Anatomy of the talus
The talus is the small bone that forms the lower part of the ankle joint, and allows for flexion and extension of the ankle. It essentially connects the leg to the foot, and sits between the ankle mortise formed by the ends of the tibia and fibula. Underneath the talus is the calcaneus (heel bone), and the joint they form (the subtalar joint) is responsible for side-to-side movement of the foot. The front of the talus forms a third joint with the navicular (talonavicular joint), which has a complicated biomechanical function controlling flexibility and the arch of the foot. The talus has no muscle or tendon attachments, and is largely covered by cartilage, and this makes fractures very difficult to heal.
How do talus fractures occur?
Fractures of the talus are usually the result of high-energy injuries, such as a fall from great height, a motor vehicle accident or severe twisting of the ankle. The symptoms include severe ankle pain, inability to walk, swelling and tenderness.
How are talus fractures diagnosed?
A history, physical examination and x-rays of the affected ankle are required to make the diagnosis. Given that these fractures often involve the surrounding joints, a CT scan is also usually needed to gain a full understanding of the fracture pattern and plan treatment. Due to the high-energy causes of these fractures, history and examination to rule out injuries to other body parts is also required.
What are the treatment options?
Treatment is based on displacement of the fracture parts and involvement of the surrounding joints. The Hawkins classification is used to stratify different fracture types and guide treatment and prognosis.
Non-surgical treatment: If the bone has not moved out of alignment, and the joints are well aligned, complete immobilisation in a below knee cast may be recommended for 6 to 8 weeks. Patients who smoke, have poor blood circulation or who have diabetes are also treated non-operatively sometimes due to the high risks of surgery in this fracture type.
Surgical treatment: Most talus fractures require surgical treatment. The aim of surgery is to restore the normal architecture of the talus, and re-align the surrounding joints. This can be very challenging in talus fractures due to the multiple fragments of bone.
Surgery involved open reduction and internal fixation, usually via two incisions, one on either side of your ankle. The bone fragments are then pieced back together and held with screws and/or small plates. After surgery, a cast is usually required for 6 to 8 weeks until complete healing.
Physical therapy exercises are needed after removal of the cast to restore movement and strength.
How long does it take to recover?
Talus fractures are severe injuries, and recovery can take many months. Patients are usually non-weightbearing for 8 to 12 weeks after the injury or surgery. Prolonged physiotherapy can be needed after this to maximise function. Swelling and stiffness is likely to be present for many months.
Long term pain and disability are unfortunately common after this injury, even after good non-operative or operative treatment. Patients in manual labour jobs can take 6-12 months to return to work.
The biggest risks with talus fractures are that the fractures don’t heal (non-union), or the bone dies from loss of blood supply (avascular necrosis). Both of these complications are more common with increasing severity of the injury, and they can lead to significant pain, deformity and arthritis requiring additional surgery.