AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Background

Fractures of the talus can be divided into types based on the 3 main anatomic divisions of the talus: body, neck, and head. Fractures of the body of the talus are further subdivided based on whether they traverse the main portion of the body or are fractures involving the talar dome, lateral process, or posterior process. Mechanisms of injury, treatment, and prognosis of the different types of talar fractures are markedly dissimilar. (See also the Medscape General Medicine article Fractures of the Talus: Anatomy, Evaluation, and Management and the eMedicine articles Osteochondral Lesions of the Talus; Fractures, Ankle; and Fractures, Foot.)

For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education articles Ankle Fracture and Broken Foot.

Frequency

United States

Talus fractures reportedly make up 3-5% of foot fractures. However, they are probably underreported, especially osteochondral fractures and fractures of the lateral and posterior processes of the talus, which are radiographically difficult to detect.

Approximately 50% of fractures of the talus involve the talar neck. The most common fracture of the talar body is the osteochondral fracture, followed by fractures of the posterior and lateral processes. Fractures of the main portion of the talar body and of the talar head are uncommon.

Mortality/Morbidity

Fractures of the talus can lead to avascular necrosis (AVN), arthritis, and, when unrecognized, chronic pain and nonunion. These develop as follows:

• AVN of the body of the talus - This condition develops primarily after a displaced fracture of the talar neck—which disrupts the blood supply to the talar body—has occurred. The risk of AVN can be estimated by the Hawkins classification (discussed below). An adequate blood supply to the talus can be inferred when a Hawkins sign is present (see Image 24).^{1, 2}
• Arthritis - A common complication following talar fracture, talus-related arthritis can involve the tibiotalar, subtalar, or talonavicular joints. Exact surgical reduction is a goal in the prevention of posttraumatic arthritis.
• Chronic pain and nonunion - These complications are not infrequent following undetected talar fractures. Osteochondral fractures of the talar dome, posterior process fractures, and lateral process fractures may be difficult to detect radiographically; clinically, they may be mistaken for ankle sprain. Patients with an undetected talar fracture present later with chronic pain and often with nonunion of the lateral or posterior process, at which time the fragment may require excision. Undetected osteochondral fractures may progress to loose bodies within the joint.

Age

Fractures of the talar dome, lateral process, and posterior process occur primarily in young athletes. Other talar fractures occur at any age, usually as a result of motor vehicle accidents or falls from a height.

Anatomy

The talus is unique in that no tendons attach to it. It is held in place by ligamentous and bony structures. The talus articulates superiorly with the tibia, medially and laterally with the medial and lateral malleoli (respectively), inferiorly with the calcaneus, and anteriorly with the navicular.

The talus can be divided into 3 main parts: body, neck, and head.

Body

The body, which is the largest portion of the talus, is divided into 4 parts, as follows:

• Dome - The dome articulates with the tibial plafond. Although termed a dome, it is shaped like a pulley, being convex from front to back but slightly concave from medial to lateral. Plantarflexion and dorsiflexion take place at the tibiotalar joint.
• Central portion - The central portion has articular facets medially and laterally that articulate with the malleoli, as well as an inferior articular facet that articulates with the posterior facet of the calcaneus. Inversion and eversion, as well as plantarflexion and dorsiflexion, take place at the posterior subtalar joint.
• Posterior process - The posterior process of the talus projects from the posteroinferior aspect of the talar body and is nonarticular.
• • The flexor hallucis longus (FHL) tendon courses between medial and lateral tubercles of the posterior process. Fractures of the posterior process can affect the FHL.
  • The posterior process of the talus can be present as a separate ossicle, the os trigonum.
• Lateral process - The lateral process of the talus protrudes beneath the tip of the fibula. On a lateral radiograph, it forms a wedge shape at the anterior aspect of the posterior subtalar joint, with the apex of the wedge pointing inferiorly. The posterior subtalar facet extends into this region, and fractures of the lateral process often involve that joint.

Neck

The neck of the talus is roughly cylindrical in shape and is considerably narrower than the body. The talar neck is separated from the calcaneus by the fat-filled sinus tarsi.

The main blood supply of the talar body enters the talar neck from the sinus tarsi (a fat-filled space between the talar neck and the calcaneus) and proceeds retrograde to supply the talar body. Thus, fractures of the talar neck can compromise the vascularity of the body of the talus.

Head

The head of the talus is convex anteriorly and articulates with the navicular. Abduction and adduction are the primary motions at the talonavicular joint.

Clinical Details

The mechanism of injury and clinical presentation of each of the 6 main types of talar fracture vary markedly. For purposes of conciseness and clarity, they are discussed below in the Radiograph/Findings section.

Preferred Examination

Plain radiographs of the foot and ankle are used to diagnose talar fractures. The views obtained depend on the particular fracture and are discussed separately (see below). Computed tomography (CT) scanning is used to evaluate displacement and to plan surgery. CT scanning and magnetic resonance imaging (MRI) are used to diagnose clinically occult fractures.

Limitations of Techniques

A close, directed scrutiny of radiographs is needed to detect many talar fractures. Fractures of the lateral process are especially difficult; they may be visible on the anteroposterior (AP) ankle radiograph, the Broden view (45° internal oblique), or only on the lateral view of the foot.

CT scanning and MRI are used to detect radiographically occult fractures of the talus but must be performed with high resolution and attention to patient positioning. MRI can be difficult to interpret if planes orthogonal to the long axis of the talus are not used. CT scanning should be performed in the coronal and axial planes; otherwise, fractures may be missed.

DIFFERENTIALS

Section 3 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Other Problems to Be Considered

Hindfoot pain, chronic
Ankle sprain

RADIOGRAPH

Section 4 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Talar Body Fractures

• Mechanism of injury - Axial load or shear
• Associated injuries - Calcaneus, tibia, talar neck
• Radiographic assessment - AP, mortise (15° internal oblique), lateral, and Broden views (It is important to quantify the degree of articular involvement and displacement.)
• Displacement of articular facet of posterior subtalar joint - Broden view, CT scan
• Advanced imaging - CT scan in coronal plane (defined as coronal relative to the tibia) to assess comminution, articular disruption, and associated fractures
• Treatment - Open reduction and internal fixation (ORIF)
• Complication - High incidence of subtalar arthritis

Osteochondral fractures of the talar dome

The terms osteochondral fracture, transchondral fracture, and osteochondritis dissecans (OCD) are used interchangeably in the region. However, the first 2 terms are preferable because the fracture is caused by a single episode of trauma. These fractures are most commonly classified by the system devised by Berndt and Harty, which has been modified to include MRI findings.

Table 1. Classification of Osteochondral Fractures of the Talar Dome

*T2WI= T2-weighted imaging

**Stage 2a is a variant in which a cyst forms in the subcortical bone

• Mechanism of injury - Inversion injury of the ankle. A lateral osteochondral fracture results from shearing of a small fragment of cartilage and bone; compression of the talar dome causes medial fracture.
• Associated injuries - These include tears of the lateral collateral ligament of the ankle.
• Location - Injury occurs in the lateral or medial aspect of the talar dome.
• Radiographic assessment - AP and mortise views. Sensitivity is increased if the mortise view is performed in plantarflexion and dorsiflexion.
• Advanced imaging - MRI to evaluate cartilage and the presence of a loose fragment. CT arthrography also can be used.^{3, 4}
• Classification - The most commonly used classification is the Berndt and Harty system (containing later modifications to incorporate MRI findings).
• Treatment - Drilling may be performed in the early stages to promote healing.^{4, 5} Large fragments may be reattached or removed. (See also the article Fresh Osteochondral Grafting in the Treatment of Osteochondritis Dissecans of the Talus, on Medscape.)
• Complications - Injury may lead to ankle arthritis and loose bodies.

Posterior process fractures

• Terminology - Occasionally known as Shepherd's fracture
• Mechanism of injury - Hyperplantarflexion or avulsion of the posterior talofibular ligament; also, stress fracture in athletes and (especially) ballet dancers
• Associated injuries - Talar body fracture, injury of FHL tendon (see Anatomy)
• Radiographic assessment - Seen on lateral radiograph; must differentiate this injury from an os trigonum (a nonunited, accessory center of ossification of the posterior process)
• Advanced imaging - Not needed (although posterior process fractures are readily seen on axial CT scans)
• Treatment - Conservative; removal of fragment if there is painful nonunion
• Complications - May result in chronic pain and nonunion

Lateral process fractures

• Terminology - Also known as snowboarder's fracture⁶
• Mechanism of injury - Eversion injury. The lateral process is caught between the lateral malleolus of the fibula above it and the calcaneus below it. The injury may also be caused by inversion and dorsiflexion. It is increasing in incidence.
• Radiographic assessment - Mortise or Broden view. The fracture is vertically oriented, and the fragment varies in composition from a small flake of cortical bone to most of the lateral process. The degree of involvement of the subtalar joint should be assessed. The fracture may be radiographically occult.
• Advanced imaging - MRI or CT scanning are useful for occult fractures. These modalities can be used to assess the subtalar joint and evaluate for nonunion.⁷
• Treatment - Nonarticular chip fractures are treated conservatively. Articular fragments may be excised or treated with ORIF. There is a high incidence of nonunion and osteoarthritis of the subtalar joint.

Talar Neck Fractures

The classification system created by Hawkins, as modified by Canale and Kelly, should be used.¹

Table 2. Hawkins Classification of Talar Neck Fractures

• Three mechanisms of injury
• • The most common mechanism is a dorsally directed force on a braced foot, such as that encountered in head-on motor vehicle accidents. Talar neck fractures were once known as "aviator's astragalus," because World War I pilots suffered the fracture during plane crashes in which their foot was dorsiflexed on the floorboard of the plane.
  • Another mechanism is inversion of the ankle, with impingement of the talar neck against the medial malleolus.
  • A third mechanism is a direct blow to the dorsum of the foot.
• Radiographic assessment
• • A lateral radiograph of the foot should be employed. The injury is difficult to see on AP of the foot unless displacement has occurred. An angled view was described by Canale and Kelly but is difficult to perform.
  • Follow-up radiographs should be evaluated for the presence of a Hawkins sign, a subcortical lucency that is caused by hyperemia and consequent bone resorption. If a Hawkins sign appears, this indicates that AVN will not develop.
• Advanced imaging - CT scanning can be used to confirm presence of a subtle fracture and to evaluate reduction.
• Complications - Since most of the blood supply to the talar body comes by way of the talar neck, fractures of the neck place the patient at risk of developing AVN.
• Treatment - ORIF is employed, with attention to precise anatomic reduction, especially of the articular surfaces.⁸
• Complications - AVN and subtalar arthritis can occur.

Talar Head Fractures

• Mechanism of injury - Axial compression; can also occur secondary to talonavicular joint dislocation
• Associated injuries - Other foot fractures, dislocation of the talonavicular joint
• Radiographic assessment - AP and lateral radiographs of the foot (The fractures are usually obliquely oriented.)
• Advanced imaging - Not routinely indicated; may be useful to assess the talonavicular joint
• Treatment - Reduction of joint, occasionally ORIF

Degree of Confidence

Several fractures of the talus can be difficult to detect radiographically, including osteochondral fracture, lateral process fracture, and nondisplaced talar neck fracture. Whenever trauma radiographs of the foot or ankle are obtained, a high degree of attention should be paid to the areas where these subtle fractures occur. If doubt exists as to the presence of a fracture, MRI is the test of choice. CT scanning also shows occult fractures, but unlike MRI, it cannot differentiate between stage II and stage III osteochondral fractures.

False Positives/Negatives

The os trigonum, an accessory center of ossification for the posterior process of the talus, must be differentiated from a posterior process fracture. The following criteria are used:

• A fracture line is sharply angled relative to the remainder of the bone, while an accessory center of ossification tends to be shaped like a smooth pebble.
• The pieces of a fractured bone fit together precisely, like 2 pieces of a jigsaw puzzle, while an accessory ossicle usually does not fit tightly with the parent bone. CT scanning may occasionally be necessary to make this differentiation.
• An acute fracture line will not have a sclerotic margin, while an accessory ossicle is surrounded by dense, cortical bone.

CT SCAN

Section 5 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

CT scan findings are integrated with plain radiographic findings for each type of fracture (see Radiograph/Findings).

MRI

Section 6 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

MRI findings are discussed above with plain radiographic findings (see Radiograph/Findings).

NUCLEAR MEDICINE

Section 7 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Findings

Nuclear medicine currently has little role in the evaluation of talus fractures. MRI has equal sensitivity to nuclear medicine imaging techniques but with much greater specificity. However, a bone scan performed to evaluate chronic pain will show uptake corresponding to the fracture site.

INTERVENTION

Section 8 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Medical/Legal Pitfalls

• Many talar fractures are subtle and easily missed; however, they can lead to long-term disability when there is a disruption of the subtalar or talonavicular joints. In a patient with a history of ankle injury, careful radiographic scrutiny should be given to the talar neck, head, and lateral process. The amount of joint involvement should be estimated because this is an important prognostic factor and influences treatment. CT scanning should be recommended if the radiologist is unsure of the extent of the fracture or to guide surgical intervention.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

Media file 1:  Talar body fracture, anteroposterior radiograph. There is a sagittally oriented fracture through the body of the talus and disruption of the tibiotalar and subtalar joints. The injury was from a motor vehicle accident.
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Media file 2:  Talar body fracture, lateral radiograph (same patient as in Image 1). There is a significant degree of comminution of the talar fracture, with comminuted fracture lines extending into the posterior and lateral processes of the talus.
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Media file 3:  Talar body fracture (same patient as in Images 1-2). Coronal computed tomography (CT) scan through the posterior subtalar joint. There is wide separation of the talar fragments. The degree of the subtalar joint dislocation and the marked comminution of the medial portion of the talus are evident.
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Media type:  CT

Media file 4:  Talar body fracture, anteroposterior radiograph. This patient had a fall resulting in a pilon fracture of the tibia, a sagittally oriented fracture of the body of the talus, and a central compressive fracture of the calcaneus.
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Media file 5:  Talar body fracture, lateral radiograph (same patient as in Image 4). The fracture of the talus, existing purely in the sagittal plane, is not visible on the lateral radiograph. However, the central compressive calcaneal fracture is well visualized.
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Media file 6:  Lateral process fracture, anteroposterior radiograph. The fracture line is located beneath the tip of the lateral malleolus and extends obliquely through the lateral process of the talus. LM=lateral malleolus, LP=lateral process of talus
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Media file 7:  Lateral process fracture (same patient as in Image 6). Axial computed tomography (CT) scan; the involvement of the subtalar joint is more easily seen on a CT scan.
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Media file 8:  Patient OA. Lateral process of talus fracture, anteroposterior radiograph. The fracture line (arrows) is nondisplaced and medially located at the junction of the lateral process and central body of the talus, making it difficult to see.
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Media file 9:  Patient OA. Lateral process of talus fracture, lateral radiograph. The fracture line is better appreciated on this image, which isolates a triangular fragment at the tip of the lateral process of the talus.
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Media file 10:  Patient OA. Lateral process of the talus fracture. Lateral view of technetium-99m (99mTc) bone scan at 5 hours following injection. The fracture site shows a markedly increased uptake of radionuclide.
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Media file 11:  Patient OA. Lateral process fracture; sagittal, fast spin-echo, inversion recovery magnetic resonance image. The tip of the lateral process shows high signal intensity consistent with edema. The magnetic resonance imaging (MRI) scan was performed several months after the fracture, and the fracture line has partially healed.
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Media type:  MRI

Media file 12:  Posterior process fracture, lateral radiograph. The fracture is acute, which means that there is an absence of cortex around the posterior process fragment, clearly differentiating this from an os trigonum (see Image 13). Note also the ankle joint effusion and soft-tissue swelling adjacent to the fracture site.
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Media file 13:  Os trigonum (OT), lateral radiograph. The ossicle is shaped like a smooth pebble and is well corticated.
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Media file 14:  Fractures of the lateral and posterior processes of the talus, axial computed tomography (CT) scan. These fractures were associated with a talar body fracture.
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Media file 15:  Stage 2A osteochondral fracture of the lateral talar dome, anteroposterior radiograph. There is a semicircular subcortical lucency at the lateral aspect of the talar dome, and a slight cortical depression is present.
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Media file 16:  Stage 4 osteochondral fracture of the talar dome, mortise radiograph. A small cortical fragment has become dislodged, leaving a small bony defect at the most lateral aspect of the talar dome.
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Media file 17:  Axial computed tomography (CT) scan showing an osteochondral fracture lesion. On an axial image, the area of the osteochondral fracture is circular, and the density within it is heterogeneous.
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Media file 18:  Patient BM. Coronal, T1-weighted magnetic resonance image of a stage 3 osteochondral fracture. A thin cortical fragment is seen; it is separated from the concave bony defect beneath it by intermediate–signal-intensity material. A stage 3 lesion is confirmed on T2-weighted and fast spin-echo, inversion recovery images.
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Media file 19:  Patient BM. Coronal, fast spin-echo, T2-weighted magnetic resonance image with fat saturation, showing a stage 3 osteochondral fracture of the talar dome. A tiny cartilage defect is seen in the talar dome, showing the higher signal intensity of fluid compared to the intermediate signal intensity of cartilage. Fluid is also seen between the osteochondral fragment and adjacent bone, indicating that the fragment is detached but nondisplaced.
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Media type:  MRI

Media file 20:  Patient BM. Sagittal, fast spin-echo, inversion recovery magnetic resonance image showing a stage 3 osteochondral fracture. On a fast spin-echo, inversion recovery image, the high–signal-intensity line around the osteochondral fragment is better seen.
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Media type:  MRI

Media file 21:  Hawkins type I fracture of the talar neck, lateral radiograph. These fractures are quite subtle. Disruption of the dorsal cortex of the talar neck is visible, and the fracture line can be faintly followed vertically through the talar neck. Computed tomography (CT) scanning is useful to confirm the fracture.
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Media file 22:  Hawkins type III fracture of the talar neck, lateral radiograph. The fracture of the talar neck is completely displaced dorsally. The posterior subtalar joint is dislocated, and the articular facet of the talus (arrows) is seen lying behind the articular facet of the calcaneus. The tibiotalar joint is subluxed.
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Media file 23:  Avascular necrosis (AVN) of the talar body, lateral radiograph. The entire talar dome is sclerotic because of AVN, which occurred as a complication of a talar neck fracture.
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Media file 24:  Partial Hawkins sign, anteroposterior radiograph. Following open reduction and internal fixation of a Hawkins type II fracture, a Hawkins sign (arrows), indicating intact vascularity, is seen over most of the talar dome. Laterally, however, the Hawkins sign is absent. The lateral portion of the dome is sclerotic, representing a small focus of avascular necrosis that has developed there.
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Media file 25:  Medial fracture dislocation of the talonavicular joint, anteroposterior (AP) radiograph. On the AP radiograph, the medial dislocation of the talonavicular joint is evident. More difficult to see is the oblique fracture through the head of the talus.
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Media file 26:  Lateral radiograph of a talonavicular fracture dislocation.
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REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Differentials
• Radiograph
• CT Scan
• MRI
• Nuclear Medicine
• Intervention
• Multimedia
• References

1. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. Jul 1970;52(5):991-1002. [Medline].
2. Hawkins LG. Fracture of the lateral process of the talus. J Bone Joint Surg Am. Sep 1965;47:1170-5. [Medline].
3. De Smet AA, Fisher DR, Burnstein MI, et al. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. AJR Am J Roentgenol. Mar 1990;154(3):555-8. [Medline]. [Full Text].
4. Yulish BS, Mulopulos GP, Goodfellow DB. MR imaging of osteochondral lesions of talus. J Comput Assist Tomogr. Mar-Apr 1987;11(2):296-301. [Medline].
5. Loomer R, Fisher C, Lloyd-Smith R. Osteochondral lesions of the talus. Am J Sports Med. Jan-Feb 1993;21(1):13-9. [Medline].
6. von Knoch F, Reckord U, von Knoch M, et al. Fracture of the lateral process of the talus in snowboarders. J Bone Joint Surg Br. Jun 2007;89(6):772-7. [Medline].
7. Sanders TG, Ptaszek AJ, Morrison WB. Fracture of the lateral process of the talus: appearance at MR imaging and clinical significance. Skeletal Radiol. Apr 1999;28(4):236-9. [Medline].
8. Daniels TR, Smith JW. Talar neck fractures. Foot Ankle. May 1993;14(4):225-34. [Medline].
9. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. Sep 1959;41-A:988-1020. [Medline].
10. Cantrell MW, Tarquinio TA. Fracture of the lateral process of the talus. Orthopedics. Jan 2000;23(1):55-8. [Medline].
11. Crim JR, Cracchiolo A, Hall RL. Injuries of the foot. Imaging Foot Ankle. 1996;54-64.
12. Dipaola JD, Nelson DW, Colville MR. Characterizing osteochondral lesions by magnetic resonance imaging. Arthroscopy. 1991;7(1):101-4. [Medline].
13. Ebraheim NA, Karkare N, Gehling DJ, et al. Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus. J Orthop Trauma. Sep 2007;21(8):579-82. [Medline].
14. Higgins TF, Baumgaertner MR. Diagnosis and treatment of fractures of the talus: a comprehensive review of the literature. Foot Ankle Int. Sep 1999;20(9):595-605. [Medline].
15. Tezval M, Dumont C, Stürmer KM. Prognostic reliability of the Hawkins sign in fractures of the talus. J Orthop Trauma. Sep 2007;21(8):538-43. [Medline].
16. Thordarson DB, Kaku SK. Results of step-cut medial malleolar osteotomy. Foot Ankle Int. Dec 2006;27(12):1020-3. [Medline].

Article Last Updated: Nov 16, 2007