Tag Archives: Talar fracture

Fracture of the Posterior Process of Talus with Pilon Fracture: A case report

by SS Suresh MS Orth, MCh Orth

The Foot and Ankle Online Journal 3 (12): 1

Fractures of the posterior process of the talus are extremely rare and more so when it is associated with a pilon fracture. Anatomical reduction and fixation of these injuries are important to prevent post traumatic ankle and subtalar arthritis and nonunion. The author presents a case of fracture of the posterior process of the talus with pilon fracture. In addition to these he also had ipsilateral, undisplaced extra articular fracture of the calcaneum, undisplaced fracture of the navicular and fracture of the first metatarsal.

Key words: Talus; Posterior process; Foot; Fracture.

Accepted: November, 2010
Published: December, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0312.0001

The posterior process of the talus has two tubercles, the medial and lateral, with the groove for the flexor hallucis longus tendon in between. The more prominent of these is the lateral tubercle. The posterior process is an intra articular component to the subtalar and ankle joints and any incongruity to the posterior process can lead to early degenerative arthritis of both joints.

Fracture of the entire posterior process of the talus is a very rare injury with only 13 cases reported to date. [1,2,3,4] Pilon fractures of the tibia account for 1-10% of lower limb fractures5, and is usually the result of high energy trauma in active people. Concomitant injuries reported with posterior process fracture include medial malleolus fracture [1], and subtalar dislocation6. Pilon fracture in association with fracture of entire posterior process of the talus is not reported so far. The patient in this study also had ipsilateral extra articular os calcis fracture, fracture of the navicular and fracture of the first metatarsal bone.

Case Report

A 29 year-old male expatriate worker was brought to the accident and emergency with history of a heavy sheet falling on his both lower legs. The right ankle and lower leg was grossly swollen. There was mild swelling of the left ankle with tenderness over the lateral malleolus. He didn’t have any co-morbid medical illness. He also had a puncture wound over the medial malleolus on the right. There was no distal neurovascular deficit.

X-rays performed in the emergency department showed comminuted fracture of the right distal tibia extending to the tibial plafond and the medial malleolus, with suprasyndesmotic fracture of the fibula. (Figs. 1 A and B, and 2) In addition, he so had undisplaced fracture of the right os calcis, navicular and first metatarsal bone. X-rays of the left ankle showed an undisplaced fracture of the lateral malleolus.

Figure 1 A and B Lateral (A) and anterior posterior (B) view x-rays of the ankle showing the extent of injury.

Figure 2 Lateral view of ankle showing posterior process fracture. (see arrow)

The puncture wound over the right medial malleolus was debrided in the emergency department operating room, and a back slab was given for comfort. Antibiotic prophylaxis was started with intravenous cephradine due to fear of infection on the medial side. Computed tomography (CT) scan of the right ankle showed minimally displaced fracture of the posterior process of the talus without significant comminution. (Fig. 3)

Figure 3A and 3B Computed tomography (CT) scan showing posterior process fracture. (A)  Fractured posterior talar process on axial CT. (B)

He was taken for surgery the very next day. Under epidural anaesthesia the fibular fracture was fixed first with a third tubular plate. The wound over the medial malleolus was debrided again and the pilon fracture was fixed through a minimally invasive approach, with stab incisions, and a spoon plate was used for stabilization. The fixation was checked with imaging intra operatively and the posterior process fracture was found minimally displaced. This was approached by extending the lateral incision and fixation was done with a 4 mm partially threaded cancellous screw. The peroneal tendons were displaced to visualize the fracture.

The soft tissue attachments to the fragment were not disturbed. The wound was closed in layers with a drain on the lateral side. Post operatively the leg was immobilized in a slab for 6 weeks. The patient remained in the hospital for 11 days due to necrosis of skin on the lateral side which eventually healed with dressings.

X-rays taken during the post operative period showed acceptable reduction of all fractures. (Figs. 4) The patient was followed up at 6 weeks where the immobilization was removed. The patient was also advised non weight bearing mobilization of the ankles. We were unable to follow up this patient as went to his home country and attempts to contact him failed. The patient was informed that data regarding his case would be used for publication and gave his written consent.

Figure 4A and 4B X-rays showing fixation of the fractures. (A)  X-rays Oblique view of ankle showing reduction of the posterior process fracture. (B)


Fractures of the posterior process of the talus are very rare injuries with only few published reports in the English literature. [1,3,7] Fracture of the posterior process of the talus involves both medial and lateral tubercles There are few reports of isolated fracture of the posterior process after the first report by Nasser and Manoli. [4,8,9] Subsequent to this reports of posterior process fracture with other ipsilateral injuries have been reported.

The posterior process of the talus has two tubercles, medial and lateral, with the groove for flexor hallucis longus in between. Lateral tubercle is the larger one and this projects more posterior than the medial tubercle. [4] The fractures of the posterior process cause damage to two joints; the posterior facet of the subtalar joint and the ankle joint. Forced plantar flexion of the foot compressing the posterior talus between the calcaneum and tibia is presumed to be the mechanism of injury. [2,3,8] Another mechanism documented is forceful inversion of the foot. [9]

Prompt diagnosis and appropriate reduction and internal fixation are needed to prevent complications of malunion; non union and post traumatic arthritis. [6] Management varies from conservative treatment [10] to immediate open reduction. [6]

Anatomical reduction is important to prevent avascular necrosis and also helps in early mobilization. Moreover presence of an os trigonum can add to the confusion. [4,11] Failure to diagnose undisplaced fracture can cause painful non-union and significant disability. [2,4,12] The commonest fracture in the posterior aspect of the talus is fracture of the lateral tubercle. Lateral tubercle fractures are often missed and misdiagnosed as ankle sprains. [12]

Posteromedial approach, [9] after mobilization of the neurovascular bundle is used by most of the authors. This fracture can be approached either through a posterolateral or posteromedial approach. [9] Nadim recommends open reduction if the displacement of the fragment is more than 3 mm. [1,9] Though conservative treatment is recommended for minimally displaced or undisplaced fractures the patients can have poor outcomes with persisting painful limitation of ankle movements and recurrent effusion. [12]

A CT scan can show the amount of displacement and the degree of comminution. [12] Reduction and stabilization of the fracture through a posteromedial incision is with risk of damage to the neurovascular structures. Flexor hallucis longus tendon may prevent accurate reduction by closed methods. [6] In the series by Bhanot, et al., one case was fixed through a separate postero lateral incision though the fracture was visualized and reduced through the medial approach. [1] In the case report by Naranja the fracture was approached through the posterolateral route. [6] The soft tissue attachments (insertions of the posterior talofibular ligament and the deltoid ligament) should be carefully preserved during surgery. [7]

Excision of the posterior part of the talus is suggested by Nyska in late diagnosed cases, though there are no published reports. [12] Concomitant fractures are not reported [6,7], and to the author’s knowledge the only report is that of medial malleolus and posterior process fracture by Bhanot, et al.,. [1] Naranja, et al., reported on a case of open medial subtalar dislocation in association with fracture of posterior process of the talus. [6]


High index of suspicion is needed to diagnose isolated posterior process fracture, but if associated with concomitant injuries the diagnosis becomes easy. A CT scan is useful to determine the amount of displacement. Early operative intervention and fixation prevents post traumatic arthritis.


1. Bhanot A, Kaushal R, Bhan R, Gupta PN, Gupta RK, Bahadur R. Fracture of the posterior process of talus. Injury 2004; 35: 1341-1344.
2. Ahmad R, Ahmad SMY. Fracture of the posterior process of the talus: An unusual injury. Emerg Med J 2007: 24: 867.
3. Prasad G, Mittal D, Harlekar V, Raut VV. Fracture of the posterior process of the talus: A case report. Eur J Orthop Surg Traumatol 2007; 17: 417-419.
4. Nakai T, Murao R, Temporin K, Kakiuchi M. Painful nonunion of fracture of the entire posterior process of the talus: a case report. Arch Orthop Trauma Surg 2005; 125(10) 721-724.
5. Sirkin M, Sanders R. The treatment of Pilon fractures. Orthop Clin North Am 2001; 32(1): 91-102.
6. Naranja RJ Jr, Monaghan BA, Okereke E, Williams GR Jr. Case report: Open medial subtalar dislocation associated with fracture of the posterior process of the talus. J Orthop Trauma 1996; 10(2): 142-144.
7. Chen YJ, Liang SC, Huang TJ. Fracture of entire posterior process as an obstacle to reduction of an anterior talar subluxation: Case report. J Trauma 1997; 42(2): 314-317.
8. Nasser S, Manoli A. Fracture of the entire posterior process of the talus: a case report. Foot Ankle 1990; 10(4): 235-238.
9. Nadim Y, Tosic A, Ebraheim N. Open reduction and internal fixation of fracture of the posterior process of the talus: A case report with review of the literature. Foot Ankle Int 1999; 20(1): 50-52.
10. Jimulia TR, Parekh AN. Fracture of the entire posterior process of the talus. J Postgrad Med 1995; 41: 54-55.
11. Kose O, Okan AN, Durakbase MO et al. Fracture of the os trigonum: a case report. J Orthop Surg 2006; 14(3): 354-356.
12. Nyska M, Howard CB, Matan Y, Cohen D , Peyser A, Garti A, Bar-Ziv J. Fracture of the posterior body of the talus-the hidden fracture. Arch Orthop Trauma Surg 1998; 117: 114-117.

Address correspondence to: SS Suresh MS Orth, MCh Orth, PO Box 396, Ibri 516, Oman email: dr.s.s.suresh@gmail.com

1 Head of Department of Orthopaedics, Department of Orthopaedics, Ibri Regional Referral Hospital, PO Box 46 Ibri 516, Sultanate of Oman.

© The Foot and Ankle Online Journal, 2010

Talar Neck Fracture Reduced and Stabilized with an Ilizarov External Fixator: A case report with three year follow up

by Sutpal Singh, DPM, FACFAS, FAPWCA1 , Chih-Hui (Jimmy) Tsai, DPM2,
Albert Kim, DPM3, Timothy Dailey, DPM4

The Foot and Ankle Online Journal 3 (7): 1

The authors report a case of a Grade 3 Tscherne, isolated Hawkins Type III fracture that was treated with open reduction and external fixation. The Ilizarov technique simplified the surgery by allowing the reduction of the diastasis using a tensioned olive wire, providing distraction of fracture bones externally, and aid in reduction of the talus without the need for multiple, extensive dissection. The patient responded very well to the surgery, despite occurrence of avascular necrosis of the talus and three years status post surgery. The patient has good range of motion, is pain-free, and ambulates without difficulty despite having avascular necrosis.

Key words: Talar fracture, Hawkins classification, Hawkins sign, Ilizarov technique, diastasis, avascular necrosis.

Accepted: June, 2010
Published: July, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0307.0001

Talar fractures have been described since the early 1600’s. [1] In early literature, open talar fractures had an 84% mortality rate. [3] Due to the high mortality rate, surgeons advised extreme measures such as below knee amputations or talectomy. [1] Since then, the surgical technique for these fractures has vastly improved. However, these types of fractures, thought not fatal, still prove to be very challenging today. Talar fractures are rare, making up only 3% of all foot fractures.

Talar fractures can be classified as open or closed. The Tscherne soft tissue classification system describes both open and closed fractures. [9,17] (Table 1) For the closed soft tissue injuries, Tscherne uses a grading system from 0-3 and is based on the amount of the injury. Grade 0 is minimal soft tissue damage from indirect violence. Grade 1 is a superficial abrasion or contusion caused by pressure from within. Grade 2 is a deep contaminated abrasion associated with local skin or muscle contusion and may encompass a compartment syndrome. Grade 3 consists of extensive skin contusion or crushing, underlying severe muscle injury, decompensated compartment syndrome, and associated vascular injury. [9]

Table 1  Tscherne Classification.

Talar fractures can be further divided into three anatomical locations: neck, body and head. Talar neck fractures comprised of 50% of all talar fractures. [2] The most commonly used classification system for talar neck fractures is Hawkin’s Classification (Table 2). This classification has four types, which are differentiated by the degree of displacement. Type I is a non-displaced talar neck fracture. Type II is a talar neck fracture with mild displacement and subluxing from the subtalar joint. Type III is displacement of the talar body with dislocation of subtalar and ankle joint. Type IV is a combination of Type III with dislocation of the talonavicular joint. [1] The higher the grade, the greater the risk is for complications.

Table 2  Hawkins Classification. (AVN – avascular necrosis)

Blood supply to the talus may be an issue if one delays reduction or inadequately treats these fractures. [3] Avascular necrosis (AVN) of the talar body and arthrosis after displaced talar neck fractures is quite common; the higher the grade, the larger chance of AVN. In an article by Gholam et al, they described nine cases of Hawkins Type III fractures, and eight of the nine developed arthrosis.3 In Hawkins Type I fractures, it is quite rare to see AVN. However in Hawkins Type II, there is a 15.8%-75% chance. [1] In Hawkins Type III, the chance of AVN increases to 33-75%. [1]

Hawkins Type IV has the highest chance, reaching almost 100% due to the amount of displacement and disruption of the blood supply to the talus. [1] Subchondral atrophy of the talar dome, also called Hawkins Sign, indicates an intact blood supply to the talus. [3] It is essential to be aware of AVN so it can be treated promptly.

Various treatment options exist for talar neck fractures. Some surgeons prefer using a compression screw across the fracture fragment, while others prefer a plate. In a study performed by Charlson, et al., plate fixation and screw fixation were compared. No statistical difference between either method was found. Plate fixation may provide more control of the anatomical alignment, but has no biomechanical advantage over screws alone. [4] There are very few cases reported in the literature of an isolated talar neck fractures treated with external fixation. However, there are many cases of multiple fractures (talus with calcaneus or talus with medial/lateral malleolus) successfully treated with external fixation. The purpose of this paper is to report a Grade 3 Tscherne, isolated and displaced Hawkins Type III talar neck fracture that was specifically treated with open reduction and external fixation. By determining how much soft tissue injury and the extent of talar fracture, external fixation can be more superior to internal fixation. In this case, the Ilizarov technique is ideal when there is soft tissue injury, vascular compromise, and displaced talar neck fracture.

Case Report

The patient is a 40 year-old correctional officer who was riding a recreational vehicle at the time of his injury. (Fig. 1A and B) He reported jumping off the vehicle due to faulty breaks, resulting in a severe talar neck fracture. (Fig. 2A and B). The mechanism of the traumatic injury was that of hyperdorsiflexion of the foot against the tibia in an axial force with impingement of the talar neck.


Figure 1A and B  Note the severe contracture of all the toes. (A) Note the contracted hallux and lack of blood flow to the medial ankle where the talar body is compressing the skin and posterior tibial artery. (B)


Figure 2A and B Non-weight bearing lateral view.  Note the overlap of the talus onto the calcaneus. (A) Note the fracture fragments in the ankle. (B)

As the force continued, there was a medial and dorsal displacement fracture of the talus, and disruption of the interosseous talocalcaneal ligament. Also, the posterior and subtalar joint capsule were disrupted. As the ankle supinated, there was increased force of the talar neck against the medial malleolus resulting in subluxation of the subtalar joint and ankle joint. It was quite severe such that the medial ankle was blanching and becoming necrotic.

The flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons were also contracted, such that the hallux and lesser toes were severely plantarflexed.

The dorsalis pedis artery was palpable, but the posterior tibial (PT) artery was being compressed and not palpable or heard using a Doppler. There was soft tissue damage and vascular supply was compromised. The patient opted to have surgery and informed consent was obtained from him to allow us to study and present this case. An open reduction was performed with the use on an Ilizarov frame immediately.

Surgical Technique

A large curvilinear incision was made on the medial ankle overlying the talus, extending distally and proximally from the area of blanching. (Fig. 3) The incision was deepened to the subcutaneous tissue and then to the deep tissue. The entire talar dome was noted at the incision site. (Fig. 4) The deep tissue was retracted. Once past the deep tissue, we noted that the posterior tibial artery was being compressed by the talar body. The talar body was exposed, and it was completely displaced and rotated out of the ankle and subtalar joint. There was a large hematoma and multiple small fracture fragments in the ankle joint. The hematoma was evacuated, and the small fracture fragments were removed. The wound was also copiously irrigated with bacitracin-impregnated saline. Then, attempt at relocating the dislocated and fractured talus was performed; however, there was much contraction of the tibia onto the calcaneus that it was extremely difficult to retract. Thus an external fixator was employed to distract the tibia from the calcaneus in order to relocate the talus.

Figure 3  1)  Medial surface of the talus.  2) Anterior or distal surface of the talus.  3) Lateral surface of the talus.    4) Posterior process of the talus with entrapped flexor hallucis longus (FHL) and  posterior tibial (PT) tendons and PT artery.   Note that the toes are at the upper left and the leg is at the lower right.

Figure 4  Dislocated and rotated talus.  1) Medial surface of the talus where the deltoid ligament is shown to be torn.  2) The posterior aspect of the talus: The posterior tibial tendon, posterior tibial artery and FHL are entrapped.  3) Lateral surface of the talus.  4) Talar dome.  5) Anterior surface of the talus.

First, two tibial rings were applied to the lower leg. Then a foot plate was applied, and all the wires were appropriately tensioned. Several distraction rods were used to connect the tibial rings to the foot plate, and then the foot was distracted. By distracting the tibia from the calcaneus, it made it much easier to rotate the talus and slide it between the tibia and calcaneus back into anatomical alignment. The fractured talus was anatomically reduced and held in place by an external fixator. Once the fracture was reduced, the severe skin tension on the medial side of the foot decreased.

A Doppler placed over the PT artery now showed good blood flow. Also, the FHL and FDL tendons became more relaxed, and the contracture over the hallux and lesser toes were reduced. A series of photographs shows the alignment of the Ilizarov frame directly after surgery (Figs. 5A and B, 6) and at 3 weeks after surgery. (Figs. 7A and B)


Figure 5A and B  Post-operative site with the Ilizarov Frame.

Figure 6  Post-operative reduction of the talar fracture in good alignment.


Figure 7A and B  Three weeks post- operative view.


A one year follow-up showed that his hallux range of motion was normal and his ankle healed in good alignment and anatomical position. This was accompanied with good range of motion, without pain, and with normal ambulation. However, despite the proper care and good post operative alignment, there was still sclerosis of the talar body which indicated that there was indeed avascular necrosis present. He remained non-weight bearing for 6 months and then weight bearing using a pneumatic cam walker for an additional 6 months. After this the patient went back to working 8 hours a day as a corrections officer and it was explained to him of the possible collapse and further complications from the osteonecrosis of the talus and to limit any vigorous activities. He was again followed up at 2 years and at 3 years after the initial traumatic event. He did have an increase in plantar flexion, and adequate dorsiflexion towards the end of the follow-up. He had no pain and was satisfied with the surgical outcome. He however, did have sclerosis of the talus but without any evidence of collapse. (Table 3)

Table 3  Patient 3 year follow-up results. (DF – dorsiflexion, PF – plantarflexion, AVN – avascular necrosis)


The complex nature of high energy talus fractures can pose complications that can challenge most foot and ankle surgeons. The complexity arises because of the blood supply to the talus being extremely vulnerable after a traumatic injury. [10] Short term complications can result in skin necrosis, wound dehiscence, and infection. [11,12] Additional complications of comminuted fractures involving the talar neck and body carry a risk of AVN due to the retrograde blood supply. [13] Injury to the joints surrounding the talus can cause irreversible osteochondral damage that could lead to possible early post traumatic arthritis or arthrosis. In this report, we have a patient with a closed talar neck fracture with vascular comprise. The case is further complicated by additional factors that included the medial ankle developing blanching and ultimately becoming necrotic, the posterior tibial artery being compressed, and the FHL and FDL tendons being contracted such that the hallux and lesser digits were severely plantarflexed.

Treatment options evolved from reduction and immobilization, to limited fixation, and currently, open reduction internal fixation being performed on most talar fractures. [14] Included in the literature are recommendations for primary arthrodesis or talectomy for severe talar fractures. [15] In this case, an external fixator was applied due to the severe contracture of the tibia onto the calcaneus. The Ilizarov external fixator allowed for distraction of the tibia from the calcaneus and this allowed for reduction and rotation of the talar body in its anatomical location.

Also, because of the volatile nature of the fracture and the additional soft tissue complications and its increased probability for an osteonecrosis sequelae, external fixation was utilized because it is commonly implemented and indicated for compromised soft tissue structures and gross instability. [16]

In this case, the patient was destined to have avascular necrosis due to the talar neck fracture which according to the literature has up to a 75% chance to develop the condition even with the utmost care and precautions. [1,14] This was exacerbated by the ruptured medial deltoid ligaments causing a dislocation of the talus. In examining the talus, it is a unique bone in the foot in that it has no muscular attachments with about 60% of the talus is covered with articular cartilage. These anatomical features make the talus vulnerable to dislocation. Extreme forces can cause dislocation of the talus out of the ankle mortise with disruption of the strong ligamentous attachments and this may have accounted for the medial deltoid ligament ruptures present in this patient.

This dislocation most likely caused tremendous vascular damage to this already intricate arrangement of vessels that are highly vulnerable to injury. The anterior tibial, PT, and perforating peroneal arteries serve as the vascular supply to the talus. The artery of the tarsal canal is a branch of the PT, and it supplies most of the talar body, the medial talar wall, and the undersurface of the talar neck. The artery of the tarsal canal anastamoses with the artery of the sinus tarsi, which is a branch of the perforating peroneal artery, and these vessels supply the inferior aspect of the talar body and neck. [18]

As the talus dislocates from the ankle mortise, there is sequential failure of the talar blood supply. Since the blood supply to bone and soft tissue are so intertwined, it has been noted that osteonecrosis was highest in cases in which no soft tissues remained attached to the talus. [19]

In this patient, this risk of avascular necrosis was increased and seen when the soft tissue along the medial aspect of the foot became de-vascularized and necrotic.

It is recommended that the patient should be non-weight bearing or protected weight bearing until the avascular necrosis resolves, [19,20] however there is no definitive evidence to suggest that full weight bearing with avascular necrosis leads to secondary complications such as collapse of the talar dome and tibiotalar arthritis. [21] This is further exemplified by this case where the patient, even at a three year follow up with avascular necrosis of the body of the talus, shows that his ankle is in good alignment, has not collapsed, shows no evidence of varus or valgus, has good range of motion, no pain, and ambulates normally. (Figs. 8A and B, 9, 10A and B)


Figure 8A and B   Six months after surgery.

Figure 9 Three years after the initial injury.


Figure 10A and B  Weight-bearing lateral view of the ankle, three years status post-operative, shows AVN of the talus, but good alignment.  There is no pain, no collapse of the talus, and the patient has good ankle range of motion. (A) Weight-bearing anterior posterior view of the ankle, three years status post-operative shows AVN of the talus, but good ankle joint congruity. (B)

By using the Ilizarov External Fixator, the talus was immobilized and held in place such that no axial pressure was placed onto the talus while healing took place.


Talar fractures are very complicated with a high incidence of AVN. We feel that if there is much difficulty in reducing the talar fracture from the tight tibial collapse onto the calcaneal surface, an external fixator is very beneficial in distracting the tibia from the calcaneus. In the above case, we used the multiplaner Ilizarov external fixator. He did have a severe fracture and dislocation of the talus which eventually resulted in AVN. At this moment, the patient states that he is pain free, and examination showed good ankle and subtalar joint range of motion. It is very important to have the patient frequently visit the office to make sure the talus is not collapsing and to explain to the patient that possible future surgeries, such as total ankle joint implant, subtalar joint arthrodesis, triple arthrodesis, or ankle fusion, may be necessary if the talus collapses as a consequence of AVN.


1. Banks AS, Downey MS, Martin DE, Miller SJ. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Vol 1, 3rd edition. Philadelphia: Lippincott Williams and Wilkins; 2001.
2. Juliano P, Dabbah M, Harris TG. Talar neck fractures. Foot Ankle Clinics 2004 9: 723-736.
3. Pajenda G, Vecsei V, Reddy B, Heinz T: Treatment of talar neck fractures: Clinical results of 50 patients. J Foot & Ankle Surg 2000 39(6) 365-375.
4. Charlson MD, Parks BG, Weber TG, Guyton GP. Comparison of plate and screw fixation and screw fixation alone in a comminuted talar neck fracture model. Foot Ankle Int 2006 27 (5): 340-343.
5. Marion H. Talar Shift: The stabilizing role of the medial, lateral and posterior ankle structures. Clinical Orthopedics Rel Res 1990 257: 177-183
6. Comfort TH, Behrens F, Gaither DW, Denis F, Sigmond M. Long term results of displaced talar neck fractures. Clin Orthopedics Rel Res 1985 199: 81-87.
7. Grob D, Simpson LA, Weber BG. Operative treatment of displaced talus fractures. Clin Orthopedics Rel Res 1985 199: 88-96.
8. Greenleaf J, Berkowitz RD, Whitelaw GP, Seidman GD. Hawkins Type III Fracture – Dislocation of the talus and diastasis of the tibiofibular joint without concomitant fracture of the malleolei. Clin Orthopedics Rel Res 1992 279: 254-57.
9. Frank T, Joseph B. Soft-tissue injury associated with closed fractures: Evaluation and management. J Am Academy of Orthopedic Surgeons. 2003 V:11 N:6, 431-438.
10. Baumhauer JF, Alvarez RG. Controversies in treating talus fractures. Orthop Clin North Am 1995 26(2): 335-351.
11. Fulkerson EW, Egol KA: Timing issues in fracture Management: a review of current concepts. Bulletin of the NYU hospital for joint diseases 67(1): 58-67, 2009.
12. Roberts C, Pape H, Jones A, Malkani A, Rodriguez J, Giannoudis P: Damage control orthopaedics evolving concepts in the treatment of patients who have sustained orthopaedic trauma. JBJS 2005 87(2): 434-449.
13. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J. Fractures of the talus: experience of two level 1 trauma centers. Foot Ankle Int 2000 21(12):1023-1029.
14. Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ: Talar neck fractures: results and outcomes. JBJS 2004 86A(8): 1616-1624.
15. Gunal I, Atilla S, Arac S, Gursoy Y, Karagozlu H: A new technique of talectomy for severe fracture-dislocation of the talus. JBJS 1993 75B (1): 69-71.
16. Sirkin M, Sanders R, DiPasquale T, Herscovici D: A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthopaedic Trauma 2004 18 (8 Suppl): S32-38.
17. Tscherne H, Schatzker J (editors). Major Fractures of the Pilon, the Talus, and the Calcaneus: Current Concepts of Treatment. Berlin, Germany: Springer-Verlag, 1993.
18. Schuberth J, Alder D. Talar fractures. In: Banks A, Downey M, Martin D, Miller S editor. McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery. Philadelphia: Lippincott Williams and Wilkins; 2002, 1866-1867.
19. Hiraizumi Y, Hara T, Takahashi M, Mayehiyo S. Open total dislocation of the talus with extrusion: A report of two cases. Foot Ankle Int 1992 13: 473-477.
20. Brewster N, Maffulli N. Reimplantation of the totally extruded talus. J Orthop Trauma 1997 11: 42–45.
21. Vallier H, Barei D, Bernischke S, Sangeorzan B. Surgical treatment of talar body fractures. JBJS 2003 85A: 1716-1724.

Address Correspondence to: Sutpal Singh, DPM. FACFAS. FAPWCA

1  Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina, Fellow of the American College of Foot and Ankle Surgeons, Fellow American Professional Wound Care Association. Private practice in Southern California.
2  Doctor of Podiatric Medicine (R3) ,Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
3  Doctor of Podiatric Medicine (R2) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA
Doctor of Podiatric Medicine (R1) Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36), West Covina, CA

© The Foot and Ankle Online Journal, 2010