2. Case
ชาย 22 ปี ไม่มีโรคประจาตัว
CC : ปวดเท้าซ้าย 4 ชม ก่อนมาโรงพยาบาล
PI : 4 ชั่วโมงก่อนมา รพ ขับจักรยานยนต์ เสียหลักชน
ต้นไม้ ใช้เท้าซ้ายยันต้นไม้ไว้ เจ็บบริเวณเท้าซ้ายมาก มี
เท้าผิดรูป มีแผลถลอกเล็กน้อย จาเหตุการณ์ได้ ไม่สลบ
3. Primary survey
•A : can speak, can flex neck
•B : spontaneous breathing, CCT neg
•C : BP 163/86 mmHg, P 112/min ,not seen bleeding, Abd
soft not tender
•D : E4V5M6,pupil 3 mm RTLBE
•E : Deformity at left foot and ankle, no bleeding
4. Secondary survey
•A : no history allergy
•M : no current medication
•P : no known underlying
•L : 20.00 o’clock 10/11/59
•E : ตาม present illness
5. Physical examination
• GA : A Thai man ,good conscious
• V/S : BP 163/86 mmHg , P 112/ min, RR 20 / min , Temp 37 *C
• HEENT : not pale conjuntivae, anicteric sclerae
• Respiratory : equal breath sound, no adventitious sound
• CVS : normal S1 S2, no murmur
• Abdomen : soft , not tender
• Extrimities : left foot deformity neurovascular intact
10. Talus bone
•2nd largest of tarsal bone
•60 percent covered by articular cartilage
•No muscular attachment
•Articulation 1.Tibio-talar 2.Subtalar 3.Talo-navicular
16. Hawkins Type I Talar Fractures
- non displaced fractures of the talar neck without dislocation
- important challenge with this injury is ensuring that anatomic reduction is obtained
with no varus rotation;
- treated closed, usually w/ short leg cast w/ foot in slight equinus;
- leg is kept non-weight bearing for 4 weeks, & then wright bearing is allowed in cast for
another 8 weeks or until healing is evident by x-ray (evidenced by trabeculations across
fracture site);
- AVN : 10%
17. Hawkins Type II Talar Fractures
- displaced fracture of the talar neck with subluxation or dislocation of the sub-talar
joint (subtalar joint subluxation is usually dorsal) and the ankle remains aligned
- type II injuries are caused by the destruction of the talocalcaneal ligament
- it is difficult to perform closed reduction of the dorsal and supination deformity
- if closed reduction is possible then 8-12 weeks is necessary for healing (trabeculation
across the fracture site);
- ORIF is needed if there is more than 3-5 mm of dorsal displacement and any rotational
deformity
- AVN : 30%
18. Hawkins Type III Talar Fractures
- displaced frx of talar neck w/ dislocation of body of talus from both subtalar joint and
the ankle joint
- when body dislocates, it is usually found on posterior medial aspect adjacent to the
Achilles tendon;
- in this location, there can be compression of neurovascular structures, & care must be
taken when approaching by open means dislocated body of the talus;
- talocalcaneal ligament is ruptured when there is dorsal displacement of the distal
fragment;
- requires ORIF
- AVN: 90%
19. Hawkins Type IV Talar Fractures
- 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
20. Hawkins Sign
- appearance of decreased subchondral bone density in the dome of talus 6 to 8
weeks following injury indicates that there is sufficient
- vascular supply to bone to allow normal disuse osteopenia to occur;
- resorption of subchondral bone is a consequence of disuse osteoporosis and
suggests that the bone segment has adequate circulation, and that normal
healing is occuring
