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Review article

Talar neck fracture: a review of clinical presentation and treatment methods

Jovana Grupković1, Uroš Dabetić1, Marko Simić1
  • University Clinical Center of Serbia, Clinic for Orthopedic Surgery and Traumatology, Belgrade, Serbia

ABSTRACT

The talus transfers the weight of the whole body onto the foot and is therefore an important factor of stability and posture. The prerequisite for successful treatment of talus neck fractures is knowledge of anatomy, understanding of the mechanisms that lead to fractures of the talus neck, knowledge of the potential complications of all treatment methods, as well as knowledge of indications for surgical treatment.

About 55% of the talus surface is covered with articular cartilage, and displaced fractures lead to the destabilization of several joints. Since fractures are caused by high energy trauma, the result can easily be comminution and/or dislocation (displacement). Fractures of the talus neck can occur as an isolated injury, as well as part of polytrauma (falls from height, traffic accidents). The X-ray is the basic diagnostic tool for making an accurate diagnosis, in case of suspect talus fracture. Multi-slice computerized tomography is the most useful method for studying fracture patterns and is indispensable in planning surgical treatment. The Hawkins classification of talus neck fractures, from 1970, has remained in use to this day, while recommended treatment methods vary depending on the type of fracture. The main goal of treatment is anatomical reduction.

The anatomical characteristics of the talus, the particular blood supply, as well as the "high energy" mechanism of fracture, pose a challenge for clinical evaluation and optimal treatment of talus fractures. This paper highlights the necessity of the knowledge of surgical techniques for the selection of an adequate method of treatment, in order to prevent unwanted consequences for the patient, which in the case of suboptimal treatment can be severe.


INTRODUCTION

The talus transfers the weight of the entire body to the foot, which is why it represents an important factor of stability and posture. The mechanism of talus fracture is primarily fall from height or a deceleration injury with the foot in dorsiflexion [1],[2]. Talar neck fractures are especially important due to the particular, retrograde vascularization of the talus, whose obstruction may lead to avascular necrosis [3].

Since fractures of the talus represent 1% (0.1% to 2.5%) of all fractures [4], research and literature on the methods of their treatment is scarce. However, although the predominance of these fractures is relatively small, it is of great importance to orthopedic surgeons to be well acquainted with the principles of treatment, bearing in mind that the effects of inadequate treatment may bring about severe consequences to the patient, a significant decrease in the quality of life, as well as a high rate of invalidity [5].

The prerequisite for successful treatment of talus neck fractures is knowledge of anatomy, understanding of the mechanisms that lead to fractures of the talus neck, knowledge of the potential complications of all treatment methods, as well as knowledge of indications for surgical treatment.

The aim of this paper is to present the most important anatomical characteristics, the clinical presentation, as well as the bases of the diagnostics and principles of talar neck fracture treatment.

CLINICAL ANATOMY

The talus is made up of the head, neck and body. What is characteristic of this bone is that it has no muscular attachments and 55% of its surface is covered by cartilage [6].

With its superior articulating surface, the talus articulates with the tibia; with its inferior articulating surface, it articulates with the calcaneus; with its anterior articulating surface, the talus articulates with the navicular bone; and with its lateral and medial surfaces it articulates with the malleoli. Thus, displaced fractures of the talus lead to the destabilization of several joints.

In relation to the talar body, the neck is angled medially (10° - 44°) and plantarly (5°- 50°). Also, as compared to the body and head, it has fewer trabeculae, which are of a different orientation. The sharp change in the orientation of the trabeculae on the talar neck render it more prone to fracture [7].

Fractures of the talus occur as the result of powerful force, very frequently with a rotation component, which is why comminution and/or dislocation may easily occur (varus) [8]. In a large number of cases (up to 28%), talar neck fracture is compounded by the fracture of the medial malleolus [9].

Vascularization

A larger part of the talus is covered with cartilage, while a lesser part is accessible for blood supply. It is known that the talus has three major sources of blood supply – the posterior tibial artery, (47%), the anterior tibial artery (36%), and the peroneal artery (17%) [10].

The tarsal sinus is limited by the talar neck, superiorly, and by the anterosuperior surface of the calcaneus, posteriorly, and it opens medially into the tarsal tunnel, posteriorly from the sustentaculum tali of the calcaneus. This is a structure that divides the anterior from the posterior subtalar joint. This is also the site of anastomosis of the tarsal tunnel artery, originating from the posterior tibial artery, and the tarsal sinus artery, originating from the anterior tibial artery. In this region, on the posterior surface of the talar neck, a dense vascular net is located, which is considered the most important structure in the vascular supply of the talus.

Such characteristic vascularization distribution requires detailed knowledge of anatomy, detailed understanding of the injury mechanism, minute knowledge of fragment dislocation and of potential injury to blood vessels, when planning the surgical approach and the method of fixation.

CLINICAL PRESENTATION AND DIAGNOSTICS

Since talus fractures occur as the result of high energy injury [11], the clinical presentation may vary, ranging from swelling, localized painful sensitivity, and reduced scope of movement in the region of the ankle, to significant dislocation and consequent deformity, including open fractures, which require immediate treatment.

Talar neck fractures may occur as an isolated injury or within polytrauma (fall from significant height, traffic accidents) [12].

In fractures with dislocation and visible deformity, the talar body may be palpated distally, in relation to the malleoli, and anteriorly, in relation to the Achilles tendon. The head and neck of the talus may be palpated anteriorly and below, in relation to the ankle.

In such fractures with visible deformity and obvious dislocation, swift repositioning is essential, in order to avoid soft tissue complications (skin necrosis) [1].

As in all orthopedic injuries, neurovascular status assessment and regular monitoring is necessary, bearing in mind that any deficit requires urgent intervention.

In open fractures of the talus, in 84.3% of the cases, there are also associated injuries, i.e., fractures of the talus occur within polytrauma. The risk of early infection is as high as 41.2%, which is why immediate surgical treatment is necessary [13].

For establishing the precise diagnosis, when talus fracture is suspected, the basic diagnostic tool is the X-ray. Radiographies are necessary in three directions, i.e., views: the frontal, i.e., anteroposterior (AP) view, the lateral view, and the oblique view (tunnel). The oblique view is the most important one in the imagining of the talar neck; the ankle needs to be in full plantar flexion with 15-degree foot pronation. Exposition is achieved at a 75-degree angle of the X-ray tube [14].

Multi-slice computerized tomography (MSCT) is the most useful method for analyzing the pattern of the fracture, and it is indispensable in planning surgical treatment. In their study, which included 132 patients with fracture of the talus, Dale et al. concluded that, in as many as 93% of cases, the MSCT showed fracture lines which were not detectible on X-ray images [15]. Also, MSCT is the most reliable diagnostic tool for appropriate classification of talar neck fractures.

When fracture of the talus is confirmed or suspected, it is indicated that MSCT should be performed. Overlooked fractures of the talus, even with minimal dislocation at the time of the examination, may have severe consequences.

CLASSIFICATION

In 1970, Dr Leland Hawkins made the classification of talar neck fracture, which has remained in use to this day [16]. He classified talar neck fractures according to radiographically confirmed dislocation. Initially, he described three types of fracture, and, subsequently, the fourth type was added to his classification [17]. Vallier et al. divided Type II into two subcategories – IIa and IIb [18].

  • Type I – Nondisplaced fracture

Nondisplaced fractures of the talus are quite rare. Even minimal dislocation is treated as Type II. Only one source of blood supply is endangered.

  • Type II – Dislocation/subluxation of the subtalar joint

Two out of the three sources of blood supply are damaged. Theoretically, in this type of fracture, the only source of vascularization is the deltoid branch of the posterior tibial artery, which is why, in any procedure carried out, the aim should be preserving the deltoid ligament, when possible.

  • Type III – Subtalar and tibiotalar dislocation

Theoretically, in this type of fracture, all three sources of vascularization are jeopardized. The talar body migrates posteriorly and medially. A large number of fractures belonging to this type are open fractures, which is why infection is the most common complication.

  • Type IV – Subtalar, tibiotalar and talonavicular dislocation (Table 1) [17],[18]

In their study, Pearce et al. stated that the risk of avascular necrosis increases with each type of fracture [19].

Table 1. The Hawkins Classification for Talus Fractures

10 01t

TREATMENT METHODS

The recommended treatment methods vary depending on the type of fracture. The main goal of treatment is anatomical reduction, i.e., the reconstruction of the length, rotation and angling, as well as rigid fixation [1].

The timing of the operation is somewhat controversial. Although it was previously believed that immediate fixation of the talar neck fracture decreased the risk of avascular necrosis (AVN), new studies have shown no correlation between the time of the surgical procedure and the development of AVN [20]. The following have been named as factors affecting the development of AVN the most: initial degree of dislocation (type of fracture) comminution of the fracture, and open fracture.

However, talar neck fractures must be repositioned at admission, in order to preserve soft tissues and blood supply, as well as prevent skin necrosis. If the fracture is repositioned, studies show that postponement of the surgical procedure, until the recovery of the soft tissues, reduces the risk of complications, such as wound dehiscence, skin necrosis, and infection, which, even in ideal conditions, occur in as many as 10% of cases [21].

TYPE I

Bearing in mind that this is a nondisplaced fracture, the recommended method of treatment is immobilization for 6 – 8 weeks, with the patient being prohibited from putting weight on the injured leg.

Frequent X-ray and MSCT check-ups are necessary, in order to make sure that displacement of the fracture has not occurred (Figure 1).

10 01

Figure 1. Type I – Nondisplaced fracture (multi-slice computerized tomography – MSCT)

TYPE II

Depending on the degree of dislocation, the surgical approach is selected. Closed reduction of the fracture needs to be performed at admission, through manipulation of plantar flexion and the calcaneus. The reduction needs to be verified with radiographies.

If the fracture is minimally dislocated (IIa), the method of choice is closed reduction and percutaneous fixation (pinning) of the fracture (Figure 2 and Figure 3).

10 02

Figure 2. Type II – Percutaneous fracture fixation (operating theater fluoroscope)

10 03

Figure 3. Type II – Percutaneous fracture fixation

In medial comminution of talar neck fracture, varus deformity occurs, which is why open reduction and internal fixation with screws, or the appropriate plate, is the recommended method of treatment. Dual medial and lateral approach offers the best visualization, as well as accessibility of the dislocated fragments, and represents the best option for achieving anatomical reduction. In this approach, care must be taken to preserve the deltoid branch of the posterior tibial artery, since it is probably the only source of vascularization for the talus [22],[23].

TYPE III

At admission, repositioning (reduction) must be performed. The degree of fracture dislocation dictates whether open or closed reduction is necessary.

Once the fracture is repositioned, depending on the state of the soft tissues, an optimal timing for definitive fracture fixation may be determined. This type of fracture is often compounded by fracture of the medial malleolus.

After surgical treatment, patients are at increased risk of the development of AVN, posttraumatic subtalar arthritis, and arthritis of the ankle, malunion and nonunion [1].

TYPE IV

As in Type II and Type III, the recommended method of treatment is open reduction with internal fixation. Since a large number of the fractures belonging to this type are open fractures, sometimes surgical treatment is necessary immediately upon admission [24],[25] (Figure 4 and Figure 5).

10 04

Figure 4. Type IV

10 05

Figure 5. Type IV - Surgical treatment

Also, in this type of fracture, it is necessary to provide congruence of the talonavicular (TN) joint, which is essential in metatarsal movement. Arthrodesis of the TN joint must be viewed as a salvage procedure. In these patients, the risk of the development of avascular necrosis is almost 100%, regardless of the treatment method [1],[13],[17],[18],[23].

CONCLUSION

Anatomical features and the characteristic vascularization of the talus, as well as the fact that fractures of this bone mainly occur as the result of powerful force, disturbing the already delicate anatomy, make the assessment and treatment of the fracture of the talus a great challenge.

Indicating radiographies in three views, as well as MSCT imaging, when talar neck fracture is suspected, as well as repositioning (reduction) of the fracture (in types II, III, and IV) at admission, represent the basis of good clinical practice.

Knowledge of surgical techniques and the selection of appropriate treatment methods is necessary, since, although the incidence of these fractures is small, the consequences suffered by the patient, in case of suboptimal treatment, may be very severe.

  • Conflict of interest:
    None declared.

Informations

Volume 3 No 1

Volume 3 No 1

March 2022

Pages 100-107
  • Received:
    18 February 2022
  • Revised:
    23 February 2022
  • Accepted:
    15 March 2022
  • Online first:
    25 March 2022
  • DOI:
Corresponding author

Uroš Dabetić
Clinic for Orthopedic Surgery and Traumatology, University Clinical Center of Serbia
2 Pasterova Street, 11000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


  • 1. Sundararajan SR, Badurudeen AA, Ramakanth R, Rajasekaran S. Management of Talar Body Fractures. Indian J Orthop. 2018 May-Jun;52(3):258-68. doi: 10.4103/ortho.IJOrtho_563_17.[CROSSREF]

    2. Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, et al. Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. J Orthop Surg Res. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8.[CROSSREF]

    3. Dhillon MS, Rana B, Panda I, Patel S, Kumar P. Management Options in Avascular Necrosis of Talus. Indian J Orthop. 2018 May-Jun;52(3):284-96. doi: 10.4103/ortho.IJOrtho_608_17.[CROSSREF]

    4. Schwartz AM, Runge WO, Hsu AR, Bariteau JT. Fractures of the Talus: Current Concepts. Foot Ankle Orthop. 2020 Feb 13;5(1):2473011419900766. doi: 10.1177/2473011419900766.[CROSSREF]

    5. Saravi B, Lang G, Ruff R, Schmal H, Südkamp N, Ülkümen S, et al. Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications. Int J Environ Res Public Health. 2021 Aug 4;18(16):8274. doi: 10.3390/ijerph18168274.[CROSSREF]

    6. Khan IA, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Foot Talus. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31082130.[HTTP]

    7. Whitaker C, Turvey B, Illical EM. Current Concepts in Talar Neck Fracture Management. Curr Rev Musculoskelet Med. 2018 Sep;11(3):456-74. doi: 10.1007/ s12178-018-9509-9.[CROSSREF]

    8. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. doi: 10.5435/00124635-200103000- 00005.[CROSSREF]

    9. Adelaar RS. Fractures of the talus. Instr Course Lect. 1990;39:147-56. PMID: 2186095.

    10. Miller AN, Prasarn ML, Dyke JP, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the talus with gadolinium-enhanced magnetic resonance imaging. J Bone Joint Surg Am. 2011 Jun 15;93(12):1116-21. doi: 10.2106/ JBJS.J.00693.[CROSSREF]

    11. Al-Jabri T, Muthian S, Wong K, Charalambides C. Talus Fractures: All I need to know. Injury. 2021 Nov;52(11):3192-9. doi: 10.1016/j.injury.2021.10.008.[CROSSREF]

    12. Hierro-Cañas FJ, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez MA, Cano-Luis P. Talus fractures. Functional results for polytraumatized patients. Rev Esp Cir Ortop Traumatol (Engl Ed). 2019 Sep-Oct;63(5):336-41. English, Spanish. doi: 10.1016/j.recot.2019.04.004.[CROSSREF]

    13. Liu X, Zhang H, Liu L, Fang Y, Huang F. Open Talus Fractures: Early Infection and Its Epidemiological Characteristics. J Foot Ankle Surg. 2019 Jan;58(1):103- 8. doi: 10.1053/j.jfas.2018.08.020.[CROSSREF]

    14. Thomas JL, Boyce BM. Radiographic analysis of the Canale view for displaced talar neck fractures. J Foot Ankle Surg. 2012 Mar-Apr;51(2):187-90. doi: 10.1053/j.jfas.2011.10.037.[CROSSREF]

    15. Dale JD, Ha AS, Chew FS. Update on talar fracture patterns: a large level I trauma center study. AJR Am J Roentgenol. 2013 Nov;201(5):1087-92. doi: 10.2214/AJR.12.9918.[CROSSREF]

    16. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970 Jul;52(5):991-1002. PMID: 5479485.[HTTP]

    17. Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures. Clin Orthop Relat Res. 2015 Sep;473(9):3046-9. doi: 10.1007/s11999-015-4136-x.[CROSSREF]

    18. Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014 Feb 5;96(3):192-7. doi: 10.2106/JBJS.L.01680.[CROSSREF]

    19. Pearce DH, Mongiardi CN, Fornasier VL, Daniels TR. Avascular necrosis of the talus: a pictorial essay. Radiographics. 2005 Mar-Apr;25(2):399-410. doi: 10.1148/rg.252045709.[CROSSREF]

    20. Buckwalter V JA, Westermann R, Mooers B, Karam M, Wolf B. Timing of Surgical Reduction and Stabilization of Talus Fracture-Dislocations. Am J Orthop (Belle Mead NJ). 2017 Nov/Dec;46(6):E408-13. PMID: 29309454.[HTTP]

    21. Fournier A, Barba N, Steiger V, Lourdais A, Frin JM, Williams T, et al. Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res. 2012 Jun;98(4 Suppl):S48-55. doi: 10.1016/j.otsr.2012.04.012.[CROSSREF]

    22. Shakked RJ, Tejwani NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013 Oct;44(4):521-8. doi: 10.1016/j.ocl.2013.06.007.[CROSSREF]

    23. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. doi: 10.5435/00124635-200103000- 00005.[CROSSREF]

    24. Maher MH, Chauhan A, Altman GT, Westrick ER. The Acute Management and Associated Complications of Major Injuries of the Talus. JBJS Rev. 2017 Jul;5(7):e2. doi: 10.2106/JBJS.RVW.16.00075.[CROSSREF]

    25. Shakked RJ, Tejwani NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013 Oct;44(4):521-8. doi: 10.1016/j.ocl.2013.06.007.[CROSSREF]


References

1. Sundararajan SR, Badurudeen AA, Ramakanth R, Rajasekaran S. Management of Talar Body Fractures. Indian J Orthop. 2018 May-Jun;52(3):258-68. doi: 10.4103/ortho.IJOrtho_563_17.[CROSSREF]

2. Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, et al. Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. J Orthop Surg Res. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8.[CROSSREF]

3. Dhillon MS, Rana B, Panda I, Patel S, Kumar P. Management Options in Avascular Necrosis of Talus. Indian J Orthop. 2018 May-Jun;52(3):284-96. doi: 10.4103/ortho.IJOrtho_608_17.[CROSSREF]

4. Schwartz AM, Runge WO, Hsu AR, Bariteau JT. Fractures of the Talus: Current Concepts. Foot Ankle Orthop. 2020 Feb 13;5(1):2473011419900766. doi: 10.1177/2473011419900766.[CROSSREF]

5. Saravi B, Lang G, Ruff R, Schmal H, Südkamp N, Ülkümen S, et al. Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications. Int J Environ Res Public Health. 2021 Aug 4;18(16):8274. doi: 10.3390/ijerph18168274.[CROSSREF]

6. Khan IA, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Foot Talus. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31082130.[HTTP]

7. Whitaker C, Turvey B, Illical EM. Current Concepts in Talar Neck Fracture Management. Curr Rev Musculoskelet Med. 2018 Sep;11(3):456-74. doi: 10.1007/ s12178-018-9509-9.[CROSSREF]

8. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. doi: 10.5435/00124635-200103000- 00005.[CROSSREF]

9. Adelaar RS. Fractures of the talus. Instr Course Lect. 1990;39:147-56. PMID: 2186095.

10. Miller AN, Prasarn ML, Dyke JP, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the talus with gadolinium-enhanced magnetic resonance imaging. J Bone Joint Surg Am. 2011 Jun 15;93(12):1116-21. doi: 10.2106/ JBJS.J.00693.[CROSSREF]

11. Al-Jabri T, Muthian S, Wong K, Charalambides C. Talus Fractures: All I need to know. Injury. 2021 Nov;52(11):3192-9. doi: 10.1016/j.injury.2021.10.008.[CROSSREF]

12. Hierro-Cañas FJ, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez MA, Cano-Luis P. Talus fractures. Functional results for polytraumatized patients. Rev Esp Cir Ortop Traumatol (Engl Ed). 2019 Sep-Oct;63(5):336-41. English, Spanish. doi: 10.1016/j.recot.2019.04.004.[CROSSREF]

13. Liu X, Zhang H, Liu L, Fang Y, Huang F. Open Talus Fractures: Early Infection and Its Epidemiological Characteristics. J Foot Ankle Surg. 2019 Jan;58(1):103- 8. doi: 10.1053/j.jfas.2018.08.020.[CROSSREF]

14. Thomas JL, Boyce BM. Radiographic analysis of the Canale view for displaced talar neck fractures. J Foot Ankle Surg. 2012 Mar-Apr;51(2):187-90. doi: 10.1053/j.jfas.2011.10.037.[CROSSREF]

15. Dale JD, Ha AS, Chew FS. Update on talar fracture patterns: a large level I trauma center study. AJR Am J Roentgenol. 2013 Nov;201(5):1087-92. doi: 10.2214/AJR.12.9918.[CROSSREF]

16. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970 Jul;52(5):991-1002. PMID: 5479485.[HTTP]

17. Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures. Clin Orthop Relat Res. 2015 Sep;473(9):3046-9. doi: 10.1007/s11999-015-4136-x.[CROSSREF]

18. Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis? J Bone Joint Surg Am. 2014 Feb 5;96(3):192-7. doi: 10.2106/JBJS.L.01680.[CROSSREF]

19. Pearce DH, Mongiardi CN, Fornasier VL, Daniels TR. Avascular necrosis of the talus: a pictorial essay. Radiographics. 2005 Mar-Apr;25(2):399-410. doi: 10.1148/rg.252045709.[CROSSREF]

20. Buckwalter V JA, Westermann R, Mooers B, Karam M, Wolf B. Timing of Surgical Reduction and Stabilization of Talus Fracture-Dislocations. Am J Orthop (Belle Mead NJ). 2017 Nov/Dec;46(6):E408-13. PMID: 29309454.[HTTP]

21. Fournier A, Barba N, Steiger V, Lourdais A, Frin JM, Williams T, et al. Total talar fracture - long-term results of internal fixation of talar fractures. A multicentric study of 114 cases. Orthop Traumatol Surg Res. 2012 Jun;98(4 Suppl):S48-55. doi: 10.1016/j.otsr.2012.04.012.[CROSSREF]

22. Shakked RJ, Tejwani NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013 Oct;44(4):521-8. doi: 10.1016/j.ocl.2013.06.007.[CROSSREF]

23. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. doi: 10.5435/00124635-200103000- 00005.[CROSSREF]

24. Maher MH, Chauhan A, Altman GT, Westrick ER. The Acute Management and Associated Complications of Major Injuries of the Talus. JBJS Rev. 2017 Jul;5(7):e2. doi: 10.2106/JBJS.RVW.16.00075.[CROSSREF]

25. Shakked RJ, Tejwani NC. Surgical treatment of talus fractures. Orthop Clin North Am. 2013 Oct;44(4):521-8. doi: 10.1016/j.ocl.2013.06.007.[CROSSREF]

1. Sundararajan SR, Badurudeen AA, Ramakanth R, Rajasekaran S. Management of Talar Body Fractures. Indian J Orthop. 2018 May-Jun;52(3):258-68. doi: 10.4103/ortho.IJOrtho_563_17.[CROSSREF]

2. Fan Z, Ma J, Chen J, Yang B, Wang Y, Bai H, et al. Biomechanical efficacy of four different dual screws fixations in treatment of talus neck fracture: a three-dimensional finite element analysis. J Orthop Surg Res. 2020 Feb 11;15(1):45. doi: 10.1186/s13018-020-1560-8.[CROSSREF]

3. Dhillon MS, Rana B, Panda I, Patel S, Kumar P. Management Options in Avascular Necrosis of Talus. Indian J Orthop. 2018 May-Jun;52(3):284-96. doi: 10.4103/ortho.IJOrtho_608_17.[CROSSREF]

4. Schwartz AM, Runge WO, Hsu AR, Bariteau JT. Fractures of the Talus: Current Concepts. Foot Ankle Orthop. 2020 Feb 13;5(1):2473011419900766. doi: 10.1177/2473011419900766.[CROSSREF]

5. Saravi B, Lang G, Ruff R, Schmal H, Südkamp N, Ülkümen S, et al. Conservative and Surgical Treatment of Talar Fractures: A Systematic Review and Meta-Analysis on Clinical Outcomes and Complications. Int J Environ Res Public Health. 2021 Aug 4;18(16):8274. doi: 10.3390/ijerph18168274.[CROSSREF]

6. Khan IA, Varacallo M. Anatomy, Bony Pelvis and Lower Limb, Foot Talus. 2021 Aug 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–. PMID: 31082130.[HTTP]

7. Whitaker C, Turvey B, Illical EM. Current Concepts in Talar Neck Fracture Management. Curr Rev Musculoskelet Med. 2018 Sep;11(3):456-74. doi: 10.1007/ s12178-018-9509-9.[CROSSREF]

8. Fortin PT, Balazsy JE. Talus fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Mar-Apr;9(2):114-27. doi: 10.5435/00124635-200103000- 00005.[CROSSREF]

9. Adelaar RS. Fractures of the talus. Instr Course Lect. 1990;39:147-56. PMID: 2186095.

10. Miller AN, Prasarn ML, Dyke JP, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the talus with gadolinium-enhanced magnetic resonance imaging. J Bone Joint Surg Am. 2011 Jun 15;93(12):1116-21. doi: 10.2106/ JBJS.J.00693.[CROSSREF]

11. Al-Jabri T, Muthian S, Wong K, Charalambides C. Talus Fractures: All I need to know. Injury. 2021 Nov;52(11):3192-9. doi: 10.1016/j.injury.2021.10.008.[CROSSREF]

12. Hierro-Cañas FJ, Andrés-Cano P, Rabadán-Márquez G, Giráldez-Sánchez MA, Cano-Luis P. Talus fractures. Functional results for polytraumatized patients. Rev Esp Cir Ortop Traumatol (Engl Ed). 2019 Sep-Oct;63(5):336-41. English, Spanish. doi: 10.1016/j.recot.2019.04.004.[CROSSREF]

13. Liu X, Zhang H, Liu L, Fang Y, Huang F. Open Talus Fractures: Early Infection and Its Epidemiological Characteristics. J Foot Ankle Surg. 2019 Jan;58(1):103- 8. doi: 10.1053/j.jfas.2018.08.020.[CROSSREF]

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