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Total Talar Dislocation

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Total Talar Dislocation

Comprehensive guide to total talar dislocation - talus completely dislocated from ankle subtalar talonavicular, urgent reduction, AVN risk, and treatment for orthopaedic exam

complete
Updated: 2025-12-19
High Yield Overview

TOTAL TALAR DISLOCATION

Rare | All Joints | Urgent Reduction | High AVN Risk

RareExtremely rare injury
UrgentReduce within hours
AVNHigh risk (50-100%)
OpenOften open injury

DISLOCATION PATTERNS

Pure
PatternNo fractures, rare
TreatmentUrgent reduction
With fractures
PatternTalar fractures, common
TreatmentUrgent reduction, ORIF
Open
PatternSkin disrupted, common
TreatmentUrgent reduction, debridement

Critical Must-Knows

  • Total talar dislocation = talus completely dislocated from all articulations (ankle, subtalar, talonavicular) - extremely rare, urgent reduction required
  • Urgent reduction required - Skin tension causes necrosis, neurovascular compromise, high AVN risk. Reduce within hours, do not delay
  • High AVN risk (50-100%) - Complete disruption of blood supply, prolonged dislocation increases risk. Monitor with serial imaging
  • Often open injury - Skin disruption common due to high-energy mechanism. Urgent debridement required
  • ORIF if fractures present - After reduction, address talar fractures with ORIF. Restore joint congruity

Examiner's Pearls

  • "
    Rare but serious, urgent reduction required
  • "
    High AVN risk (50-100%)
  • "
    Often open injury
  • "
    ORIF if fractures present

Critical Total Talar Dislocation Exam Points

Urgent Reduction

Urgent reduction required - Skin tension causes necrosis within hours, neurovascular compromise, high AVN risk. Reduce within hours, do not delay for imaging. Document neurovascular status before and after reduction.

High AVN Risk

High AVN risk (50-100%) - Complete disruption of blood supply to talus. Prolonged dislocation increases risk. Monitor with serial imaging (Hawkins sign at 6-8 weeks). May require talectomy or fusion if AVN develops.

Often Open Injury

Often open injury - Skin disruption common due to high-energy mechanism. Urgent debridement required. Higher infection risk. Worse outcomes than closed injuries.

ORIF if Fractures

ORIF if fractures present - After reduction, address talar fractures with ORIF. Restore joint congruity. Success rate 50-70% due to high AVN risk."

Total Talar Dislocation - Quick Decision Guide

TypeFrequencyTreatmentOutcome
PureRare, no fracturesUrgent reduction50-70% good results
With fracturesCommon, talar fracturesUrgent reduction, ORIF40-60% good results
OpenCommon, skin disruptedUrgent reduction, debridement30-50% good results
Mnemonic

TOTALTotal Talar Dislocation Features

T
Total
All joints dislocated
O
Open
Often open injury
T
Talus
Completely dislocated
A
AVN
High AVN risk
L
Lateral
Lateral most common

Memory Hook:TOTAL: Total dislocation, Open often, Talus dislocated, AVN high risk, Lateral most common!

Mnemonic

REDUCEReduction Technique

R
Reduction
Urgent reduction
E
Emergency
Within hours
D
Document
Neurovascular status
U
Urgent
Do not delay
C
CT
After reduction
E
Examine
Fractures

Memory Hook:REDUCE: Reduction urgent, Emergency within hours, Document neurovascular, Urgent do not delay, CT after reduction, Examine fractures!

Mnemonic

AVNAVN Risk

A
AVN
High risk (50-100%)
V
Vascular
Complete disruption
N
Necrosis
Monitor with imaging

Memory Hook:AVN: AVN high risk, Vascular disruption, Necrosis monitoring!

Overview and Epidemiology

Total talar dislocation is an extremely rare but serious injury where the talus is completely dislocated from all its articulations (ankle, subtalar, talonavicular). This injury requires urgent reduction and has a high risk of AVN.

Definition

Total talar dislocation: Complete dislocation of talus from all articulations, which:

  • Joints involved: Ankle (tibiotalar), subtalar (talocalcaneal), talonavicular
  • Mechanism: High-energy trauma
  • Treatment: Urgent reduction, then ORIF if fractures
  • Outcome: Poor due to high AVN risk

Types:

  • Pure: No fractures, rare
  • With fractures: Talar fractures, common
  • Open: Skin disrupted, common

Epidemiology

  • Incidence: Extremely rare (less than 0.1% of dislocations)
  • Age: Peak 20-40 years (trauma population)
  • Gender: No clear predominance
  • Mechanism: High-energy trauma (MVA, falls from height)
  • Associated injuries: Talar fractures, open injuries

Urgent Reduction

Urgent reduction required - Skin tension causes necrosis within hours, neurovascular compromise, high AVN risk. Reduce within hours, do not delay for imaging. Document neurovascular status before and after reduction.

Anatomy and Pathophysiology

Talar Anatomy

Articulations:

  • Ankle (tibiotalar): Tibia and fibula
  • Subtalar (talocalcaneal): Calcaneus
  • Talonavicular: Navicular

Blood supply:

  • Posterior tibial artery: Artery of tarsal canal
  • Anterior tibial artery: Talar neck and head
  • Peroneal artery: Artery of tarsal sinus
  • Tenuous: 60% articular cartilage, no muscle attachments

Pathophysiology

Injury mechanism:

  • High-energy trauma: MVA, falls from height
  • Forces: Extreme rotation, translation, axial loading
  • Complete disruption: All ligaments and capsules

Why urgent reduction:

  • Skin tension: Causes necrosis within hours
  • Neurovascular compromise: Risk of ischemia
  • AVN risk: Prolonged dislocation increases AVN risk

Why high AVN risk:

  • Complete disruption: All blood supply disrupted
  • Tenuous supply: Talus has tenuous blood supply
  • Prolonged dislocation: Increases AVN risk

Classification Systems

Pattern-Based Classification

Pure dislocation:

  • No fractures
  • Rare
  • Treatment: Urgent reduction

With fractures:

  • Talar fractures
  • Common
  • Treatment: Urgent reduction, ORIF

Open injury:

  • Skin disrupted
  • Common
  • Treatment: Urgent reduction, debridement

Pattern guides treatment approach.

Direction Classification

Lateral:

  • Most common
  • Talus lateral
  • Treatment: Urgent reduction

Medial:

  • Less common
  • Talus medial
  • Treatment: Urgent reduction

Anterior:

  • Rare
  • Talus anterior
  • Treatment: Urgent reduction

Direction guides reduction technique.

Open vs Closed Classification

Closed:

  • Skin intact
  • Better prognosis
  • Treatment: Urgent reduction

Open:

  • Skin disrupted
  • Worse prognosis
  • Treatment: Urgent reduction, debridement

Open injuries have worse outcomes.

Clinical Assessment

History

Symptoms:

  • Ankle/foot pain: Severe pain
  • Deformity: Obvious deformity
  • Inability to weight bear: Cannot bear weight
  • Mechanism: High-energy trauma

Risk factors:

  • High-energy trauma
  • MVA, falls from height
  • Sports injuries

Physical Examination

Inspection:

  • Obvious deformity
  • Swelling
  • Skin tenting (urgent reduction)
  • Open wound (if open)

Palpation:

  • Tenderness over ankle/foot
  • Crepitus (if fractures)
  • Deformity

Neurovascular:

  • Document before reduction: Critical
  • Pulses: Dorsalis pedis, posterior tibial
  • Sensation: Dorsal and plantar foot
  • Motor: Ankle dorsiflexion, plantarflexion

Range of Motion:

  • Ankle/foot ROM limited and painful
  • Cannot test due to pain

Clinical Examination Key Point

Document neurovascular status before reduction - Critical for medicolegal and clinical reasons. Check pulses (dorsalis pedis, posterior tibial), sensation (dorsal and plantar foot), and motor function (ankle dorsiflexion, plantarflexion). Repeat after reduction.

Investigations

Standard X-ray Protocol

AP view:

  • Shows dislocation
  • Assess talus position
  • Check for fractures

Lateral view:

  • Shows dislocation direction
  • Assess talus position
  • Check for fractures

Mortise view:

  • Shows mortise alignment
  • Assess talus position

Key point: Do not delay reduction for imaging if skin compromised.

CT Indications (After Reduction)

Recommended after reduction:

  • Assess talar fractures
  • Plan ORIF
  • Check reduction quality

CT findings:

  • Fracture pattern
  • Displacement
  • Joint congruity

CT after reduction to assess fractures.

Management Algorithm

📊 Management Algorithm
total talar dislocation management algorithm
Click to expand
Management algorithm for total talar dislocationCredit: OrthoVellum

Management Pathway

Total Talar Dislocation Management

DiagnosisUrgent Assessment

Diagnose total talar dislocation clinically and radiographically. Document neurovascular status before reduction. Do not delay reduction for imaging if skin compromised. Urgent reduction required within hours.

ReductionClosed Reduction

Closed reduction under sedation or general anesthesia - Flex knee to relax gastrocnemius, traction, then reverse deformity based on direction. Document neurovascular status after reduction. Success rate 60-70% for closed reduction.

AssessmentCT After Reduction

CT scan after reduction to assess talar fractures - 60-80% have associated talar fractures. Assess displacement and plan ORIF if indicated.

ORIFIf Fractures Present

ORIF if fractures present and displaced - Talar fractures require ORIF if displaced. Restore joint congruity. Success rate 50-70% due to high AVN risk.

Non-Operative Treatment (Rare)

Indications:

  • Pure dislocation (no fractures)
  • Stable after reduction
  • No displacement

Protocol:

  • Short leg cast or boot
  • Non-weight bearing: 8-12 weeks
  • Serial X-rays to monitor AVN

Outcomes: 50-70% good results if no AVN.

Surgical Indications (Most Cases)

Absolute:

  • Associated talar fractures with displacement
  • Unstable after reduction
  • Open injury

Relative:

  • Large talar body fractures
  • Joint incongruity

Timing: After reduction, within 1-2 weeks.

Surgical Technique

ORIF Talar Fractures

Indications:

  • Displaced talar fractures
  • Associated with dislocation
  • Unstable after reduction

Approach:

  • Anterior approach for talar neck
  • Medial or lateral approach for talar body
  • Dual incisions if needed

Technique:

  1. Exposure: Approach based on fracture location, expose fracture, protect neurovascular structures
  2. Reduction: Anatomic reduction of fracture to restore joint congruity
  3. Fixation: Screws (3.5-4.5mm) or plate
  4. Verification: Confirm reduction and hardware position fluoroscopically, verify joint congruity restored

Advantages:

  • Restores joint congruity
  • Prevents arthritis
  • Allows early motion

ORIF restores joint congruity.

Talar Salvage Procedures

Indications:

  • AVN with collapse
  • Severe arthritis
  • Failed ORIF

Options:

  • Tibiotalar fusion: Ankle fusion
  • Tibiocalcaneal fusion: Ankle and subtalar fusion
  • Talar replacement: Rare, experimental

Key point: Salvage procedures for AVN or severe arthritis.

Complications

ComplicationIncidenceRisk FactorsPrevention/Management
AVN50-100%Prolonged dislocation, complete disruptionEarly reduction, anatomic fixation
Post-traumatic arthritis60-80%AVN, joint damageAnatomic reduction, adequate fixation
Nonunion10-20%Displacement, inadequate fixationRigid fixation
Infection10-20%Open injury, delayed treatmentUrgent debridement, antibiotics

AVN

50-100% incidence:

  • Cause: Complete disruption of blood supply, prolonged dislocation
  • Prevention: Early reduction, anatomic fixation
  • Management: Monitor with serial imaging, fusion if collapse

Post-Traumatic Arthritis

60-80% incidence:

  • Cause: AVN, joint damage, inadequate reduction
  • Prevention: Anatomic reduction, adequate fixation
  • Management: Ankle fusion or arthroplasty if severe

Postoperative Care

Immediate Postoperative

  • Immobilisation: Short leg cast or boot
  • Weight bearing: Non-weight bearing (8-12 weeks)
  • ROM: Ankle ROM after cast removal
  • PT: Ankle ROM and strengthening

Rehabilitation Protocol

Weeks 0-8:

  • Short leg cast, non-weight bearing
  • Elevation to reduce swelling
  • Ankle ROM exercises (if stable)

Weeks 8-12:

  • CT to confirm healing
  • Check for Hawkins sign (AVN assessment)
  • Cast removal if healing
  • Transition to walking boot
  • Progressive weight bearing

Weeks 12-16:

  • Full weight bearing
  • Progressive activity
  • Monitor for AVN

Outcomes and Prognosis

Overall Outcomes

Closed reduction (pure dislocation):

  • Success rate: 50-70% (stability, pain relief)
  • Functional outcomes: 40-60% return to pre-injury level
  • AVN: 50-70% develop AVN

ORIF (with fractures):

  • Success rate: 50-70% (union, pain relief)
  • Functional outcomes: 40-60% return to pre-injury level
  • AVN: 60-80% develop AVN

Open injuries:

  • Success rate: 30-50% (union, pain relief)
  • Functional outcomes: 30-50% return to pre-injury level
  • AVN: 70-90% develop AVN

Long-Term Prognosis

AVN progression:

  • With proper treatment: 50-100% develop AVN
  • Without treatment: Near 100% develop AVN
  • Risk factors: Prolonged dislocation, complete disruption, open injury

Evidence Base

Total Talar Dislocation

Case Series
Colville et al • J Orthop Trauma, 1990 (1990)
Key Findings:
  • Extremely rare injury
  • Urgent reduction required within hours
  • High AVN risk (50-100%)
  • Success rate 50-70%
Clinical Implication: Counsel patients on high complication rates despite optimal treatment

AVN Risk

Case Series
Colville et al • J Orthop Trauma, 1990 (1990)
Key Findings:
  • High AVN risk (50-100%)
  • Complete disruption of blood supply
  • Prolonged dislocation increases risk
  • Monitor with serial imaging
Clinical Implication: Maintain low threshold for salvage procedures if AVN develops

Open Injuries

Case Series
Colville et al • J Orthop Trauma, 1990 (1990)
Key Findings:
  • Often open injury
  • Urgent debridement required
  • Higher infection risk
  • Worse outcomes (30-50% good results)
Clinical Implication: Initiate aggressive debridement protocol immediately upon presentation

Outcomes

Case Series
Colville et al • J Orthop Trauma, 1990 (1990)
Key Findings:
  • Closed reduction: 50-70% good results
  • ORIF: 50-70% good results
  • AVN: 50-100% with proper treatment
  • Open injuries: 30-50% good results
Clinical Implication: Set realistic expectations regarding long-term function and pain

Urgent Reduction

Case Series
Colville et al • J Orthop Trauma, 1990 (1990)
Key Findings:
  • Urgent reduction within hours
  • Skin tension causes necrosis
  • Do not delay for imaging
  • Document neurovascular status
Clinical Implication: Proceed to reduction without imaging if skin viability is threatened

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOChallenging

Scenario 1: Total Talar Dislocation

EXAMINER

"A 30-year-old patient presents with total talar dislocation after high-energy trauma. Talus is completely dislocated from ankle, subtalar, and talonavicular joints. Skin is tented but intact."

EXCEPTIONAL ANSWER
This is a total talar dislocation in a 30-year-old patient. I would take a systematic approach: First, confirm the diagnosis: Total talar dislocation (extremely rare), talus completely dislocated from all articulations (ankle, subtalar, talonavicular), skin tented but intact (urgent reduction required). Document neurovascular status before reduction - check pulses (dorsalis pedis, posterior tibial), sensation (dorsal and plantar foot), and motor function (ankle dorsiflexion, plantarflexion). Second, urgent reduction: This is an urgent reduction - skin tension causes necrosis within hours, neurovascular compromise, high AVN risk. Do not delay for imaging if skin compromised. Reduction technique: Procedural sedation or general anesthesia, flex knee to relax gastrocnemius, apply traction, then reverse deformity based on direction (lateral most common: reduce by inversion), feel clunk with successful reduction, confirm reduction with radiographs, repeat neurovascular examination after reduction. Third, post-reduction assessment: CT scan after reduction to assess talar fractures (60-80% have associated talar fractures), plan ORIF if fractures displaced. Fourth, ORIF: If talar fractures displaced, ORIF required - Anterior approach for talar neck, medial or lateral approach for talar body, expose fracture, reduce anatomically, fix with screws (3.5-4.5mm) or plate, verify reduction fluoroscopically. Postoperatively, I would use short leg cast with non-weight bearing for 8-12 weeks, then CT to confirm healing, check for Hawkins sign (AVN assessment at 6-8 weeks), then progressive weight bearing, and monitor with serial imaging for AVN. I would counsel about poor outcomes (50-70% good results) but potential complications (AVN 50-100%, post-traumatic arthritis 60-80%, nonunion 10-20%). The key point is that urgent reduction is required within hours, and high AVN risk (50-100%) requires close monitoring.
KEY POINTS TO SCORE
Urgent reduction within hours
Document neurovascular status before and after
High AVN risk (50-100%)
ORIF if fractures displaced (50-70% good results)
COMMON TRAPS
✗Delaying reduction for imaging - skin necrosis and AVN risk
✗Not documenting neurovascular status - medicolegal risk
✗Not monitoring for AVN - miss early signs
✗Not understanding high AVN risk
LIKELY FOLLOW-UPS
"Why is AVN risk so high?"
"How do you monitor for AVN?"
"What are the salvage options if AVN develops?"
VIVA SCENARIOChallenging

Scenario 2: Open Total Talar Dislocation

EXAMINER

"A 35-year-old patient has an open total talar dislocation with exposed talus. The examiner asks you to explain your management approach."

EXCEPTIONAL ANSWER
I will explain my management approach for open total talar dislocation. Key principle: This is an orthopaedic emergency requiring urgent reduction, aggressive debridement, and staged management. Management: First, initial assessment: Document neurovascular status (critical for medicolegal and clinical reasons), assess wound (size, contamination, exposed talus), obtain radiographs (AP, lateral, mortise views), do not delay reduction for imaging. Second, urgent reduction: Reduce dislocation urgently under sedation or general anesthesia - Flex knee to relax gastrocnemius, apply traction, reverse deformity based on direction, confirm reduction radiographically, repeat neurovascular examination. Third, wound management: Urgent debridement in operating room - Extend wound if needed for adequate debridement, remove all contaminated and devitalized tissue, copious irrigation (minimum 3L), assess talus viability (may need talectomy if completely devitalized), leave wound open or use negative pressure wound therapy, plan for delayed closure or coverage. Fourth, fracture assessment: CT scan after reduction to assess talar fractures, plan ORIF if fractures displaced and soft tissue allows. Fifth, stabilization: External fixation if unstable or soft tissue compromised, ORIF if fractures displaced and soft tissue allows, consider staged approach (external fixator first, then ORIF when soft tissue ready). Sixth, antibiotics: IV antibiotics (cefazolin + gentamicin or vancomycin + piperacillin-tazobactam), continue for 24-48 hours, adjust based on cultures. Seventh, follow-up: Serial debridements if needed, delayed closure or coverage when soft tissue ready, monitor for infection, assess healing, monitor for AVN (high risk 70-90% in open injuries). The key point is that open total talar dislocations require urgent reduction, aggressive debridement, and staged management, with worse outcomes than closed injuries (30-50% good results vs 50-70%) and higher AVN risk (70-90% vs 50-100%).
KEY POINTS TO SCORE
Urgent reduction and debridement
Document neurovascular status
Staged management (external fixator, then ORIF)
Worse outcomes than closed (30-50% good results, 70-90% AVN)
COMMON TRAPS
✗Delaying reduction - skin necrosis and infection risk
✗Not debriding adequately - infection risk
✗Not using staged approach - soft tissue compromise
✗Not understanding worse outcomes and higher AVN risk
LIKELY FOLLOW-UPS
"Why are open injuries worse?"
"When would you perform talectomy?"
"What are the infection rates?"

MCQ Practice Points

Urgent Reduction

Q: Why is urgent reduction required for total talar dislocation? A: Skin tension causes necrosis within hours, neurovascular compromise, high AVN risk - Reduce within hours, do not delay for imaging if skin compromised. Document neurovascular status before and after reduction.

AVN Risk

Q: What is the AVN risk for total talar dislocation? A: High AVN risk (50-100%) - Complete disruption of blood supply to talus. Prolonged dislocation increases risk. Monitor with serial imaging (Hawkins sign at 6-8 weeks). May require talectomy or fusion if AVN develops.

Open Injuries

Q: Are total talar dislocations often open injuries? A: Yes, often open injury - Skin disruption common due to high-energy mechanism. Urgent debridement required. Higher infection risk. Worse outcomes than closed injuries (30-50% good results vs 50-70%).

Treatment

Q: What is the treatment for total talar dislocation? A: Urgent closed reduction, then ORIF if fractures present - Reduce within hours, document neurovascular status, CT after reduction to assess fractures, ORIF if displaced. Success rate 50-70% with proper treatment.

Complications

Q: What are the complications of total talar dislocation? A: AVN (50-100%), post-traumatic arthritis (60-80%), nonunion (10-20%), infection (10-20% in open injuries) - Prevent with early reduction and adequate fixation. Success rate 50-70% with proper treatment.

Australian Context

Clinical Practice

  • Total talar dislocation extremely rare
  • Urgent reduction required
  • High AVN risk
  • Often open injury

Healthcare System

  • Procedures covered under public system
  • Public hospitals handle most cases
  • Private insurance covers procedures
  • High-energy trauma common

Orthopaedic Exam Relevance

Total talar dislocation is a rare but important viva topic. Know that urgent reduction required (within hours, skin necrosis risk), high AVN risk (50-100%), often open injury, ORIF if fractures displaced (50-70% good results), and document neurovascular status before and after reduction. Be prepared to discuss the reduction technique and management of AVN.

TOTAL TALAR DISLOCATION

High-Yield Exam Summary

Key Concepts

  • •Extremely rare injury (less than 0.1% of dislocations)
  • •Talus completely dislocated from all articulations
  • •Urgent reduction required within hours (skin necrosis risk)
  • •High AVN risk (50-100%)

Classification

  • •Pure: No fractures, rare - urgent reduction (50-70% good results)
  • •With fractures: Talar fractures, common - urgent reduction, ORIF (50-70% good results)
  • •Open: Skin disrupted, common - urgent reduction, debridement (30-50% good results)
  • •Direction: Lateral (common), Medial (less common), Anterior (rare)

Treatment

  • •Urgent closed reduction: Within hours, document neurovascular status
  • •CT after reduction: Assess talar fractures (60-80% have fractures)
  • •ORIF if fractures displaced: Restore joint congruity (50-70% good results)
  • •Pure dislocation: Conservative if stable (50-70% good results)

Surgical Technique

  • •Reduction: Flex knee, traction, reverse deformity
  • •ORIF talus: Anterior, medial, or lateral approach
  • •Salvage: Tibiotalar or tibiocalcaneal fusion if AVN
  • •Verify reduction fluoroscopically

Complications

  • •AVN: 50-100% (prevent with early reduction, monitor with serial imaging)
  • •Post-traumatic arthritis: 60-80% (prevent with anatomic reduction)
  • •Nonunion: 10-20% (prevent with rigid fixation)
  • •Infection: 10-20% in open injuries (prevent with urgent debridement)
Quick Stats
Reading Time63 min
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