Overview
Talar fractures are difficult because of complex anatomy, variable patterns and a precarious blood supply. Most of the talus is covered by articular cartilage and its superior surface bears more load per unit area than any other bone, so accurate reduction is essential. Even a few degrees of varus malunion of the neck is almost uniformly associated with a poor outcome. (Campbell)
Blood Supply (Campbell)
Head and neck: richly supplied by superior neck vessels (dorsalis pedis) and the artery of the sinus tarsi; head osteonecrosis is rare.
Body (vulnerable; osteonecrosis can approach 100% with displacement):
Artery of the tarsal canal (from the posterior tibial artery about 1 cm above its bifurcation): the most consistent supply, 4 to 6 direct vessels to the body.
Deltoid artery (branch of the tarsal canal artery): medial one fourth to one half of the body; may be the only remaining supply after dislocation.
Artery of the sinus tarsi: lateral one eighth to one fourth, anastomosing with the tarsal canal artery.
Posterior tubercle branches; and a direct branch to the medial neck at risk in the anteromedial approach but preserved with medial malleolar osteotomy.
Overall contribution: posterior tibial about 47%, anterior tibial about 36%, peroneal about 17%.
Classification and Prognosis (Campbell)
Hawkins / Canale-Kelly type | Description | Reported osteonecrosis |
|---|---|---|
I | Nondisplaced vertical neck fracture | 0% (Hawkins); occasional in later series |
II | Displaced, subtalar subluxation or dislocation | about 42% to 50% |
III | Subtalar and ankle dislocation of the body | about 91% |
IV | Type III plus talonavicular subluxation or dislocation | highest |
Vallier subdivided type II: IIA without subtalar dislocation (no osteonecrosis) and IIB with dislocation (about 25%). Initial displacement correlated with osteonecrosis more than operative timing.
In modern series osteonecrosis is 20% to 49%, post-traumatic arthritis 36% to 94% and secondary surgery 17% to 44%. Even type I fractures can lead to arthritis and poor results, so counsel patients.
Evaluation (Campbell)
AP, lateral and oblique ankle views, an AP foot view and a Canale view (foot internally rotated 15 degrees, beam 75 degrees from horizontal) to profile the neck; contralateral images help restore normal parameters.
CT for all talar fractures: many apparent type I fractures show subtle displacement.
Look for associated injuries: medial malleolar fracture (common with displaced neck fractures), peroneal dislocation with lateral process fractures, and the lumbar spine after axial loading.
Treatment Principles (Campbell)
Type I (CT-confirmed nondisplaced, subtalar joint clear): below-knee cast for 8 to 12 weeks with weight bearing delayed until trabeculation crosses the fracture; follow closely for displacement.
Types II to IV: early ORIF, since closed anatomic reduction is difficult. Prompt reduction relieves soft-tissue tension, but definitive fixation can be delayed until swelling subsides; delays averaging about 13 days did not increase osteonecrosis or arthritis in a military series.
Types III and IV are emergencies: the extruded body threatens skin and neurovascular structures, and the deltoid branch may be kinked. Reduce closed if possible and fix electively; treat irreducible dislocations emergently with open reduction.
Current literature favors dual anterior approaches (anteromedial and anterolateral) over the posterolateral approach.
Technique 93.8: Open Reduction of the Talar Neck (Campbell)
Anteromedial approach: start proximal and just anterior to the medial malleolus and curve distally and plantarward to the medial navicular, in the interval between the anterior and posterior tibial tendons. Do not incise the posterior tibial tendon or the neurovascular structures below the malleolus, to preserve the remaining medial blood supply.
If the body is extruded, a medial malleolar osteotomy eases exposure and reduction.
Preserve as much soft tissue as possible around the head and neck.
Anterolateral approach: a 5-cm incision over the sinus tarsi toward the fourth metatarsal base; protect the intermediate dorsal cutaneous nerve, incise the inferior extensor retinaculum and reflect extensor digitorum brevis plantarward.
Insert two small threaded K-wires into the head fragment medially and laterally as joysticks; distract and irrigate debris.
Look for interdigitating fracture lines to key the reduction. Medial comminution is common, and the key to reduction is often lateral. Hold with longitudinal K-wires and compare the intraoperative Canale view with the contralateral image to avoid varus.
Fixation: 4.0-, 4.5- or 6.5-mm cannulated screws with countersunk heads; use fully threaded screws across comminution to prevent medial collapse. Lateral mini-fragment plates help with comminution or limited head space. The authors prefer a medial screw with a lateral mini-fragment plate to maintain length and prevent varus.
Posterior-to-anterior screws (biomechanically strongest): posterolateral approach lateral to the Achilles, between FHL and peroneals; start above the lateral posterior process aiming at the lateral head under fluoroscopy to avoid the subtalar joint.
For fragile bone or distal fractures, consider bridge plates. Fix a medial malleolar osteotomy with two malleolar screws.
Postoperative Care (Campbell)
Below-knee cast with the foot neutral and well molded into the arch. At 6 to 8 weeks, depending on early union, change to a walking boot and allow weight bearing; some patients must wait 12 weeks.
Talar Head Fractures (Campbell)
Account for 5% to 10% of talar injuries (axial loading or dorsal compression against the anterior plafond). CT is often needed. Displaced shear or impacted fractures need ORIF without stripping the vascular supply; elevate impacted fragments and bone graft behind them. Fix with lag, headless compression screws or bioabsorbable pins, and stabilize an unstable talonavicular joint with a K-wire or external fixator or spanning plate to keep medial column length. Start motion at about 2 weeks if fixation is secure, with no weight bearing for at least 6 weeks. Head osteonecrosis is about 10%. Talonavicular arthrodesis is reserved for severe cases; avoid shortening the medial column into varus.
Complications (Campbell)
Osteonecrosis: a subchondral lucent line along the dome (Hawkins sign) at 6 to 8 weeks indicates vascularity and excludes osteonecrosis; its absence is sensitive but not specific. Delay MRI 2 to 3 months to let edema resolve. Bone grafting, early subtalar or ankle fusion and prolonged non-weight bearing have not reliably prevented collapse.
Malunion or nonunion (Zwipp-Rammelt types I to V): for types I to III with preserved cartilage, corrective osteotomy or revision with bone grafting and stable fixation can avoid arthrodesis, with high satisfaction; otherwise corrective fusion.
Post-traumatic subtalar and ankle arthritis, skin necrosis and infection, especially with comminuted or open fractures.
Additional Detail from Rockwood and Green
Epidemiology and mechanism (Rockwood)
The talus is the second most commonly fractured tarsal bone and links the ankle, subtalar and transverse tarsal joints, so any injury can impair all three.
Talar neck fractures are mostly due to falls from height and motor vehicle collisions (about 46% in one review). Cadaver work could not reproduce neck fractures with hyperdorsiflexion alone; they occurred with an axial plantar force under the midfoot while the ankle was dorsiflexed (as with a foot on the brake pedal), the distal tibia striking the neck. Higher energy brings more comminution, soft-tissue damage and joint disruption.
Talar body fractures share the mechanism but occur more posteriorly, with axial compression as the anterior plafond strikes the dome.
Author's preferred algorithm for talar neck fractures (Rockwood)
Nondisplaced: cast immobilization, or percutaneous fixation.
Displaced, noncomminuted (Hawkins II): attempt closed reduction. If successful, percutaneous fixation for an isolated injury, or ORIF in polytrauma; if closed reduction fails, ORIF through dual approaches.
Hawkins III or IV, or comminuted: ORIF through dual approaches, using a joint distractor or malleolar osteotomy as needed.
Talar body fractures (Rockwood)
Most need surgery; incomplete, undisplaced or stress fractures can be treated with immobilization and no weight bearing. Any displacement in these highly constrained joints rapidly leads to arthrosis.
Attempt closed reduction before surgery. Irreducible tibiotalar dislocation or threatened soft tissues require urgent open reduction with internal or external fixation.
Expect associated injuries (medial malleolus, navicular, extension into neck or head). An existing medial malleolar fracture can be used instead of an osteotomy.
Setup: radiolucent table, supine with a bump under the ipsilateral hip and the heel at the table edge, fluoroscopy from the opposite side, thigh tourniquet (typically 250 to 325 mm Hg) after exsanguination. Have mini- and small-fragment screws, headless screws, K-wires, joysticks, a femoral distractor or external fixator, bioabsorbable pins and a microsagittal saw available.
Medial malleolar osteotomy: extend the anteromedial incision proximally and place it slightly more posterior than usual. Predrill two parallel 2.5-mm pilot holes, protect the posterior tibial tendon with a retractor, cut transversely with a microsagittal saw and complete through the joint with an osteotome for interdigitation. Enter the joint at the shoulder where the malleolus meets the plafond to avoid the weight-bearing surface, and keep the deep deltoid intact, since it may carry the only remaining blood supply to the talus.
Lateral: standard anterolateral approach; if a lateral malleolar osteotomy is needed, extend the incision over the anterior fibula toward the sinus tarsi along the fourth ray.
Minimize soft-tissue stripping; dissection into the talar neck and talonavicular capsule is usually unnecessary.
References
Fractures and dislocations of the foot. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 93, Fractures of the talus.
Sanders DW, Inculet CI. Fractures and dislocations of the talus. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Wolters Kluwer; 2024 (Turkish edition: Erişkin Kırıkları). Chapter 66.