Talar body fracture combined with bimalleolar fracture

Ankle fractures combined with a talar body fracture imply either the medial or the lateral malleolus. The only report of a talar fracture combined with a bimalleolar ankle fracture found in the literature is referred to a talar neck fracture. We report a case of a simultaneous talar body fracture and bimalleolar ankle fracture in a young patient. This combined injury pattern appears to be very rare; one similar case was reported in the literature. An open reduction and internal fixation of the talar body fracture as well as the bimalleolar fracture, followed by a prolonged non-weight bearing, led to a fracture healing with no evidence of osteonecrosis. At the last follow-up, the functional result was satisfactory.

To determine whether fracture of the lateral process (LP) elevates the risk of development of radiographic subtalar arthrosis in patients with talar body and neck fractures. Retrospective review. Level 1 academic trauma center. Eighty-two patients with 43 talar neck and 43 talar body fractures treated over a 5-year period. Preoperative and postoperative radiographs were evaluated for fracture of the LP of the talus and subsequent development of radiographic subtalar arthritis. Radiographic evidence of subtalar arthritis. Seventy-six percent of talar neck fractures with involvement of the LP went on to develop radiographic evidence of subtalar arthrosis compared with 36% of talar neck fractures without LP involvement (P = 0.035). Thirty of the fractures involving the LP had a separate LP fragment. Fifteen of the 30 fractures with a separate LP fragment that underwent reduction and fixation developed radiographic evidence of subtalar arthrosis, whereas all 13 fractures with an independent LP fragment that did not have fixation of the LP went on to develop radiographic evidence of subtalar arthritis (P = 0.001). Comminution of the inferior talar articular surface was found to significantly increase the risk of radiographic subtalar arthritis in both talar body and talar neck fractures (P = 0.0003). An anatomic reduction of both talar neck and body fractures was found to be associated with a lower incidence of radiographic subtalar arthritis (P = 0.00001). Comminution of the inferior articular surface of the talus elevates the risk of subtalar arthritis in patients with both talar neck and body fractures. Fracture of the LP is a marker for injury to the talar inferior articular surface and increases the risk for the radiographic finding of subtalar arthritis in patients with talar neck fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Talar neck and body fractures are rare. Major posttraumatic complications with a potential reduction in the quality of life are arthrosis and necrosis due to the specific vascular supply. The aim of the study was to evaluate mid-term results of surgery for talar fractures of neck and body. Parameters that potentially affected/influenced treatment outcomes were analysed exploratively. 24 patients with 24 talar neck and body fractures (Marti type II n = 9, type III n = 12, type IV n = 3) were retrospectively examined for radiological and clinical functional outcomes. The independent parameters evaluated included age (< 40, ≥ 40 years), sex (male, female), general overall extent of injury (polytrauma/multiple injuries/multiple fractures of the extremities, additional injuries to the same foot, isolated talus fracture), soft tissue damage (open, closed), surgical latency (< 6, ≥ 6 h), fracture classification/displacement (undisplaced [= Marti II], displaced [= Marti III, IV]) and fracture type (talar body, neck fracture). The potential influencing parameters were analysed by univariate analyses. With an average follow-up of 8.7 years (1,25 - 16 years) the AOFAS score was 71.4 ± 22.9 points, the Foot Function Index score 35.9 ± 28.3 points; the physical and mental component summary scores of the Short Form 36, version 2, was 43.8 ± 10.9 and 47.4 ± 13.6 points (mean ± standard deviation), respectively. Thus, the patient reported physical health of the patients was slightly reduced compared to the German population, while the mental health remained largely unaffected. Two patients developed partial avascular necrosis (8%), 10 patients developed osteoarthritis (42%). Of the independent parameters, only the general overall extent of injury showed a significant influence on osteoarthritis (p = 0.002). In the evaluation of undisplaced (n = 9) and displaced (n = 15) fractures, surgical treatment after more than 6 hours did not result in a worse outcome. The clinical outcome of internal fixation of talar neck and body fractures can be classified as good. In the study group, there was no correlation between the occurrence of arthrosis and the Marti fracture classification.

BackgroundThe talus has a very complex anatomical morphology and is mainly fractured by a major force caused by a fall or a traffic accident. Therefore, a talus fracture is not common. However, many recent reports have shown that minor injuries, such as sprains and slips during sports activities, can induce a talar fracture especially in the lateral or posterior process. Still, fractures to the main parts of the talus (neck and body) after ankle sprains have not been reported as occult fractures.MethodsOf the total 102 cases from January 2005 to December 2012, 7 patients had confirmed cases of missed/delayed diagnosis of a talus body or neck fracture and were included in the study population. If available, medical records, X-rays, computed tomography scans, and magnetic resonance imaging of the confirmed cases were retrospectively reviewed and analyzed.ResultsIn the 7-patient population, there were 3 talar neck fractures and 4 talar body fractures (coronal shearing type). The mechanisms of injuries were all low energy trauma episodes. The causes of the injuries included twisting of the ankle during climbing (n = 2), jumping to the ground from a 1-m high wall (n = 2), and twisting of the ankle during daily activities (n = 3).ConclusionsA talar body fracture and a talar neck fracture should be considered in the differential diagnosis of patients with acute and chronic ankle pain after a minor ankle injury.

Talar fractures are uncommon and talar body fracture dislocations are still rare. We present the case of patient who sustained a simultaneous fracture dislocation of talar body and avulsion of lateral process with fracture of medial malleolus and tibial pilon. No similar cases are reported in the literature to the best of our knowledge. The patient was treated with open reduction and internal fixation of talus through the malleolar fracture. The prognosis after this fracture dislocation is poor because of the very high risk of avascular necrosis. INTRODUCTION Fracture dislocations of the talar body are rare and a source of serious injuries. Simultaneous fracture of the talus and the ankle are exceptional. These fractures result from high injury. The prognosis after talar body fracture dislocation is determined by the severity of the injury and the quality of reduction and internal fixation. The case reported is unusual combination of multiple articular fractures of the distal tibial with a fracture dislocation of the body of talus. CASE REPORT A 26-year-old man, admitted to our Emergency Department, had sustained a close injury to his right ankle after an axial compression injury with inversion. The physical examination revealed an obvious deformity of the ankle with his foot lying supinated and adducted, intact skin with no neuro-vascular deficit. Radiograph revealed a displaced oblique fracture of the medial malleolus and tibial pilon with an associated posterior dislocation of the talar body and minor avulsion of lateral process (fig.1). Figure 1 Figure 1: Pre operative radiographs Open reduction and internal fixation was performed through a medial approach. The talar body was found completely rotated behind the tibia. After gross reduction of the talar body, fine reduction of the fracture is achieved and fixed with two cancellous screws from medial side. The medial malleolus and tibial pilon fracture were reduced and fixed with two cancellous screws and k-wires. The stability of the construct was assessed and found to be satisfactory requiring no further fixation. Post-operative radiographs were satisfactory (fig.2). A below knee cast applied for six weeks and the patient was kept nonweight bearing for another 6 weeks. Unusual fracture dislocation of the ankle 2 of 4 Figure 2 Figure 2: Post operative anteroposterior and lateral view He was allowed to partially weight bear at three months and full weight bearing was commenced at four months. At 12 months follow up, the patient had dorsi flexion of 15°, planter flexion of 20° and full range of subtalar joint mouvements. He had a stable ankle and minimal pain on walking uneven ground. The radiographs taken at this time showed no evidence of avascular necrosis (fig.3). Figure 3 Figure 3: Anteroposterior and lateral radiographs at 12 months follow up DISCUSSION Fractures of the talus have a relatively low incidence accounting for 0.3 % of all bone fractures and 3-6 % of all foot fractures (1, 2, 3, 4) These injuries affect the neck of the talus more than the head or the body. Talar body fractures of the talus are uncommon accounting for 7-38 % of all talus fractures (4, 5, 6). A combined talar body fracture and medial malleolus fracture is exceptional. We identified only 3 cases of this combination (5,7, 8) without any dislocation of the talar body fragment or pilon fracture. We could not find any reports in literature mentioning this combination of talar body fracture dislocation and medial malleolus with pilon fracture. The mechanism of injury of these fractures is not clear but is thought to be similar to the one of talar neck and pilon fractures, dorsi flexion but with added axial compression. The axial force is transmitted through the sagittal axis of the dome of talus and usually produces comminution of the talar body or tibial pilon. Supination may have contributed to this injury in view of the medial malleolus fracture. In our case, there is a significant displacement of the talar body fragment with concurrent sub dislocation of the ankle. Peterson (9) proposed in this displacement fracture, that the talus acts as a cantilever between the distal tibia and the strong sustentaculum tali of the calcaneus. If the energy is not exhausted, the talar body is extruded posterioly with deltoid ligament. This mechanism is facilitated by the displaced fracture of the medial malleolus. Sneppen (6) classified talar body fractures into five groups: Compression injuries ; Shear fracture(Coronal, sagittal or horizontal) ; Fracture of the posterior process ; Fracture of the lateral process ;

Fractures of the talus in the pediatric patient

Talar fractures are relatively uncommon, with an incidence of 0.1% to 0.85% of all fractures and 3% to 6% of all foot fractures. Among these, talar neck fractures are more common than those of the talar body, typically occurring in the coronal plane. Restoration of joint congruency is necessary to reduce the incidence of osteonecrosis and post-traumatic osteoarthritis. Most fractures occur in the talar neck or body in the coronal plane. In the present case report, authors present a sagittal plane fracture of the talar body in combination with a bimalleolar fracture in a 45-year-old female, managed with open reduction and internal fixation using screws. In the present case, the dual approach, which is ideal, could not be performed due to the condition of the wound over the lateral aspect of the ankle. Proper planning regarding the timing of surgery, considering the swelling and soft tissue status, alongside proper anatomic reduction and rigid fixation with good surgical technique and postoperative rehabilitation, are key to achieving favourable clinical outcomes.

目的 探讨距骨体与距骨颈骨折患者采用切开复位内固定术在治疗和预后上的差异.方法通过对1996年4月～2003年9月间17例SneppenⅡ型距骨体骨折患者与19例Hawkins Ⅰ、Ⅱ型距骨颈骨折患者均采用切开复位内固定,将Hawkins评分优良率、距骨缺血坏死率、胫距关节创伤性关节炎发生率和距下关节创伤性关节炎发生率进行对比,使用x2检验确切概率法分析.结果SneppenⅡ型距骨体骨折患者Hawkins评分优良率为64.7%(11/17),距骨缺血坏死率17.6%(3/17),胫距关节创伤性关节炎发生率41.2%(7/17),距下关节创份性关节炎发生率64.7%(11/17).Hawkins Ⅰ、Ⅱ型距骨颈骨折患者Hawkins评分优良率为73.7%(14/19),距骨缺血坏死率15.8%(3/19),胫距关节创伤性关节炎发生率15.8%(3/19),距下关节创伤性关节炎发生率36.8%(7/19).四种评价指标两组之间比较,差异无显著性意义(P＞0.05).结论距骨体和距骨颈骨折仅是解剖学上的概念,目前对于两种骨折的预后没有区分意义.对有移位(≥2 mm)的距骨体或距骨颈骨折患者均应视软组织条件行切开复位内固定,保护残存血运,解剖复位,减少创伤性关节炎和距骨缺血坏死的发生。

As reported by Coltart [5], Fabricius von Hilden first described talus injuries in 1608, and in 1919, Anderson et al. [1] reported a series of talus fracture dislocations in which they emphasized dorsiflexion as the mechanism of injury and coined the term ‘‘aviator’s astragalus’’ (astragalus being another term for talus) because of the impressive frequency with which the mechanism—aircraft accidents— was associated with the injury in question. In 1952, Coltart [5] reported on 228 talus injuries treated by surgeons in the British Royal Air Force in an attempt to describe the variety of injuries that occur to the talus and surrounding joints. He described various talus fracture patterns, fracture-dislocation combinations, and isolated peritalar dislocations [5]. Others have presented case series of talus injuries and associated rarely used classification schemes [15, 19], but all have noted high complication rates with injuries to the talus [5, 11, 15, 19]. In 1970, proposed treatment strategies for vertical fractures of the talar neck ranged from nonoperative management to urgent open reduction internal fixation, bone graft augmentation, fusion of the dorsal talus to the distal tibia, and even complete talectomy [11]. Although the importance of early, anatomic reduction of these injuries was noted at that time, the incidence of avascular necrosis (AVN) was not. In 1970 Hawkins [11] described injury patterns and AVN rates in a series of 57 vertical talar neck fractures in 55 patients from three different institutions. All 55 patients sustained forced dorsiflexion injuries, similar to the mechanism described by Anderson et al. [1] in pilots.

Patient: Male, 37Final Diagnosis: Talar neck fracture dislocation combined with bimalleolar ankle fractureSymptoms: Mild ankle painMedication: —Clinical Procedure: Open reduction and internal fixationSpecialty: Orthopedics and TraumatologyObjective:Rare co-existance of disease or pathologyBackground:Fractures of the talus are uncommon injuries that usually involve the talar neck, rather than the talar body. This report is of a rare case of combined left talar neck fracture and adjacent joint dislocation with an ipsilateral bimalleolar ankle fracture.Case Report:A 37-year-old man presented with an injury to his left foot following a motor vehicle accident. When he presented to the hospital emergency department, his left foot and ankle were swollen, the overlying skin was intact but badly contused, and there was no neurovascular deficit. Radiographs of the left ankle showed a fracture of the talar neck and bimalleolar fracture. An initial closed reduction under anesthesia failed. Therefore, open reduction and rigid stabilization of all fractures were achieved surgically, followed by the application of an external fixator spanning the ankle and the subtalar joints. The external fixator was removed at six weeks, range of motion (ROM) exercises were commenced, and a non-weight-bearing mobilization protocol was continued for 12 weeks. At four-year follow-up, radiographs confirmed solid union of all fractures, and although avascular necrosis (AVN) of the talus and secondary ankle arthritis developed, the functional outcome was satisfactory.Conclusions:The immediate management of talar neck fracture with dislocation combined with a bimalleolar fracture is important to prevent soft tissue complications and to improve the functional ROM of the ankle. However, AVN and post-traumatic osteoarthritis at both the ankle and the subtalar joints are still common sequelae of talus fracture.

Fractures of the lateral process of the talus have been associated with snowboarding, so much so that they have earned the nickname “snowboarder’s ankle”; these typically occur with relatively low-energy injuries when compared with fractures of the talar head, neck, and body. We have observed that snowboarding portends a higher risk of talus fractures when compared with skiing and can include higher energy injury patterns. This study describes a series of talar head, neck, and body fractures caused by snowboarding, their treatment, and outcomes. A retrospective chart review was performed on all surgical cases collected from 2007 to 2012 to include talar head, neck, body, or lateral process fractures sustained while snowboarding. Radiographs were reviewed and the fractures were characterized. Questionnaires, including the Foot and Ankle Disability Index (FADI), were mailed to the patients. The pre-operative reports, surgical treatments, and outcomes were evaluated. Nine patients were identified with fractures of the talus caused by a snowboarding injury. One patient sustained an isolated talar head fracture, three sustained isolated talar neck fractures, one patient had an isolated talar body fracture, and two patients had isolated lateral process fractures. Two patients had a combination of talar injuries. At 2.5 years mean follow-up (range 6 months to 5 years), none of the patients developed avascular necrosis, nonunion/malunion, or required subsequent surgery. FADI scores indicated good to excellent results post-operatively.

To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors. Retrospective chart review. 21 US trauma centers and 1 UK trauma center. Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation. The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes. In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions. Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

A rare combination of talar neck fracture (Hawkins 3) and bimalleolar ankle fracture: A case report

The treatment of talar neck and/or body fractures is known to be difficult and challenging, with significant impact on the long-term functional outcome for the patient. The optimal management, including the choice of surgical approaches and implants, are still under constant discussion. The purpose of the study was to investigate the clinical effects of lateral mini-plate combined with medial lag screws for the treatment of complicated central talar fractures. The data of eight patients with complex central talus fractures treated between June 2019 and January 2021 were retrospectively analyzed. There were six males and two females, ranging in age from 15 to 66 years, with an average age of 37.4 years. There were three cases on the left and five cases on the right. All fractures were comminuted, including talar neck with talar body fracture in seven cases and talar body comminuted with subluxation of subtalar joint in one case. All patients were treated with the anteromedial combined anterolateral approach, lateral talar mini-plate fixation and medial lag screw fixation. Fracture reduction quality, union time, and complications were recorded, and functional outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) scoring system. The time from injury to surgery was 1-6 days, with an average of 3.38 days. The follow-up period was 34-53 months (mean 44.88 months). All fractures healed with a mean healing time of 16.75 weeks (13-23 weeks). Anatomical reduction was observed in six cases and near in two cases. After operation, there was no loosening or breakage of implant, loss of fracture reduction, and irritation of skin and soft tissue by internal fixation. The average AOFAS score was 87.38 (48-100), with excellent five cases, good two cases and poor one case, and the excellent and good rate was 87.5%. Superficial skin necrosis in one surgical incision healed after dressing exchange. No deep infection occurred. One case (1/8, 12.5%) developed avascular necrosis of the talus without collapse. Posttraumatic arthritis was found in four cases (4/8, 50%). The utilization of lateral mini-plates in combination with medial screws for treating complex central talar fractures results in satisfactory reduction and stable fixation, mitigating complications associated with poor reduction. However, due to the absence of an anatomical mini-plate, pre-contouring is necessary when applying the lateral plate. This demands a surgeon's thorough familiarity with the anatomical morphology of the talus and proficiency in surgical techniques. Posttraumatic arthritis is the most common complication of complex central talar fractures.