Talar Head Fractures – Causes, Symptoms, Treatment

Talar head fractures are types of fractures of the foot talonavicular, talotibiofibular articulation that occurs in the talar bone due to insufficient muscular attachment, predominantly extraosseous absence of a secondary vascular supply with a high frequency of co-existing foot fractures. Talus seats above your heel bone (calcaneus), forming your subtalar joint and also joints the tibia fibula with one another by tendon, cartilage, ligament that are helping to maintain side to side movement, balance, weight bear, etc.

Causes

• The repetitive impact – to the lower limb bone with weight-bearing exercises, occupational work cause microfractures, which consolidate to stress fractures.[rx]
• Heavy impact – The force of a jump or fall down from height can result in a broken ankle. It can happen in foot bone fractures even if you jump from a low height.
• Missteps – You can cause a fracture of the ankle if you put your foot down awkwardly abnormally. Your ankle might twist or roll your foot joint to the side as you put weight on it. It can also happen in stare up or stare down unawkwardly.
• Sports – High-impact sports such as football cricket, hockey, volley boll involve intense movements that place stress on the joints, including the ankle bone fracture examples of high-impact sports include, cricket, racer of the bike, soccer, football, Horseback riding, Hockey, Skiing Snowboarding In-line skating, Jumping on a trampoline and basketball.
• Car collisions – The sudden, heavy impact of a car accident, bike accident can cause metatarsal bone fractures. Often, these types of injuries need surgical repair. The crushing types of injuries common in car accidents may cause breaks that require surgical repair.
• Falls from height – Tripping, and falling when walking on uneven surfaces can break bones in your ankles and metatarsal bone, phalanges fractures, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down the wrong way can result in a twisting injury that can cause a broken bone. Fracture also occurs when stairs up or stairs down, especially older people.
• Unconsciously Toilet Use – It is a very common and day by day increasing incidence of fracture of the ankle joint, foot bone, metatarsal bones, tarsal bone, phalanges, especially high comodo using time and lower limb fractures.
• High hell Use – It is the most common cause of fracture in the ankle, foot, lower limb fracture, especially for women, abnormal arch, foot angle, the lake of the flat foot, abnormal sole of your footwear, muscle, tendon, cartilage, ligament weakness in the knee, ankle joints.
• On a battlefield – with the increasing of technology, nuclear weapons, one country is involved in the war from one country to another country. On the battlefield, millions of armies and general people are falling in injury that is gradually causing ankle, foot, metatarsal, tarsal bone fractures.
• Have osteoporosis –  a disease of your bone that weakens your bones gradually due to inadequate intake of calcium or vitamin D.
• Weak low muscle mass or poor muscle strength – lack agility or older age muscle strength, mass, power, endurance become weak, and poor balance conditions make you more likely to fall and cause a fracture.
• Walk or do other activities in the snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing,  Skiing Snowboarding, in-line skating, Jumping, playing lead to fracture of the bone in the lower limb.
• Insufficient vitamin D and sunlight – Insufficient vitamin D and sunlight decrease the intestinal absorption of calcium which leads to abnormal regulation of parathyroid hormone (PTH). Vitamin D also works to upregulate the transcription of genes involved in neovascularization in areas of endochondral ossification such as a healing fracture site. Vitamin D deficiency is typically characterized as a serum level of 25-hydroxyvitamin D3 of less than 20 ng/mL and sufficiency is between 20 and 31 ng/mL.[rx]

Symptoms

Symptoms of bone fractures include

• Intense pain, swelling, tenderness, limited range of motion is the first
• May present with pain, swelling, tenderness, hematoma directly over the mid-foot in athletes, and construction workers may present with various pain and swelling over the foot which worsens with exercise and walking.
• Pain with or after normal activity
• Pain that goes away when resting time and then returns when standing, walking, or during activity
• Pinpoint pain at the site of the fracture when touched
• Swelling but no bruising may be present if it becomes microtrauma
• Bruising or discoloration that extends to nearby parts of the foot bones.
• Pain with walking and weight-bearing
• Swelling in the heel area
• Pain may decrease with rest but increases again with activity.
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site after some days.
• Bruising that develops soon after the injury time.
• Inability to walk; it is possible to walk with less severe breaks, and fractures so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the color and appearance of the ankle will look different from the other ankle.
• Bone protruding fracture through the skin is a sign that immediate emergency care is needed. Fractures that pierce the skin require attention because they can lead to severe infection and take a prolonged time to recover.
• This pain may occur or feel in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with pain or pain of worsening quality or duration over time.

Diagnosis

Laboratory tests should be done as an adjunct in overall medical status for surgical treatment.

• CBC, ESR test
• Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
• Microscopic urine examination test, and stool test.
• ECG, EKG test for heart abnormality is present
• Ultrasonography test in some cases.
• Normalized hemoglobin, hematocrit test
• Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
• Thromboplastin time and platelet counts will be needed for operative intervention.
• Serum creatinine test,
• Serum lipid profile
• Serum uric acid test

Imaging

• X-ray – Radiography is typically chosen as the first examination to gauge a suspected astragalus fracture. Radiography assessment is usually performed with three standard projections: anteroposterior (AP) and lateral-lateral (LL) views of the ankle, and therefore the so-called “mortise view” (AP with 30°internal rotation of the foot). The mortise view allows for better visualization of the lateral aspects of the talus with no superimposition of the fibular malleolus. AP, oblique, and lateral projections of the foot also are generally performed. due to the superimposition of ankle and foot structures, radiography has low sensitivity and specificity for talar fractures. Moreover, patients are frequently in critical conditions and it’s not always possible to get good quality radiographs.
• CT Scan – in particular, talar dome osteochondral fracture, lateral process fracture, and posterior process fracture are the foremost frequently missed fracture sites. Given these findings, computerized tomography (CT) is the gold standard for diagnosis, though only 91% of fractures were properly evaluated with a CT scan at A level trauma center. CT should be a part of routine surveillance of ankle injuries that have swelling and pain disproportionate to radiographic findings, as 6.9% of talus fractures were undiagnosed at the time of presentation. Even when an x-ray demonstrates the fracture pattern, CT provides additional information on the degree of comminution, articular involvement, and surgical planning.
• Multi-Detector computerized tomography (MDCT) images have both higher sensibility and specificity than radiography. CT images are often more easily interpreted even when anatomical relations are subverted. MPR images should be performed along the anatomical axes of the foot. MDCT evaluation with MPR and VRT reconstruction is recommended to best assess fracture(s), anatomical relationship, degree of comminution, eventual intraarticular loose bodies. CT is additionally needed to guide management decisions and for surgical planning
• Ultrasound (US) and resonance Imaging (MRI) has a limited role within the acute setting of astragalus fractures. they will be useful during a re-evaluation for the evaluation of the soft-tissue injury, especially for the evaluation of the posterior talo-tibial ligament.

Treatment

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, play cricket gets into a car accident, or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in your leg, foot, ankle joint, and part of your leg closer to the base of your leg. If the accident is major you keep your leg at the same heart position and then clean and treat any wounds on the skin of the injured leg.
• Aggressive wound care – It is very important for patients to reach a safe position with the proper ventilation needed for contaminated wounds. Injured are clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all, that is needed to treat a traumatic fracture of the foot, ankle, tarsal and metatarsal fracture. Sometimes rest is the only treatment needed to eradicate healing of a stress or traumatic fracture of a metatarsal bone fracture.
• Compression – a bandage will limit swelling, edema, and help to rest the joint. A tubular compression bandage is frequently used but should be removed at night by easing it off gradually. Put it on again before you are from out of bed in the morning. Mild to moderate pressure that is not too uncomfortable or too tight, and does not stop blood flow, is ideal. Depending on the amount of swelling. pain, edema you may be advised to remove the bandage for good after 48 hours.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot upright on a chair or pillow to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in fractures.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing strong stiff-soled shoes to protect the toe and help keep it properly positioned. Use of a postoperative splint, shoe, or boot walker is also helpful.
• Avoid the offending activity – Because fractures result from repetitive stress, the trauma it is important to avoid the activity that led to the fracture more seriously. Crutches or a wheelchair, or other types of supporting splint are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Do no HARM for 72 hours after injury

• Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
• Alcohol –  stimulates the central nervous system that can increase bleeding and swelling and decrease healing.
• Running and movement – Running and walking may cause further damage, and causes healing delay.
• Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long term treatment

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, dexlansoprazole, etc.
• Muscle Relaxants –  These medications provide relief from spinal muscle spasms, spasticity.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, contracture.
• Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, osteoarthritis.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
• Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
• Dietary supplement – To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses &  improved health.
• Cough Syrup – If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, post-surgical breathing problem, then advice you to take bronchodilator cough syrup.
• Teriparatide – Teriparatide may be a recombinant human parathormone (PTH) that stimulates osteoblasts to grow new bone cells when given intermittently. Use in treatment for osteoporosis, osteoarthritis, all kind of fractures has been shown to be successful results, and there are now some scientists to support the use it in treating fractures and nonunions. The medication was administered via daily injections of 20 μg about a month[rx] [rx]

What To Eat and What  to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

• Broken bones or fractures bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
• Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
• Important vitamins that are needed for bone healing include vitamin C (needed to make collagen that your body essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
• Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Surgery

Surgically treatment depends on the individual fracture characteristics, the size of fractures, the degree of displacement, the location, comminution, the condition of integrity of the soft tissues of the foot, the presence of associate bones, ligament injuries on the foot, comorbidities, and overall functional movement status.[rx]

Lateral Plate Fixation for Talus Neck Fractures

Talar neck fractures account for 50% of talus fractures. Plate fixation for talar neck fractures has been well described. In additional severe talar neck fractures, comminution is usually present both dorsally and medially along the dominant fracture line. Accurate reduction is important to stop shortening of the neck and prevention of a varus malunion.16 In most neck fractures, there’s a transparent reduction possible at the lateral aspect of the talar neck where the fracture fails in tension. More severe neck fractures may have comminution both medially and laterally. All neck fractures ideally require both medial and lateral incisions to assess rotation and acquire an accurate reduction. A pointed reduction clamp could also be placed on the distal portion of the talus just proximal to the talar head with one tine inserted within the medial incision and one tine inserted within the lateral incision. K-wires are inserted into the distal portion of the talus both medially and laterally. Using the reduction clamp to regulate the distal segment, the fracture line on the lateral aspect of the neck of the talus is reduced and a K-wire is advanced to supply provisional fixation. Rotation is assessed medially, and if correct, a K-wire is advanced along the medial side of the talus. If severe comminution is present, fully threaded wires could also be wont to prevent shortening. A lag bolt could also be placed laterally if there’s no communition present. alittle plate is then placed along the confluence of the lateral process and talar neck. this is often typically a 2.0 or 2.4 mm plate. Screws inserted within the proximal portion of the plate are directed into the body of the talus and therefore the distal screws are directed into the neck of the talus. The lateral plate is a tension band preventing medial shortening also as prevents rotation from occurring. Fixation on the medial side may contains a positional screw to stop shortening and rotation of the medial side or alittle plate in cases of severe comminution. Low rates of malunion are related to the utilization of plates in comminuted neck fractures.

Medial Plate Fixation for Talar Neck Fractures

Fixation of the medial side in talar neck fractures is important . Most talar neck fractures present with comminution of the dorsal and medial aspect of the neck of the talus. Anatomic reduction is critical, as varus malalignment leads to marked decrease in subtalar motion because the hindfoot is locked in an inverted position.16 Talar neck malalignment also increases peak pressures across the subtalar joint, predisposing it to subtalar arthritis. The goal of medial fixation in talus fractures is to stop varus and extension from occurring. If screws are used, they ought to be inserted in nonlag fashion to take care of the length of the medial side. A mini fragment plate could also be used along the medial neck of the talus. A plate along the medial talar neck bridges the zone of comminution and prevents shortening. If severe comminution exists, the plate also will assist in holding the comminuted fragments in correct position. Plate placement is restricted to the tiny extraarticular area between the medial side of the talar dome and therefore the talar head. Impingement of the plate on the medial malleolus during dorsiflexion and plantar flexion and on the navicular during inversion-eversion must be avoided. After the plate is positioned, K-wires are inserted through the proximal and distal ends of the plate. The ankle and subtalar joint are then put through a variety of motion to make sure no plate impingement is happening . Screws are then placed within the plate, completing fixation. Medial plate fixation provides equivalent stability to posterior to anterior directed screws.

Spring Plates and Plates as a Washer

Plates could also be used as spring plates to carry key segments in position. These fracture segments may contains fragments which are extraarticular but essential for anatomic reduction like on the dorsal aspect of the neck. Occasionally, a fraction will contain a mixture of extraarticular and articular surface. A spring plate could also be wont to hold these segments in position. The plate is typically a shorter plate. The plate is over-bent in order that when a screw is inserted within the plate, it straightens out, exerting continuous pressure on the surface because it tries to regain its curve . additionally , small plates are often used as a washer to carry fragments in position that are too small for screw fixation alone.

Plate Fixation for Securing Bone Graft

In severe open fractures, there could also be loss of bone necessitating bone grafting. Recreating the general shape of the talus is imperative to functional outcome. Plate fixation over areas where cancellous bone graft has been inserted will help prevent migration of bone graft out of the world of application. Loose cancellous graft within the subtalar joint will interfere with future joint function and potentially damage to the articular surface from particulate debris. Larger defects requiring tricortical grafting require improved stability for incorporation. Plates are often wont to provide length stable fixation, prevent rotation, and hold the graft in position. Tricortical segments held with screws are subject to rotational forces and should fracture at the time of drilling or screw
insertion and risk loss of structural integrity.

Posterior Fractures

Fractures of the posterior portion of the talar body are amenable to plate fixation. These fractures are often unrecognized but generally do poorly with nonoperative treatment. The patient is positioned prone for addressing these fractures. A rolled blanket is placed under the contralateral hep internally rotate the limb improving access to the posteromedial ankle. A second rolled blanket is placed under the mid portion of the tibia to flex the knee. this may elevate the surgical foot slightly off the operative table improving the power to get lateral imaging without obstruction from the contralateral foot. Posterior talus fractures are treated through a posteromedial approach utilizing the interval between the flexor hallucis longus and therefore the Achilles tendon. Excessive medial retraction should be avoided to stop injury to the medially located neurovascular bundle. Simple fractures could also be treated with interfragmentary screws. Washers aren’t needed with screw fixation because the talus is dense bone and is insufficient to deal with the tiny comminuted fragments often seen in these fractures. Mini fragment plating along the extraarticular portion of the posterior talus best addresses the comminution frequently seen in these injuries. Often, the plate will dwell the groove for the flexor hallucis longus and therefore the low profile of the mini fragment implants will limit irritation to the tendon. Anatomic reconstruction is important for both the ankle and subtalar joints and prevents instability. Plate application follows the quality principles already reviewed with other plating techniques including anatomic reduction, provisional K-wire fixation, sliding the plate over K-wires, and punctiliously replacing the wires with rigid screw fixation. A medially placed distractor or external fixator may aid in direct visualization of the articular reductions. Postoperatively, it’s crucial to encourage early range of motion of the good toe, because the flexor hallucis longus is susceptible to scarring down at the posterior aspect of the talus, leading to markedly restricted motion. Nonweight bearing is important for 12 weeks postoperatively. Range of motion exercises of the ankle and subtalar joint is started at 4–6 weeks postoperatively. The hardware is merely removed if it causes irritation to the flexor hallucis longus, which is rare.

References