May 25, 2018
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Several clinical factors determine management of talar fractures

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A paper published in EFORT Open Reviews and written by Harron Majeed, MBBS, MRCS, MSc, FEBOT, FRCS, and colleagues revealed appropriate management of talar fractures depends on size, location and displacement of the fragment, the degree of articular cartilage damage and instability of the subtalar joint.

“Persistent pain after an ankle sprain must raise a high index of suspicion for talar process fractures,” Majeed told Healio.com/Orthopedics. “Missed or delayed diagnosis can result in significant disability, and an early diagnosis and appropriate management can prevent long-term problems of malunion, nonunion and subtalar arthritis.”

The Hawkins classification of talus fractures identifies lateral process fractures of the talus as either simple fractures (type 1), comminuted fractures (type 2) and chip fractures (type 3), according to Majeed and colleagues. Similarly, the Boack-modified classification system identifies lateral or posterior process fractures of the talus as either a small chip or avulsion fractures (type 1), an intermediate fragment with some displacement (type 2), a large fracture fragment with associated damage to both the ankle and the subtalar joints (type 3), or a severe form of fracture of either of the processes and associated instability or dislocation of the subtalar joint (type 4). Each type of fracture in the Boack-modified classification is subdivided based on severity of the bony injury, degree of chondral lesion and ligamentous stability.

For Hawkins type 1 fractures, researchers noted open reduction and internal fixation yielded better outcomes vs. nonoperative treatment, while arthroscopic assessment and arthroscopic debridement is the most suitable treatment option for Hawkins type 2 fractures, depending on the chondral damage and size of the comminuted fragments. Nonoperative treatment with plaster cast immobilization has been shown to yield good outcomes with Hawkins type 3 fractures, according to researchers.

Researchers also noted below-knee plaster cast and partial weight-bearing for a period of 6 weeks should be used in the management of Boack-modified classification talar fractures with an extra-articular or undisplaced small avulsion fragment. Surgical treatment is recommended for displaced fractures involving the articular surface, while talar fractures with minimally displaced fragments should be treated with subtalar arthroscopy and excision.

After arthroscopic assessment, either arthroscopic debridement or arthroscopic-assisted reduction and internal fixation are recommended for Boack type 2 fractures, depending on the chondral damage and size of the comminuted fragments. To achieve optimum outcomes and avoid articular damage by the prominent head of the conventional screw, researchers recommend arthroscopic or open reduction and anatomical fixation with headless compression screw for treatment of a single, large displaced fragment. Finally, emergency management to relocate the subtalar joint is recommended for patients with associated subtalar dislocation, according to researchers, and the articular surface should be arthroscopically assessed, and any loose fragments excised. – by Casey Tingle

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Disclosures: The authors report no relevant financial disclosures.