Introduction

The talus, a key ankle bone, enables load transfer from the tibia to the foot. Its distinct anatomy—consisting of a head, body, and neck—is devoid of muscular attachments, with stability provided by ligaments and articular cartilage. Fracture-dislocations of the talus are fractures of the bone in conjunction with joint dislocations, typically due to high-energy trauma, such as falls or motor vehicle crashes. These fractures contribute 0.1–2.5% to all fractures, and are male-dominated (60–77%) with a peak in the 30s. Such injuries are of clinical importance due to complications such as avascular necrosis (AVN) and post-traumatic arthritis that result in permanent disability.¹

Mechanisms of injury

Talar fracture-dislocation usually results from high-energy injury, and the mechanisms entail multifaceted force vectors and torsional stress. Such injury tends to be disabling because the talus is functionally paramount to ankle mechanics and has an unstable blood supply. 

Principal mechanisms

Axial loading with dorsiflexion

Compulsive dorsiflexion of the ankle (as with a car accident or a fall from distance) forces the talar neck onto the tibia, inducing fractures. Frequently, this also occurs with dislocation of the subtalar joint

Example: Dorsiflexion-positioning fall from distance compresses the talus between the tibia and the calcaneus, resulting in fractures of the talar neck.

Inversion/eversion with rotation

Medial subtalar dislocation: Forceful inversion of a plantarflexed foot along with external rotation causes the rupture of talonavicular ligament followed by interosseous ligament.

Lateral subtalar dislocation: Forceful eversion of a dorsiflexed foot with external rotation ruptures the deltoid ligament and interosseous ligament.

Excessive supination/pronation

Total talar extrusion results from extreme supination (resulting in lateral dislocation) or pronation (resulting in medial dislocation).

Staged dislocation patterns

Leitner's stages:

• Subtalar joint dislocation
• Talonavicular joint dislocation
• Complete talar extrusion

High-risk scenarios

• Motor vehicle crashes (axial loading)
• Falling from more than 6 meters (dorsiflexion stress)
• Sports (e.g., snowboarding – fractures of lateral process)

These mechanisms tend to compromise the blood supply of the talus (mainly from anterior/posterior tibial arteries), putting it at a higher risk of avascular necrosis. Early anatomic reduction and fixation are essential to avoiding complications.²

Clinical presentation and diagnosis

Symptoms: Severe pain, swelling, inability to weight-bear.

Physical exam: Tenderness, deformity, and neurovascular examination for compartment syndrome.

Imaging:

• X-rays (AP, lateral, mortise) identify displacement
• CT scans define fracture patterns for surgical planning
• MRI assesses soft-tissue injury and early AVN³

Treatment challenges

Vascular compromise and avascular necrosis (AVN)

• The talus receives a precarious blood supply, leaving it extremely prone to AVN following dislocation. Hawkins type IV injuries heighten this danger due to extrusion and complete displacement, which compromises essential vessels such as the artery of the tarsal canal
• AVN rates are greater than 50% in Hawkins IV fractures, even when reduction is promptly achieved
• Post-reduction CT scans are needed to evaluate vascular integrity and fracture patterns

Anatomic reduction and fixation challenges

Stable anatomic alignment is essential but problematic due to:

• Fracture patterns: Simultaneous talar neck or body fractures with medial malleolar fractures (as in case reports) necessitate double surgical approaches (medial and lateral) or malleolar osteotomy for visualisation
• Soft tissue limitations: Excessive swelling or open wounds can postpone definitive fixation, with temporary external fixation being used

High risk of infection and osteomyelitis

Open injuries or extruded talus situations (frequent in Hawkins IV) have a 20–40% risk of infection:

• Immediate debridement and antibiotic prophylaxis are imperative
• External fixators are frequently utilised to stabilise the joint while the soft tissues are managed

Post-traumatic arthritis

With successful reduction, 60–80% of patients will end up with subtalar or tibiotalar arthritis due to damage to the cartilage.

Weight-bearing protocols remain contentious, and early weight-bearing is often left at 12+ weeks as non-weight-bearing.

Surgical timing and decision-making

• Time-dependent reduction: Subtalar/tibiotalar dislocations need urgent closed reduction (<3 hours) to prevent AVN and soft tissue necrosis
• Reimplantation vs. salvage: Exposed talus reimplantation within 3 hours can salvage function, but delayed presentations (>24 hours) can necessitate tibiocalcaneal arthrodesis

Multidisciplinary management

Best results require teamwork among:

• Orthopaedic surgeons (for fixation)
• Plastic surgeons (for soft tissue cover)
• Infectious disease specialists (for antibiotic protocols)

Even with advances, Hawkins IV talus fracture-dislocations carry significant complication rates, with AVN, arthritis, and infection leading to long-term disability. Precise surgical technique, patient counseling regarding possible outcomes, and formal rehabilitation are essential for reducing these challenges.¹

Treatment approaches

Talar fracture-dislocations are infrequent and troublesome injuries that should be treated urgently and delicately because of the talus' essential role in ankle and foot motion and its fragile blood supply. Anatomical reduction, maintenance of vascularity to avoid avascular necrosis (AVN), and reduction of late complications like arthritis are aims in the treatment.

Emergency management

• Immediate reduction: Immediate reduction of the dislocated talar fracture is a medical emergency to minimise vascular compromise and optimise outcomes. Early reduction minimises the risk of avascular necrosis by re-establishing blood supply to the talus
• Closed reduction attempts: Closed reduction is usually tried initially in the emergency department. However, it most commonly fails in dislocated talar neck fractures because of soft tissue interposition, like the flexor hallucis longus muscle

Definitive surgical treatment

• Open reduction and internal fixation (ORIF): Closed reduction fails if open reduction is needed, or the fracture is displaced. ORIF is the method of choice to anatomically restore the talar surfaces with screws and plates for fragment stabilisation
• Surgical approaches: Two approaches (anteromedial and anterolateral) are frequently employed to expose the talus for fixation. Osteotomy may be required at times to properly visualise and reduce the fracture
• External fixation: For those with excessive swelling or open fractures, a temporary external fixator can be applied to stabilise the ankle prior to final ORIF

Postoperative care and follow-up

• Immobilisation: After surgery, the ankle is immobilised, most often in a short leg cast, with non-weight bearing for 6 to 12 weeks based on fracture severity
• Long-term monitoring: Patients need long-term follow-up to observe for complications like avascular necrosis and post-traumatic arthritis. MRI is the optimal imaging test for AVN diagnosis
• Treatment of complications: Arthritis is frequent, particularly in Hawkins III or IV fractures, and can need arthrodesis (subtalar, tibiotalar, or triple arthrodesis) or talectomy with tibiocalcaneal fusion in the presence of talar dome collapse and persistent pain⁴

Complications

Avascular Necrosis (AVN): The blood supply to the talus is tenuous and can be compromised by fracture-dislocation, particularly in fractures of the talar neck. This results in bone death and collapse, leading to pain, loss of function, and arthritis. AVN is more common in neck fractures and open injuries, and may occur even with proper surgical intervention.

Post-Traumatic Osteoarthritis: Injury to the articular cartilage at the time of injury or due to bone collapse secondary to AVN can result in subtalar and ankle joint arthritis. This causes chronic pain, stiffness, and impairment of function. Rates of arthritis are higher following joint dislocation and in fractures of the neck or head.

Non-union and malunion: Fracture failure to unite can lead to chronic pain, deformity, and joint mechanical impairment. Non-union occurs more frequently with open fractures.

Infection: Surgical procedures and open fractures risk deep infection that hinders healing and may require further surgery.

Joint Stiffness and Chronic Instability: From injury and immobilisation, patients can suffer from restricted motion and instability at the ankle and hindfoot joints.

Secondary Surgeries: Secondary operations such as joint fusion (arthrodesis) or replacement of the ankle may be necessary because of AVN, arthritis, or infection.¹

Prognosis and functional outcomes

Recovery depends on the type of fracture, timing of reduction, and surgical accuracy.

Improvements: 3D printing for preoperative planning, biologics (BMPs) to augment healing, and minimally invasive procedures that minimise soft-tissue damage.

Early multidisciplinary treatment—integrating trauma surgery, imaging, and rehab—is critical to prevent complications and enhance functional results.

Summary

Displaced talar fractures continue to pose a therapeutic problem for orthopaedic surgeons. Talar body and neck fracture-dislocation in combination with an associated concomitant ankle fracture is a rare and catastrophic injury. These injuries typically result from high-energy trauma. Computed tomography is required, along with radiographs. Poor outcome resulting from osteoarthritis or osteonecrosis of the talus following dislocation from trauma correlates with the original injury due to vascular compromise following subtalar dislocation.

Therefore, treatment algorithm includes immediate reduction of any tibiotalar or subtalar dislocation followed by final fixation once soft tissue permits through dual medial and lateral approach with medial or lateral malleolar osteotomy depending on the specific fracture configuration. Attention to detail such as associated fractures (such as medial malleolus in our patient) is crucial. Good results can be achieved despite the potential high rate of complication.¹