The Diagnosis, Management and Complications Associated with Fractures of the Talus

The double dislocation with postero-medial extrusion of the talus places the posterior tibial neurovascular bundle at high risk (22, 96). The Hawkins classification was subsequently modified by Canale and Kelly in 1978 after the analysis of seventy-one fractures of the neck (22) (tab. 1). Peterson et al experimented mechanisms of neck fractures on twenty cadavers. A stronger force may result in subtalar or tibiotalar dislocations. The widely accepted definition is the one proposed by Inokuchi S, who examined 215 fractures of the talus; this classification is based on the location of the inferior fracture line. These fractures were historically considered as the most frequent of the talus (16, 21, 93).

Aviator’s Fracture – Bilateral Fracture-Dislocation of Talus in a 29-year-old Patient: A Case Report

Also, the Mongolians and other cultures used animals’ talus bones as dice for fortune-telling . In Latin literature, the word talus is first documented in the Miles Gloriosus by Plautus, where it is used in the double meaning of part of the ankle and gaming dice . The blooming of orthopaedic surgery at the end of nineteenth century and the high volume of traumas managed in the World Wars brought a better understanding of fracture patterns and their operative treatment.

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Canale and Kelly also were unable to identify a way to predict which Type II injuries would progress to have AVN develop . Hawkins was the sole author on his landmark 1970 paper ; as such, he was the only observer to classify the injury patterns he described, therefore he could not provide interobserver reliability data, and he also did not provide intraobserver reliability. In 2013, Halvorson et al. validated the rates of AVN based on the modified Hawkins injury classification . Talus fracture, Calcaneus fracture, Osteonecrosis, Os trigonum, Mondor sign, Hawkins sign, Bohler’s angle, Aviator’s astralgus They are treated by stabilizing the fracture fragment with screws (Figure 11).

Optimizing Orthopedic Outcomes in Complex Bilateral Talus Fracture-dislocations with Medial Malleolu…

Chronic, repetitive abnormal stress placed on normal bone, resulting in bony remodeling and microfracture 20 Symptoms can include a weak pincer grip and pain over the metacarpophalangeal (MCP) joint 16. S. Campbell documented a specific overuse injury pattern seen amongst Scottish gamekeepers who used their thumbs as a focal point to break the necks of rabbits and fowl 16. It can sometimes be seen in motor vehicle accidents, where abrupt deceleration forces resulting in significant neck whiplash can reproduce this injury 14. In 1904, Just-Marie-Marcellin Lucas-Championnière, a French orthopaedic surgeon, observed an emerging type of radial fracture amongst cab-drivers and chauffeurs 8. Sudden hyperextension and abduction injury of the wrist, with impaction of the radial styloid process by the scaphoid bone 7

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Talar neck fractures are by far the most common, accounting for 50% of these injuries, and are classified using Hawkins classification. Larger fractures and displaced fractures are treated with open reduction and internal fixation 33, 34. For all other talar head fractures, operative fixation is advised .

Bilateral talus fracture dislocation: Is avascular necrosis inevitable?

Treatment should be expedited where there is evidence of neurovascular deficit or open injury. Where a fracture is non-displaced and small, it may be managed with cast immobilisation. They may be difficult to diagnose on plane x-ray and clinically can appear similar to an ankle sprain. They are usually sustained when the foot is plantar flexed and there is a forced axial load. These include talectomy, pantalar arthrodesis, tibiotalar arthrodesis and tibiocalcaneal arthrodesis.

Treatment Options and Outcomes

He did not report on comminuted fractures or those involving the body of the talus, as he believed these to be more problematic injuries and outside the scope of his article . Talus fractures were historically referred to as “Aviator’s astralgus.” In the early 20th century, plane crashes at sub-lethal speeds were common, resulting in high-impact injuries to the foot including talus fractures. One of the most common injuries is a thoracolumbar spine fracture, which occurs in 10% of patients with calcaneal fractures. They are classified, with increasing severity, as nondisplaced; displaced but with an intact ankle joint; and displaced with subluxation/dislocation of both the subtalar joint and ankles joints.

Treatment / Management

Unnatural posture, together with WBV and prolonged use of HSM, contributes to a 67% 12-month prevalence of neck pain, 48% prevalence of low back pain, and 43% prevalence of shoulder pain over the same period in RWA pilots (Posch et al., 2019). For astronauts, the neck is similarly vulnerable with nine instances of trauma to the neck reported in United States astronauts (the eighth leading cause of in-flight musculoskeletal injury to astronauts) (Scheuring et al., 2009). Pilots often report previous exposures that may predispose them to chronic pain or degenerative pain including hard landing, autorotation, parachute landings, and exercise injuries (Walters et al., 2013; Jones et al., 2015).

Description of Hawkins Classification

In his series of 228 talar fractures treated by Airforce surgeons, published in 1952, 106 of the most severe injuries affected combat air crash survivors. In the 1930s, with the publication of several important studies on fracture patho-biomechanics, the concept of accurate anatomical reduction of closed talar fractures as extolled by Miller and Baker in 1939 was the first scientifically informed attempt improving prognosis. Around the same period, Ernst Von Bergmann ventured to perform what is thought to be https://lopesezorzo.com/ the first open reduction of a fracture dislocation of the talus . Minimally displaced fractures, compound fractures and self-reduced dislocations kept their secrets from the all-seeing X-ray eye and continued to be managed as ankle sprains . In 1818, Cooper published a case series of talus fractures, complete with the description of each injury and clinical decision-making based on severity . Examining the wound, he estimated that the conic-cylindric bullet was in the body of the talus, shown also by the great quantity of talar bone fragments in the wound.

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In more experienced crew, the pain is understood as a degenerative change or inability of an aging body to perform under repeated stress, a concept that is supported by MRI evidence of increased degenerative cervical spine changes in the IVD of pilots (Johnston et al., 2010). In the first group, the pain could be best understood because of adaption to new forces on an unconditioned body. For astronauts, in-flight neck and shoulder pain during use of the Materials Science Glovebox on Spacelab was attributed to severe neck flexion and a hunched posture required in its operation (Whitmore et al., 1996).

• Furthermore, the undersurface of the combined tubercles articulates with 25% of the posterior facet of the calcaneus.
• Talus is the only bone of the lower
• The authors described 48 patients in Northern Australia with orbital fractures who were transported via airlift to a hospital for more definitive care.
• Avascular necrosis of the talus occurred after one Hawkins 3 injury.
• The talus classified as Hawkin type III on the right ankle and

Current Concepts in Talar Neck Fracture Management

Hindfoot fractures frequently occur in association to subtalar dislocations; there could be fractures of the posterior process of the talus, osteochondral fractures and calcaneus fractures. Fractures of the talus can be classified by their anatomical locations, and include talar neck, head, body, lateral process and posterior process fractures. Traumatic arthritis of the ankle and subtalar joint were found by Canale and Kelly to be a significant problem after talus fracture, occurring in more than 1/2 of their patients, 1/3 of whom had a malunion . Based on additional detail provided by advanced imaging, Williams et al. proposed differentiating the talar neck from talar body fractures by defining body fractures as those involving the tibiotalar joint and the subtalar joint; neck fractures are anterior to the joints . The purpose of his publication was to describe vertical fractures of the neck of the talus, their common correlation with adjacent joint dislocations, and report the incidence of AVN in the body of the talus after these injuries . In 1970 Hawkins described injury patterns and AVN rates in a series of 57 vertical talar neck fractures in 55 patients from three different institutions.

A violent-type hyperflexion injury of the neck, with resultant counterforce produced by the trapezius / rhomboid muscles or the supraspinous / interspinous ligaments 11 When bracing for impact, the sole of the pilot’s foot is pressed against the rudder bar, where the talus absorbs the force of the axial load and becomes the centre of fracture 3. The authors described ophthalmic injuries from 17 patients with injuries ranging from periorbital edema and ecchymosis to retinal hemorrhages and optic atrophy. His injury resulted in concussion, vitreous hemorrhage, retinal edema, enophthalmos, large orbital blowout fractures, and inferior and medial rectus muscle entrapment. Typical etiologies of orbital fractures include motor vehicle collisions, assault, and sports-related injuries 2, 3.

It confirmed the long-held suspicion that talar fractures are seldom isolated, and that the accurate patho-anatomy of dislocated or subluxed fractures can be extraordinarily complex 49,50,51,52. He proved that the risk profile of talar fractures remained severe even in the face of diagnostic and technical advancement. In that year, Professor LD Hawkins of Iowa published a study on talar fractures and the risk of avascular necrosis. Scientific tributes to talar fractures kept increasing, with names as great as Tillaux, Chaput, Destot and Labbe entering the arena. The innovation did prove valuable, but not game changing, as far as talar fractures were concerned .

First described talar fracture: the injury of Darius I

Furthermore, the undersurface of the combined tubercles articulates with 25% of the posterior facet of the calcaneus. The posteromedial tubercle provides attachment to the posterior third of the deltoid ligament superiorly and the medial limb of the bifurcate talocalcaneal ligament inferiorly. Conservative treatment was considered the mainstay; however, studies with long term-follow-up revealed that large intra-articular fragments more frequently ended up into mal union or non-union, if treated conservatively 12, 13, 14, 15. Computed tomography scan must be done in all suspected cases of Cedell’s fracture .

Prompt transportation to an orthopedic care facility is recommended for the patient if a clinician is unavailable. Patients will need non-weight-bearing and immobilization if deemed appropriate for 6 to 8 weeks until the fracture healing is confirmed. The authors also reported an association with poor patient-reported outcomes and the development of postoperative complications.

• They are not common as they account for 3-5% of ankle and foot fractures and 0.85% of all body fractures.
• The authors achieved this eliminating all movements in the ankle joint and fixing the body of the talus as a cantilever between the tibia and the calcaneus.
• High-energy impact is necessary to cause hindfoot fractures and this may cause other injuries to the lower limb.
• Injuries caused by brake pedal loading of the midfoot.
• Of the tibial malleolus and ankle brace (walker brace).

Isolated lateral process fractures are usually difficult to detect during standard initial radiographs (81). Os trigonum (A, B) has round or oval shape and smooth edges, with complete cortical covering and does not fit with the posterior aspect of the talus. Differential diagnosis between os trigonum and posterior process fracture. Pain could also be seen with passive handling of the toe because of the anatomic location of flexor hallucis longus tendon in the hindfoot near the posterior lateral tubercle. Different types of lesions have different treatment and prognosis. The reported incidence of talar body ranges from 13% to 61% (16, 67).

TALAR BODY FRACTURES

The risk of avascular necrosis in talar neck fractures is 10% or less if the fracture is not displaced; the risk is close to 100% if there is disruption of subtalar, ankle and talonavicular joints. Lindvall E, Haidukewych G, DiPasquale T, Herscovici D, Sanders R. Open reduction and stable fixation of isolated, displaced talar neck and body fractures. In a series of 70 talar neck fractures, Sanders et al, demonstrated that the incidence of foot and ankle reconstructive surgery following https://xolivi.com/ fixation increased over time. Fractures of the talus are the second most common injuries of all tarsal bone fractures, with talar neck fractures accounting for approximately 50% of all talus fractures.

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The concern remains that loss of BMD and changes in bone architecture in microgravity can contribute to the risk of injury in astronauts which may persist for months after return to Earth’s gravity (Lang et al., 2004; Vico et al., 2017). Bone mineral density loss can also predispose to fracture, but none of over 50 fractures in active United States astronauts can be definitely attributed to exposure to microgravity (Ramachandran et al., 2018a). This suggests a degenerative component analogous to that implicated in the development of spine injury in other aviators, especially RWA pilots subjected to whole body vibration (WBV) (Walters et al., 2013). Computer modeling suggest these changes in both cortical and trabecular bone result in significant overall loss of bone strength that predisposes to injury and long-term sequelae if reconditioning does not sufficiently recover pre-flight strength (Keyak et al., 2009). Evidence suggests that many pilots do not report pain or injury and continue to fly because of fear of losing flight status (Kikukawa et al., 1995; Kerstman et al., 2012; Posch et al., 2019). The same period prevalence for neck and back pain in the general population is approximately 37 and 15%, respectively (Andersson, 1999; Fejer et al., 2006).