In this article, we will describe the most common injuries that occur in the talus foot, the main causes, and symptoms.
Additionally, we will explain how the diagnosis of these injuries is made and the main surgical and non-surgical treatments available for the talus foot.
What is the talus?
The talus is a bone component that is part of the structure of the foot. It is characterized by being short and having a flat upper portion.
The talus foot is connected to the other elements of the tarsus forming the talocalcaneal and talonavicular joints. Additionally, anatomically, its parts are:
- head
- neck
- crest, and
- different facets that make this bone component unique
This bone element does not have muscular or tendinous insertions on its surface, which is covered with cartilage over 60%-70% of its extension, remaining in position thanks to the capsular, ligamentous, and synovial structures that connect it to the adjacent bones (2).
What does a fracture of the talus foot consist of?
Fractures in the talus foot are not very common, as they represent less than 1% of the total in the foot and ankle, and approximately 50% occur at the neck level (1).
They usually occur in young patients and are associated with high-energy trauma. In fact, epidemiological studies show that these fractures account for approximately 50% of the total fractures of this bone (3).
The percentage of fractures corresponding to the body of this bone is around 20%, while those associated with the head account for 5-10% (4).
These injuries or fractures are often related to severe trauma and usually occur in the foot or other parts of the ipsilateral lower limb. For this reason, their treatment is very complicated (1).
The osteochondral fracture is very similar to ankle sprains, making the diagnosis somewhat confusing, as they present similar symptoms (3).
Therefore, when a person experiences symptoms of an ankle sprain that do not resolve after 4-5 weeks of traditional treatment, it is recommended to consider a computed tomography scan and additional evaluation to rule out tarsal coalition or osteochondral fracture of the talus foot (3).
Main causes of injuries in the talus foot
This type of injury usually has a traumatic origin. This means they originate from a direct blow, such as a fall, or from repetitive microtrauma, which would include performing certain types of exercises repetitively.
On other occasions, as we have mentioned, it can be confused with the diagnosis of an ankle sprain, but if in this case, it does not improve after being treated correctly, a possible injury to the talus foot is proposed (3).
Another factor that influences is related to age, as it increases the possibility of suffering from chronic instability in the ankle joint, or due to necrosis (lack of blood supply in the area), among other options.
Injuries to the talus foot are often associated with a high percentage of complications and symptoms such as avascular necrosis (AVN),
collapse, malunion, pain, and post-traumatic arthritis (7).
Descubre cuáles son los factores de riesgo más importantes a tener en cuenta para prevenir lesiones. Aprende paso a paso, un práctico programa de ejercicios para prevenir lesiones musculares.
Types of injuries and symptoms in the talus foot
Among the most common injuries in the talus foot are impingement or compression syndromes, fractures, and osteochondritis dissecans.
Generally, pain is the main symptom that starts as a mild discomfort until it becomes a more acute and localized pain in the front part of the ankle, even limiting the range of joint mobility of the talus.
Additionally, in dorsiflexion and/or plantar flexion of lateral X-rays, the contact between the joint connecting the tibia and fibula can be observed, as well as the widening of the posterior space of the joint.
Osteochondritis dissecans
[article ids=”8243″] Osteochondritis dissecans of the talus was first described in 1888 by Konig as “loose bodies in the knee joint due to spontaneous bone necrosis.” Since then, it has been studied and classified by various authors such as Berdnt and Harty in 1959 (3).
In 1959, Berdnt and Harty demonstrated that both the lesions in the medial and lateral parts of the talus of the foot causing osteochondritis dissecans were osteochondral fractures resulting from trauma (12).
These authors classified the lesions into four different stages (12):
- Stage I: small area of compression of the subchondral bone
- Stage II: partially detached osteochondral fragment
- Stage III: completely detached osteochondral fragment without displacement
- Stage IV: completely detached osteochondral fragment with displacement.
Impingement syndrome
Impingement syndromes, described as “osteochondral ridges” or “exostoses,” occur in adolescent athletes. This syndrome often occurs in runners and jumpers, especially in the distal area of the tibia, where it is generally located in the anterior and lateral region (9,10,11).
The pain and tenderness are located on the posterior and lateral side of the ankle behind the peroneal tendons. It is also important to highlight here the reduction of physical activity as treatment along with anti-inflammatory drugs (3).
Waller (13) characterized this type of syndrome in the anterior and lateral corner of the talus foot, with pain also located in the anteroinferior region of the fibula, attributing inversion foot injuries to the patient in question.
Hidden stress or avulsion fractures
These injuries also occur in the foot area, specifically in the talus.
In this regard, it is worth highlighting the trigonal bone, as an additional (accessory) bone that sometimes develops behind the ankle bone, that is, in the talus foot. In fact, some authors consider this bone as an old fracture rather than a small bone separate from the talus, with fractures of the adjacent posterior tubercle being very difficult to recognize (14).
Watson and Dobas, in 1976, classified the posterior tubercle of the talus into four stages (15):
- Stage I: normal talar process without clinical significance
- Stage II: enlarged posterolateral tubercle of the talus, which may be fractured during extreme plantar flexion in ankle injuries
- Stage III: accessory trigonal bone, which may be irritated by repetitive microtrauma
- Stage IV: trigonal bone with a cartilaginous or synchondrosis connection with the talus that may fracture through acute trauma.
The most common symptom of this type of fracture is pain on palpation, specifically in the region of the posterolateral tubercle of the talus. Edema is located on each side of the Achilles tendon. The lateral X-ray is the best option to diagnose a fracture with an ununited secondary ossification center (3).
Diagnosis
Treatment for displaced fractures of the talus
The standard treatment for displaced fractures of the talus foot is open reduction and internal fixation (ORIF). However, we must consider the possible complications that may occur during this treatment.
Previous studies, notably those by Hawkins, Canale & Kelly, reported a high incidence of avascular necrosis, as well as some more frequent studies, highlighting that between 30-100% belong to displaced fractures. Similarly, the incidence percentage for post-traumatic arthritis corresponds to 50-100% (8).
The hypothesis of these studies is that in severe injuries, surgical treatment with ORIF causes serious complications that may require new interventions in the operating room. Therefore, these clinical trials examined the long-term complications in 20 patients with a fracture of the neck of the talus foot (8).
Generally, physical activity is usually limited in young patients who have a condition in the talus foot, although it could also be combined with an anti-inflammatory medication or a cortisone injection.
However, occasionally it is necessary to resort to arthroscopy or arthrotomy for the excision of a bone spur or distal osteophytes from some area of the talus foot (3).
There are three different types of treatment for the fracture of the talus foot (3): surgical treatment, ankle arthrotomy technique, and Thompson and Loomer technique.
Non-surgical treatment
The non-surgical treatment of the talus foot consists of applying a short cast, an ankle-foot orthosis, arch supports, or lace-up leather boots above the joint (8).
However, there is the possibility of requiring surgical treatment in cases where the pain of the talus foot is intense, and after 6 months of conservative treatment, there is still some limitation of physical activity. In this case, we will resort to the ankle arthrotomy technique and Thompson and Loomer technique.
Ankle arthrotomy technique
If surgery is necessary to treat the anomaly of the talus foot, the fragment can be removed by arthrotomy or arthroscopy.
Parisien et al. explained all the arthroscopic techniques for the treatment of osteochondritis dissecans of the ankle joint, although these techniques are complicated and require great experience in using the appropriate instrumentation to perform the technique (16,17).
An arthrotomy should be performed if the removal of the entire fragment is not safe after arthroscopy. However, if open arthroscopic techniques are used, the best results are obtained with drilling and excision of the crater.
If arthrotomy is performed after arthroscopy, a second sterile drape is applied, and gloves and gown are changed, continuing with the arthrotomy through the anterolateral or anteromedial hole of the arthroscopy. However, if not done after arthroscopy, a vertical incision about 1.5 centimeters long is made at the anterolateral or anteromedial level, taking care with the extensor tendons and the neurovascular bundle.
Thompson and Loomer technique
This technique involves making a curved, convex, and centered incision on the talus foot about 10 cm behind the medial malleolus.
After this, a 2 cm longitudinal incision is made in the capsule at the anteromedial level, which will extend from the tibia to the talus of the foot, leaving it in a position of maximum plantar flexion. In this way, the superomedial part of the talar dome will be observed.
If the anomaly cannot be completely detected, curettage and drilling will be performed through a curved incision over the posterior tibial tendon.
Once the above has been considered, the foot will adopt a dorsiflexion position, so that the superomedial part of the talar dome will be observed. Thus, the injury can be adequately observed and treated by excision or curettage.
Once surgery has been performed on the talus foot, joint exercises will begin, and attempts to walk gradually until this part of the foot is tolerated by the patient. The return to sports activity is usually between 12-16 weeks.
Conclusion
The talus foot is a bone that can occasionally suffer some types of serious injuries, whose main symptom is pain in the ankle joint area.
Among the most common injuries in the talus foot are impingement or compression syndromes, fractures, and osteochondritis dissecans.
Additionally, there are some standard treatments to relieve the symptoms of this foot anomaly, however, those we have discussed in this article are the most common: non-surgical treatment, ankle arthrotomy technique, and Thompson and Loomer technique.
It is worth noting that studies have shown that surgical treatment with ORIF can cause serious complications that may require new interventions in the operating room after surgery. Therefore, long-term complications have been examined in 20 patients with a fracture of the neck of the talus foot (8).
References
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- Injuries of the talus and its joints. Clin Orthop 1976;121:243-62.
- Muñoz-Sánchez, J.L. & Navarro-Marruedo, J. (2015). Lesiones de astrágalo que pueden ser confundidas con esguinces de tobillo. Revista Internacional de Ciencias Podológicas2015, 9(2): 106-116.
- Sneppen, O. et al. (1977). Fracture of the body of the talus. Acta Orthop Scand, 48(3): 317-24.
- Vallier, HA. et al. (2003). Surgical treatment of talar body fractures. J Bone Joint Surg Am, 85(9): 1716-24.
- Lindvall E. et al. (2004). Open reduction and stable fixation of isolated, displaced talar neck and body fractures. J Bone Joint Surg Am; 86(10): 2229-34.
- Azziz, A. & Filomeno, P. (2018). Fracturas de astrágalo y cuello de pie, una asociación lesional poco frecuente. Revisión sistematica bibliográfica a propósito de un caso. Tobillo y pie, 10(2): 107-116.
- Macklin, Vadell, A. et al. (2022). Fracturas graves del cuello del astrágalo. Análisis del tratamiento en 20 casos. Revista de la Asociación Argentina de Ortopedia y Traumatología, 87(1), 15–22. Link
- Hontas, M. J. et al. (1986). Conditions of the talus in the runner. Am J Sports Med; 14(6):486–90.7.
- Kleiger, B. (1982). Anterior tibiotalar impingement syndromes in dancers. Foot Ankle; 3(2): 69–73.
- Parkes, J.C. et al. (1980). The anterior impingement syndrome of the ankle. J Trauma. 1980; 20(10): 895–8.
- Berndt, A. L. & Harty, M. (1959). Transchondral fracture of the talus. J Bone Joint Surg; 41(A): 988-1029.
- Waller, J. F. et al. (1982). Hindfoot and midfoot problems of the runner. Symposium on the Foot and Leg in Running Sports.
- Rosenmuller, P., quoted in Holland, C. T. (1921). On rarer ossifications seen during x-ray examinations. J Anat; 55: 235–40
- Watson, C. A; & Dobas, D. C. (1976). The os trigonum: a discussion and case report. Arch Podiatr Med Foot Surg, 3: 17–21
- Parisien, J. S. (1986). Arthroscopic treatment of osteochondral lesions of the talus. Am J Sports Med; 14(3): 211–7
- Parisien, J. S. (1985). Diagnostic and operative arthroscopy of the ankle technique and indications. Bull Hosp Joint Dis;45(1): 38–47
