Case for small group discussion Talar fracture Case for small group discussion AOTrauma—Foot & Ankle Module 2b: Hindfoot trauma—talar fractures Stefan Rammelt, DE

Case description 42-year-old man Motorcycle accident Obvious foot deformity Neurovascular status: intact Tense, closed soft tissues

Discussion Patient transferred with a splint 1 day post injury CT scan already completed How would you treat this fracture? This is not useful for planning. It is superfluous, a waste of time and exposes patient unnecessarily to radiation

Closed reduction (1 day post injury)

Discussion Which type of fixation would you employ? Which approaches would you use?

Choice of approach after CT

Choice of approach after CT Anteromedial approach to talar neck, head, and medial facet Oblique lateral approach to talar neck, head, and lateral process

Reconstruction Axis, length, rotation Subtalar joint (anteromedial, lateral, and posteromedial)

Intraoperative images

Fixation with minifragment plates

6 weeks postoperative Hawkins sign

1-year follow-up

Take-home messages Emergent reduction of dislocations No need for immediate definitive fixation CT scans essential for planning approaches/reduction Anatomical reduction of the joint facets and realignment In case of central comminution, fixation with minifragment plates Early motion (after soft-tissue consolidation) Hawkins sign with 100% specificity

References Rammelt et al. Injury. 2009;40:120–135. Rammelt et al. Oper Orthop Traumatol. 2013; 25:525–541. Rammelt S, Zwipp H. Talar neck and body fractures. Injury. 2009 Feb;40(2):120–135. Rammelt S, Winkler J, Zwipp H. [Operative treatment of central talar fractures]. Oper Orthop Traumatol. 2013 Dec;25(6):525–541.