Talar Dome Fracture

Summary

Talar dome injuries result from trauma to the ankle including ankle sprains (6-38% of all ankle sprains), fractures (greater than 70% of all ankle fractures). (1,2,3) Talar dome injuries create a focal defect in the dome of the talus that results in injury to the cartilage and underlying bone. Talar dome injuries are often missed on initial examination of a routine ankle sprain, only to be diagnosed weeks after the injury. Injuries to the talar dome are called talar dome lesions, osteochondral lesions (OLT's), transchondral fractures, osteochondral fractures, bone contusions, or osteochondral defects (OCD's.) Talar dome injuries occur equally in men and women.

Symptoms

• Deep ankle pain following an injury to the ankle.
• Pain increases with increased activity or time spent on the feet.
• Bruising is common at the time of initial injury.
• Chronic swelling and deep ankle pain continue well past the time of initial injury.
• Crepitus or catching of the ankle may be present.

Description

The human ankle is a complex, load-bearing joint that consists of just three bones. These three bones are the tibia, fibula, and talus. These three unique bones work in conjunction to provide the range of motion necessary to complete our daily activities such as walking, jumping, or running. Injuries of the ankle joint can be complex and debilitating. This article discusses injuries of the talar dome. The talar dome is the rounded portion on the top of the talus that articulates with the bones of the leg (tibia and fibula.)

Injuries of the talar dome were first discussed in the medical literature by Kappis in 1922.(4) In 1959, Berndt and Harty were the first to recognize the unique nature of these injuries.(5) They called these injuries transchondral fractures. What Berndt and Hardy described was a classification of fractures found immediately beneath the surface of the cartilage of the talar dome. Berndt and Hardy described four stages of transchondral fractures.

Berndt and Harty Classification of Talar Dome Fractures:

Stage I - Focal compression of the subchondral bone (bone beneath the cartilage)

Stage II - Focal compression of the subchondral bone with partial detachment of a fragment of cartilage

Stage III - Focal compression of the subchondral bone with a fully detached fragment of cartilage, still situated in place at the site of injury

Stage IV - Focal compression of the subchondral bone with a fully detached fragment of cartilage, detached from the site of injury and floating in the joint space. 

A newer method of classification of transchondral talar dome fractures which uses MRI as the basis of classification is called the Bristol classification. The Bristol classification was described by Hepple et.al. in 1999.(6)

The talus is designed to carry load evenly distributed over the entire surface of the talus, thus decreasing load in any one particular spot. The mechanism of injury of a talar dome fracture involves focused load in one specific spot of the talar dome. In an inversion sprain of the ankle, the typical position of the foot and ankle at the time of injury is with the foot inverted and the ankle slightly plantarflexed. As the talus rocks out of position during the sprain, the position of the foot and ankle places the posterior medial aspect of the talar dome in a position where focused load is applied by the tibia to the talus as the body weight pushes down, compressing the ankle and talar dome. This mechanism of injury accounts for the fact that the 56.3% of talar dome fractures are found on the posterior medial aspect of the talar dome.(5)  43.7% of remaining transchondral fractures of the talus occur in the middle third of the lateral talar dome.(5)

The term transchondral refers to an injury applied to the bone across the cartilage. "Across the cartilage" is actually a very accurate description of how transchondral fractures occur. As an analogy, think of the injury sustained by an apple when it falls from a tree. The skin of the apple appears normal, yet the underlying supporting structure of the flesh of the apple is damaged. This example is very similar to what happens in a transchondral talar dome fracture. As the force of an injury is applied to the cartilage, the subchondral bone collapses in a localized fracture. As a result, the surface of the ankle joint becomes irregular. Motion on this irregular surface creates pain and inflammation within the joint. In severe cases, such as stages III and IV, the injured fragment of bone and cartilage becomes detached, creating even greater irregularities in the surface of the joint.

In a talar dome fracture, the injury to the subchondral bone crushes the normal blood supply to the site of the injury. The term aseptic necrosis is used to describe this type of an injury to the bone. Aseptic (no infection) necrosis (death) of the talus is the single greatest influence that inhibits healing of talar dome fractures. It's interesting to note that the cartilage of the ankle derives most of its nourishment from the fluid in the ankle joint, called synovial fluid, and not from the same blood supply that supplies the damaged bone. This explains why the cartilage at the site of a talar dome fracture can remain viable as the bone beneath it fails to heal.

Causes and contributing factors

Talar dome fractures are directly related to ankle trauma.  Contributing factors may include ligamentous laxity and recurrent ankle sprains. Talar dome lesions do occur with no history of trauma. In these cases, lesions may be due to osteonecrosis, endocrine disorders or genetic factors. (8,9)

Differential diagnosis

The differential diagnosis of a talar dome lesion includes:

Ankle arthritis
Ankle fracture
High ankle sprain
Septic arthritis
Sinus tarsitis
Talar neck fracture
Soft tissue adhesion/defect within the ankle

Treatment

Initial treatment of talar dome fractures is often delayed due to the fact that the symptoms of a talar dome fracture are very similar to the symptoms of an ankle sprain.(9) The decision to treat talar dome fractures conservatively or surgically is based on the radiographic appearance, size, and location within the joint and the stage of injury. Stages I through IV may at some time require surgical correction based upon the response to conservative care.

Treatment of Talar Dome Fractures by Stage:

Stage I - Weight bearing/non-weight bearing casting, rest, physical therapy.

Stage I defects may respond to rest. Rest may include decreased activity, use of an ankle brace or use of a walking cast.  The size and location of the talar dome fracture plays a big role in the time that it takes to return to normal, pain free activity. Also, stage I lesions do not result in significant collapse of the talar dome or focal avascular necrosis. Therefore, the prognosis for stage I OCD's is very good. Once a Stage I lesion has fully healed, a residual flat spot, or defect may remain on the surface of the talus. If this defect results in chronic pain with activity, it may require surgical repair.  Healing of stage I OCD's may take up to 12 months.

Stage II - Arthroscopic debridement of the injury with subchondral drilling.

Stage II lesions rarely respond to rest and typically will require at least an arthroscopic procedure to repair the residual defect found in the surface of the talus. Arthroscopic procedures are performed through small 1/4 incisions to gain access to the ankle joint. Arthroscopy is used to debride, or grind away the damaged or collapsed bone and cartilage. In addition to arthroscopic debridement, subchondral drilling (also called microfracture) is used to stimulate blood flow to the injury site. Subchondral drilling is a surgical technique used to break through the thick subchondral bone (beneath the cartilage.) This can be accomplished with a drill or wire and completed through the same small incisions used for arthroscopic surgery. Medial dome lesions can be difficult to access through an anterior approach. Medial dome lesions can be accessed by drilling through the medial malleolus using a Micro Vector Drill Guide.

Arthroscopic debridement of the ankle (with or without drilling) is performed in a hospital or surgery center. Anesthesia is usually a general although a spinal block can be used. The procedure takes about 45 minutes to perform. Most patients are able to bear weight on the ankle the same day of surgery. Sutures will be in place for two weeks, during which time the patient will be allowed to return to many of their normal activities. The majority of healing following this procedure takes place within the first two months after surgery, although remodeling of the cartilage may take up to a year to complete.

Stage III - Arthroscopic debridement of the injury, subchondral drilling, and synovectomy of the joint.

Stage III lesions may respond to arthroscopic techniques and transchondral drilling. In many cases, the body of the talus may require bone grafting to insure proper healing. This type of grafting incorporates both donor bone and donor cartilage in a technique called an OAT's procedure (osteo-articular transfer procedure.) Osteochondral grafts are performed for two reasons: (a) restore the supporting surface of the joint and (b) replace damaged bone and cartilage that has failed to heal after a reasonable period of conservative care. Donor graft for an OAT's procedure can come from three different sources. (8) Autogenous osteochondral (bone and cartilage) can be harvested from non-weight bearing surfaces of the knee and transplanted into the sited of the talar fracture. (6) A number of companies manufacture synthetic graft material that can also be used including Nexa Orthopedics. (7) Fresh frozen osteo-chondral allografts may be used for OAT's procedures with success rates reported as high at 75% at 5 years post surgery and 63% at 14 years post surgery. An allograft is a graft taken from a human donor other than the recipient. Fresh means that the graft was harvested within 24 hours of the donor's death and the time from graft harvest to implantation is 7 days or less. Recent studies have shown that fresh allografts can be refrigerated prior to implantation for up to 44 days with chondrocyte viability of 67%. This time between harvest and implantation is important in that it allows the graft supplier adequate time to prepare, test, and sterilize the graft.

The method of treatment for stage III lesions varies, therefore it is difficult to determine normal healing times for repair of stage III lesions. In most cases, we can assume that the treatment for stage III lesion will be similar to stage II but the operative time and healing time will take a bit longer than that of a stage II lesion. Many cases will require a period of non-weight bearing in a hard cast below the knee.

Stage IV - Arthroscopic debridement with subchondral drilling and possible revision of the injured talus with a bone graft.

Stage IV lesions may respond to arthroscopic techniques but typically require open revision with curettage or OAT's grafting. Most lateral dome fractures can be reached with arthroscopic techniques since they tend to occur in the anterior lateral aspect of the ankle. Medial dome lesions, on the other hand, tend to occur in the posterior aspect of the ankle and are difficult to access with arthroscopy. To access the medial aspect of the ankle, the tibia often has to be broken and retracted to visualize the medial dome lesion.

The location of the transchondral fracture is important when determining the type of graft to be used in a stage III-IV lesion. Autogenous grafts taken from the knee can only be used in areas that are flat. Flat grafts are appropriate for the central dome, but most transchondral fractures of the talus occur on the shoulders of the talus. Since the shoulders are round, a rounded graft is needed to contour to the shape of the talus.

The following images show a trans-tibial approach for a stage 4 medial talar dome lesion with a free osteochondral graft taken from the great toe joint. Medial talar dome lesions are typically found in the central to posterior aspect of the talar dome and are therefore often inaccessible to arthroscopic procedures and techniques. Therefore, an osteotomy must be placed through the tibial to access the ankle. Image 1 shows access to the ankle through the tibia and site preparation of the talar dome. Due to hardening of the talar dome, a new fresh bone bed is stimulated by drilling the bone and placing synthetic bone dowels in the dome of the talus. Image 2 shows the graft donor site (under the text) and osteochondral graft ready for placement. Image three shows the graft in position and held in place by two small 1.5mm screws. Post-operative management for this case includes 6 weeks in a hard cast followed by 4 weeks in a walking cast.

Long-term follow-up of talar dome lesions shows that despite the type of treatment, many patients with talar dome transchondral fractures will continue to have ankle pain and swelling over the course of their lives. The prognosis for transchondral fractures depends in part upon the severity of the injury, the age and general health status at the time of injury, and whether the patient is a smoker. Grafting used in stage III and IV lesion is rarely successful in patients who are smokers. Both autogenous and allogenic grafts depend upon the ingrowth of new blood vessels. This process is called angiogenesis. Angiogenesis is significantly inhibited in smokers.

Revascularization of a talar dome fracture can be monitored over time with serial x-rays. The first radiographic indicator of vascular ingrowth in the site of a talar fracture is reactive hyperemia. Reactive hyperemia is aggressive vascular ingrowth that results in loss of bone stock. Loss of bone stock can be visualized as a focal, darkened area at the fracture site. This radiolucency is referred to as Hawkin's sign. Hawkin's sign suggests sufficient vascularity of the fracture to ensure healing of the talar dome.(10)

When to contact your doctor

Post-traumatic ankle pain that fails to respond to conservative care should be evaluated by your podiatrist or orthopedist.

References

1. Boisen WR, Staples OS, Russell SW. Residual disability following acute ankle sprains.  J bone Joint Surg Am  1955;37:1237-1243.
2. Leontaritis N, Hinojosa j, Panchbhavi VK, Arthroscopically detected intra-articular lesions associated with acute ankle fractures.  J bone Joint Surg Am 2009;91;333-339.
3. Takao m, Uchino Y, Naito K, Fukazawa I, Ochi M. Arthroscopic assessment for intra-articular disorders in residual ankle disability after sprain. Am J of Sports Med 2005;33:686-692.
4. Kappis M. Weitere beitrage zur traumatisch-mechaniischen entstehung der "spontanen" knorpela biosungen. Dtsch Z Chir 1922;171:13-29.
5. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus.  J Bone Joint Surg Am 41: 988-1020, 1959.
6. Hepple S, Winston I, Lew D.  Osteochondral lesions of the talus: a revised classification.  Foot Ankle Int 20:789-793, 1999.
7. Seil R, Kohn D.  Osteochondral lesions of the talus - a rarity?  Orthopade 30:1-2, 2001.
8. Schachter AK, Chen AL, Reddy PD, Tejwani NC.  Osteochondral lesions of the talus.  J Am Acad Orthop Surg 13:152-158, 2005.
9. Barnes CJ, Ferkel RD Arthroscopic debridement and drilling of osteochondral lesions of the talus.  Foot Ankle Clin 8:243-257, 2003.
10. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970;52 (5): 991-1002. J Bone Joint Surg Am 

Author(s) and date

This article was written by Myfootshop.com medical advisor Jeffrey A. Oster, DPM.  

Competing Interests - None

Cite this article as: Oster, Jeffrey. Talar Dome Fracture.  https://www.myfootshop.com/article/talar-dome-fracture

Most recent article update: January 15, 2021.
 

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