Courtesy: Lyndon Mason FRCSOrth, Liverpool Foot and Ankle, UK

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Overview

• Talar fractures are uncommon injuries

• There are no studies higher than Level III evidence

• The majority of available literature consists of Level IV and Level V studies

• Current management principles are therefore based largely on accepted clinical wisdom

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Accepted Principles (“Accepted Wisdom”)

Management of talar fractures is guided by three core objectives:

1. Maintain blood supply

2. Correct deformity

3. Achieve active fracture union

Despite optimal management, complications such as:

• Avascular necrosis (AVN)

• Post-traumatic arthritis

remain common.

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Deformity and Injury Pattern

• Most talar fractures are the result of high-energy trauma

• Associated deformity often involves:

  • Subtalar joint

  • Tibiotalar joint

  • Talonavicular joint

• Severity of deformity correlates strongly with complications

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Classification of Talar Fractures

Hawkins Classification (Talar Neck Fractures)

• Type I:
  Talar neck fracture without displacement

• Type II:
  Talar neck fracture with subtalar dislocation

• Type III:
  Talar neck fracture with subtalar and tibiotalar dislocations

• Type IV:
  Talar neck fracture with subtalar, tibiotalar, and talonavicular dislocations

Increasing Hawkins grade is associated with increasing risk of AVN.

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Talar Body Fracture Classification

• Compression fracture

• Coronal shear fracture

• Sagittal shear fracture

• Fracture involving the posterior tubercle

• Fracture involving the lateral tubercle

• Crush fracture

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Surgical Approaches

Anterolateral / Lateral Approach

• Relatively less disruption of remaining blood supply

• Provides better visualization of:

  • Talar neck

  • Talar body

• Allows access to most talar fractures

Key Surgical Principle

• Avoid medial approaches where possible, as they may further compromise vascularity

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Fixation (“Metal Work”)

• Screw fixation is the most common method

• Posterior-to-anterior screw direction provides superior compression

• Use small-footprint screws to minimize cartilage damage

• Avoid passing screws through the flexor hallucis longus (FHL) groove

• Limited biomechanical evidence exists to guide optimal fixation strategy

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Subtalar Dislocation – Key Considerations

• Often associated with high-energy talar neck or body fractures

• Urgent reduction is required to:

  • Restore alignment

  • Protect soft tissues

  • Improve chances of revascularization

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Complications

• Overall incidence of:

  • Avascular necrosis

  • Post-traumatic osteoarthritis

• Approximately 30–40%

Risk Factors for Complications

• High-energy injury mechanisms

• Higher Hawkins fracture types

• Use of combined surgical approaches

• Not significantly related to fixation strategy

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Results and Fixation Techniques

• Successful internal fixation has been reported using:

  • Two Steinmann pins

  • Passed proximally across:

    • Navicular

    • Talar head

    • Fracture site

    • Talar body

• Maintains:

  • Neck length

  • Alignment

  • Stability during healing

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Does Avascular Necrosis Matter?

• In one series:

  • 71.4% (10 of 14) developed talar body AVN

  • However, secondary surgery was required in only 30% (3 of 10)

? Presence of AVN does not always correlate with poor clinical outcome

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Hawkins Sign

Definition

• A subchondral radiolucent band in the talar dome

• Indicates preserved talar vascularity

Characteristics

• Appears on anteroposterior radiographs

• Rarely visible on lateral views

• Seen between 6 and 9 weeks post-injury

Clinical Significance

• Absence of Hawkins sign strongly suggests AVN

• Presence reliably excludes AVN

Diagnostic Performance

• Sensitivity: 100%

• Specificity: 57.7%

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Summary

• Talar fractures are rare but high-risk injuries

• Management is guided by accepted principles:

  • Maintain blood supply

  • Correct deformity

  • Promote active union

• Lateral / anterolateral approaches provide access to most talar fractures

• Avoid medial approaches when possible

• Bridge plating and AP screws help maintain talar neck length

• AVN rates related to Hawkins classification have evolved with modern management

• Presence of AVN does not always mandate further surgery

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Key Take-Home Messages

• Perfect reduction matters more than fixation choice

• Blood supply preservation is paramount

• Radiographic follow-up for Hawkins sign is essential

• Complications are common but not always clinically catastrophic