fixation to restore anatomy and allow early motion, in order to improve outcomes and reduce complications like malunion and avascular necrosis.

1. TALUS AND CALCANEUS
FRACTURES
By k/mariam Ab OTSR III
Date 27/09/2012

2. OUT LINE
• INTRODUCTION
• ANATOMY
• MECHANISMS OF INJURY
• CLINICAL PRESENTATION
• RADIOLOGICAL EVALUATION
• CLASSIFICATIONS
• TREATMENT
• COMPLICATIONS

3. INTRODUCTION
• ‘’Man's foot is all his own. It is unlike any other foot. It is the
most distinctly human part of his whole anatomical makeup. It
is a human specialization and, whether he be proud of it or
not, it is his hallmark and so long as Man has been Man and
so long as he remains Man, it is by his feet that he will be
known from all other members of the animal kingdom.’’
Frederick Wood Jones, 18th-century British anatomist
• “The man who breaks his heel bone is done.” 1916, Cotton
and Henderson

4. TALUS FRACTURE

5. Anatomy
• Surface 60% cartilage
• No muscular insertions

6. BLOOD SUPPLY
Arterial supply:
• Artery of tarsal canal
• Artery of tarsal sinus
• Dorsal neck vessels
• Deltoid branches
medial
lateral
Inferior view of talus, showing
vascular anastomosis

7. VASCULARITY
• Artery of tarsal canal supplies majority of
talar body
Side View
Top View
Deltoid Branches
Posterior
tubercle
vessels
Artery of
Tarsal
Sinus
Artery of
Tarsal Canal
Superior Neck
Vessels
Superior Neck
Vessels
Artery of
Tarsal
Sinus
Artery of
Tarsal Canal
Posterior
tubercle
vessels

8. INCIDENCE
• 2 % of all fractures
• 6-8% of foot fractures
• Importance due to high
complication rates
– avascular necrosis
– post-traumatic arthritis
– malunion

9. MECHANISM OF INJURY
• Hyperdorsiflexion of the foot on the leg
• Neck of talus impinges against anterior distal
tibia, causing neck fracture
• If force continues:
– Talar body dislocates posteromedial
– Often around deep deltoid ligament

10. Cont’d….
• Previously called “aviator’s astragalus”
• Usually due to motor vehicle accident or falls
from height
• Approximately 50 % have multiple traumatic
injuries

11. IMAGING
• Canale View:
– Ankle plantarflexion
– 15 degree pronation
– Tube 15 degree off
vertical
• Standard ankle and foot
radiographs

12. • CT SCAN:
– Can be a useful
assessment tool
– Confirms truly
undisplaced fractures
– Demonstrates subtalar
comminution,
osteochondral fractures

13. • MRI SCAN:
– Primary role in talus
injuries is to assess
complications, especially
avascular necrosis
– May be poor quality if
extensive hardware
present

14. TALAR NECK FRACTURES CLASSIFICATION
• Hawkins 1970
Predictive of AVN rate
Widely used

15. Hawkins I
• Undisplaced
• AVN 0 – 13 %
• “There is no room for
the term ’a minimally
displaced type I talar
neck fracture

16. HAWKINS II
• Displaced fracture
• Subtalar subluxation /
dislocation
• Closed reduction can
successful
• AVN 20 – 50 %

17. HAWKINS III
• Subtalar and ankle joint
dislocated
• Talar body extrudes
around deltoid ligament
• AVN 83 – 100 %
• These injuries are most
commonly irreducible
by closed means

18. HAWKINS IV
• Incorporates
talonavicular
subluxation
• Rare variant
• Complex talar neck
fractures which do not
fit classification can be
included

19. GOALS OF MANAGEMENT
• Immediate reduction of dislocated joints
• Anatomic fracture reduction
• Stable fixation
• Facilitate union
• Avoid complications

20. Treatment of talar neck fractures
• Emergent reduction of dislocated joints
• Stable internal fixation
• Choice of fixation and approach depends upon
personality of fracture

21. • Post operative rehabilitation:
• Sample protocol:
– Initial immobilization, 2-6 weeks depending upon
soft tissue injury and patient factors, to prevent
contractures and facilitate healing
– Non weight-bearing, Range of Motion therapy
until 3 months or fracture union

22. HAWKINS I FRACTURE
Options:
• Non-Weight-Bearing
Cast for 4-6 weeks
followed by removable
brace and motion
• Percutaneous screw
fixation and early
motion

23. HAWKINS II, III, AND IV FRACTURES
• The vast majority of displaced fractures of the talar
neck and body are treated operatively
• Results dependent upon development of
complications
– Osteonecrosis
– Malunion
– Arthritis

24. • Surgical timing:
– Emergent reduction of dislocated joints
– Allow life threatening injuries to take priority and
resuscitate adequately first

25. • Closed reduction:
– May be very useful, particularly if other life threatening
injuries preclude definitive surgery
– Difficult in Hawkins’ 3 and 4 injuries
• Technique:
– Adequate sedation
– Flex knee to relax gastrocs
– Traction on plantar flexed forefoot to realign head with
body
– Varus/valgus correction as necessary

27. • Percutaneous Fixation:
– When a closed reduction has been successful at
achieving an anatomic result ( hawkin II, III )
– Truly undisplaced talar neck fracture with
anatomic alignment ( hawkin I )

29. EXTERNAL FIXATION
• Limited roles:
– Multiply injured patient
with talar neck fracture in
whom definitive surgery
will be delayed
– Temporizing measure to
stabilize reduced joints
– Highly contaminated open
fractures to facilitate soft
tissue management
– Following talectomy as a
temporary means to
maintain length and
alignment while further
surgical intervention is
being determined.

30. SURGICAL APPROACHES
1. Incision techniques:
 Anteromedial or Anterolateral
 Problem: difficult to visualize talar neck and
subtalar joint without significant soft tissue
stripping
 Benefit: potentially less skin injury

31. 2. Incision technique:
 Anteromedial and direct lateral
 Problem: 2 skin incisions, close together
 Benefit: excellent fracture visualization at critical
sites of reduction and subtalar joint

32. • Anteromedial :
– Medial to TA and
Anterior Compartment
contents
– Make incision more
posterior for talar body
fractures to facilitate
medial malleolar
osteotomy
– Provides view of neck
alignment and medial
comminution

33. • Direct Lateral:
– Tip of Fibula directly
anterior
– Mobilize EDB as sleeve
– Protect sinus tarsi
contents , Visualizes
Anterolateral alignment
and subtalar joint
– Facilitates Placement of
“Shoulder Screw”

34. • Posterior approach
• Combined approach
– Reduction will be easy
– Judgment of anatomic reduction
– Preservation of blood supply

35. • Fixation Options:
– Stable Fixation to allow
early motion is the goal
– 1200 N stress across talar
neck during early motion
(Swanson JBJS 1992)
• Anterior
– Partial threaded screws
– Fully threaded screws
– Mini-fragment plates
• Posterior
– Lag screws
IP

36. • Posterior to Anterior
Fixation:
– stronger than anterior to
posterior fixation with 2
screws
– Able to withstand the
theoretical shear force
of active motion
– Screws perpendicular to
fracture site

37. • Anterior Screw
Fixation:
Non-comminuted
fractures:
– Easy to insert under
direct visualization and
no cartilage damage
– Displaced type 2: 3 A-P
screws including medial
“buttress” fully threaded
cortical screws and
lateral “shoulder” screws

38. cont’d….
• Comminuted
fractures:
– Buttress screw:
comminuted column;
compression screws
through non-
comminuted column
– Mini-fragment screws
for osteochondral
fragments
– Consider Titanium for
MRI

39. • Anterior Plate Fixation:
– Comminuted fractures:
Medial and / or lateral
mini-fragment plates

40. COMPLICATIONS
• AVN: incidence after talus fracture
• Canale (1972)
– I: 15 %
– II: 50 %
– III: 85 %
– IV: 100 %
• Behrens (1988)
– Overall 25 %
• Ebraheim/Stephen (2001)
– Overall 20 %

41. • Diagnosis
– Hawkins’ Sign: Xray
finding 6-8 weeks post
injury
Presence of subchondral
lucency implies
revascularization
– Plain radiographs:
sclerosis common,
decreases with
revascularization
– MRI: very sensitive to
decreased vascularity

42. • AVN Treatment:
– Precollapse:
Modified WB
PTB cast
Compliance difficult
Efficacy unknown
– Postcollapse:
Observation
Blair fusion if symptomatic

43. • Malunion: Incidence
– Common: up to 40 %
– Most often Varus
• Mechanical effects known
– > 3 degrees: decreased ROM
– > 2mm: altered subtalar contact forces
• Malunion:
– More pain
– Less satisfaction
– Less ankle motion
– Worse functional outcome

44. • Malunion Rx:
– Calcaneus osteotomy
– Tendo Achilles
Lengthening

45. • Post Traumatic
Arthritis:
–Incidence of post-
traumatic arthritis
• 30-90 %
– Most commonly involves
Subtalar joint
• Rx: Arthrodesis

46. • Nonunion:
– Uncommon, even with AVN
– Delayed Union very common
– Frequently results in late malalignment

47. TALAR BODY FRACTURES
• Treatment strategy
similar to talar neck
fractures
• Medial or Lateral
Malleolar Osteotomy
frequently required

49. Visualize body through the fibula fracture

50. • Primary Arthrodesis:
– primary arthrodesis may be the appropriate
treatment for nonreconstructible fractures of the
talar body
– Primary arthrodesis offers the potential advantage
of earlier return to function compared to
unsuccessful attempts at open reduction and
internal fixation

52. • Osteochondral injuries:
– Frequently encountered with talus neck and body
fractures
– Require small implants for fixation
– Excise if unstable and too small to fix

53. TALAR HEAD AND PROCESS FRACTURES
• Treat according to injury
• Operate when associated with joint subluxation,
incongruity, impingement or marked displacement
• Fragments often too small to fix and require excision
• Subtle on plain xray
• Usually require CT scan
• Required 2 incisions to debride subtalar joint from
lateral approach, and reduce / stabilize fracture from
medial

55. • Lateral process
fracture:
– Usually require CT scan
– Often excised due to size
of fragments
– Difficult to achieve union

56. SUBTALAR DISLOCATIONS
• Spectrum of injuries
– Relatively Innocent
– Very Disabling

57. • Classification:
– Usually based upon
direction of dislocation:
– Medial dislocation: 85 %,
low energy
– Lateral dislocation: 15 %,
high energy

59. • Prognostic factors
– Open vs Closed
– High or low energy mechanism
– Stable or unstable post reduction
– Reducible by closed means or requiring open
reduction
– Associated impaction injuries

60.  Management of subtalar dislocation
• Urgent Closed reduction:
– Adequate sedation
– Knee flexion
– Longitudinal foot traction
– Accentuate, then reverse deformity
• Succesful in up to 90 % of patients

61. • Open reduction:
– More likely after high
energy injury
– More likely with lateral
dislocation
– Cause:
soft tissue interposition
(Tib post, FHL, extensor
tendons, capsule)
bony impaction between
the talus and navicular

62. • Rehabilitation:
– Stable injuries:
4 weeks immobilization
Physio for mobilization
– Unstable injuries:
Usually don’t require internal fixation once reduction
achieved
If large or multiple bone fragments required removal,
stability may be less than ideal
Internal fixation with smooth wires across the subtalar
and talonavicular joints may be necessary to maintain
the reduction

63. • Outcome of Subtalar dislocations:
– Less benign than previously thought
– Subtalar arthritis:
Up to 89 % radiographically
Symptomatic in up to 63 %
– Ankle and midfoot arthritis less common

64. AUTHOR'S PREFERRED METHOD OF TREATMENT IN CALCANEUS(ROCKWOOD AND
GREEN 8TH EDITION)

65. • REVIEW:
– Urgent reduction of displaced fractures and dislocations
remains the standard of care to protect the soft tissue
envelope and neurovascular structures
– Delayed definitive fixation has proven to be safe
– CT is the imaging modality of choice to fully identify the
fracture pattern and associated injuries
– Anatomic reduction and restoration of the peritalar
articular surfaces are the pillars of talar neck fracture
treatment
– Dual incision approach with plate and screw fixation has
become the modern surgical strategy of choice to
accomplish these goals
– Although complications such as osteonecrosis (ON) and
posttraumatic arthritis (PTA) can still occur at high rates,
treatment should be dictated by patient symptoms
(https://doi.org/10.1007/s12178-018-9509-9, 4 July 2018)

66. CALCANEUS FRACTURES

67. ANATOMY

69. CALCANEAL BONE FRACTURE
• The calcaneus is the most commonly fractured
tarsal bone
• Crush injuries are likely to be followed by long-
term disability

70. EPIDEMIOLOGY
• 1-2 % of all fractures
• 60-70 % of all tarsal bones
• M:F = 2.4:1
• 75% is intra articular
• 70% is fall down accident
• 90% is posterior facet fracture

71. MECHANISM OF INJURY
• Axial loading
• Twisting forces
• Avulsion fractures
• Stress fractures

72. Associated Injuries
• 50% have associated injuries
– 10 % thoracolumbar injuries
– 25 % lower extremities injuries
– 5-10 % contralateral injuries

73. CLASSIFICATION
• INTRAARTICULAR FRACTURES(75%)
– Essex-lopresti
o Joint depression vs Tongue type
– Sanders
• EXTRAARTICULAR FRACTURES(25%)
– Fractures of the calcaneal tuberosity
– Fractures of the sustentaculum tali
– Fractures of the anterior and medial process of
the calcaneus

74. INTRAARTICULAR FRACTURES

81. EXTRAARTICULAR FRACTURES
• FRACTURES OF THE CALCANEAL TUBEROSITY

84. • FRACTURES OF THE SUSTENTACULUM TALI

85. • FRACTURES OF THE ANTERIOR PROCESS OF THE CALCANEUS

86. RADIOGRAPHIC ANATOMY
Lateral radiograph
Bohler’s Angle
Gissanes angle
“Double density” sign
Shows joint-depression or
tongue-type

87. The “double density”; a joint-depression–type fracture where the lateral portion of
thejoint is impacted but both Böhler and Gissane angles are normal

88. Ap radiograph
Extension of fracture line into CCJ
Harris axial view
Angulation of the tuberesity
Height of calcaneous
Width of the calcaneous
Broden view
Visualizes articular surface of the posterior facet on
plain radiographs
CT scan
Axial, 30-degree semicoronal, and sagittal planes

89. Clinical evaluation
• Hx
– Bleeding injury site
– Un able to weight bear or with pain
– Limping
– Mm of injury

90.  p/E
– Grossly swollen foot
– Tender
– echymossis
– Open wound
– Gross deformity
– Limited ROM
• Don forget to examine
other systems

91. TREATMENT
• Goals
Joint congruency restoration
Calcaneal height restoration
Reduction of calcaneal width
Valgus tuberisity restoration
Reduction of calcaneocuboid joint

92. Factors vs treatment options
• Age
• Health status
• Fracture pattern
• Soft tissue injury
• Patient compliance

93. TREATMENT OPTIONS
No reduction, with elevation of the foot,
compression dressing, and early ROM
Closed reduction, with elevation of the foot,
compression dressing, and early motion

94. cont’d…..
Percutaneous reduction techniques
Open reduction and internal fixation
Primary arthrodesis

95. NON OPERATIVE
»Indications include:
• Nondisplaced or minimally displaced extra-articular
fractures
• Nondisplaced intra-articular fractures
• Anterior process fractures with less than 25%
involvement of the calcaneal–cuboid articulation
• Fractures in patients with severe peripheral vascular
disease or insulin-dependent diabetes
• Fractures in patients with other medical
comorbidities prohibiting surgery

96. Cont’d….
• Fractures in patients who are heavy smokers (two or
more packs per day)
• Elderly patients who are household ambulators
• Fractures associated with blistering and massive
prolonged edema, large open wounds, or life
threatening injuries

97. NONE OPERATIVE RX
• Placement of a bulky Jones dressing
• Leg elevation
• Supportive splint
• Early subtalar and ankle joint ROM exercises
• Non–weight-for approximately 10 to 12 weeks, until
radiographic union

98. OPERATIVE
• Indications
Displaced intra-articular fractures involving the
posterior facet
 Anterior process of the calcaneus fractures with
>25% involvement of the calcaneal–cuboid
articulation

99. Cont’d….
Displaced fractures of the calcaneal tuberosity,
with or without skin compromise
Fracture-dislocations of the calcaneus
Open fractures of the calcaneus

100. GENERAL FACTS
• Surgery should be within 3 weeks
• Positive wrinkle test
• No edema
Bulky jones dressing
Foot elevation
Ice compression
Pneumatic intermitent compression foot pump

101. Percutaneous and Minimally Invasive Fixation
• Indications:
 Sanders 2C tongue-type fractures in which the entire
posterior facet is attached to the tongue fragment
 displaced calcaneal tuberosity or beak fractures
 emergent reduction and temporary stabilization of
fractures with severe or impending soft tissue
compromise from displaced fracture fragments
 fractures in patients with relative contraindications to
open surgery, such as heavy smokers or patients
requiring chronic anticoagulation

104. SURGICAL APPROACHES
• Lateral approach
• Medial approach
• Both

105. Lateral approach

107. PLATES

109. Fixation of body. A: Lateral wall replaced, and low-profile plate applied. B–D: Radiographs of
final fixation, showing anatomic reduction of the articular surface, anterior process, and
tuberosity

110. Locking plate fixation in patient with seizure disorder and osteopenic bone with (A) lateral, (B)
Broden, and (C) axial views demonstrating satisfactory reduction and fixation.

111. EXTRA ARTICULAR FRACTURES
• Anterior process fractures
involving >25% of the calcaneal–cuboid
articulation on CT scan evaluation
small or mini-fragment screws

112. Anterior process of calcaneus fracture

113. TUBEROSITY (AVULSION) FRACTURES
• The posterior skin is at risk from pressure from the
displaced tuberosity
• The posterior portion of the bone is extremely
prominent and will affect shoe Wear
• The gastrocnemius–soleus complex is
incompetent
• The avulsion fragment involves the articular
surface of the joint

114. CALCANEUS BODY FRACTURES
• Minimally displaced fractures (<1 cm)
 early motion
 non–weight bearing for10 to 12 weeks
• Significant displacement
 varus/valgus deformity
 lateral impingement
 loss of heel height
 = ORI

115. Calcaneal beak/tuberosity avulsion fracture

116. MEDIAL PROCESS FRACTURES
• Rare and usually nondisplaced
• Nondisplaced fractures can be treated with a short
leg weightbearing cast until the fracture heals at 8 to
10 weeks
• When fractures are displaced, closed manipulation
may be considered

117. Medial sustentacular fractures of the calcaneus(A), Broden (B), and axial (C)
views

118. PRIMARY SUBTALAR OR TRIPLE ARTHRODESIS
comminuted that anatomic reduction is not
possible
posttraumatic arthritis reduction
overall long-term recovery is shortened
 a second operation avoided.
Initial ORIF of patients with displaced intra-
articular calcaneal # minimized the likelihood that
subtalar fusion would be required

119. Cont’d…..
• A distinct patient group at high risk of subtalar fusion
 Male
 Heavy labor work
 Böhler angle less than 0° (10 times)
 Sanders-type IVcalcaneal fractures (5.5times)
 Initial treatment was nonoperative (6 times)

120. Primary fusion for a type IV fracture

121. POSTOPERATIVE MANAGEMENT
• Drainage tube
• Splinting with ankle neutral
• Elevation
• Early supervised subtalar range-of-motion exercises
• Non–weight bearing for 8 to 12 weeks
• Full weight bearing by 3 months

122. COMPLICATIONS
1.Wound Necrosis
secondary infection
 exposure of the bone and fixation hardware
• Risk factors
peripheral vascular disease or
systemic disease such as diabetes mellitus
• prevention
maintaining a full-thickness flap
using gentle retraction of the flap (which avoids the
kinking of the flap)
 avoiding prolonged operating times
 tension-free closure

123. 2. Infection
Cellulitis
deep infection with osteomyelitis
• Antibiotics
• I&D
3. Subtalar Joint Arthritis
inadequate reduction
123
calcaneal fracture

124. 4. Malreduction of the Fracture
Deformed foot
weakness in pushoff
difficulty with shoeware
impingement on the peroneal tendons or tip of the
fibula, which can lead to chronic pain and tendinitis

125. SUMMARY
• OPERATIVE
Malunion
Stiffness
Subtalar arthritis
Peroneal tendons
Sural nerve pain
Heel pad problems
• NON-OPERATIVE
 Malunion
 Varus hindfoot
 Shortened foot =short
lever arm
 Peroneal impingement/
 dislocation
 Shoe wear problems
 Stiffness, arthritis(ST)

126. AUTHOR'S PREFERRED METHOD OF TREATMENT IN CALCANEUS(ROCKWOOD AND
GREEN 8TH EDITION)

127. • REVIEW:
– No significant difference between treating Sanders type IV
fractures with either ORIF or ORIF + PSTA. It remains the
choice of the surgeon and patient to take into account
patient specific factors to determine treatment. However,
ORIF + PSTA may be advantageous for both patients with
Sanders type IV fractures and the health care system as
patients heal quickly. Furthermore, ORIF + PSTA may
prevent the need for late secondary subtalar fusion adding
to increased costs and lost time from work
( 10.1097/BOT.0000000000000191, J Orthop Trauma )

128. REFERENCES
 ROCKWOOD AND GREEN FRACTURES IN ADULT 8TH
EDITION
 CAMPBELL’S OPERATIVE ORTHOPEDICS 13TH EDITION
 BROWNER'S MUSCULOSKELETAL TRAUMA 4TH
EDITION
 NETTER ATLAS OF HUMAN ANATOMY

129. THANK YOU