The os trigonum syndrome: use of bone scan in the diagnosis. Treatment Inability … Foot Ank Int 2008;29(3):318-324. Taymaz A, Gunal I. J Bone Joint Surg 1936;18:212-214. talus and are responsible for the sur-vival of the talus in severe injuries. Rahul Banerjee and Florian Nickisch Malunion after talar neck fracture is a vexing problem. These findings support the concept that damage to a significant portion of the talar blood supply is directly related to fracture displacement.110,119 Unfortunately, disability, chronic pain, and impairment, Fractures of the talar body associated with dislocation, The decision whether a malleolar osteotomy is required, As with talar neck fractures, the surgical approach to, Although these fractures often appear daunting on the, Talar body fractures are relatively rare, so, Appropriate care should be taken to avoid “iatrogenic, With respect to implants, the availability of, Despite the best surgical intentions, preparations, and, Fracture of the head of the talus is a very uncommon, Talar head fractures result from an axial load applied, The clinical presentation of these injuries ranges from, Anteroposterior, lateral, and oblique radiographs of the, Principles of treatment include maintenance of the, Displaced fractures and those associated with joint subluxation or dislocation require open reduction and internal fixation (, Displaced fractures of the talar head are prone to the development of talonavicular arthritis (, Malunion may also occur. cases, closed reduction is aided by the use of a transverse pin placed The body and neck of the talus are not coaxial because, in the horizontal plane, the neck angles medially with a variable angle of declination.134 J Trauma 1964;4:845-849. The neck of the talus has four surfaces: superior, lateral, medial, and inferior and is one of the few areas of the talus not covered by articular cartilage. Although early reports indicated poor vascular flow, more recent investigators note the presence of an extensive extraosseous and intraosseous blood supply to the talus.59,110 However, because most of the talar surface is covered with articular cartilage and no muscles originate or insert into this bone, the areas available for vessels to enter are few.59,76,110 Fractures or dislocations of the talus are often associated with disruptions in the blood supply and thus pose potential problems for the healing and integrity of the talus. Pinzur MS, Meyer PR Jr. The superior surface of the talar body is completely covered with articular cartilage and is shaped like a pulley, with the groove of the pulley (trochlea) closer to the medial border. The fixation can be inserted from posteromedial, This forms the angle E, or the angle of inclination. The superior surface of the neck is limited posteriorly by the anterior border of the trochlea of the talus (the dome or body) and anteriorly by the articular surface of the talar head. First, it sends branches to the superior surface of the talar neck. necrotic bone with vascularized bone. In some preserved in its entirety. In most cases, screws will need to be placed through the articular surface and therefore should be countersunk, or headless screws should be used.9 Large impaction injuries may require cancellous bone grafting and/or temporary spanning of the talonavicular joint with the small external fixator until healing has occurred. They typically occur following high-energy trauma, such as a fall from height or road traffic accident, during which the ankle is forced in to dorsiflexion; this causes the talus to press against the tibial plafond, resulting in a fracture. poor. Harnroongroj T, Vanadurongwan V. The talar body prosthesis. J Bone Joint Surg 1985;67A:1432-1433. Injuries that could cause a talus fracture include a fall from a great height or a car accident. Early motion may be instituted depending upon the stability of Incidence Sangeorzan BJ, Hansen ST. Between the head and the body is the neck, which does not articulate with the ankle and sits over the sinus tarsi below. Chapman MW. Arthroscopy is used to look inside your ankle to check for signs of fracture or injury. In many cases, a cortical fragment is visible at the anterolateral Grantham SA. similar dorsomedial direction. Orthop Clin North Am 1980;11:579-591. subcutaneous dissection to avoid neurovascular injury.52,149. Injuries to the talus are serious because this bone is the critical link between the subtalar, transverse tarsal, and ankle joint complex.134 The variety of coupled actions occurring from the motion of this bone or surrounding bones permit the effortless flexibility of the hindfoot and midfoot. The second type of talar head fracture is a result of shear, secondary to an inversion injury. In unusual, Unfortunately, osteonecrosis is often associated with, Tibiocalcaneal arthrodesis is an alternative option in, In summary, osteonecrosis of the talus is a significant, Anatomic reduction is essential to achieving a good. He based his suggestion on the known mortality of 84% following such an injury at that time. After anatomic reduction of the fragments and provisional Kirschner (K)-wire fixation, fixation is performed with mini- or small-fragment (1.5, 2.0, or 2.7 mm) lag screws. Blair tibiotalar arthrodesis for injuries to the talus. Introduction. Read More, Copyright ©2010 Lippincott Williams & Wilkins, > Table of Contents > Section Four – Lower Extremity > 58 – Talus Fractures, Fractures of the talus are difficult injuries. CT scans give excellent, The routine use of CT to assess comminuted talar, Magnetic resonance imaging (MRI) has an important role in, Fractures of the talus are a heterogeneous group of, The most commonly used classification for talar neck fractures is that described by Hawkins, The Hawkins type II fracture refers to a talar neck fracture with associated subluxation or dislocation of the subtalar joint (, A Hawkins type III fracture involves a dislocation at the ankle as well as at the subtalar joint (, The Hawkins type IV fracture was described by Canale and Kelly, The most comprehensive classification of talus fractures, Although the Hawkins classification is commonly applied. They complain of pain over the dorsal aspect of the foot in the region of the talonavicular joint.24,77,116 Usually, point tenderness and swelling are located over the talar head, and the motion of the midtarsal joint reproduces the pain. prognosis compared to medial subtalar dislocations. Careful evaluation of the outline of the talar head and neck on the lateral and AP views is particularly important in making the diagnosis and determining displacement.35 Isolated talar head fractures are subtle and may occasionally be missed, so careful scrutiny of radiographs is required. Exposure of the Artery of the Tarsal Sinus A stress fracture of the talus is causes an increasing amount of pain deep within the ankle joint over a period of weeks. Preservation of the deltoid artery branches is extremely important and deserves care when performing a medial malleolar osteotomy because this may be the only remaining source of blood supply to the talar body in the case of a displaced talar neck fracture. The second branch derived from the posterior tibial artery consists of a vascular plexus over the posterior medial tubercle of the talus. The superior surface of the neck is limited posteriorly by the anterior border of the trochlea of the talus (the dome or body) and anteriorly by the articular surface of the talar head. This problem is lessened when titanium implants tissues and to facilitate wound care. Late results after vertical fracture of the talus. B, Middle third. Niazi TB, Joshi RP, Johnson PG. After anatomic reduction of the fragments and provisional Kirschner (K)-wire fixation, fixation is performed with mini- or small-fragment (1.5, 2.0, or 2.7 mm) lag screws. J Bone Joint Surg 1971;53A:1289-1297. In 1909, Stealy149 reviewed the literature to that date and noted a 50% mortality rate after open fracture-dislocation of the talus. The body includes the dome of the talus at the ankle joint and the posterior facet at the subtalar joint. The second type of talar head fracture is a result of shear, secondary to an inversion injury.81 This in turn causes midtarsal adduction and results in the navicular shearing off a portion of the medial talar head at the articulation. FRACTURES OF THE POSTERIOR PROCESS  revascularize without collapse. It is Finally, the deltoid branches medially anastomosed with branches from the artery of the tarsal canal in 3% of patients. present in 50% of normal feet.109 This small ossicle arises from a separate ossification center just posterior to the lateral tubercle. The line perpendicular to a is drawn (b) until it bisects OC. The mechanism of total dislocation of the talus. 20, 58, 150 Posttraumatic arthritis is common after a peritalar. challenging group of patients, 6 of the 8 patients were described as Pehlivan O, Akmaz I, Solakoglu C, et al. Fracture blisters 4. The land-mine foot: its description and management. Mulfinger GL, Trueta J. J Orthop Trauma 1997;11:42-45. stabilized, usually with screws ranging from 2.0 to 3.5 mm in diameter. Mills HJ, Horne G. Fractures of the lateral process of the talus. J Trauma 1988;28:692-694. The variability of the anastomotic network and the susceptibility to injury also require careful fracture manipulation and minimal soft tissue stripping during surgery to prevent further insult to the blood supply. Its. Posterior Tibial Artery Coltart. In addition, these vessels anastomose to form several vascular networks that surround and supply blood to the talus.59,76,110,140 According to Wildenauer,166 the talar vascular supply arising from these three main arteries reaches the talus through a vascular network that covers all its cartilage-free surfaces. Dennis MD, Tullos HS. This required an osteotomy and repositioning of the fragment to correct the problem successfully. Persistent instability is fortunately uncommon. This socket is formed by the calcaneal middle and anterior surfaces, connected to the large navicular articular surface by the inferior and superomedial calcaneonavicular ligaments. The head of the talus has two sources of blood supply. necessary. the strategy of preserving and reimplanting the talus was followed. 39-6). Percutaneous pinning of talar neck fractures. First, the posterior tibial artery gives rise to the artery of the tarsal canal (see following discussion). They complain of pain over the dorsal aspect of the foot in the region of the talonavicular joint. It is formed by calcaneal branches of the posterior tibial artery and an anastomosis with branches from the peroneal artery.59,76,110,140. The trochlea, or superior surface, supports the body weight and transmits loads to the inferior aspect of the tibial plafond (, The internal architecture of the talus reflects its, The neck of the talus has less cartilaginous coverage than the remainder of the talus (, The lateral process of the talus is wedge-shaped. J Foot Surg 1989;28:208-212. The lateral Clin Orthop 1985;199:108-113. Orthop Clin North Am 2001;32:65-77. Fracture of the lateral talus process: a case report. Incidence  Chapter Contents The neck of the talus has four surfaces: superior, lateral, medial, and inferior and is one of the few areas of the talus not covered by articular cartilage. Peterson and Goldie119 emphasize that these posterior vessels also provide communication between the intraosseous blood supply of the tibia and that the talus through the posterior capsule of the talotibial joint. Fractures of the talar neck and body are often seen in, Only 2% of all lower extremity injuries and 5% to 7% of, Injuries to the soft tissue envelope are seen in, When the talus is dislocated, an urgent reduction is, Neurovascular injury associated with talus fractures can, Although perfusion to the foot is usually intact in talar fractures, it may at times be compromised. The anterior tibial, or dorsalis pedis, artery also provides blood to the talus from two groups of vessels. Radiologic Evaluation  Acta Orthop Scand 1974;45:296-306. The mildly convex medial surface provides an area for insertion of the talonavicular ligaments. The os trigonum. Open Talar Neck Fractures  mortise, provided it is possible to achieve a clean surgical bed. Medial subtalar dislocation: five cases with a common etiology. The use of immediate internal fixation in open fractures. (Modified from Sarrafian SK: Anatomy of the foot and ankle, Philadelphia, 1983, Lippincott.) J Bone Joint Surg 1955; 37A:89-95. Can J Surg 1967;10:322-324. The inferior portion is nonarticular, and its anterior half is a depressed surface perforated by numerous vascular foramina. The head is the portion that articulates mostly with the navicular. Smaller fragments may place pressure on the skin and may occasionally block talonavicular or ankle motion. weeks. Radiologic Evaluation  Open reduction and internal fixation is the current standard treatment for displaced fractures of the talar body. Treatment for a talus fracture: Treatment for the minimally displaced or stable fracture can sometimes be treated with immobilization such as a cast. capsular and ligamentous supports. Osteonecrosis of the talar body is a common problem. Peterson et al. The body of the talus is supplied by vessels that enter through five surfaces: the superior surface of the talar neck, the anterolateral surface of the talar body, the inferior surface of the talar neck (roof of the tarsal canal), the medial surface of the talar body (deltoid ligament), and the posterior tubercle.59,76,110,140 The main blood supply to the lateral two thirds of the talar body is from the artery of the tarsal canal, which provides four or five main branches into the body, and the medial one third of the body is supplied by the deltoid branch, which enters from the medial surface of the talus.59,119,134 The arteries that enter the superior aspect of the neck send one or two branches into the central anterosuperior aspect of the body. The injury was described in 1974 by Cedell. With respect to the talus, the irregular shape Secondary surgery was commonly substitution, although this may occur very slowly. 29th ed. talonavicular changes were noted in the subtalar joint in several patients Gelberman RH, Mortensen WW. This socket for the talar head allows the midfoot to swivel about the talar head and consists of the calcaneal middle and anterior surfaces connected to the large navicular articular surface by the inferior and superomedial calcaneonavicular ligaments. 39-4). The body and neck of the talus are not coaxial because, in the horizontal plane, the neck angles medially with a variable angle of declination.134, Figure 39-1 Anatomy of the talus. are Treatment of malunion varies. the patients had injuries to the head, abdomen, or chest.9. Foot Ankle Int 1999;20:192-195. Further experience with peritalar dislocation. They complain of pain over the dorsal aspect of the foot in the region of the talonavicular joint.24,77,116 Usually, point tenderness and swelling are located over the talar head, and the motion of the midtarsal joint reproduces the pain. A, Lateral. immobilize the hindfoot when the reduction is not stable due to Those with nondisplaced fractures fared Talar body fractures. The lateral surface consists of a large articular surface, the facies malleolaris lateralis, which articulates with the distal fibula.134 Along the anterior, inferior, and posterior perimeter of this lateral articular surface is the lateral process, a nonarticular component of the talus. The body of the talus is arbitrarily divided into five surfaces: lateral, medial, superior, inferior, and posterior. In 1909, Stealy149 reviewed the literature to that date and noted a 50% mortality rate after open fracture-dislocation of the talus. Johnson RP, Collier BD, Carrera GF. Major injuries of the talus. Tibiocalcaneal Fusion  fracture line are used to lag the fracture fragments together. Seybold D, Schildhauer TA, Muhr G. Combined ipsilateral fractures of talus and calcaneus. Treatment  These branches arise either directly from the anterior tibial artery as medial tarsal branches or indirectly as branches of the anteromedial malleolar artery. Foot Ankle 1982;3:81-84. Talar neck fractures and rates of avascular necrosis. The development of a malunion can occur in several ways. Kleiger B. Fractures of the talus. If the joint remains unstable, it should be reduced and temporarily pinned with a 1.6-mm or 2-mm K-wire for 4 to 6 weeks. Symptoms of a stress fracture of the talus develop gradully over time and … Delayed Union and Nonunion of the Talar Neck  In most cases, screws will need to be placed through the articular surface and therefore should be countersunk, or headless screws should be used. Foot Ank Int 2008;29:245-247. in a short leg cast for approximately 6 weeks. Clin Orthop 1989;240:105-114. an anatomic reduction. Vascular Various mechanisms have been proposed. The significance of this classification was its prognostic value with respect to avascular necrosis (AVN). Peterson and colleagues160 The lateral surface of the neck provides an insertion for the medial aspect of the inferior extensor retinaculum.134 The lateral cortex of the talar neck is concave and flares as it approaches the lateral cortex. Two thirds of the talar surface is covered with articular cartilage, and neither tendons nor muscles insert or originate from this bone. Sixty-five percent of the patients regained their C = cuneiform bone, Cal = calcaneus, Cu = cuboid bone, F = fibula, M = metatarsal bones, N = navicular bone, Ph = phalanges, STJ = posterior facet of the subtalar joint, Tb = talar body, TD = talar dome, Th = talar head, Ti = tibia, Tn = talar neck. Results  J Bone Joint Surg 1954;36A: 299-306. Snowboarder’s talus fracture. A note on the fracture of the os trigonum: report of a case. FRACTURES OF THE POSTEROMEDIAL TUBERCLE  Isolated displaced fracture of the posterior facet of the talus. the fragments. A… Associated soft tissue injury of fracture of the body of talus. Plate Fusions  The terms talus and astragalus date back to the pre-Christian era and relate to the manufacture of dice. 39-5). TOTAL DISLOCATION OF THE TALUS  Classification  The talus has been referred to as “the universal joint of the foot” because of its multiple articulations.24 Fractures of the talus are uncommon, accounting for approximately 1% of all fractures, and are frequently the result of high-energy trauma, such as motor vehicle collisions and falls from height.132 A, Lateral. Coltart55 and others77,116 recommended excision of these small fragments. Whatever its origins, the sinus tarsi artery was the principal supplier of the intrasinus structures and of the talus. (Copyright Jesse C. DeLee, MD.). The talus has been referred to as “the universal joint of the foot” because of its multiple articulations. Am J Orthop 2002;31:76-78. Smaller fragments may place pressure on the skin and may occasionally block talonavicular or ankle motion. Undisplaced or reduced fractures may be treated with immobilization in a short leg cast or cast brace. 39-6). Peterson L, Romanus B, Dahlberg E. Fracture of the collum tali—an experimental study. The lateral surface of the neck provides an insertion for the medial aspect of the inferior extensor retinaculum. As with most severe talus fractures and dislocations, Initial treatment is directed to the soft tissues. Because the talus is important for ankle movement, a fracture often results in substantial loss of motion and function. Leitner B. Orthopedics 1985;8:1234-1240. placement. the talus is revascularized slowly via creeping substitution of Displaced fragments are reduced and The two types of fractures of the talar head are compression fractures and shear fractures. All Rights Reserved. In addition, lateral dislocations are anesthetic can be useful as an assistive diagnostic modality. If the talus is damaged, the universal combined motion of the foot and ankle becomes compromised, and severe disability can result. Smaller fragments may place pressure on the skin and may occasionally block talonavicular or ankle motion. Adelaar RS. reimplantation, suggesting complete osteonecrosis. Thus, talus fractures are relatively uncommon, comprising less than 1 percent of all fractures [ 1 ]. © 2021 - TeachMe Orthopedics. Obstacles to reduction in subtalar dislocations. Med Record 1941;154:90-92. following talectomy. Hindfoot symptoms may also be common but are not always due solely to revascularized without collapse. In addition, a talus fracture that does not heal properly can lead to serious complications, including chronic pain. Grob D, Simpson LA, Weber BG, et al. been subject to artifact from the placement of significant volume of Peterson and Goldie119 emphasize that these posterior vessels also provide communication between the intraosseous blood supply of the tibia and that the talus through the posterior capsule of the talotibial joint. Figure 39-4 The talocalcaneal angle demonstrates medial deviation of the talus on the calcaneus, not only from the declination angle of the talar neck but also from the subtalar articulation. Howse A.JG. Hawkins LG. Posttraumatic Arthritis  Dunn et al35 preferred a triple arthrodesis for isolated talonavicular arthritis. Talar Neck  Philadelphia: Lea and Febiger, 1973. This artery of the tarsal canal passes anteriorly between the sheaths of the flexor digitorum longus and flexor hallucis longus muscles to enter the tarsal canal. The talar neck is angled at a mean of 24 degrees medially (range, 10-44 degrees) and plantarly (range, 5-50 degrees), and it is the portion of the talus most vulnerable to fracture (Fig. (From Sarrafian SK: Anatomy of the foot and ankle, Philadelphia, 1983, Lippincott. The transverse diameter of the superior surface is greater anteriorly than posteriorly and resembles a keystone. The inferior portion is nonarticular, and its anterior half is a depressed surface perforated by numerous vascular foramina. As such, wherever possible, treatment The sinus tarsi artery was formed in all cases from anastomoses among various arteries of the lateral region of the foot. Under the tail of the superior surface, the posterior half of the inferior portion consists of a large oval area that provides insertion for the deep component of the deltoid ligament.134. These findings support the concept that damage to a significant portion of the talar blood supply is directly related to fracture displacement.110,119. If you are a New Jersey worker who has suffered a work-related fracture or amputation, contact us today for a free initial consultation by calling 1-800-LAW-2000 or using our online form. The talotibial capsule inserts along this superior surface just proximal to the insertion of the capsule of the talonavicular joint. Incidence  In rare cases with severe comminution or articular injury to the talar head or the navicular, primary talonavicular arthrodesis may be considered. Detenbeck LC, Kelly PJ. Clinical Evaluation Talar neck fractures. J Anat Physiol 1882; 18:79-81. J Bone Joint Surg 1963;45A:221-245. J Bone Joint Surg 1970;52B:36-48. Therefore he recommended below-knee amputation for these injuries, a procedure that still produced a mortality rate of 25% in his era. The. Finally, the deltoid branches medially anastomosed with branches from the artery of the tarsal canal in 3% of patients. Branches from the anterior tibial (dorsalis pedis) artery supply the superior medial half, and the lateroinferior half is supplied directly from the arteries of the tarsal sling.59,76,110 Inferiorly, the part of the talar neck that forms the anterior boundary of the tarsal sinus is the entryway for the intraosseous circulation to the talar head of the talus. Branches from the anterior tibial (dorsalis pedis) artery supply the superior medial half, and the lateroinferior half is supplied directly from the arteries of the tarsal sling. After anatomic reduction of the fragments and provisional Kirschner (K)-wire fixation, fixation is performed with mini- or small-fragment (1.5, 2.0, or 2.7 mm) lag screws. Fractures of the neck of the talus. Jerome JT, Varghese M, Sankaran B. Anteromedial subtalar dislocation. Coronal computed tomographic (CT) scan (a) and sagittal T1-weighted magnetic resonance (MR) image (b) demonstrate the normal skeletal anatomy of the foot and ankle. Coltart24 credits Fabricius of Hilden41 with the first account of an injury to the talus in 1608. It is formed by calcaneal branches of the posterior tibial artery and an anastomosis with branches from the peroneal artery. The lateral talocalcaneal ligament inserts at the inferior tip of the lateral process. The disability arising from these fractures primarily results from involvement of the articular surface with pain on weight bearing secondary to the development of posttraumatic talonavicular arthritis. The talus, a pivotal bone in the foot, mainly serves to invert or evert the foot. E, Middle talus. medial column of the foot due to the displaced fracture. Fracture of the lateral process of the talus. The posterior tibial tendon should be protected as much as The talus bone is the bone at the top of the ankle which the tibia or shin bone sits on. Tech Orthop 1987:2:42-54. If routine radiographs do not give a clear indication of fracture location and size, particularly in longitudinal or oblique (nonimpaction) fractures, computed tomography (CT) is recommended. injuries, including talar neck and body fractures and peritalar dislocation.154 The body includes the dome of the talus at the ankle joint and the posterior facet at the subtalar joint. Mitchell JI. Support devices such as casts and removable boots prevent ankle movement and help your talar fracture heal. (Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery: Mulfinger GL, Trueta J: The blood supply of the talus. Two thirds of the talar surface is covered with articular cartilage, and neither tendons nor muscles insert or originate from this bone.134 The talus is composed of three parts—the head, neck, and body—and two processes—the lateral and posterior. The posterolateral tubercle may appear as an oversized trigonal process known as the Stieda process or as a separate accessory bone, the os trigonum, which is seen in approximately 3% to 8% of the population.55,134 stable, I prefer to begin mobilization in a removeable splint after 2 For example, von Knoch et al. form the artery of the sinus tarsi. Verhaar164 reported a case of recurrent midtarsal dislocation secondary to a malunion of the talar head. tendon, it may not function normally after the reduction, leading to First, small branches from the peroneal artery join with the calcaneal branches of the posterior tibial artery to form the vascular plexus over the posterior tubercle of the talus. This may Mac SS, Kleiger B. tensioned. Talar head fractures are usually the result of falls or motor vehicle accidents. Although all three arteries provide some supply to the talus, the relative importance of each artery has been studied and debated. risk of complications particularly related to skin necrosis. The posterior tibial artery supplies the talus through two branches. Wildenauer,166 Schwarzenbach et al,140 and others59,76,81 believe that the arteries of the tarsal sinus and tarsal canal, together with the medial periosteal network, are the most important sources of blood supply to the talus. to full sports activities. Results  Talar Avascular Necrosis Christopher F. Hyer William T. DeCarbo Avascular necrosis (AVN) or osteonecrosis is defined as a disease resulting from temporary or permanent loss of the blood supply to bone (1). Vascular  The body of the talus is supplied by vessels that enter through five surfaces: the superior surface of the talar neck, the anterolateral surface of the talar body, the inferior surface of the talar neck (roof of the tarsal canal), the medial surface of the talar body (deltoid ligament), and the posterior tubercle.59,76,110,140 The main blood supply to the lateral two thirds of the talar body is from the artery of the tarsal canal, which provides four or five main branches into the body, and the medial one third of the body is supplied by the deltoid branch, which enters from the medial surface of the talus.59,119,134 The arteries that enter the superior aspect of the neck send one or two branches into the central anterosuperior aspect of the body. Talar Head Early JS. E, Middle talus. Occult fractures following subtalar joint injuries. In this tunnel, it gives rise to branches that enter the inferior aspect of the talar neck.76 Mulfinger and Trueta110 found this anastomosis in all their specimens.