What is the treatment for a fractured talus?

Treatment for Fractured Talus

The treatment for a talus fracture depends on the fracture characteristics, with surgical intervention being necessary for displaced, comminuted, or intra-articular fractures, while simple immobilization is appropriate for small, non-displaced, or non-articular fractures. 1

Initial Assessment and Diagnosis

Imaging

• Initial evaluation should include standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) 2
• CT is the first-line advanced imaging study after radiographs to determine:
  • Extent of fracture
  • Displacement
  • Comminution
  • Intra-articular extension
  • Associated injuries 1
• MRI may be indicated for:
  • Assessment of associated soft tissue injuries
  • Evaluation of bone marrow edema
  • Detection of osteochondral lesions
  • Evaluation of talus fracture sites at risk for osteonecrosis 1, 2

Special Considerations

• The Broden view (supine flexed knee view with 30-45° internal rotation) may be useful for better visualization of lateral process fractures of the talus 1
• Weight-bearing radiographs, if possible, provide important information about fracture stability 2

Treatment Algorithm

Non-Displaced Fractures

1. Simple immobilization is appropriate when fracture fragments are:

   • Small
   • Non-articular
   • Minimally displaced 1, 2

2. Conservative management includes:

   • Protection and immobilization with a cast or walker boot
   • PRICE protocol (Protection, Rest, Ice, Compression, Elevation)
   • NSAIDs for pain and inflammation control 2
   • Non-weight bearing initially, progressing to partial and then full weight bearing as healing occurs

Displaced, Comminuted, or Intra-articular Fractures

1. Surgical intervention is indicated for:

   • Displaced fractures
   • Comminuted fractures
   • Intra-articular fractures
   • Open fractures 3, 4

2. Surgical approach:

   • Open reduction and internal fixation (ORIF) with screws and/or plates 3, 5
   • Dual incisions may be required for complex fractures 4
   • Anatomic reduction is critical to restore joint congruity and prevent post-traumatic arthritis 3
   • Early definitive fixation (within 24 hours) is safe and effective 6

3. Post-operative management:

   • Non-weight bearing until radiographic evidence of healing
   • Progressive rehabilitation based on healing progress
   • Regular radiographic follow-up at 3 weeks and at cessation of immobilization 2

Complications and Prognosis

Major Complications

• Osteonecrosis (10-50% of cases, higher in displaced fractures) 3, 5
• Post-traumatic arthritis (common in tibiotalar and subtalar joints) 3
• Malunion or nonunion 4
• Infection (particularly with open fractures) 3

Prognostic Factors

• Poor prognostic indicators:
  • Open fractures
  • Comminuted fractures
  • Associated talar neck fractures
  • Displacement/dislocation 3
• Hawkins type I and II fractures have better outcomes (95% excellent or good) compared to type III (70% good) and type IV (10% good) 5

Rehabilitation

Rehabilitation Protocol

• Traditional protocol: 4 weeks immobilization with progressive weight bearing, return to activity in 18-19 weeks
• Accelerated protocol: Early mobilization and weight bearing, return to activity in 13-14 weeks 2
• Proprioceptive training is essential to prevent chronic instability 2

Special Considerations

• If a fractured extremity appears blue, purple, or pale, activate emergency response system immediately 1
• For open fractures with severe bleeding, follow first aid for severe external bleeding 1
• Cover open wounds associated with fractures with a clean dressing to reduce risk of contamination and infection 1

Talus fractures are serious injuries that can significantly impact foot and ankle function. The treatment approach must be tailored to the specific fracture pattern, with the goal of restoring joint congruity and preventing complications. Early appropriate treatment is crucial for optimizing outcomes and preventing long-term disability.