Talar Neck Fracture

Talar neck fractures may be defined as the fracture and dislocation in the neck of the talus extending through the thinnest cross-sectional portion of the talus, just near the talar head. The talus is located anatomically in the hindfoot and permits pain-free motion of the ankle, subtalar, and transverse tarsal joints lie between the lower end of the tibia- fibula and talonavicular joint that attaches by the tendon, cartilage, ligament that is helping to maintain side to side movement, balance, weight bear, etc. Fractures are causes of repeater compression more commonly seen in combination with other fractures and injury of the foot as a result of excessive foot eversion, hyper-plantarflexion, and falling with the foot in a plantarflexed and inverted position.

Classification

Hawkins in 1970 developed a classification system for talar neck fractures; this classification was for vertical neck fractures and based on X-ray appearance at the time of the injury, the classification depends on the degree of original displacement and the number of joints involved, it is the most commonly used:

• Type 1: (Non-displaced). Is a non-displaced vertical neck fracture with no subluxation. The fracture is extending to the subtalar joint between the middle and posterior facets.
• Type 2: (dislocated at the subtalar joint). It is a displaced vertical talus neck fracture with subtalar subluxation or dislocation, the ankle joint must be intact.
• Type 3: (dislocated at subtalar and tibiotalar joints). Includes complete displacement of the talar neck, from the body of the talus and which displaced from subtalar and ankle joints.

In this type, Hawkins found that over half them are open and have associated neurovascular and/or skin compromise with an infection rate as high as 38%.

In 1978, Canale and Kelly included Type 4 to Hawkins classification:

• Type 4: (Dislocation at Subtalar, Tibiotalar and Talonavicular joints)

This includes talar neck fracture with dislocation of the talar body from the ankle and subtalar joints and dislocation of the talar head from the talonavicular joint. Canale and Kelly reported 4% of their series as of type 4 with unsatisfactory results.

This classification has been found to be of prognostic value in predicting outcome and therefore the occurrence of Avascular necrosis (AVN). it’s been found that with more talar neck displacement; the incidence of mal-union, osteoarthritis, and osteonecrosis are going to be higher.

Another classification introduced by Marti:

• Type 1: Fractures of the talar neck “distal” and including talar head and process fractures.
• Type 2: undisplaced talar proximal head and body fractures.
• Type 3: displaced talar neck and body fractures.
• Type 4: Talar neck and body fractures with dislocated talar body.

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, sudden landings from the plane in the war field, violent trauma, etc.
• Driving and compressing in break – It is one of the major causes of foot microtrauma for the driver of the car, motorbike, truck, bus, bicycle runner. During the time of driving such kind of vehicle frequently have compress break to maintain the speed of the vehicle. Repeated compression causes, microtrauma, tendon, cartilage, ligament degeneration, and weakness that may lead to injury in the foot.
• 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 Test

• X-ray – The evaluation of a talar neck fracture should begin with plain radiographic imaging with an appropriate plain-film X-ray series consisting of anteroposterior (AP), lateral, and Canale views. The Canale view provides the simplest visualization of the talar neck. it’s obtained by angling the x-ray beam 75 degrees from the horizontal and positioning the foot within the maximum equinus with varying degrees of eversion (usually 15).
• CT scan – The computerized tomography (CT) scans have drastically improved the evaluation of talar neck fractures by allowing visualization of complex periarticular anatomy. CT is the best study to assess the degree of displacement, congruity of the articular surfaces, and comminution of those fracture patterns, with additional information gained in 93% of cases. Three-dimensional (3-D) reconstructions of CT imaging demonstrates sagittal or coronal alignment and facilitate surgical planning. resonance imaging (MRI) features a limited role in evaluating talar neck fractures within the acute setting.
• 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]

Fixation Materials and Preferred methods

All the mentioned approaches are utilized in combination with various permutations and combinations possible.

Fortin et al. described the medial approach through incision medial to tibialis anticus tendon starting at the extent of navicular tuberosity and may be extended proximally to repair malleolar fractures. Attention should be paid to avoid stripping the dorsal neck blood vessels and people entering at the extent of the deep deltoid ligament. Some authors also described the anterolateral approach; this starts lateral to common extensor digitorum longus peroneus tertius sheath; this provides exposure to the stronger lateral talar neck.

A posterior approach is suggested for a far better mechanical fixation with an incision either lateral or medial to the Achilles tendon. Adelaar also recommends employing a small anterolateral incision also to get an accurate reduction of the talar neck. a mixture of either anteromedial or anterolateral approaches for initial reduction and temporary fixation with Kirschner wires followed by a posterolateral approach for screw insertion from posterior to the anterior direction.

Fixation are often achieved using AO cancellous screws, AO malleolar screws, cannulated screws, and Kirschner wire under image intensifier control to get reduction and maintain rotational control.

Fortin et al. advocate the utilization of headless lag screws if anterior to posterior screw insertion is required as headed screws can interfere with the talonavicular joint if the top is slightly prominent. Post-operative instructions will include eight to 12 weeks of non-weight bearing.

In the Hawkins series 1970, 42% of those fractures developed AVN, but all of them had a union.

Adelaar et al. 1997 advised against a closed reduction for displaced talar neck fractures and therefore the use of K-wires as a sole means of treatment as they need been found to be weaker than screws. He recommends screw insertion from posterior to anterior direction instead of the opposite way round as they supply a far better biomechanical stability. He also recommends the utilization of titanium screws in unstable fractures with more risk of osteonecrosis just in case we’d like to use an MRI scan, the latter are often utilized in the presence of those screws

References

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