4/14/2015 talar fractures anatomy, imaging, classification · pdf filedisplaced fractures of...
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Talar Fractures:Anatomy, Imaging, Classification
Clifford B. Jones, MD FACSOrthopaedic Associates of Michigan
Clinical Professor, Michigan State University/CHMAdjunct Professor, Van Andel Research Institute
Grand Rapids, MI
Talar Fractures:Anatomy, Imaging, Classification
Clifford B Jones, MD
The following relationships exist:
Partial Owner: Midtowne Surgical Center
Grants: OTA, NIH/FAITH, DOD/METRC
Boards non reimbursed: OTA, MAOA, MOS
Talar Fractures
• Talar Neck
• Talar Process
– Lateral Process
– Posterior Process
• Talar Dome
• Talar Head
• Usually high energy – fall, MVA
• Associated Fractures
Neck > Body > Lateral/Medial Process
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Evaluation
Integument/Skin
Tendon/Function
Vascular
Neural
Medial
Lateral
Clawing of Toes
Tendon Entrapment
Blistering of Skin Ecchymosis
Osseous Anatomy
DorsalPlantar
Lateral Medial
60% Articular Surface
Multiple 3D Articulations
Determine Motion
No Muscle Attachments
Minimal Ligament Attachments
Ligament Anatomy
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Vascularity
Vascular Anatomy
Many disrupted at time of injury
Careful to maintain dorsal capsule and inferior
ligaments
Radiographic Imaging• Lateral Ankle
– Neck & Posterior Process
• Mortise Ankle
– Talar Dome & Lateral Process
• Broden
– Lateral Process
• Canale
– Talar Body & Neck
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CT Imaging
• Reconstruction
– Axial
– Coronal
– Sagittal
• 3D with & without other osseous structures
– True anatomical relationships
– Determine other associated injuries
OTA/AO Classification
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Hawkins ClassificationHawkins, LR, JBJS, 52A: 991, 1970
I) Nondisplaced<10%, OTA 81-B1
II) Subtalar Displacement<40%, OTA 81-B2
III) Subtalar & TC~90%, OTA 81-B3
IV) *Pantalar100%
*Canale, ST, JBJS, 60A: 143, 1978
81-B1 81-B2
81-B3
Example – Hawkins 1 or 2
Hawkins 2
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Hawkins 2 with lateral process fx
Hawkins 3
Hawkins III with Talar
Dome
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Lateral Process Fractures
Frequently missed (40%)
Suspect in all ankle injuries
Snowboarders
Dorsiflexion Inversion
External rotationBoon A.J., et.al. Am J Sports Med 2001
May July29(3):333-8
Skate boarder
Posterior Process Talus
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Talar Body
Fracture
Talus Conclusion
• Injury
– High Energy – Fall, MVA
• Anatomy
– Complex 3D Articulations
– No Muscular Attachments
• Vascularity
– Sinus Tarsi a.
– Tarsal Canal a.
• Classification
– OTA/AO
– Hawkins
Thank You
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Dolfi Herscovici, Jr, DOFoot Ankle/Trauma Service
Tampa General HospitalTampa, Florida
The author has not received anything of value from a commercial company or institution related directly or indirectly to the subject of this presentation
SLACK IncorporatedRoyalties
Full Disclosure Online at AAOS.org
EPIDEMIOLOGY
0.34% of all fractures
30-50% of all talar fractures are necks
3.4% of all foot fractures
13% Neck fxs present as open injuries
Mechanism of injury: Dorsiflexion/Axial load
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Occur infrequently at a rate of 1% of all talar fractures
Not much in literature, most are discussed as part of talar neck injuries
Mechanism of injury Axial compression of
talus between calcaneus and tibial plafond
During weight
bearing > 90%
of the load
applied to the
central part of
the talar dome.
– Kimizuka et al. Arch Orthop Trauma Surg1980; 96:45-49.
Decrease in 42 percent of contact of the tibio-talar joint with 2mm of displacement
Ramsey/Hamilton, JBJS-Am, 1976
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2 mm neck displacement alters mechanics of the ant and middle facets of the subtalar joint
Sangeorzan et al, J Orthop Res, 1992
Indications: Non-Displaced Fractures of the Talus Need to be certain that
this is truly a nondisplaced fracture. Any displacement indicates some degree of subtalar subluxation
CT scan
Indications: Any Displaced
Body or Types II-IV Neck Fractures
ALL NEED SURGICAL TREATMENT!!!
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The Key is to recognize the injury
60 y/o F, fell through attic
Day 39
Open fracture?
No: Elective treatment
Yes: Emergent Treatment
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Is there a dislocation?
No: Elective treatment Yes: Emergent reduction
Physical Examination Foot is often swollen
Ecchymosis, Blisters +/-
Check for wounds
Neurovascular exam Pulses
Temperature
Refill
Sensation
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Until good wrinkling of the skin is noted
Make take 2-3 weeks
Don’t fit them conveniently into surgery schedule
Splint all patients
See them at weekly intervals
Day of Injury
Day 17
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All displaced fractures body and neck need surgery
Emergent Care
Dislocated fractures
Open fractures
Wait for skin wrinkling
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Current Concepts in Talus Surgery
April 14, 2015
Demonstrate familiarity with…
•Dual approach
•Posteromedial approach to talus
Introduce typical fixation constructs
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Medial Lateral
Superior Inferior
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Anterior Posterior
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Medial LateralAssess dorsomedial Extra-articular neck
comminution Subtalar debris
Lateral process fx
CombinedRotational reduction
Axial alignment
Medial Approach
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Inaccessible medial body fx
Precise aim toward medial shoulder
Drill prior to osteotomy
Osteotomy
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Distraction to facilitate visualization
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Summary:
Dual approaches required
Lateral: Subtalar joint, lateral process, extra-articular neck
Medial: Assess comminution
Both: Rotational and axial alignment
Small caliber implants
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Thank you!
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Peter A. Cole, MDProfessor, University of Minnesota
Chief of Orthopaedic Surgery, Regions Hospital
April 14, 2015
Vu Medi Webinar
Lateral Process
Talar Fractures
“The Ankle Sprain that isn’t”Steve Benirschke, MD
Lateral Process Fractures
39 Year old twisted ankle playing soccer.
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6 Months Later
AP MORTISE
LAT
RadiographsMortise, Lateral, Canale
CT SCAN
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X-rays Mortise View
X-rays Lateral View
X-rays Canale View
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Canale View
Canale et al, JBJS 62A, 1978
Fracture Patterns
Small Substantial ( % of SubTalar Joint)
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Treatment Decision
Based upon SIZE and % of SubTalar Joint
Fix
Vs
Debride
Small Fragment & Small %
Immobilize/Cast 6 weeks
If chronic pain or nonunion
Debride Later
Fixation: Implant Selection
Mini Frag 1.0mm – 2.7mm ø Screws
Single Large Fragment
2.7mm ø Screw Adequate
Comminuted Fracture
2.0mm Buttress plate
fits hollow of hard lat talar process shelf & Talar Neck Junction
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Surgical Approach
Incision
Over Sinus Tarsi
Ant Distal Lateral Mal
to
Base of 4th Metatarsal
Soft Tissues
Extensor Brevi mobilize anteriorly
Sinus Tarsi Fat
– debrided for adequate exposure
Preserve capsular & ligamentous attachments when possible.
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Deltoid Artery and Artery of the Tarsal Sinus
Mulfinger & Trueta, JBJS, 1970
Wound Closure
A
L
L
G
Ö
W
E
R
D
O
N
A
T
T
I
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CASE 1 29 Year old boyfriend jumping out 2nd story.
Axial CT CutsPerpendicular to Subtalar Joint
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CASE 3 CASE 249 Year old
female
stepping off
icy curb.
Surgery: 12 weeks post injury
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CASE 3 15 YO BOY BASEBALL SLIDE
Orif 3 Months Post Injury
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Take Home Messages
“The ankle sprain that isn’t.”
Mortise & Lateral X-ray
Simple vs comminuted
% of Subtalar Joint
Debride vs Fix
MinFragment fixation (1.2 mm-2.7)
Immobilize 10 days, NWB for 6-8 weeks
T H A N K Y O U