18 Fractures of the Talus (Student Copy Updated).pdf

Fractures of the Talus Learning Objectives u Identify the mechanisms of injury for talar fractures u Talar head u Lateral process of the talus u Posterior process of the talus u Talar neck u Talar body u Talar dome Learning Objectives u Identify the classific...

Fractures of the Talus Learning Objectives u Identify the mechanisms of injury for talar fractures u Talar head u Lateral process of the talus u Posterior process of the talus u Talar neck u Talar body u Talar dome Learning Objectives u Identify the classification systems of talar fractures and correlate them to outcomes and/or treatments u Talar neck fractures à Hawkins u Talar body fractures à Sneppen u Talar dome fractures à Berndt and Harty u Recognize proper management principles for: u Proper patient work-up u Conservative treatment u Surgical treatment Anatomy (Dome) Netter, Frank H. 516. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. Anatomy (Dome) Netter, Frank H. 516. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019.  Anatomy Posteromedial tubercle of Posterolateral tubercle of the the posterior talar process posterior talar process Netter, Frank H. 517. Atlas of Human Anatomy, Seventh Edition. Philadelphia, PA: Elsevier 2019. Anatomy u Critical link between the leg & foot u Component of 3 joints: u Ankle joint u Subtalar joint u Talonavicular joint u 60% of the talar surface is cartilage u Injuries likely to be intra-articular u No muscular origins or insertions u Ligamentous attachments only Sarrafian SK. Anatomy of the Foot and Ankle : Descriptive, Topographic, Functional. 1st ed. Philadelphia: Lippincott; 1983. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Anatomy u Blood supply is tenuous due to lack of soft tissue attachments & abundance of cartilaginous Surfaces Sarrafian SK. Anatomy of the Foot and Ankle : Descriptive, Topographic, Functional. 1st ed. Philadelphia: Lippincott; 1983. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203.  Blood Supply u All 3 main distal arteries of the leg provide vascularity to the talus u Posterior tibial artery u Deltoid branches u Artery of the tarsal canal u 2/3 Talar body u Anterior tibial artery u Dorsalis pedis u Talar head and neck u Peroneal artery u Artery of the tarsal sinus Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Blood Supply u Vascular sling à Main blood supply to the talar body u Posterior tibial artery u Artery of the tarsal canal u Most important supply of the talar body u Peroneal artery u Artery of the tarsal sinus u Disruption = Disaster Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Blood Supply u Extensive intraosseous anastomoses exists among the 3 main arteries u Posterior tibial artery u Artery of the tarsal canal u Most important supply of the body u Peroneal artery u Artery of the tarsal sinus u “Potentially” possible to restore blood flow to the talus if 1/3 arteries remains intact Mulfinger G.L., Trueta J.: The blood supply of the talus. J Bone Joint Surg Br 1970; 52: pp. 160-167. Overview of Talar Fractures u Relatively rare, comprising 3-8% of all foot fractures. u Usually arise from high energy injuries. u Motor Vehicle Accidents (MVA) u Falls from height u High complications rates u Avascular necrosis (AVN) u Post-traumatic arthritis u Described according to region u Talar head u Lateral process of the talus u Posterior process of the talus u Talar neck u Talar body u Talar dome Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Evaluation of the Acute Talar Fracture Patient u Thorough medical history u Detailed description of the mechanism of injury u Physical exam u Evaluate for concomitant injuries u Vertebral compression fractures are common u Ecchymosis u Edema u Decreased/painful ROM u Radiographs u AP, MO, and Lat u Canale & Kelly view Gumann G. Fractures of the Foot and Ankle. Philadelphia: Elsevier Saunders; 2004. u CT scan Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint u 10% of talar head fractures develop AVN Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint u 10% of talar head fractures develop AVN Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint u 10% of talar head fractures develop AVN Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint Gumann G. Fractures of the Foot and Ankle. u 10% of talar head fractures develop AVN Philadelphia: Elsevier Saunders; 2004. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint Gumann G. Fractures of the Foot and Ankle. u 10% of talar head fractures develop AVN Philadelphia: Elsevier Saunders; 2004. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint Gumann G. Fractures of the Foot and Ankle. u 10% of talar head fractures develop AVN Philadelphia: Elsevier Saunders; 2004. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Talar Head Fractures u Very rare at < 10% of all talar fractures. u Mechanism of injury u Violent dorsiflexion of a fully plantarflexed foot. u Usually divides the head into medial and lateral fragments u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Generally invade the T-N joint Gumann G. Fractures of the Foot and Ankle. u 10% of talar head fractures develop AVN Philadelphia: Elsevier Saunders; 2004. Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203.  Fractures of the Lateral Process u Account for 20% of talar fractures u Incidence has increased with the popularity of snowboarding u “Snowboarder’s fracture” u Mechanism of injury u Compression during inversion and dorsiflexion u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced/small comminuted fractures à NWB SLC 4 – 6 weeks Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Lateral Process u Account for 20% of talar fractures u Incidence has increased with the popularity of snowboarding u “Snowboarder’s fracture” u Mechanism of injury u Compression during inversion and dorsiflexion u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced/small comminuted fractures à NWB SLC 4 – 6 weeks Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Lateral Process u Account for 20% of talar fractures u Incidence has increased with the popularity of snowboarding u “Snowboarder’s fracture” u Mechanism of injury u Compression during inversion and dorsiflexion u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced/small comminuted fractures à NWB SLC 4 – 6 weeks u Large, displaced, intra-articular fragments à ORIF Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Lateral Process u Account for 20% of talar fractures u Incidence has increased with the popularity of snowboarding u “Snowboarder’s fracture” u Mechanism of injury u Compression during inversion and dorsiflexion u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced/small comminuted fractures à NWB SLC 4 – 6 weeks u Large, displaced, intra-articular fragments à ORIF Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Fracture of the Posterior Talar Process u Posterolateral tubercle fractures u “Shepherd’s fracture” u More common than medial tubercle fractures u Mechanism of injury u Forced plantarflexion compressing the process between the tibia and calcaneus u Often misdiagnosed as an os trigonum u And vice versa u Nutcracker sign u Pain with forced plantarflexion of the ankle u Most reliable clinical test u Treatment is usually conservative u WB SLC for 4-6 weeks u Fragment with residual symptoms can be excised Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203.  Fractures of the Posterior Talar Process u Posteromedial tubercle fractures u “Cedell fracture” u Less common u Mechanism of injury u Forced dorsiflexion and pronation u Rupture of the deep posterior tibiotalar ligament u Avulsion fragment of the posteromedial tubercle u Treatment is usually conservative u WB SLC for 4-6 weeks u Fragment with residual symptoms can be excised Cedell C-A. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta orthopaedica scandinavica. 1974;45(1-4):454-461.  Fractures of the Talar Body u Account for 13-23% of talar fractures u Mechanism of injury u Axial compression with plantarflexion upon impact u Almost always high-energy injuries u Comminuted talar body fractures rarely involve dislocations of adjacent joints u Less comminuted fractures often involve ankle and/or STJ dislocations u High energy injuries require dissipation of that energy u Comminuted fractures à energy dissipated into the bone u Less comminuted fractures à energy dissipated into the bone and ligaments Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Body u Treatment depends on displacement, joint involvement, and comminution. u Non-displaced fractures à immobilized 6-8 weeks u Displaced fractures require ORIF u Surgical approach can be difficult u Access is rarely achieved with a single incision u Medial malleolar osteotomy is often required Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Body u 3 types: u Compression u Shearing u Crush u Classified by Sneppen based on location u Group I (A) à Compression fracture u osteochondral dome fracture u Group II à Shearing fractures u (B) Coronal (more proximal than a talar neck fracture) u (C)Sagittal u Transverse u Group III à (D) Posterior process fracture u Group IV à (E) Lateral process fracture u Group V à (F) Crush injury Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of the body of the talus. Acta orthopaedica scandinavica. 1977;48(3):317-324.  Goals of Talar Body Management u Evaluate extent of injuries u Radiographs u CT scan u Immediate reduction of dislocated joints u Closed reduction in the ER is ideal u Anatomic reduction of fractures with stable fixation u Facilitate union of fractures u Decrease occurrence of AVN u Proper post-operative care to decrease complications Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Goals of Talar Body Management u Evaluate extent of injuries u Radiographs u CT scan u Immediate reduction of dislocated joints u Closed reduction in the ER is ideal u Anatomic reduction of fractures with stable fixation u Facilitate union of fractures u Decrease occurrence of AVN u Proper post-operative care to decrease complications Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Talar Neck Fractures u 2nd most common talar fracture u Mechanism of injury u Forced axial load of the tibia through the talus u The anterior tibia shears off the talar head. u As force continues, the talar body can dislocate around the deltoid ligament. u Most common cause is MVA and falls from height u Treatment depends on displacement, joint involvement, and comminution. Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Talar Neck Fractures u Classified by Hawkins (1970) u Correlates well with prognosis u Predictive of the rate of AVN Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Hawkins Classification u Hawkins I u Nondisplaced talar neck fracture u AVN rate of 0-13% u Best prognosis u Treatment is typically conservative u NWB SLC for 6-8 weeks Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Hawkins Classification u Hawkins II u Displaced talar neck fracture with subtalar joint dislocation u AVN rate of 20-50% u Treatment is surgical u ORIF u NWB SLC for 8 weeks Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Hawkins Classification u Hawkins III u Displaced talar neck fracture with subtalar and ankle joint dislocations u AVN rate of 83-100% u Treatment is surgical u ORIF u NWB SLC for 8 weeks u Talar body is tethered by the deltoid ligament Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Hawkins Classification u Hawkins IV u Displaced talar neck fracture with subtalar, ankle, and talonavicular joint dislocations u AVN rate of > 91% u Treatment is surgical u ORIF u NWB SLC for 8 weeks u Very rare occurrence Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery, Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Hawkins Sign u Subchondral radiolucency seen on AP/Mortise view u Result of osteopenia secondary to resorption of bone from an intact blood supply. u Seen 6 weeks to 3 months after injury u 100% sensitive for absence of AVN u If you see a Hawkins sign, AVN is very unlikely u 57.7% specificity for absence of AVN u Lack of a Hawkins sign does not necessarily mean AVN will occur Tezval M, Dumont C, Stürmer KM. Prognostic reliability of the hawkins sign in fractures of the talus. Journal of orthopaedic trauma. 2007;21(8):538-543. Goals of Talar Neck Fracture Management u Evaluate extent of injuries u Radiographs u CT scan u Immediate reduction of dislocated joints u Closed reduction in the ER is ideal u Anatomic reduction of fractures with stable fixation u Facilitate union of fractures u Decrease occurrence of AVN u Proper post-operative care to decrease complications  Avascular Necrosis (AVN) of the Talus u Due to arterial injury resulting in ischemia u Hallmark signs of AVN u Sclerosis of the talus Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Due to arterial injury resulting in ischemia u Hallmark signs of AVN u Sclerosis of the talus u Signal changes on MRI u Gadolinium increases accuracy Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Due to arterial injury resulting in ischemia u Hallmark signs of AVN u Sclerosis of the talus u Signal changes on MRI u Gadolinium increases accuracy u Collapse of the talar dome Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Pre-collapse treatment options: u Conservative u Patellar Tendon Bearing (PTB) Brace u Compliance can be problematic u Hyperbaric Oxygen Therapy (HBOT)??? u Evidence is anecdotal u Cost prohibitive Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Pre-collapse treatment options: u Surgical u Core decompression u Intact cartilage u Based of studies of femoral head AVN u Decrease internal pressure of the talus u Allow revascularization Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Pre-collapse treatment options: u Surgical u Core decompression u Intact cartilage u Based of studies of femoral head AVN u Decrease internal pressure of the talus u Allow revascularization u Fresh en bloc talar allograft u Cartilage involvement u Replaces necrotic cartilage and bone Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Post-collapse treatment options: u Conservative u Observation u Symptom management u Bracing u Think about doing surgery Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Post-collapse treatment options: u Surgical u Tibiotalocalcaneal (TTC) fusion Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Post-collapse treatment options: u Surgical u Tibiotalocalcaneal (TTC) fusion u Tibiocalcaneal (Blair) fusion Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Avascular Necrosis (AVN) of the Talus u Post-collapse treatment options: u Surgical u Tibiotalocalcaneal (TTC) fusion u Tibiocalcaneal (Blair) fusion u Total Ankle Replacement??? Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Avascular Necrosis (AVN) of the Talus u Post-collapse treatment options: u Surgical u Tibiotalocalcaneal (TTC) fusion u Tibiocalcaneal (Blair) fusion u Total Ankle Replacement??? u Current standard component TARs are contra-indicated with AVN, however…  Fractures of the Talar Dome u Rhetoric Review u Talar OCD u Osteochondritis dessicans u Osteochondral defect u Talar dome lesion u Osteochondral lesion of the talus u Transchondral lesion of the talus Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Talar Dome lesions account for 1% of all talar fractures u Localized injury to the articular cartilage as well as the subchondral bone u Clinical presentation u History of ankle fracture or inversion ankle sprain u Improvement of pain, edema, ecchymosis, and reduced motion following an ankle sprain, but never reaching an asymptomatic state u Initial improvement following injury with a delayed onset of symptoms u Pain u Swelling u Locking of the ankle joint u Ankle instability u Decreased ROM Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Mechanism of injury depends on location u Anterolateral lesions à dorsiflexion/inversion u Posteromedial lesions à plantarflexion/inversion Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Mechanism of injury depends on location u Anterolateral lesions à dorsiflexion/inversion u Posteromedial lesions à plantarflexion/inversion u “DIAL a PIMP” u Dorsiflexion/Inversion à AnteroLateral u Plantarflexion/Inversion à Medial Posterior Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Morphology of lesions u Posteromedial lesions u Deep and cup shaped u More likely to be asymptomatic u Anterolateral lesions u Shallow and wafer (flake) shaped u More likely to be symptomatic Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Morphology of lesions u Posteromedial lesions u Deep and cup shaped u More likely to be asymptomatic u Anterolateral lesions u Shallow and wafer (flake) shaped u More likely to be symptomatic u “Flakes live in LA” Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Classified by Berndt & Harty (1959) u Stage I lesion u Small area of subchondral compression u Stage II lesion u Partially detached osteochondral fragment u Stage III lesion u Fully detached without displacement u Stage IV lesion u Fully detached and displaced Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. The journal of bone and joint surgery american volume. 2004;86(6):1336-1336.  Fractures of the Talar Dome u Classified by Berndt & Harty (1959) u Stage I lesion u Small area of subchondral compression u Stage II lesion u Partially detached osteochondral fragment u Stage III lesion u Fully detached without displacement u Stage IV lesion u Fully detached and displaced u Stage V lesion u Radiolucent defect underlying the lesion Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus. The american journal of sports medicine. 1993;21(1):13-19.  Fractures of the Talar Dome u Treatment depends on location, staging, and symptoms. u Stage I & II lesions à conservative treatment (WB SLC) u Stage III medial lesions à conservative treatment (WB SLC) u Stage III lateral lesions à surgical treatment u Stage IV lesions à surgical treatment Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Fractures of the Talar Dome u Surgical treatment options: u Ankle arthroscopy u Debridement of OCD à Facilitate ingrowth of fibrocartilage u Micro-fracture (marrow stimulation) u Implantation of chondrocytes u Ankle arthrotomy u Debridement of OCD u Microfracture (marrow stimulation) u Osteochondral Autologous Transplantation u Mosaicplasty u En bloc talar shoulder Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Microfracture (Marrow Stimulation) of a Talar OCD Courtesy of Sean Grambart, DPM, FACFAS Osteochondral Autologous Transplantation u Mosaicplasty Hangody L. The mosaicplasty technique for osteochondral lesions of the talus. Foot Ankle Clin. 2003 Jun;8(2):259-73.  Osteochondral Autologous Transplantation u En bloc talar shoulder transplantation Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Osteochondral Autologous Transplantation u En bloc talar shoulder transplantation Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013.  Osteochondral Autologous Transplantation u En bloc talar shoulder transplantation Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. Recommended Reading & References u Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. The journal of bone and joint surgery american volume. 2004;86(6):1336-1336. u Canale ST, Kelly FB Jr. Fractures of the neck of the talus. long-term evaluation of seventy-one cases. The journal of bone and joint surgery american volume. 1978;60(2):143-156. u Cedell C-A. Rupture of the posterior talotibial ligament with the avulsion of a bone fragment from the talus. Acta orthopaedica scandinavica. 1974;45(1-4):454-461. u Fallat, Lawrence M. Christensen, Jeffrey C. Hord, Jacob A. Chapter 54: Osteochondroses of the foot and ankle. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. u Hangody L. The mosaicplasty technique for osteochondral lesions of the talus. Foot Ankle Clin. 2003 Jun;8(2):259-73. u Hyer, Christopher F. DeCarbo, William T. Chapter 115: Talar Avascular Necrosis: McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. u Loomer R, Fisher C, Lloyd-Smith R, Sisler J, Cooney T. Osteochondral lesions of the talus. The american journal of sports medicine. 1993;21(1):13-19. u Mulfinger G.L., Trueta J.: The blood supply of the talus. J Bone Joint Surg Br 1970; 52: pp. 160-167. u Schuberth, John M. Rush, Shannon M. Jennings, Meagan M. Chapter 108: Talar Fractures. McGlamry’s Comprehensive Guide to Foot and Ankle Surgery,Fourth Edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2013. u Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of the body of the talus. Acta orthopaedica scandinavica. 1977;48(3):317-324. u Summers NJ, Murdoch MM. Fractures of the talus: a comprehensive review. Clinics in podiatric medicine and surgery. 2012;29(2):187-203. Copyright No,ce: u This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.