talus avulsion fracture

talus avulsion fracture

There are different type of avulsion fractures, the Avulsion Fractures of the ankle is one the common one.

An avulsion fracture is the type of fracture where a fragment of bone is just pulled away at the ligamentous or tendinous attachment. It can be caused by traumatic traction that is the repetitive long term or even a single high impact traumatic traction of a ligament or a tendon.

This happens as tendons shockingly can bear more load than the bone. It can happen at numerous sites in the body, however few areas are more sensitive to these types of fractures than the others, like at the ankle which mostly happens at the lateral aspect of the medial malleolus or in the foot where these avulsion fractures are more common at the base of the fifth metatarsal, however also at the talus and the calcaneus.

Down below I have tried to explain everything related to avulsion fractures in general and in the ankle.

 

What is the anatomy and description related to talus avulsion fracture?

What are the types of talus avulsion fracture?

What is the epidemiology or etiology of talus Avulsion fracture?

What are the characteristics of talus avulsion fracture?

What are the Differential Diagnosis for talus avulsion fracture ?

What are the Diagnostic Procedures that can be done for talus avulsion fracture ?

What is the way for examination in avulsion talus fracture?

What are the ways of Medical Management available for talus avulsion fracture ?

What are the things that could affect your recovery of talus avulsion fracture?

What is the mode of treatment available for talus avulsion fracture?

What are the pain management ways for talus avulsion fracture?

What are the complications of talus avulsion fracture?

 

 

What is the anatomy and description related to talus avulsion fracture?

There are many bones which makeup the ankle talus is one among them, it's the bone that makes up the lower part of the ankle joint as on the other side that's upper side the tibia and fibula make up the upper part.

The ankle joint allows the foot to move up and to move down. The talus also sits above the heel bone which is also called calcaneus. Together, these two, the talus and calcaneus form a joint called the subtalar joint.

This is the joint that allows the foot to move inward and outward, that is important for walking on the uneven ground.

The talus bone is the main connector between the foot and leg, and helping to transfer weight , pressure forces from across the ankle joint. It is almost  covered by articular cartilage from every side , the white slippery material which covers all joint surfaces is the articular cartilage. The use of this cartilage is that it allows the talus to move smoothly against its neighbouring  bones.

Avulsion fracture can occur in all parts of the talus bone, however most often  the talus break happens in its mid-portion, called the neck. This  neck lies in between the body of the talus, which is under the tibia, and the head of the talus, located further down near the foot.

The talus may also fracture at the prominence on the outside of the this bone called lateral process. Lateral process fractures happen when the ankle is forced out to the side and are very commonly seen in the snowboarders.

 

What are the types of talus avulsion fracture?

Talus fractures can be classified into few types based on how much the pieces of bone have moved out of their normal position in the ankle. There are many different types of talus fractures, that includes avulsions, talus  neck, talus head, talus  body, and the lateral process fractures. 

The Avulsion fractures for the most part are the nonoperative injuries incurred in association with the ankle sprains. The talus neck fractures can be treated nonoperatively if in case they are nondisplaced and the articular surface is intact however most of these cases require operative fixation that is a surgery in general.

Displacement which is greater than 2 mm requires the operative treatment for most talus  head, body, and lateral process fractures . Some of these talus fractures are emergencies and need urgent care.

The following are the different type or subtypes of the talus bone fractures:

  • Minimally displaced or also called as stable fractures:These type of fractures are barely out of place, that is there is minimum damage . The broken ends of the very bones line up almost correctly. In such minimally displaced fracture, the bones mostly stay in place during the healing. In most cases surgery to repair the bones is not required at all.
  • Displaced fracture :  the displaced fracture happens  when the bone which is affected breaks and the pieces move out of their anatomical position. The amount of displacement of the bone relates and depends on  the force of the injury. Highly displaced fractures are likely to be unstable as most of the bone is displaced . They mostly  require surgery to restore the displaced alignment and give the best chance for a return of normal function in the foot and ankle.
  • Open fractures : When the broken bones break through the skin layer, the injury is called an open or a compound fracture. Open fractures mostly  involve greater injury to the surrounding area including the muscles, tendons, and the ligaments. In addition to this, open fractures expose the fracture site to the outside environment, allowing the debris from outside to penetrate the wound that can be the reason for such patients having a higher risk of infection and mostly take  longer period  to heal.

 

What is the epidemiology or etiology of an avulsion fracture?

As we have already discussed this talus fracture is a break in one of the bones which forms the ankle , most of the talus fractures are the result of some high-energy trauma like a car collision or a fall , or Injuries due to sports like  snowboarding, are another cause for talus fracture though less common.

Talus fractures in general rank second in the frequency among the tarsal bones of the foot , with only calcaneus fractures being more common than talus . The Chip and avulsion fractures of talus are the most common fractures of the talus itself followed by the talar neck fractures .

Fractures that take place at the lateral process of the talus are common in people who do snowboarding and  account for about 15% of snowboarding injuries in this the ankel and foot . As mentioned above maximum serious injuries to the talus are high energy in nature,  that is they are due to MVA injuries about the foot and ankle.

The most common mechanism for the talus neck fractures is a hyper dorsiflexion injury . The concerning talar body fractures can occur in concert with talus  neck fractures, the mechanism of injury is typically an axial load to the foot and to the ankle .

In contrast, the lateral process fractures are mostly  caused by the lower energy inversion or eversion activities and mechanisms

Patients who are with avulsion talus fractures usually experience following:

  • Acute pain
  • They are mostly unable to even walk or bear any weight on the affected foot
  • Considerable swelling, tenderness and sometimes even bruising

Out of all fractures 5 to 6% happen in primary settings, with a yearly incidence of approximately 67 out of 100,000 account for the fifth metatarsal fractures. The usual cause of the injury is an inversion of the foot, which generates tension along with the plantar aponeurosis insertion leading to avulsion fracture.

The twisting injury to the ankle  can lead to an avulsion fracture at any of these locations. There is a classification called Lawrence and Botte’s , according to this there are three types of proximal fifth metatarsal fractures based on the mechanism of injury, the location, the treatment options, and lastly prognosis.

During the foot inversion in the Zone 1 fracture, the forces exerted by the peroneus brevis or by the lateral band of the plantar fascia causes avulsion fracture of tuberosity with or without the further involvement of the tarsometatarsal articulation. In the Zone 2 the fractures are at the metaphysis-diaphysis junction, which then extend into the fourth-fifth intermetatarsal facet, this is caused by forced forefoot adduction with the hind foot in plantar flexion.

In the Zone 3 fractures there are proximal diaphyseal fractures, distal to the fourth and fifth metatarsal base articulation that are caused by excessive bearing of the region or by chronic overloading as in stress fractures.

 

What are the characteristics of avulsion fracture of the ankle?

The characteristics of  avulsion fractures differ from than those of a ligament rupture. Unlike the non-operative choice of medical treatment for lateral ligament rupture, the non-operative medical treatment of avulsion fractures does not yield any satisfactory results.

The symptoms of pain and signs of the ankle avulsion fractures are very similar to that of an ankle sprain and it is very difficult to differentiate these two without an X-ray or an MRI scan.

Pain is mostly felt in the ankle immediately post the injury with an immediate onset of severe swelling. Bruising may also develop and the patient will have difficulty in walking or during weight bearing on the ankle.

If in case an avulsion fracture of ankle is present, there will be immediate pain over the outside aspect of the foot that is injured plus it will be associated with significant swelling and localised tenderness over the 5th metatarsal in the foot .

History of the injury taken place will be same as that of an ankle sprain that's the plantar flexor inversion.

 

What are the Differential Diagnosis for avulsion fracture of the ankle?

  • There’s a fracture called Jones fracture which occurs as a result of a stress fracture to the 5th metatarsal, because of the repetitive loading of the outside part of the foot from the patient’s underlying foot pattern or from the lower extremity alignment. Unlike the Dancer’s fracture , the Jones fracture may not even heal so simply and often requires a surgery.
  • Stress fractures
  • Mid-shaft fractures

 

What are the Diagnostic Procedures that can be done for talus avulsion fracture ?

  • An X-ray can be ordered by the surgeon before proceeding to further diagnosis. Avulsion fractures of talus can sometimes be confused  with an ankle sprain or can be overlooked or where an injury to the 5th metatarsal occurs together with a simple ankle sprain.
  • Other imaging methods that are useful and recommended like MRI, CT Scan or scintigrams.
  • Outcome Measures can help in diagnosis.
  • Olerud ankle score is a score that can be helpful too.
  • Examination of talus and whole ankle can help in diagnosis too.
  • Proper history helps everywhere, so history of injury is taken, like mechanism, the pain level and swelling. Palpation may also be useful in some cases

.

What is the way for examination in avulsion talus fracture?

  • Doctor Examination: Most people who are with avulsion talus fractures will go to an urgent care hospital or emergency room for initial treatment because of the severity of their symptoms as it's very painful and serious.
  • Physical Examination After reviewing the  symptoms and the medical history, the doctor will do a careful physical examination. During the physical exam, the doctors will:
  • Examine the foot and ankle carefully to see if there are any cuts or bleeding from the injury.
  • Check to see if the person can move the toes, and can feel things from the bottom side of the foot. In few cases, nerves can be injured at the same time that the bone gets broken.
  • A person should check pulse at key points of the foot just to be sure that there is good oxygen and blood supply to the foot and toes.
  • It's important to check to see that pressure from fluids is not building up in the muscles of the leg it's a condition called compartment syndrome which can result in loss of sensation and function in the leg and requires emergency surgery once it the diagnosis is done.
  • Its important to determine if a person has any other injuries so examining the rest of the injured foot, as well as the legs, pelvis and the spine is usual.
  • Imaging Tests Information from the diagnostic imaging tests helps the doctor to decide whether surgery is required and will be very critical for surgical planning.
  • X-rays are the one of the most common and widely available diagnostic imaging technique. An x-ray can show clearly if the bone is broken and whether there is any displacement or not that is fragments are out of place. It can also show how many pieces  the bone has broken in .
  • Computerized tomography scan: It's mostly known as CT scan if the doctor still needs more information and assurance after viewing the x-rays, he will order a CT scan also. CT scan shows the cross-sectional image of the foot. It can also provide valuable information about the severity of the fracture that x-rays can't by helping the doctor see the fracture lines more clearly

 

What are the ways of Medical Management available for talus avulsion fracture ?

  1. An avulsion fracture of the talus which is at the base of 5th metatarsal is usually treated conservatively. In case the bone is not displaced, a walking boot or even a walking cast can be used, which will remain in place for 4 to 6 weeks. Mode of surgery is only recommended where the bone is dislocated or displaced from its normal position or where more than 30% of the cubometatarsal joint has involvement. The bone will be removed or or will be fixed with the osteosynthesis material. Crutches can be used to avoid weight bearing on injured foot.
  2. Physical Therapy Management : Avulsion fractures of talus are often treated as ankle sprains as are confused with them , with the dysfunctional movement and the impairments treated alongside fracture, so it is very important to individualise the treatment plan accordingly because an inappropriately managed avulsion fractures can lead to a long-term and significantly to a functional disability. Thankfully most fractures heal well, however following a strict immobilisation term normal arthrokinematics, strength of  lower extremity muscles, proprioception, and the very functional movement for chosen sport/or other activities need to be regained.

 

Rehabilitation following an talus avulsion fracture consists of 3 phases; the acute, the recovery, and the functional phase, each discussed below:

  • Acute phase: It can start after 2 weeks post operatively. This phase includes passive range of motion exercises and some cryotherapy and is based on the reduction of level of pain, inflammation, and the edema, while keeping the muscle atrophy of lower limb at a minimum.
  • Recovery phase: starts once the goals of the acute phase has reached its level . This phase in particular can be divided further into 3 stages:
  1. Weeks 0-6: here active ROM exercises for the toes and the MetaPhallagensT joints, strengthening exercises for the talus, ankle and foot are still premature, however. In the second week there are some isometric exercises for the dorsiflexors, plantarflexors, invertors, and evertors of the foot, along with some active talus  ROM movements can be started and mostly helpful.
  2. Weeks 6-8: some active and passive ROM exercises for the talus or ankle and the subtalar joint with other Isometric and isotonic exercises. Exercises in particular for proprioception and proximal strength and for control can be done is this phase
  3. At 8-12 weeks: strengthening exercises for all dorsiflexors, inventors, plantarflexors,  evertors, long flexors and long extensors of the toes are recommended. Full weight-bearing exercises are also permitted in this phase and are very helpful.
  • Functional phase: begins  at 6 to 8 weeks post operatively and it's a phase which involves ongoing strength and conditioning of the lower limb, increasing the neuromuscular control and utilising a sport or a specific activity training.

 

What are the things that could affect your recovery of talus avulsion fracture?

Mostly maximum  of the healing happens between six to 12 weeks, however can take several months for the symptoms to completely settle or go away. It is not unusual at all to have aches and discomfort beyond this time period, often when a person does activities he hasn't done for a while.

Sometimes in few cases the area is more sensitive for few months and this is very normal no need to worry. However there are certain things which can affect the healing process of talus avulsion fracture or the fractures in general:

  • Smoking : It slows the fracture healing time , even in some people, it can stop the healing altogether. This is why its suggested to reduce the amount or stop smoking if a person gets a fracture or we can say during the healing phase to ensure the best recovery possible
  • Some medical diseases can slow down the healing process, like diabetes.
  • Eating a healthy nutritional diet and being active will help in the recovery process.
  • Medication : It is very important that if a person is on any prescription medication which he takes  regularly and at the recommended dose. It is very important to speak with the local pharmacist, or to a practicing  nurse or to a general physician prior to any change in the dose or in the medication.

 

What is the mode of treatment available for talus avulsion fracture?

Immediate first aid medical treatment for a talus avulsion fracture, as with any painful ankle injury, is to apply a well-padded splint just around the back of the foot and around the leg to immobilize and protect the limb from further damage .  

The splint should extend from the toe of the injured foot to the upper calf.  Elevating the foot just above the level of the heart helps in  minimizing the swelling and pain.

Specific treatment is done which depends upon the severity and the type of talus fracture, so it is important to seek immediate medical attention so the treatment can be started accordingly

  • Nonsurgical Treatment: There are many talus fractures which require immediate surgery because of the high-energy force which creates the injury at first place. Stable factures, well-aligned fractures can mostly be treated without any surgery. This is often done with a combination of immobilization and then doing the rehabilitation.
  • Casting : A cast will hold the bones in the foot in place during the healing process. One will have to wear the cast for 6 to 8 weeks. During this healing time, one will be asked to limit the amount of pressure he or she puts on the foot. The main goal is for the bone to heal enough so to bear the weight on it without the risk of the bone moving  out of position.
  • Rehabilitation: When the cast is removed at the end the doctor will give few exercises to the patient to help restore range of motion and to strengthen the foot and ankle.
  • Surgical Treatment : If the bones have shifted out of place  that is are displaced , surgery is done to internally set and stabilize the broken pieces which results in the best outcome and also reduces the risk of future complications.
  • Open reduction and internal fixation: During this procedure , the bone fragments are first repositioned into their normal places . Then they are held together with special screws or metal plates and screws which are specifically made for human bodies

 

What are the pain management ways for talus avulsion fracture?

Bones have some remarkable capacity for healing .

The more severe the injury is , the longer it's gonna take for recovery. After the surgery is performed the foot will be in a splint or in a cast for about 2 to 8 weeks. The duration mostly depends on the nature of the injury and how well the healing process progresses. The doctor will take x-rays just to ensure that the bones stay in their position and are healing properly.

  • Pain Management : After the surgery is performed , the person will feel some pain of course. It's  a natural part in the healing process. The doctor and nurses will work in order to reduce the pain, which can help a person to recover from the surgery faster. Some medications are often prescribed for the short-term pain relief after the surgery is performed. Different types of medicines are available to help in managing the pain, including some opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and few local anesthetics. The doctor may use a combination of some of these medications to improve the pain relief, as well as to minimize the need for opioid use. Be aware of this thing that although opioids help to relieve pain after the surgery is performed, they are a narcotic and can be addictive and lead to harm. Opioid dependency and their  overdose has become a critical public health issue world wide thus its very important to use opioids only as directed by the concerned doctor. As soon as the pain starts to improve, one should stop taking the opioids. Talk to the concerned doctor if in case the pain has not begun to improve within a few days after the surgery.
  • Early Motion : there are many doctors world wide encourage motion of the foot and ankle early in the recovery period, as soon as the pain subsides to some extent . Patients who have had a surgery are instructed to start moving the affected area as soon as the wound is done healing . However patients who are treated without a surgery by other means will work on regaining motion in the talus , foot and ankle after the white cast is removed.
  • Physical Therapy : there are some specific physical therapy exercises which can improve the range of motion in the foot and ankle, and also strengthen the supporting muscles.
  • Weight-bearing : when a person  begins walking, he may need to use a cane or the crutches and wear a special boot for motion. He or she will not be able to put all of the weight on the injured foot for up to two to three months. If one places too much weight on the injured foot too soon, there are chances the bone pieces may move out of place. So one should be sure to follow the surgeon's directions. As the broken talus heals and the pain improves, one will be allowed to put more pressure on the foot.

 

What are the complications of talus avulsion fracture?

Talus avulsion fractures come on second number but however are less common than the calcaneal ones.

Three fourths of talus fractures occur in the neck and body of talus bone . The remainder are the avulsion fractures or the chip fractures. The talar neck fractures can be associated with the talar dislocations.

Owing to the most vascular supply of the proximal talar bone , fractures at and proximal to the midpole of the talus bone it’s the area that is highly susceptible for AVN within the proximal side.

However the talus avulsion fractures are most common in the anterior-superior surface of the midtalar neck area of talus bone , that is the ankle capsule attachment site. Other avulsion fractures are seen along the lateral process of the bone.

If the  talus fracture is not treated effectively, there is issue of long-term complications in a person but if done otherwise there is no issue mostly. Two complications can develop if not treated promptly that are:

  • Avascular Necrosis (AVN)

With the unstable talus fracture, the blood supply to the bone may be disrupted during the time of the injury. Sometimes, the blood supply simply itself returns to the bone and the normal healing begins.

In some other cases, however  the bone cells die without a blood supply, which leads to a gradual and a very painful collapse of the bone. This condition is known as avascular necrosis (AVN) or the osteonecrosis.

When the bone collapses, the articular cartilage which is covering the bone is also damaged in this condition. Without this smooth cartilage, bone rubs against the opposite bone, leading to increased pain,  loss of motion and  loss of function and eventually arthritis. The more severe the talus fracture is, the more likely it is that the AVN will happen.

Even the fractures that are treated appropriately, including those that are treated through surgery can develop. Fracture healing must be assessed to determine the weight bearing status on the injured foot .

If the union of the bone has been achieved, weight bearing must be advanced even if their is any concern for AVN. Non-weight bearing is recommended to be continued if the union of bone has not been achieved yet .

Core decompression and bone grafting are two things that can be  performed for AVN of the talus, mainly in the atraumatic AVN, and where the long-term results are not available. However the results of these two procedures in the traumatic AVN population are largely unknown till this date.

AVN can happen without trauma too , particularly in the patients who are on steroids or who are with other risk factors for AVN . Limited case are present in which some benefit to core decompression prior to collapse has shown an effect.

Once the talus bone dome collapses, or for those who have  persistent pain after decompression, in them combined ankle and subtalar arthrodesis can be performed. The non-union rates are much higher than normal because the talus bone is not viable.

The non-viable talus body can be replaced with a graft of tricortical iliac crest. Side by side blair fusion that is the fusion of the viable talus neck to the anterior tibia bone or tibiocalcaneal fusion can be performed .

Both of these procedures  result in shortening of the leg who's foot is injured. For the rare case where patient is active, young the transtibial amputation may be the most functional choice of treatment

  • Posttraumatic Arthritis

Posttraumatic arthritis is a type of arthritis which  develops after an injury in the bone . Even when the bones heal normally, the articular cartilage protecting the bones can be damaged in the injury, leading to pain and stiffness over time.

The maximum of talus fractures result in some degree of posttraumatic arthritis it's very common .

In the case of extreme arthritis or avascular necrosis which limit activity, additional surgery, like a joint fusion or an ankle replacement, can be the best option to relieve the symptoms.

 

Outline:

A talus avulsion  fracture is a break in one of the bones which forms the ankle, such type of fracture often occurs during a high-energy event, like a car collision or a fall from a significant height or so.

As the talus bone is one other important bones for ankle movement and proper foot function, a fracture often results into the substantial loss of motion and function for some time.

Talus avulsion  fracture that does not heal properly can lead to many serious  complications, including a limp, arthritis, and severe chronic pain.

For this reason, most talus fractures require surgery if don't heal with normal treatment.

 

 

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All Rights Reserved © By MarsoClinic

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