The talocrural (ankle) joint is the junction of three bones: distal ends of tibia and fibular and the talus trochlear

The tibia and fibular are bound by the ligamentous structures that include the syndesmosis, anterior/posterior/transverse tibiofibular ligaments.

Collateral ligaments include the anterior and posterior fibulotalar ligaments, fibulocalcanear on the lateral side while the medial side is supported by the deltoid ligament and calcaneonavicular ligaments.

The ankle joint is not a pure hinge joint as there is some rotation around the helical axis of the joint due to the asymmetrical shape of the talus.

Precise ankle joint congruence is important for load distribution of the compressive forces across the joint.

Medial aspect of left foot

Lateral aspect of left foot

Dorsal aspect left foot

Plantar aspect left foot

Anterior axial view of right foot blood and nerve supply

The hindfoot consists of the Talus and Calcaneus.

The midfoot is formed by a cluster of small bones forming the arch of the foot and they are connected by the metatarsal bones to the toes. The bones are supported by ligaments providing support across the foot.

Talus fractures are usually the result from high energy trauma to the foot. Talar neck fractures are the common type of talar fractures with a risk of talar avascular necrosis (AVN).

Talus fractures include:

• Talar neck
• Body
• Lateral process
• Posterior process

Causes:

• Twisting/rotational movements during activity especially during sport activities
• Falls from a height
• Motor vehicle accidents

Presentation:

• Pain
• Swelling with bruising on the top and bottom of foot
• Deformity
• Inability to walk with pain that worsens with standing or walking

Clinically:

• Bruising of foot
• Hindfoot/Midfoot bone and joint tenderness
• Pain with stress testing
• Deformity
• Assess neurovascular status and compartments

Type Ⅰ: Non-displaced talus neck fracture

Type Ⅱ: Displaced talar neck fracture

Type Ⅲ: Displaced talar neck fracture with talar body dislocation

Type Ⅳ: Displaced talar neck fracture with talar body dislocation from subtalar & tibiotalar joints

Investigations:

X-ray:

• AP, Lateral & oblique and Canale (Foot in maximum equinus with 15°pronation with X-ray beam 75° cephalad from the horizontal) views.
• CT: for accurate assessment of joint congruency and also for intra-articular fracture evaluation and surgical planning. Ideal for lateral process and posterior process fracture evaluation.

Sagittal CT view showing posterior process fracture of the Talus

Type Ⅰ: Non-displaced talus neck fracture

• Conservative treatment
• Below knee Plater of Paris POP for 6-8 weeks non weight bearing

Type Ⅱ: Displaced talar neck fracture

• Attempted reduction and POP 6-8 weeks provided anatomic reduction with congruency of joints. Confirm reduction and accurate congruency with follow up assessment ensuring adequate reduction maintenance.
• Surgery

Type Ⅲ: Displaced talar neck fracture with talar body dislocation

• Surgery

Type Ⅳ: Displaced talar neck fracture with talar body dislocation from subtalar & tibiotalar joints

• Surgery

Surgery

• Open reduction and internal fixation with screw fixation

• Minimally displaced talar process or body fractures < 2mm is managed nonoperatively in a cast (Plaster of Paris)
• Displaced fractures require open reduction and internal fixation
• Symptomatic non union posterior/lateral process fractures is managed with fragment excision

Hawkins sign is a subchondral radiolucent line. Present 6-8 weeks after a talus fracture. It represents an area of osteopenia due to subchondral bone resorption, demonstrating adequate blood supply.

Approach: Anteromedial ± medial malleolus osteotomy. Additional anterolateral approach as an adjuvant approach if needed.

Drill medial malleolus and tap for lag screw fixation

Osteotomy perpendicular to screw

Perform osteotomy with oscillating saw and cut bone to the proximal articular surface, however allow final resection with osteotome

Anatomic reduction

Maintain reduction ± temporary K-wire fixation

Screw fixation

Anteromedial and anterolateral approach

Reduction

Plate and screw fixation

Foot Strengthening Exercise

Resistance Strength Exercise

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2. Fractures of the lateral process of the talus. C Tinner, C Sommer. Foot Ankle Clin. 2018 Sep;23(3): 375-395.
3. Systematic review: diagnostics, management and outcome of fractures of the posterior process of the talus. EWM Engelmann, O Wijers, JJ Posthuma, T Schepers. Injury. 2020 Nov;51(11): 2414-2420.
4. Fractures of the neck of the talus: long-term evaluation of seventy-one cases. ST Canale, FB Jr Kelly. Am 1978;60(2): 143-156.
5. Talar fractures and dislocations: A radiologist’s guide to timely diagnosis and classification. Y Melenevsky, RA Mackey, RB Abrahams, NB Thomson. RadioGraphics 2015;35:765-779.