Summary
Talus fractures account for less than 1% of all fractures. They are generally caused by high-energy trauma with axial loading (e.g., due to motor vehicle collisions) or sports injuries (e.g., snowboarder fracture). Talus fractures are classified according to their anatomical location as head, neck, or body fractures. Clinical features include acute pain, tenderness, swelling, and ecchymosis around and/or below the ankle; restricted range of motion; and inability to bear weight. X-rays of the ankle and foot should be obtained for all patients with a suspected talus fracture. CT imaging should be obtained for all patients with a confirmed talar fracture or highly suspected talar fracture with negative x-rays. Most talus fractures require surgical management, with nonoperative management reserved for certain types of nondisplaced fractures. Complications include avascular necrosis, posttraumatic arthritis, and union issues (e.g., malunion, nonunion).
Epidemiology
- Prevalence: < 1% of all fractures [1]
Epidemiological data refers to the US, unless otherwise specified.
Etiology
Talus fractures are typically caused by axial loading on a flexed or rotated foot. [1][2]
- High-energy trauma: e.g., fall from a height, motor vehicle collision
- Sports injuries: e.g., snowboarder fracture
Classification
Talar head fractures [1]
- Fractures involving the talar articular surface of the talonavicular joint
- Fracture patterns include crush and shear injury.
Talar neck fractures [2]
- Fractures occurring anteriorly or inferiorly to the lateral process of the talus and talar dome cartilage [1]
-
Hawkins-Canale classification: for talar neck fractures; high prognostic value [3]
- Hawkins I: nondisplaced fracture
- Hawkins II: fracture with talocalcaneal dislocation
- Hawkins III: fracture with talocalcaneal and tibiotalar dislocation
- Hawkins IV: fracture with talocalcaneal, tibiotalar, and talonavicular dislocation
Talar body fractures [1]
- True talar body fracture: a fracture of the talar body that involves the tibiotalar and/or talocalcaneal joint
- Osteochondral fracture of the talar dome: a fracture involving the talar dome and/or articular cartilage [1][4]
-
Lateral talar process fracture (snowboarder fracture)
- A fracture of the lateral process of the talus, typically caused by forced ankle joint dorsiflexion and inversion followed by axial loading [5][6]
- Most commonly seen in snowboarding injuries from landing after an aerial maneuver or jump
- Posterior talar process fracture
Clinical features
- Signs of fracture, e.g., pain, ecchymosis, swelling [2]
- Painful and/or restricted range of motion [1]
- Inability to bear weight on the affected ankle
Diagnosis
Clinical evaluation [2][7]
Urgent orthopedic consultation is indicated for any findings that suggest neurovascular injury or an open fracture.
-
Neurovascular examination
- Evaluate for distal sensory and motor deficits (e.g., superficial peroneal nerve injury).
- Assess capillary refill time and distal pulses (e.g., posterior tibial and dorsalis pedis pulse).
- Skin examination: Evaluate for laceration, tearing, and tenting.
- Associated injuries: Examine the foot, knee, and spine.
Talus fractures resulting from high-energy trauma with axial loading are associated with calcaneal, tibial, and vertebral compression fractures. [2]
Imaging [7][8]
Foot and ankle x-rays should be obtained for all patients with a suspected talus fracture. CT imaging should be obtained for all patients with a confirmed talar fracture or highly suspected talar fracture with negative x-rays. [2][7][8]
X-ray
- Indication: all patients with trauma to the ankle or foot who meet criteria for imaging (e.g., Ottawa ankle and foot rule)
-
Views
- Ankle: AP, lateral, and mortise
- Foot: AP, lateral, and oblique
- Talar: Canale view and Broden view
- Findings: radiographic fracture signs, displacement, and dislocation
Advanced imaging
- CT [2]
- MRI: detection and/or evaluation of occult fractures, osteochondral lesions, and soft tissue injury [2][8]
Treatment
Initial management [2][7][9]
- Provide general fracture care, including analgesia for fractures.
- Immobilize the ankle in a posterior short-leg splint.
- Establish non-weight-bearing status.
- Identify indications to consult orthopedics for fractures, e.g., Hawkins II–IV talar neck fractures
- Arrange outpatient follow-up with orthopedics within 24–48 hours.
Talus fractures typically result from high-energy trauma; follow the ATLS algorithm to stabilize patients and assess for other injuries. [2]
Nonoperative management [2][10]
- Can be considered for:
- Certain nondisplaced fractures (e.g., nondisplaced talar neck fractures or process fractures)
- Patients who are nonambulatory or too unwell to undergo surgery
- Typically involves immobilization with a short-leg cast for at least 6 weeks
- See also “Conservative treatment of fractures.”
Surgical management [7][9][10]
Most talus fractures are managed surgically.
-
Indications
- Displaced fractures
- Other indications for surgical fracture management (e.g., intraarticular fragments)
-
Procedure
- First-line: open reduction and internal fixation
- Alternative: external fixation (e.g., in patients with severe soft tissue injury) [11]
Complications
- Avascular necrosis (AVN) [9]
- Posttraumatic arthritis (e.g., talonavicular, subtalar arthritis) [9]
- Delayed union, malunion, nonunion [9]
- See also “Fracture complications.”
We list the most important complications. The selection is not exhaustive.
Prognosis
- Talar head fractures: less likely to undergo AVN than talar neck or body fractures
- Talar neck fractures: AVN risk increases with the degree of displacement (See “Hawkins classification.”) [1]
-
Hawkins sign: subchondral radiolucency of the talar dome [9]
- If present, usually seen 6–8 weeks after injury
- Indicates adequate vascularity and a low risk of AVN
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