Open Reduction and Internal Fixation of Talus Fractures: Tips and Pearls

Educational Objectives

The goal of this program is to improve management of lower extremity pathology. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and treat talar fractures.

Summary

Anatomy: articular surface covers 60% of talus with 7 articular areas; no muscular or tendinous insertions; held in position by strong capsule and ligaments; wider anteriorly than posteriorly; angles downwards (≈24° medially and plantarly); medial wall straight; lateral wall curves with good shoulder for placement of screw; blood supply includes artery of tarsal canal, artery of sinus, dorsal neck network, and deltoid ligament; anastomoses extensive; preservation of ≥1 major sources of blood allows for circulation; risk for avascular necrosis (AVN) most affected by initial displacement and quality of reduction; timing of reduction important (timing of surgery less so)

Mechanism of injury: most commonly, motor vehicle accident or fall from height; usually caused by hyperdorsiflexion of foot; dislocation most often posteromedial

Imaging: includes anterior-posterior, lateral, and 3 views of foot; Canale view — provides image of talus in profile; pronate foot and angle ≈15°; most useful intraoperatively; computed tomography — potentially useful

Hawkins classification: type I — minimally or nondisplaced; type 2 — some subluxation in subtalar joint but reduced at ankle; type III — dislocated at ankle and subtalar; type IV — also dislocated at talonavicular joint; rate of AVN 0% to 10% for type I, increasing to 90% to 100% for type IV

Treatment: urgently reduce dislocated joints; ensure accurate alignment of talar neck and stable fixation; definitive surgery can be delayed; studies show timing of fixation does not correlate with rates of AVN, nonunion, or arthritis; comminution (commonly dorsal and medial) frequently occurs because of force involved; bone graft often required

Fixation: goal to achieve sufficiently stable fixation for early motion; avoid fully compressing area with screw; lateral shoulder good place for screws if pattern of fracture allows; bury screw if placed through joint area

Postoperative protocol: patients usually immobilized for ≈2 to 6 wk; begin range of motion when wounds stable; weight-bearing usually delayed until 8 to 12 wk

Complications: include malunion, nonunion, arthritis, and arthrofibrosis; rate of osteonecrosis depends on severity of injury; associated with highly displaced fractures and malreduced fractures; not associated with timing of surgery, comminution, or surgical approach

Readings

Dodd A et al: Outcomes of talar neck fractures: a systematic review and meta-analysis. J Orthop Trauma 2015 May;29(5):210-5; Jordan RK et al: Complications of talar neck fractures by Hawkins classification: a systematic review. J Foot Ankle Surg 2017 Jul — Aug;56(4):817-21; Vallier HA: Fractures of the talus: state of the art. J Orthop Trauma 2015 Sep;29(9):385-92.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Garapati was recorded at the 19th Annual Chicago Orthopaedic Symposium, held August 16-19, 2018, in Chicago, IL, and presented by the Foundation for Education and Musculoskeletal Research. For information about upcoming meetings, visit chicagotraumasymposium.com. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OR420704

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.