What is the management of talus fracture?

Management of Talus Fractures

The management of talus fractures requires prompt surgical intervention with open reduction and internal fixation (ORIF) for displaced fractures to optimize functional outcomes and reduce complications such as avascular necrosis, malunion, and post-traumatic arthritis. 1

Initial Assessment and Classification

• CT imaging is essential after initial radiographs to determine fracture extent, displacement, comminution, intra-articular extension, and associated injuries, which guides treatment planning 2
• MRI is valuable for assessing associated soft tissue injuries, bone marrow contusions, and identifying patients at higher risk for osteonecrosis, particularly important for talus fractures 2
• Fracture location must be precisely identified (neck, body, lateral process, posterior process) as this determines the specific surgical approach 3, 1

Treatment Algorithm

Non-displaced Fractures

• Non-displaced fractures may be treated with immobilization in a cast or removable device, though this carries higher risk of nonunion compared to surgical treatment 4, 3
• Even with non-displaced fractures, close monitoring is essential as 75% will have good to excellent outcomes, but delayed union can occur in approximately 15% of cases 4

Displaced Fractures

• Displaced fractures require ORIF as the primary treatment to restore joint congruity and prevent complications 1
• Surgical outcomes are significantly better than conservative management for displaced fractures, with only 42% of displaced fractures achieving good to excellent results when treated non-operatively 4
• Dual surgical approaches are often necessary to achieve anatomic reduction, using a combination of minifragment plates and screws 1

Peripheral Talus Fractures

• Peripheral talus fractures (lateral process, posteromedial body, talar head) require particular attention as they are frequently missed on initial assessment 3
• ORIF is critical for peripheral talus fractures as they have high rates of nonunion with conservative treatment 3
• Surgical fixation allows for more rapid union, earlier joint mobilization, quicker revascularization, and lower rates of arthrosis 3

Rehabilitation Protocol

• An appropriate rehabilitation program should include early post-fracture physical training followed by long-term balance training and fall prevention 2
• Early identification of individual rehabilitation goals is essential before developing the rehabilitation plan 2
• When immobilization is discontinued, aggressive motion exercises are necessary to achieve optimal outcomes 2
• Overly aggressive physical therapy should be avoided as it may increase the risk of fixation failure 2

Complications and Their Management

• Avascular necrosis occurs in approximately 15% of talus fractures, particularly with displaced neck fractures 4
• Post-traumatic arthritis is extremely common (97% in one study), requiring long-term monitoring and management 4
• Subchondral atrophy (decreased bone density under articular cartilage) is seen in 50% of cases and may contribute to long-term morbidity 4
• Delayed union occurs in approximately 15% of cases and may require additional intervention 4

Special Considerations

• Prompt reduction of dislocations should be performed as soon as possible to reduce the risk of avascular necrosis 1
• Patients should be taken to the operating room as soon as they are medically stabilized to improve outcomes 1
• For posterior process fractures, a posteromedial approach with headless screw fixation has shown good results 5
• The high-energy nature of these injuries (motor vehicle accidents, falls from height) often means patients have associated injuries requiring comprehensive management 6, 4

Long-term Follow-up

• Regular radiographic assessment is necessary to monitor for complications such as avascular necrosis, malunion, and post-traumatic arthritis 1
• Most patients will have some degree of symptoms affecting daily activities even after optimal treatment, requiring long-term management 4
• Patient education about the burden of injury, potential complications, and expected outcomes is essential 2