Talar Neck and Body Fracture ORIF

Indication. A displaced talar neck or body fracture — a greater than 2 mm displacement, any angulation, or any fracture with an associated tibiotalar or subtalar dislocation (Hawkins II to IV) — is a surgical emergency. These are high-energy injuries, and the goals of fixation are to restore talar anatomy, protect the precarious retrograde blood supply, and prevent avascular necrosis and post-traumatic arthritis. Absolute indications - Displaced talar neck fracture (greater than 2 mm displacement or any angulation)

• Any talar neck or body fracture with tibiotalar or subtalar dislocation (Hawkins II to IV)
• Open talar fracture (Gustilo-Anderson II or III)
• Associated compartment syndrome of the foot Relative indications - Minimally displaced talar neck fracture in a young active patient (to prevent late arthritis)
• Talar body fracture with greater than 1 mm articular step-off
• Hawkins Type I fracture with a high-energy mechanism and significant soft-tissue swelling (to allow early motion) Contraindications - Absolute — a medically unstable patient for surgery, active infection at the surgical site, or severe peripheral vascular disease precluding wound healing.
• Relative — a Hawkins Type I fracture in a low-demand elderly patient (consider non-operative management with close radiographic follow-up), severe osteoporosis precluding stable fixation, or delayed presentation greater than 3 weeks with an established malunion. Timing is the single most important decision. Emergent closed reduction of any dislocated talus is mandatory within 6 hours of injury. Vallier (2004) demonstrated that delay beyond 6 hours significantly increases AVN risk in Type II and III fractures, and the later BMC series (Biz, 2019) confirmed that surgical intervention within 48 hours is associated with lower AVN rates and better functional scores, while delay beyond 72 hours markedly increased AVN and post-traumatic arthritis. Open fractures require urgent debridement and provisional stabilisation within 6 to 12 hours. Why a dual incision. A single medial or lateral approach gives inadequate visualisation of the contralateral column and carries a varus malunion rate greater than 15 percent. The combined anteromedial plus anterolateral approach allows direct assessment of reduction at both the medial and lateral talar neck cortices and the subtalar joint, and drops the varus malunion rate to less than 5 percent. Consent specifically for avascular necrosis (Type-dependent, up to nearly 100 percent in Type IV), post-traumatic subtalar and ankle arthritis, wound problems and infection, the possible need for future arthrodesis, and stiffness. Setup. Supine on a radiolucent table, a bump under the ipsilateral hip to improve lateral access, the foot at the end of the table for full ankle and subtalar motion, and a thigh tourniquet (inflate after draping and limit to 90 to 120 minutes). Image intensifier from the contralateral side; obtain AP, lateral and Canale (oblique talar neck) views before incision. The entire foot is prepped and free-draped.

The goal is to expose the talar neck and body through dual anteromedial and anterolateral incisions, reduce the fracture anatomically with zero varus, and stabilise it while protecting the deltoid branch of the artery of the tarsal canal medially and the dorsalis pedis artery and deep peroneal nerve laterally. The exposure is the heart of the operation and is laid out in full below.

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Rehabilitation | Phase | Timing | Weight-bearing & immobilisation | Therapy & monitoring | |-------|--------|--------------------------------|----------------------| | Early | 0 to 6 weeks | Posterior splint for 2 weeks, then a removable boot; non-weight-bearing for 6 to 12 weeks (12 weeks for Hawkins III and IV) | Gentle ankle and subtalar range of motion once wounds heal at 2 weeks; DVT prophylaxis (LMWH 4 to 6 weeks) in high-risk patients | | Intermediate | 6 to 12 weeks | Progressive protected weight-bearing in a boot once radiographic union appears | Range of motion and strengthening; radiographs at 6 to 8 weeks (Hawkins sign) and 3 months | | Late | 3 to 12 months | Full weight-bearing when union is confirmed; custom orthotic for the medial arch and lateral column if mild varus is present | Return to sport or heavy labour at 6 to 12 months if asymptomatic | Special case — Hawkins Type IV fractures. These carry the highest AVN risk (nearly 100 percent in some series) and are often associated with talar head or lateral process comminution. Management principles are emergent reduction of the dislocation, dual-incision ORIF with particular attention to protecting the deltoid branch, prolonged non-weight-bearing for a minimum of 12 weeks, and close radiographic surveillance for AVN. Primary subtalar arthrodesis is considered in selected cases of severe comminution but remains controversial. Special case — open talar fractures. Gustilo-Anderson Type II and III fractures require urgent debridement within 6 to 12 hours, with external fixation for provisional stabilisation if definitive fixation is delayed, and delayed primary closure or flap coverage for soft-tissue defects. The infection rate is 10 to 30 percent in Type III injuries and the AVN rate is higher than for closed fractures because of the additional vascular disruption; primary amputation may be considered in severe Type IIIB or IIIC injuries with extensive contamination. Complications

Retrograde blood supply of the talus. The talus has a precarious retrograde blood supply with no muscle attachments and a limited soft-tissue envelope, so disruption at the neck level places the body at risk of avascular necrosis. Four vessels matter: - Artery of the tarsal canal — a branch of the posterior tibial artery; it enters the tarsal canal and supplies approximately 70 percent of the talar body via retrograde flow through the sinus tarsi.

• Deltoid branch — arises from the artery of the tarsal canal and supplies the medial talar body; it must be preserved during medial approaches and medial malleolar osteotomy. After a displaced neck fracture it may be the only remaining supply to the body.
• Artery of the sinus tarsi — a branch of the dorsalis pedis or peroneal artery; supplies the lateral talar body and talar head.
• Superior neck vessels — small branches of the dorsalis pedis that supply the talar head and anterior neck. The clinical implication is that any surgical approach must protect these vessels: excessive retraction, stripping of soft tissue from the talar neck, or damage to the deltoid branch all increase AVN risk. Bony anatomy and fracture patterns. The talar neck is the narrowest portion of the talus, lying between the head and body and oriented approximately 15 to 20 degrees medial to the longitudinal axis of the foot; it is extra-articular, and fractures propagate from anterolateral to posteromedial with comminution more common medially. The talar body is largely covered by articular cartilage (approximately 60 percent of its surface): the superior dome articulates with the tibial plafond, the medial and lateral facets with the malleoli, and the posterior process carries the flexor hallucis longus groove and the posterior talofibular ligament attachment. Body fractures often extend into the subtalar joint and may involve a posteromedial fragment that is hidden behind the flexor digitorum longus and posterior tibial tendons — the reason a medial malleolar osteotomy is needed for access. Hawkins sign. At 6 to 8 weeks a subchondral lucency beneath the talar dome on the AP ankle radiograph indicates that the body is vascular and undergoing disuse osteopenia (a good prognostic sign); its absence predicts AVN. Type II versus Type III hinges on whether the subtalar joint is merely subluxated (Type II) or dislocated (Type III), with tibiotalar dislocation defining the Type IV pattern.

Key evidence. Timing and approach dominate the evidence base. Vallier (2004) showed that delay beyond 6 hours significantly increased AVN in Type II and III fractures, and the BMC series (Biz, 2019) confirmed that intervention within 48 hours lowered AVN and improved functional scores while delay beyond 72 hours worsened both. On approach, a comparative study (Parmeshwar, 2023) found the dual anteromedial-anterolateral approach achieved higher rates of anatomic reduction and lower varus malunion than single approaches by improving visualisation of both talar neck columns and the subtalar joint. Biomechanically, two parallel cannulated screws give adequate stability for a simple neck fracture, while comminuted and body fractures benefit from supplemental mini-fragment plating, with headless or countersunk screws required to avoid talonavicular impingement.