Talus Fracture

Talus Fracture

Fractures of the talus can be divided into types based on the 3 main anatomic divisions of the talus: body, neck, and head. Fractures of the body of the talus are further subdivided based on whether they traverse the main portion of the body or are fractures involving the talar dome, lateral process, or posterior process. Mechanisms of injury, treatment, and prognosis of the different types of talar fractures are markedly dissimilar.

The talus is unique as there are no tendons attach to it. It is held in place by ligamentous and bony structures. The talus articulates superiorly with the tibia, medially and laterally with the medial and lateral malleoli (respectively), inferiorly with the calcaneus, and anteriorly with the navicular. A talus fracture is immediately noticeable, as it causes intense, throbbing pain. A person may become nauseous and lightheaded because of the overwhelming pain and be unable to bear any weight on the injured foot. Swelling and stiffness occur very quickly.

The talus bone is one of the most important bones that make up the ankle joint. The talus is a compact bone that sits between the calcaneus (heel bone) and the tibia and fibula (bones of the lower leg). Much of the talus is covered with cartilage, a smooth, slippery substance that provides cushion and allows these bones to move more freely against each other. Because the talus is a primary connection between the bones of the ankle, a fractured talus can severely limit the ability to walk and bear weight.

The talus is one of the important bones that makes up the ankle joint. Over one half of the talus is covered with cartilage–it serves as an important link between the leg and the foot. The talus moves not only at the ankle joint, but also below the ankle and in the midfoot. Therefore, injuries to the talus can affect motion of the ankle and foot joints.

Symptoms:
A fractured talus causes intense pain, swelling, bruising and the inability to put any weight on the ankle. Because these symptoms are similar to those of a severe ankle sprain, it’s important to get immediate medical attention and an x-ray to determine if there is a bone fracture. To limit swelling immediately after any ankle injury, wrap the injured ankle in ice and get medical attention quickly.

Most talar fractures are marked by
acute pain
an inability to bear weight
considerable swelling and tenderness

A fracture that breaks through the skin has an increased risk of infection. Talar fractures that result from snowboarding injuries may be mistaken for ankle sprains because of the tenderness on the outer side of the ankle and severe bruising.

Causes:
Talus fractures most often result from a fall from a height, or a severe impact to the foot, such as those caused by a car or motorcycle accident. Some experts believe an increase in talus fractures among snowboarders might be related to the use of a soft boot that, unlike ski boots, aren’t stiff enough to adequately protect the ankle from injury during crashes.

Most injuries to the talus result from motor vehicle accidents, although falls from heights also can injure the talus. These injuries are often associated with injuries to the lower back. An increasing number of talar fractures result from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries.

Because talus fractures often irritate the smooth cartilage covering the talus bone, many people develop arthritis in the ankle joint after a fracture. Another more serious outcome of a talus fracture is something called osteonecrosis or avascular necrosis. Due to its location, the talus bone has a very limited blood supply. If the fracture disrupts this blood supply, the bone may fail to heal properly and may actually die. Specific imaging exams, such as an MRI, may be performed in order to monitor the blood supply to the talus as the fracture heals.

Fractures of the talus can be quite devastating. These are difficult fractures to treat, and even with good correction and fixation of the fracture, numerous complications can occur. Some of these are as a result of deformity, some from arthritis, and some occurring when the blood supply to the talus bone is damaged.

Diagnosis
Your doctor will examine your foot and ankle and ask you to describe how the injury occurred. X-rays of your foot and ankle are very likely to be required. In some cases, the X-ray will not show the fractures, so a computed tomography (CT) scan may be needed. These diagnostic tests will help pinpoint the location of the fracture. They also will show whether the bones are still aligned (no displaced fracture) or have shifted out of place (displaced fracture). Any loose bits of bone that may need to be removed also can be identified.

The doctor will check the functioning of the nerves to the foot to ensure that there is no damage. Adequate supply of blood should keep flowing to the toes and pressure building in the muscles of the foot (compartment syndrome) should be avoided.

Classification
The most commonly used classification system is the Hawkins classification of talar neck fractures.
Type I – non-displaced talar neck fracture
Type II – displaced with subluxation or dislocation of subtalar joint
Type III – displaced with dislocation of body from ankle mortise
Type IV – displaced with subluxation or dislocation of talonavicular joint
Other types of fractures include talar head fractures, talar body fractures, lateral process fractures, and posterior process fractures.

Treatment:
The specific treatment of a talus fracture generally depends upon the severity of the fracture. Small fractures that are in proper alignment may heal on their own if immobilized for several weeks with a cast or a boot. More severe fractures that result in the talus bone breaking into pieces that move out of alignment require surgery to re-align the bones and hold them together with screws or pins as they heal. Bone chips or fragments also may need to be removed to allow the joint to heal properly.

A talar fracture that is left untreated or that doesn’t heal properly will create problems later. There are increased chances of the foot function being impaired and developing arthritis, chronic pain, and also the risk of a bone collapse. Immediate first aid treatment for a talar fracture is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf. Elevate the foot above the level of the heart and apply ice for 20 minutes every hour or two until a doctor is available. Don’t put any weight on the foot.

In rare cases, a talar fracture can be treated without surgery if X-rays show that the bones have not moved out of alignment. You will have to wear a cast for at least six to eight weeks and will not be able to put any weight on the foot during that time. Afterwards, the doctor will give prescribe some exercises to help restore the range of motion and strength to your foot and ankle.

Healing Process:
Simple talus fractures may heal after six to eight weeks in a cast or a boot. If complications occur, the recovery from a talus fracture may take longer or may result in long-term ankle joint dysfunction or activity restrictions. It’s important to work with your surgeon and your physical therapist throughout your recovery in order to have the best possible outcome.

After the surgery, the foot will be put in a cast for six to eight weeks and you will not be able to put any weight on the foot for at least three months. As the bones begin to heal, the orthopedist may order X-rays or a Magnetic Resonance Image (MRI) to see whether blood supply to the bone is returning. If the blood supply is disrupted, the bone tissue could die, a condition called avascular necrosis or osteonecrosis. This could cause the bone to collapse.

Even if the bones heal properly, you may still experience arthritis in later years. Most of the talus is covered with articular cartilage, which enables bones to move smoothly against each other. If the cartilage is damaged, the bones will rub against each other, resulting in pain and stiffness. Treatments for arthritis include activity modifications, ankle-foot orthoses, joint fusion, bone grafting and ankle replacement.

The talus is a critical bone of the ankle joint. It connects the leg and the foot. Recovery after fractures of the talus can be prolonged. Walking and weight bearing on the foot cannot occur for eight to twelve weeks. Once the bone is healed, however, exercise and physical therapy is initiated to maximize the function of the ankle. If avascular necrosis of the bone occurs then one has to be more careful with the type of exercise and activities that are initiated. Walking and exercise are still permitted. There are surgical procedures that can be performed if avascular necrosis develops to try to improve the blood circulation to the talus bone.

Prevention:
Most fractures of the talus require surgery to minimize later complications. The orthopedic surgeon will realign the bones and use metal screws to hold the pieces in place. If there are small fragments of bone, they may be removed and bone grafts used to restore the structural integrity of the joint.