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SUMMARY
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Talus fractures (other than neck) are rare fractures of the talus that comprise of talar body fractures, lateral process fractures, posterior process fractures, and talar head fractures.
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Diagnosis is made radiographically with foot radiographs but CT scan is often needed for full characterization of the fracture.
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Treatment is generally nonoperative with immobilization for minimally displaced injuries and surgical reduction and fixation for displaced and intra-articular fractures.
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EPIDEMIOLOGY
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Incidence
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rare
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less than 1% of all fractures
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second most common tarsal fractures after calcaneus fxs
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Anatomic location
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talar body fractures
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account for 13-23% of talus fractures
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lateral process fractures
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account for 10.4% of talus fractures
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talar head fracture
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least common talus fracture
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ETIOLOGY
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Mechanism
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talar body
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injuries often result from high energy trauma, with the hindfoot either in supination or pronation
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lateral process of talus
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injuries result from forced dorsiflexion, axial loading, and eversion with external rotation
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often seen in snowboarders
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ANATOMY
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3D Anatomy of talus
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Talus has no muscular or tendinous attachments
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Articulation
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there are 5 articulating surfaces
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seventy percent of the talus is covered by cartilage
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inferior surface articulates with posterior facet of calcaneus
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talar head articulates with
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navicular bone
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sustenaculum tali
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lateral process articulates with
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posterior facet of calcaneus
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lateral malleolus of fibula
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this forms the lateral margin of the talofibular joint
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posterior process consist of medial and lateral tubercle separated by groove for FHL
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Blood supply
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because of limited soft tissue attachments, the talus has a direct extra-osseous blood supply
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sources include
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posterior tibial artery
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via artery of tarsal canal (most important and main supply)
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supplies most of talar body
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via calcaneal braches
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supplies posterior talus
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anterior tibial artery
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supplies head and neck
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perforating peroneal arteries via artery of tarsal sinus
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supplies head and neck
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deltoid artery (located in deep segment of deltoid ligament)
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supplies body
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may be only remaining blood supply with a talar neck fracture
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CLASSIFICATION
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Anatomic classification
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Anatomic classification
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Lateral process fracture
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Type 1
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Fractures do not involved the articular surface
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Type 2
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Fractures involve the subtalar and talofibular joint
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Type 3
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Fractures have comminution
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Posterior process
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Posteromedial tubercle
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Avulsion of the posterior talotibial ligament or posterior deltoid ligament
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Posterolateral tubercle
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Avulsion of the posterior talofibular ligament
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Talar head fracture
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Talar body fracture
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PHYSICAL EXAM
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Symptoms
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pain
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lateral process fractures often misdiagnosed as ankle sprains
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Physical exam
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provocative tests
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pain aggravated by FHL flexion or extension may be found with a posterolateral tubercle fractures
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IMAGING
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Radiographs
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recommended views
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AP and lateral
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lateral process fractures may be viewed on AP radiographs
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Canale View
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optimal view of talar neck
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technique
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maximum equinus
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15 degrees pronated
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Xray 75 degrees cephalad from horizontal
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careful not to mistake os trigonum (present in up to 50%) for fracture
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may be falsely negative in talar lateral process fx
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CT scan
- indicated when suspicion is high and radiographs are negative
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best study for posterior process fx, lateral process fx, and posteromedial process fx
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helpful to determine degree of displacement, comminution, and articular congruity
- indicated when suspicion is high and radiographs are negative
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MRI
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can be used to confirm diagnosis when radiographs are negative
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TREATMENT
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Nonoperative
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SLC for 6 weeks
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indications
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nondisplaced (< 2mm) lateral process fractures
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nondisplaced (< 2mm) posterior process fractures
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nondisplaced (< 2mm) talar head fractures
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nondisplaced (< 2mm) talar body fractures
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technique
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cast molded to support longitudinal arch
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- Operative
- ORIF/Kirshner wire Fixation
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indications
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displaced (> 2mm) lateral process fractures
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displaced (> 2mm) talar head fractures
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displaced (> 2mm) talar body fractures
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medial, lateral or posterior malleolar osteotomies may be necessary
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displaced (> 2mm) posteromedial process fractures
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may require osteotomies of posterior or medial malleoli to adequately reduce the fragments
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fragment excision
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indications
- comminuted lateral process fractures
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comminuted posterior process fractures
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nonunions of posterior process fractures
- comminuted lateral process fractures
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- ORIF/Kirshner wire Fixation
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TECHNIQUE
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ORIF/Kirshner Wires
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approaches
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lateral approach
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for lateral process fractures
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incision over tarsal sinus, reflect EDB distally
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posteromedial approach
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for medial tubercle of posterior process fracture or for entire posterior process fracture that has displaced medially
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between FDL and neurovascular bundle
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posterolateral approach
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for lateral tubercle of posterior process fractures
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between peroneal tendons and Achilles tendon (protect sural nerve)
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beware when dissecting medial to FHL tendon (neurovascular bundle lies there)
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combined lateral and medial approach
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required for talar body fractures with more than 2 mm of displacement
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Fragment excisions
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incompetence of the lateral talocalcaneal ligament is expected with excision of a 1 cm fragment
- this is biomechanically tolerated and does not lead to ankle or subtalar joint instability
- this is biomechanically tolerated and does not lead to ankle or subtalar joint instability
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COMPLICATIONS
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AVN
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Hawkins sign (lucency) indicates revascularization
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lack of Hawkins sign with sclerosis is indicative of AVN
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Talonavicular arthritis
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posttraumatic arthritis is common in all of these fractures
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this can be treated with an arthrodesis of the talonavicular joint
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Malunion
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Chronic pain from symptomatic nonunion
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may have pain up to 2 years after treatment
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- Subtalar arthritis
- found in 45% of patients with lateral process fractures, treated either non-operatively or operatively
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anatomic reduction of the articular surface can decrease incidence
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- found in 45% of patients with lateral process fractures, treated either non-operatively or operatively
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PROGNOSIS
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Lateral process injuries have a favorable outcomes with prompt diagnosis and immediate treatment
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