Overview

The talus bone is a small, irregular-shaped bone in the foot that connects the ankle to the leg. Despite its small size, it supports body weight, allows the ankle to move smoothly, maintains balance, and supports foot ligaments. 

Talus fractures typically result from incidents such as sports injuries, car accidents, or ankle twisting. They are relatively rare, accounting for less than 1% of all bone fractures and approximately 3% to 6% of foot fractures. They can lead to a loss of ankle motion and function. For mild cases, casting and rehabilitation are usually recommended. Meanwhile, for more severe cases, surgery may be necessary, especially if the bones are displaced or shattered. Untreated or incorrectly healed fractures may cause complications such as delayed union, post-traumatic arthritis, and other functional deformities.^1,2

This article will review these potential complications in detail.

Common complications of talus fractures

Delayed union

A delayed union occurs when a fracture takes longer than usual to heal. In such cases, the bone does produce healing tissue, but at a significantly slower rate, often over the course of several months.^3,4,5

What are the causes of delayed union?

• Injury-related factors: Soft tissue damage or interposition (a displaced or torn fragment of the tissue, such as a tendon, gets caught within joints or between bone fragments), fracture configuration, presence of a fracture gap, or bone loss secondary to trauma
• Patient-dependent factors: Use of certain medications, such as ibuprofen and corticosteroids, pre-existing medical conditions (e.g.diabetes), socioeconomic status, immunosuppression, or lifestyle factors, such as smoking, age, and body mass index
• Surgically related factors: Unstable fixation or poor fracture or reduction during surgery
• Mechanical factors: Multi-axial loading, hydrostatic strain, deviatoric stresses, or mechanical overload during the healing process^3,4,5

What are the symptoms of delayed union?

• Tenderness at the fracture site
• Swelling around the affected area
• Deep pain within the affected bone
• Persistent pain and weakness over time
• Inability to bear weight on the affected limb
• Limited or no use of the affected body part until proper healing occurs^3,4

How can delayed union in talus fractures be diagnosed?

• Medical history and physical examination
• X-rays
• Computerised tomography scans
• Magnetic resonance imaging scans
• Blood tests^3,4

What are the treatment options?

• Bone stimulation, or pulse electromagnetic field (PEMF) stimulators: They are the most commonly used noninvasive devices for bone growth stimulation and spinal fusion support. They promote bone healing by inducing electrical currents that activate cellular repair processes
• Continued immobilisation: Prolonged immobilisation keeps bone alignment, allowing new bone tissue to form across the fracture gap
• Surgical intervention: Surgery may be required when conservative treatments fail, particularly in cases involving instability or non-healing, to restore bone integrity and promote healing^3,4,5

Post-traumatic arthritis

Post-traumatic arthritis develops after a joint injury, particularly when the injury damages the cartilage. While bones usually heal normally, the cartilage may not, leading to pain and stiffness over time. 

This condition can develop in weeks or months after the initial injury, and while it may be temporary, it can become chronic in some cases. Post-traumatic arthritis is not common after ankle fractures, but it is common after fractures to either the calcaneus (heel bone) or the talus bone.⁶

What are the symptoms of post-traumatic arthritis?

• Joint pain
• Joint swelling
• Limited range of motion
• Difficulty bearing weight
• Grinding or crunching sensation
• Redness and tenderness
• Synovial fluid accumulation
• Difficulty with daily activities⁶

How can post-traumatic arthritis in talus fractures be diagnosed?

• Medical history and physical examination
• X-rays
• Computerised tomography scans
• Magnetic resonance imaging scans⁶

What are the management and treatment options?

1. Conservative management (Mild to Moderate Cases): 

• Pain relievers: Over-the-counter or prescription pain medications to reduce pain and inflammation
• Bracing: Supports the joint, provides stability, and may help reduce pain
• Physical therapy: Exercises to strengthen surrounding muscles, improve flexibility, and increase range of motion
• Weight loss: Reducing excess weight lessens stress on joints

2. Surgical Procedures (Severe Cases):

• Arthroscopy: A minimally invasive surgery to remove damaged tissues or loose pieces of cartilage from the joint
• Ankle fusion (arthrodesis) surgery: A surgical procedure to fusion the ankle bones to eliminate movement and reduce pain
• Subtalar fusion: A surgical procedure to fuse the bones in the subtalar joint (below the ankle) to reduce pain and improve stability
• Total ankle replacement (arthroplasty): A surgical procedure to replace the damaged ankle joint with a prosthetic implant⁶ 

Deformities

Talar fractures can lead to various deformities, including avascular necrosis (AVN), malunion, and nonunion. Among these, malunion is the most common complication following a talus fracture.

Malunion 

• A malunion occurs when the fractured bone heals in an abnormal position, leading to issues such as difficulty walking, pain, and arthritis
• Risk factors include loss of reduction or alignment after treatment, improper movement, presence of fragmented bones, delayed treatment, and patient non-compliance
• Treatment options include surgical realignment and stabilisation of bone, osteotomy, arthrodesis, and physical therapy⁷

Non-union

• A nonunion refers to a fractured bone that has not healed after an extended period. This can cause articular incongruity and malposition of the related joints, leading to osteoarthritis and long-term pain
• Risk factors include smoking, advanced age, certain medical conditions like diabetes and osteoporosis, fracture severity, open fractures, infection, and inadequate fixation
• Non-surgical treatment options include medical therapy, orthoses, bone stimulation, or biologic injections (stem cells or platelet-rich plasma therapy). Surgical treatment options include debridement, vascular surgery, bone grafting, or open reduction and internal fixation^7,8

Avascular necrosis (AVN)

• AVN occurs when there is a limited blood supply to the affected talus bone, leading to cell death and bone collapse. This collapse damages the articular cartilage covering, causing bone-on-bone friction, increased pain, arthritis, and loss of motion and function
• The risk of AVN increases with fracture severity. Nonsurgical options include non-weight bearing, protected weight bearing using splints (such as the patellar tendon brace), and extracorporeal shock wave therapy. Surgical options include joint-sparing procedures (core decompression, bone grafting – vascularized or non-vascularized autografts), joint-sacrificing procedures (partial or total talar replacement), salvage procedures (talectomy, arthrodesis of ankle, subtalar, tibionavicular, tibiocalcaneal, or tibiotalocalcaneal joints), and total ankle replacement⁹

When should you seek emergency care?

• Intense or worsening pain
• Inability to move the affected joint or part
• Suspected fracture or dislocation
• New bruising or other unusual symptoms⁶

Summary

Talus fractures, breaks in the ankle bone connecting the foot and leg, usually result from high-impact injuries like car accidents, sports injuries, or ankle twisting. These injuries can lead to loss of ankle motion and function. Treatment usually requires surgery to realign the bone fragments, and recovery can take months. The main complications associated with talus fractures include delayed union, post-traumatic arthritis, and deformities. Early recognition of persistent pain, swelling, or functional limitation is crucial for optimising outcomes and preserving long-term joint function.