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Hawkins Type III Talar Fractures

- See: Avascular Necrosis and Salvage of Talus Fractures

- Discussion:
    - displaced frx of talar neck with dislocation of body of talus from both subtalar joint and ankle joint;
    - when body dislocates, it is usually found on posterior medial aspect adjacent to the Achilles tendon;
    - body fragment rotates around intact deltoid ligament fibers to lie in soft tissues w/ frx surface pointing laterally and cephalad;
    - in this location, there can be compression of the neurovascular structures, and care must be taken when approaching by open
           means dislocated body of talus;
    - talocalcaneal ligament is ruptured when there is dorsal displacement of the distal fragment;
           - after rupture of this ligament, it is difficult to control distal talar neck fracture by closed means;

- Radiographic Evaluation:  Hawkins Sign

- Treatment:
   - surgical approaches:
       - usually there is posteromedial displacement with the deltoid ligament intact (which means that the deltoid brach artery
              is left intact)
   - medial malleolar osteotomy;
       - associated frxs of medial malleolus facilitates reduction because malleolus & attached deltoid ligament can be retracted distally,
               & ankle mortise can be opened to allow reduction of talus;
       - frequently deep fibers of deltoid lig remain attached to talar body;
               - these fibers is not be released surgically because they may carry only remaining arterial supply to the body;
               - it is preferable to osteotomize the medial malleolus and reflect it distally to facilitate reduction  rather than cutting
                         intact deltoid ligament;
       - references:
               - Reduction of irreducible Hawkins III talar neck fracture by means of a medial malleolar osteotomy: a report of three cases with a 4-year mean follow-up.  
               - Open Reduction for AO/OTA 81-B3 (Hawkins 3) Talar Neck Fractures: The Natural Delivery Method.

       - technique:
               - anterior capsule at medial axilla is exposed;
               - posterior tibial tendon sheath is incised posteriorly, exposing the posterior tibial tendon (retract the tendon posteriorly);
               - drill two holes into the medial malleolus inorder to accomodate post osteotomy screw placement;
               - care is taken to avoid trauma to the deltoid ligament;
               - 1 cm proximal to the joint line, a saggital saw is used to make a transverse cut thru the tibial cortex, parallel to the plafond;
               - this cut extends to the level of the axilla;
               - osteotome is then used to complete the ostetomy (from the axilla to the transverse cut), in an anterior to posterior direction;
   - reduction:
        - facilitated, w/ insertion of calcaneal traction pin;
        - inorder to reduce talar body into the mortise, foot is dorsiflexed w/ heel translated anteriorly;
        - the foot is then everted, and talar body translated medially, and finally is plantar flexed;
        - ref: Open Reduction for AO/OTA 81-B3 (Hawkins 3) Talar Neck Fractures: The Natural Delivery Method.
   - fixation:
        - retrograde K wires are placed through frx & out posterior lateral aspect;
        - cannulated screws are used through posterior-lateral aspect using wires;
        - ref: Treatment of Comminuted Talar Neck Fractures with Use of Minifragment Plating.

- Complications:
    - vast majority of these patients will have a poor result (infection, AVN, DJD);
    - avascular necrosis and salvage of talus fractures
            - AVN: may occur in up to 90 % of patients