Talus Fractures: Evaluation and Treatment

Christopher Lee, MD; Dane Brodke, MD; Paul W. Perdue, Jr, MD; Tejas Patel, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(20):e878-e887. 

In This Article

Evaluation

The initial evaluation of traumatically injured patients with a suspected talus fracture proceeds according to the Advanced Trauma Life Support protocol. The examination should include a survey for other orthopaedic injuries, especially ipsilateral extremity injuries, which accompany talus fractures at a rate of 48% to 59%.[12,13] A CT scan should be obtained when there is clinical suspicion for a talus fracture because the sensitivity of plain radiographs for CT-detected fractures is 74% to 78%.[11] The skin and neurovascular status of the foot and ankle should be carefully assessed. A dislocated talar body can compromise both skin and neurovascular structures, thereby necessitating urgent surgical reduction.[6] Dislocations can receive a single attempt at closed reduction with manipulation in the emergency department, although general anesthesia is frequently required to achieve reduction. In open injuries, intravenous antibiotics and tetanus prophylaxis should be administered and sterile dressings applied.[12] Dislocated tali extruded through an open wound should undergo immediate irrigation with normal saline and be reduced into the wound.[14] If an extruded talus has no soft-tissue connections, it can be placed in a sterile antimicrobial solution and transported with the patient to the operating room before being cleaned and reimplanted (Figure 2), a strategy reviewed in one series of 19 patients and found to result in infection in only 2 of the 19.[14]

Figure 2.

Radiograph of a 55-year-old man after a fall from a moving vehicle presenting with a left open talar head fracture/dislocation. A, AP image demonstrating extruded talar head. B, Lateral image demonstrating talar head extrusion. C, Intraoperative fluoroscopy showing fixation with a lateral plate and two medial screws. D, Intraoperative fluoroscopy showing reduction and fixation of the talar neck.

Although displaced neck fractures were historically considered surgical emergencies because of a concern regarding disrupted retrograde circulation to the body, the few studies that have compared early versus delayed surgical treatment have not shown differences in osteonecrosis rates.[15] A 2017 systematic review found the average interval from injury to surgery in six studies to be 2.36 days.[16] The most modern approach seems to be urgent reduction of any dislocations, with either concomitant definitive fixation or delayed fixation being acceptable after reduction is obtained.[9,17]

Standard imaging for fractures of the talus includes a routine foot series (AP, lateral, and oblique) and an ankle series (including AP and mortise) in addition to a CT of the foot. Radiographic views specific to the evaluation of talus injuries have been described, however, are more frequently used for intraoperative than preoperative assessment. The most important is the Canale view, a true anterior-posterior view of the talar neck (Figure 3).[6] This is obtained by maximally plantar flexing the foot, pronating the foot 15° to decrease overlap of the talus and calcaneus, and angling the imaging device 75° up from the horizontal.

Figure 3.

Radiograph showing a Canale view obtained by maximally plantar flexing the foot, pronating the foot 15° to decrease overlap of the talus and calcaneus, and angling the imaging device 75° up from the horizontal.

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