26

FRACTURE NECK OF TALUS

Name Age Sex RN : MBA : 40 years : Male : 03/010245

Hospital Kuala umpur

CASE REPORT
40 year ol! lorry !ri"er sustai# i#$ury to %is rig%t &oot i# a motor "e%i'le a''i!e#t( )%e lorry *%i'% %e *as !ri"i#g 'olli!e! i#to a 'ar a#! %is rig%t &oot *as su+$e'te! &or extreme !orsi&lexio#( ,# exami#atio# %is rig%t &oot *as s*olle#- !e&orme!- te#!er a#! re!u'e! ra#ge o& mo"eme#t( Bot% t%e !orsalies pe!is a#! posterior ti+ialis artery *ere palpa+le( )%e ra!iograp% exami#atio# re"eale! a &ra'ture t%ro t%e #e'. o& talus *it% !islo'atio# o& +ot% t%e a#.le a#! t%e su+talar $oi#t( /Ha*.i# type 0001 2atie#t *as su+$e'te! &or a 'lose ma#ipulati"e re!u'tio# u#!er se!atio# *ere %is a#.le $oi#t *as re!u'e! t%e# pro'ee!e! &or s're* &ixatio# o& t%e #e'. o& talus( 3#!er ge#eral a#aest%esia patie#t *as pla'e! supi#e *it% tour#i4uet &or t%e rig%t lo*er lim+( ,#'e t%e a&&e'te! area *as 'lea#e! a#! !rape! t*o K5*ires *ere i#serte! per'uta#eously *it% image i#te#si&ier gui!a#'e( '%e'.e! u#!er image i#te#si&ier( Next small s.i# i#'isio# ma!e a#! t%e +o#e pre5!rille! i# t%e same !ire'tio# o& t%e K5 *ires( )*o 4(0mm'a##ulate! s're*s *ere i#serte! /'ross5!ire'tio#1( Hea! o& t%e s're* is +urie! i# t%e arti'ular 'artilage o& t%e %ea! o& talus( 6ou#! 'lose! i# layers a#! +elo* .#ee +a'. sla+ applie! to t%e rig%t lo*er lim+( ,#e !ire'te! a#terome!ial to posterolateral a#! t%e se'o#! &rom a#terolateral to posterome!ial( )%e re!u'tio# *as

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2ost5operati"ely t%e '%e'. 75ray *as a''epta+le( 2atie#t *as !is'%arge! *it% #o#5 *eig%t +eari#g &or six *ee.s( ,# six *ee.s &ollo*5up t%e *ou#! %a! %eale! a#! patie#t *as ta.e# o&& t%e +a'. sla+ a#! su+$e'te! &or p%ysio rig%t a#.le( He *as still su+$e'te! &or #o# *eig%t +eari#g 'rut'%es( No Ha*.i#s sig# #ote! o# t%e 75ray( At 12 *ee.s &ollo*5up patie#t *as starte! o# &ull *eig%t +eari#g a#! is still o# our &ollo*5up(

DISCUSSION
0# its simplest &orm t%e &oot represe#ts a 3 legge! stool( )%e talar !ome is t%e seat a#! t%e 'al'a#eus- t%e &irst a#! t%e &i&t% metatarsal %ea!s represe#ts t%e 3 legs( )%e sta+ility o& t%ese *eig%t5+eari#g poi#ts !epe#!s o# t%e positio# a#! t%e i#tera'tio# o& t%e i#!i"i!ual +o#es o& t%e &oot( )%e talus %ol!s a# importa#t .ey to t%e a#.le $oi#tsu+talar $oi#t a#! tra#s"erse metatarsal $oi#t( A#y &ra'ture o& t%e talus !isrupti#g t%ese $oi#ts *ill re!u'e t%e ra#ge o& mo"eme#t o& t%e a#.le $oi#t- %i#! &oot a#! mi!&oot( )%e goal i# treatme#t o& t%e talus &ra'ture is to o+tai# early ra#ge o& mo"eme#t( 0# or!er to !o so o#e s%oul! u#!ersta#! its a#atomy- i#tra5arti'ular sur&a'es- +loo! supply a#! proper i#ter#al &ixatio# te'%#i4ue o& t%e talus(

ANATOMY
)%e talus %as got 8 arti'ular sur&a'es a#! sixty5per'e#t o& t%e talus is 'o"ere! +y arti'ular 'artilage( )%e talus 'o#sist o& t%e +o!y- t%e #e'. a#! t%e %ea!( )%e +o!y %as got 5 sur&a'es superior- i#&erior me!ial- lateral a#! posterior( At t%e superior aspe't t%e talar !ome arti'ulates *it% t%e ti+ial pla&o#!( Me!ially a#! laterally t%e arti'ular sur&a'e exte#!s pla#tar to arti'ulate *it% t%e me!ial a#! lateral malleoli( 0#&eriorly t%e +o!y o& t%e talus arti'ulates *it% t%e talus t%ro t%e posterior &a'et( )%e posterior sur&a'e %as me!ial a#! lateral tu+er'les separate! +y a groo"e &or t%e &lexor %allu'is lo#gus te#!o#( )%e talus %as 2 pro'esses posterior a#! lateral a#! to t%e lateral pro'ess t%ere is t%e atta'%me#t o& a#terior a#! posterior talo&i+ular ligame#ts( )%e #e'. o& t%e talus is +et*ee# t%e %ea! a#teriorly a#! t%e +o!y posteriorly( )%e #e'. is

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!e"iate! 15 to 20 !egrees me!ially a#! arti'ulates at t%e i#&erior aspe't *it% t%e suste#ta'ulum tali o& t%e 'al'a#eum( )%e i#&erior sur&a'e o& t%e #e'. also %as multiple "as'ular &orami#a( )%e %ea! o& t%e talus arti'ulates *it% t%e #a"i'ular +o#e a#teriorly /talo#a"i'ular $oi#t1 a#! i#&eriorly *it% t%e 'al'a#eum(

BLOOD SUPPLY
)%e talus !oes #ot %a"e a#y mus'le atta'%me#t t%ere&ore it is at ris. &or osteo#e'rosis &ollo*i#g i#$ury( 9as'ular a''ess to t%e talus is limite! to t%e #o# arti'ular sur&a'e *%i'% is o#ly 40:(A!elaar RS /1;;81 states t%at t%e ri'% i#terosseous a#! extra osseous +loo! supply is !eri"e! &rom 3 ma$or arteries o& t%e lo*er lim+( )%e "as'ular supply i#'lu!es artery to t%e si#us tarsi /origi#ati#g &rom pero#eal a#! !orsalies pe!is artery1- artery o& t%e tarsal 'a#al /&rom posterior ti+ial artery1 *%i'% passes t%ro t%e !eltoi! ligame#t a#! t%e !eltoi! artery /+ra#'% o& t%e posterior ti+ial artery1( )%e !eltoi! artery supplies t%e me!ial talar +o!y- 'apsular/ligame#tous a#! i#terosseous a#astomosis ()%e rest o& t%e +o!y is supplie! +y t%e artery o& t%e si#us tarsi a#! artery o& t%e tarsal 'a#al( )%e talar %ea! %as a+u#!a#t "essels e#teri#g &rom t%e superior a#! i#&erior aspe't &rom t%e a#terior ti+ial artery

INCIDENCE AND MECHANISM OF INJURY

)%irty per'e#t o& talus &ra'ture i#"ol"es t%e #e'.( )%is is usually 'ause! +y %yper!orsi&lexio# o& t%e &oot *%ere t%e #e'. o& t%e talus +e'omes *e!ge agai#st t%e a#terior margi# o& t%e !istal ti+ia( <A"iator=s astralgalus> is t%e #ame use! to !es'ri+e talar #e'. &ra'tures +e'ause pre"iously t%ey see# !ue to t%e air'ra&t impa't o# t%e &oot resti#g o# t%e ru!!er +ar( ?urre#tly &ra'ture #e'. o& talus is see# i# motor "e%i'le a''i!e#t a#! &all &rom %eig%ts( )%e me'%a#ism o& i#$ury %as +ee# stage! +y 2e##y @N /1;A01(

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Stage one Stage two Stage three

t%e ex'essi"e !orsi&lexio# 'auses rupture o& t%e posterior 'apsular ligame#t o& t%e su+talar $oi#t( t%e #e'. o& talus impa'ts agai#st t%e a#terior margi# o& t%e ti+ia( &ra'ture li#e !e"elops +et*ee# t%e posterior a#! mi!!le &a'et o& t%e talus( /&rom t%e talar sul'us to t%e i#sertio# li#e o& talo'al'a#eal ligame#t(1 *it% 'o#ti#ue! !orsi&lexio# t%e %ea! o& talus su+laxate! &or*ar!( 0& t%e &oot is i#"erte! it !islo'ate! me!ially a#! i& e"erte! it !islo'ates laterally( At t%is stage t%e +o!y o& talus is lo'ate! *it% t%e a#.le mortise +ut *it% &urt%er !orsi&lexio# t%e posterior a#.le 'apsular ligame#ts rupture( ,#'e t%is %appe#s t%e pull o& t%e !eep !etoi! ligame#t pulls t%e +o!y o& t%e talus to a posterior5me!ial positio# *%ere t%e &ra'ture! sur&a'e lies +et*ee# t%e me!ial malleolus a#! te#!o# Ar'%ilies(

Stage our

CLASSIFICATION
)alar &ra'tures are 'lassi&ie! +ase! o# &ra'ture lo'atio# talar +o!y- talar #e'.- talar %ea! a#! lateral pro'ess( Ha*.i# B /1;801 *as i#itially 'lassi&ie! i# 1;80 a#! mo!i&ie! later +y ?a#ale S) /1;8A1( )%e 'lassi&i'atio# *as +as o# t%e amou#t o& &a'ture !ispla'eme#t a#! t%e li.eli%oo! o& osteo#e'rosis o& t%e talar +o!y(
!rou" one: !rou" two: !rou" three# #o#5!ispla'e! "erti'al &ra'ture o& talar #e'. *it% talar #e'. "essels !isrupte! /ris. o& A9N C 10:1 !ispla'e! &ra'ture o& t%e talar #e'.- su+laxatio# o& t%e su+talar $oi#t *it% talar #e'. a#! tarsal 'a#al "essel !isruptio# /ris. o& A9N D 40:1 !ispla'e! &ra'ture o& t%e talar #e'. *it% !islo'ate! a#.le a#! su+talar $oi#t *it% talar #e'.- tarsal 'a#al a#! !eltoi! "essels !isruptio# /ris. o& !rou" our: A9N D ;0:1 !ispla'e! &ra'ture o& t%e talar #e'. *it% !islo'ate! a#.le- su+talar a#! talo#a"i'ular $oi#t *it% all 3 sour'es a#! talar %ea! +loo! supply !isrupte! /ris. o& A9N 100:1

0# osteo'%ro#!ral &ra'ture o& t%e talar !ome- alt%oug% MR0 %a"e resulte! i# #e* 'lassi&i'atio#- t%e system o& Ber#!t a#! Harty /1;5;1 remai#s *i!ely use!( ,# a plai# ra!iograp% o& t%e a#.le $oi#tE Stage o#e5small area o& 'ompresse! su+'%o#!ral +o#e

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Stage t*o5partially !eta'%e! su+'%o#!ral &ragme#t Stage t%ree5'ompletely !eta'%e! su+'%o#!ral &ragme#t +ut #ot !ispla'e! Stage &our5'ompletely !eta'%e! a#! !ispla'e! su+'%o#!ral &ragme#t Sig#i&i'a#t '%a#ges i# 'o#ta't '%ara'teristi's o& t%e a#.le $oi#t 'a# o''ur *%e# t%e !e&e't is larger t%a# 8(5 +y 15mm /?%riste#se# @?- 1;;41

RADIO!RAPHIC E$ALUATION
Ra!iograp%i' e"aluatio# s%oul! i#'lu!e A2- lateral- o+li4ue /mortise1 a#! ?a#ale "ie*( ,# t%e lateral "ie* t%e talar #e'. 'a# +e stu!ie! *ell( Mortise "ie* allo*s "isualiFatio# o& a#.le $oi#t 'o#grue#'y a#! also asso'iate! malleolar &ra'ture( )%e ?a#ale "ie* !emo#strates t%e 'omplete talar #e'. i# t%e a#terioposterior !ire'tio#E t%e &oot is positio#e! o# t%e x5ray 'assette i# 15 !egree pro#atio# a#! t%e a#.le i# maximum e4ui#ous( )%e x5ray +eam !ire'te! 'ep%ala! 15 !egrees &rom t%e "erti'al( ?) S'a#s may +e %elp&ul i# 'ommi#ute! to !eli#eate arti'ular i#"ol"eme#t a#! &ra'ture patter#( 0# lateral a#! posterior pro'ess &ra'tures- a ?) s'a# is #e'essary to !etermi#e t%e true amou#t o& su+talar arti'ular i#"ol"eme#t(

TREATMENT
A#y u#'orre'te! arti'ular i#'o#gruity or misalig#me#t alo#g a#y talar &ra'ture patter# results i# sig#i&i'a#t impairme#t o& &oot &u#'tio#( )%e goal o& treatme#t o& &ra'ture #e'. o& talus is to o+tai# a# a#atomi'al u#io# i# or!er to re!u'e 'ompli'atio#s li.e osteo#e'rosis a#! osteoart%rosis( Gispla'e! talar #e'. &ra'ture is 'o#si!ere! a# ort%ope!i' emerge#'yE *it% urge#t 'lose/ope# re!u'tio# re4uire! reesta+lis%i#g "as'ularity to talus( /Ga"i! @(B( Step%e# AA,S- ,K3 20001 0# type o#e u#!ispla'e! &ra'tures t%e lim+ 'a# +e immo+iliFe! i# a +elo* .#ee ?ast &or A to 12 *ee.s( ?lose &ollo*5up is re4uire! a#! stri't #o#5*eig%t +eari#g is re'omme#!e! till &ra'ture u#io# is #ote!( ,#'e &ra'ture is u#ite! t%e 'ast 'a# +e o&& a#! a'ti"e a#.le exer'ises starte!( 0#ter#al &ixatio# i# t%is &ra'ture *oul! e#a+le early

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a#.le mo+iliFatio#( /Ma#.ey M - AA,S- ,K3 1;;41 0# !ispla'e! &ra'tures /type 2- 341 'lose! or ope# re!u'tio# s%oul! +e attempte! a#! sta+iliFe! *it% s're*s( )%e 'riteria &or a!e4uate re!u'tio# are !ispla'eme#t less t%a# 5mm a#! mal5alig#me#t o& less t%a# 5 !egrees( 0# ope# re!u'tio# t%e t%ree mai# surgi'al approa'%es are a#terome!ial- a#terolateral a#! posterolateral( )%e me!ial i#'isio# allo*s /11 assessme#t o& 'ommi#utio# *%i'% may re4uire +o#e gra&t: /21 assessme#t o& "arus mal5alig#me#t a#! rotatio#al !e&ormities a#! /31 i#sertio# o& impla#ts( /Ga"i! @(B Step%e#- AA,S- ,K3 20001( 0# situatio#s o& irre!u'i+le &ra'tures or &ra'tures o& t%e talar +o!y- a me!ial malleolar osteotomy is per&orme! to a"oi! !isse'tio# o& t%e !eltoi! ligame#t- *%i'% !amage t%e !eltoi! artery o&te# t%e o#ly remai#i#g +loo! supply to t%e talus( )%e lateral i#'isio# allo*s /11 exploratio# a#! !e+ri!eme#t o& t%e su+talar @oi#t /21 rotatio#al assessme#t &or t%e stro#ger a#! less 'ommi#ute! lateral pro'ess area /31 i#sertio# o& s're*s /Ga"i! @(B Step%e#- AA,S- ,K3 20001( )%e importa#t pri#'ipal is to a'%ie"e sta+le &ixatio# a#! a"oi! o"er 'ompressio# o# t%e me!ial si!e i# t%e prese#'e o& se"ere #e'. 'ommi#utio#- *%i'% 'a# result i# "arus mal5u#io#( 0# 'ases o& extreme 'ommi#utio#- mi#i5&ragme#t plates may+e re4uire! to reesta+lis% #ormal a#atomi' talar #e'. a#atomy( Biome'%a#i'al e"aluatio# o& &ixatio# %as s%o*# t%at s're*s are &ar more superior to K5*ires- s're*s i#serte! posterior to a#terior are superior to t%ose pla'e! a#terior to posterior- t*o 4(0mm s're*s are e4ui"ale#t to si#gle H(5mm s're*( /S*a#so# )91;;21( )%e %ig%est +o#e !e#sity o''urs i# t%e lateral %ea! a#! a#terolateral part o& +o!y /I+ra%eim- 1;;H1( ,pe# &ra'ture o''urs i# up to 25: o& talar &ra'tures a#! i# as ma#y as 50: i# Ha*.i#=s type 000 &ra'tures( Gespite a!%ere#'e to t%e pri#'ipals o& treati#g ope# &ra'tures t%e i#&e'tio# rate remai#s as %ig% as 3A: i# a re'e#t stu!y /Mars% @ - 1;;51- *%i'% 'orrelates *it% a poor &u#'tio#al out'ome(

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)%e !islo'ate! talus s%oul! al*ays +e !e+ri!e! a#! pla'e! i# #ear a#atomi'al re!u'tio# a#! i# gross 'o#tami#atio# a# exter#al &ixator 'a# +e applie!( Gespite t%e a+o"e i& i#&e'tio# or osteo#e'rosis !e"elops t%e# a ti+io'al'a#eal &usio# is pre&orme! at a later !ate( 6%et%er surgi'al or #o#5surgi'al treatme#t is opte! &or t%e patie#t must +e .ept #o#5*eig%t +eari#g &or at least 3 mo#t%s till t%e &ra'ture u#ites( Iarly ra#ge o& mo"eme#t !epe#!s o# t%e &ixatio# sta+ility( PRO!NOSIS )%e out'ome o& talus &ra'ture is %ar! to a''ess !ue to it lo* o''urre#'e- *i!e spe'trum o& i#$ury patter#- t%e "aria+ility o& met%o!s use! i# its treatme#t a#! t%e la'. o& sta#!ar!iFe! out'ome measure use! &or reporti#g( I"e# i# type 0 &ra'tures #early 40550: o& patie#ts %a"e u#satis&a'tory out'ome( )%ose 'ases *%i'% *ere treate! early *it% operati"e &ixatio# %a"e A2: ex'elle#t or goo! results( /SFysF.o*itF R- 1;A51( COMPLICATIONS )%e &re4ue#'y a#! se"erity o& 'ompli'atio# !epe#!s o# t%e type o& &ra'ture !islo'atio# sustai#e! as state! +y Ha*.i#=s 'lassi&i'atio#( /11 S.i# #e'rosis a#! i#&e'tio# Gue to t%e &ra'ture !islo'atio#- pressure o# t%e s.i# arou#! t%e a#.le $oi#t 'a# o&te# 'ause ga#gre#ous '%a#ges to t%e o"erlyi#g s.i#( 0# t%ese 'ases imme!iate re!u'tio# o& t%e &ra'ture &ragme#t s%oul! +e !o#e a#! pressure o# to t%e s.i# s%oul! +e relie"e!( ?o"erage *it% a#ti+ioti' s%oul! also +e 'o#si!ere!( 0# ope# &ra'tures !e+ri!eme#t s%oul! +e 'arrie! out *ell a#! a#ti+ioti' treatme#t starte!( Gespite t%is i& osteomyelitis sets i# a#! 'a##ot +e 'o#trolle!- ex'isio# o& t%e talus &ollo*e! +y ti+io'al'a#eal &usio#/ Blair &usio# s%oul! +e 'o#si!ere!( /21 2ost traumati' art%ritis

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)%is is usually 'ause! +y arti'ular 'artilage !amage- late segme#tal 'ollapse !ue to osteoart%ritis- art%ro5&i+rosis !ue to prolo#g immo+iliFatio# o& t%e a&&e'te! $oi#t a#! mal5u#io#( )%e i#itial ma#ageme#t s%oul! +e a'ti"ity mo!i&i'atio#- +ra'i#g a#! a#ti5i#&lammatory !rugs( I&&ort s%oul! +e ta.e# to lo'aliFe t%e a&&e'te! area +y i#$e'ti#g lo'al a#aest%esia i#to suspe'te! $oi#ts a#! #oti#g t%e pai# relie&( /Ma#.ey M- 1;;41(Art%ro!esis s%oul! +e t%e last mo!e o& pai# relie&( /31 Gelaye! u#io# or #o# u#io# Gelaye! u#io# *%e# #o %eali#g is e"i!e#t at H *ee.s a#! #o# u#io# *%e# #o %eali#g at 12 *ee.s( ?a#'ellous +o#e gra&ti#g *it% a!!itio#al 'orti'al strut gra&t i# #e'. !e&e'ts %as gi"e# relia+le results( /41 Malu#io# )%e o''urre#'e o& "arus malu#io# %as +ee# reporte! to +e as %ig% as 50: +ut more li.ely i# t%e ra#ge o& 25: to 30 :(/ ?a#ale S)- 1;8A1(Biome'%a#i'al stu!ies %a"e s%o*# t%at e"e# a &e* !egrees o& "arus malu#io# 'a# 'ause %i#! &oot "arus a#! &ore&oot a!!u'tio# /Ga#iels )R- 1;;H1(I"ersio# is limite! +ut i#"ersio# is u#a&&e'te!( )%ese patie#ts *it% "arus malu#io# te#! to +ear *eig%t o# t%e lateral aspe't o& t%e &oot *%ile *al.i#g resulti#g i# 'allosity a#! pai#( )%e i#itial treatme#t *oul! +e &or 'ustom ma!e ort%osis( *oul! +e sal"age pro'e!ure su'% as triple art%ro!esis( /51 ,steo#e'rosis Ha*.i#=s 'lassi&i'atio# %as 'learly s%o*# t%e i#'i!e#'e o& osteo#e'rosis +ase! o# &ra'ture patter#( Ha*.i#s type 0 ris. is 0513:- Ha*.i#s type 00 ris. is 20550:- Ha*.i#s type 000 ris. is A35100: a#! type 09 is D 100/Ha*.i#s B- 1;801()%e prese#'e o& su+'%o#!ral lu#'e#'y /Ha*.i#s sig#1 o# a# a#terioposterior "ie* o& t%e a#.le at H5 A *ee.s is t%e +est pre!i'tor to i#ta't "as'ularity to t%e talar +o!y( A+se#'e o& t%e sig# !oes #ot a+solutely i#!i'ate osteo#e'rosis +ut prote'te! am+ulatio# is re4uire! a#! #o# *eig%t +eari#g( Re"as'ulariFatio# 'a# ta.e up to 3H mo#t%s( ate segme#tal 'ollapse +e'ause ast resort

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o& osteo#e'rosis re4uires !e+ri!eme#t o& t%e #e'roti' portio# o& t%e talus a#! ti+io'al'a#eal &usio#( )%e 'lassi' met%o! o& &usio# is t%e Blair &usio#- *%i'% is a# a#terior sli!i#g ti+ial gra&t i#to t%e remai#i#g talus #e'. )%is met%o! usually results i# a s%ort a#! sti&& extremity( ?o#temporary met%o!s i#'lu!e t%e use o& a retrogra!e i#trame!ullary #ail a#! 'ir'ular &ixatio# to allo* proximal !istra'tio# to restore leg le#gt%(

REFERANCE
1( A!elaar RS: ?omplex &ra'tures o& t%e talus i# Spri#g&lie! GS: 0#stru'tio#al 'ourse le'tures 4H( Rosemo#t- 0 - Ameri'a# A'a!emy o& ,rt%opae!i' Surgeo#s- pp323532A- 1;;8( 2( 3( 4( Ber#!t A - Harty M()ra#s'%o#!ral &ra'tures /osteo'%o#!ritis !esi'a#s1 o& t%e talus( @ Bo#e @oi#t Surg :41AE ;AA51020E 1;5; ?a#ale S)- Kelly JB: Jra'ture #e'. o& t%e talus( @ Bo#e @oi#t Surg: H0A: 1435 15HE 1;8A( ?%riste#se# @?- Gris'%oll H - a#! )e#'er AJ: ?o#ta't '%ara'teristi' o& t%e a#.le $oi#t: 2art 2( )%e e&&e'ts o& talar !ome 'artilage !e&e'ts( @ Am 2e!iatr Me! Asso'E A4E5385548:1;;4 5( Ga#iels )R- Smit% @6- Ross )0 : 9arus malalig#me#t o& t%e talar #e'.: 0ts e&&e't o# t%e positio# o& t%e &oot a#! su+talar motio#( @ Bo#e @oi#t Surg E5; : 38543 E1;43 H( 8( Ga"i! @(B( Step%e#( )alus &ra'tures( ,K3 :A#.le a#! Joot i#$uries( I!ite! +y @ames J( Kelam- )%omas @ Jis%er( AA,S(?%apter1;:2105213- 2000( I+ra%eim NA- Me.%ail A,- Salpietro B@- Mermer M@- a#! @a'.so# 6): )alar #e'. &ra'tures: A#atomi'al 'o#si!eratio# &or posterior s're* &ixatio#( @ Bo#e @oi#t SurgE 84AE 5445551E 1;;H( A( ;( Ha*.i#s B: Jra'ture o& t%e #e'. o& t%e talus( @ Bo#e @oi#t SurgE 52A:;;15 1002E 1;80( Ma#.ey M(Jra'ture o& talus( ,K3: Joot a#! A#.le( I!ite! +y MiFel M(S( AA,S( ?%apter 14: 205522H- 1;;4( utter (G-

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10( 11( 12( 13(

Mars% @l- SaltFma# ? - 0"erso# M- S%apiro GS: Ma$or ope# i#$uries o& t%e talus( @ ,rt%op )raumaE ;:381538H- 1;;5( 2e##y @#- Ga"is A: Jra'tures a#! &ra'ture !islo'atio# o& #e'. o& talus( @ )rauma 20:102;51038- 1;A0( S*a#so# )9- Bray )@ Holmes BB @r: Jra'tures o& t%e talar #e'.: A me'%a#i'al stu!y o& &ixatio#( @ Bo#e @oi#t Surg E84A :5445551- 1;;2 SFysF.o*itF R- Res'%auer R- Seggl 6: Iig%ty5&i"e talus &ra'tures treate! +y ,R0J *it% &i"e to eig%t years o& &ollo*5up stu!y o& H; patie#ts( ?li# ,rt%opE 1;;:;85108- 1;A5(