Case Report

By Dr. Aditya Mootha , Dr. Vishal Kumar , Dr. Kamal Bali , Dr. Saravdeep Dhatt , Dr. Sameer Aggarwal
Corresponding Author Dr. Aditya Mootha
Orthopaedics, PGIMER , K-154:MDH:PGIMER,Chandigarh - India 160012
Submitting Author Dr. Vishal Kumar
Other Authors Dr. Vishal Kumar
Orthopaedics, PGIMER , k-158,MDH,PGIMER,chandigarh - India 160012

Dr. Kamal Bali
Orthopaedics, PGIMER, Deptt.of Orthopaedics,PGIMER,Chandigarh - India 160012

Dr. Saravdeep Dhatt
Orthopaedics, PGIMER , Deptt.of Orthopaedics,PGIMER,Chandigarh - India 160012

Dr. Sameer Aggarwal
Orthopaedics, PGIMER, Deptt.of Orthopaedics,PGIMER,Chandigarh - India 160012


Combined,Talar Body,Medial Malleolus

Mootha A, Kumar V, Bali K, Dhatt S, Aggarwal S. Combined Talar Body And Medial Malleolus Fracture: A Case Report. WebmedCentral ORTHOPAEDICS 2010;1(10):WMC00952
doi: 10.9754/journal.wmc.2010.00952
Submitted on: 10 Oct 2010 07:35:41 PM GMT
Published on: 12 Oct 2010 03:34:31 PM GMT


The combination of ipsilateral talar body and medial malleolus fracture is rare to occur.Radiographs and Computed tomograms are main diagnostic aids.With initial conservative management till swelling subsides,open reduction and adequate internal fixation followed by supervised aggressive physiotherapy gives good functional outcome as in this case.


Fracture of talus are uncommon,and include spectrum of injuries that vary in severity(1).Fracture of body of talus occur much less commonly than fracture of the neck of talus ,with only infrequent reports in the literature. These injuries are commonly associated with significant soft-tissue injuries and frequently result in osteoarthritis of ankle and subtalar joint.Similarly ,fracture of medial mallelous also result in post-traumatic osteoarthritis and ankle instability(2).The particular combination of talar body and medial mallelous fracture that occurred in this case has rarely been documented previously.

Case Report(s)

A 48-year old male sustained an inversion injury to his left ankle after slipping from a motorbike in a roadside accident. After accident he was unable to walk and was taken to our emergency department. His physical examination revealed a grossly swollen left ankle and foot which was painful to any attempts at manipulation. There was no open wounds and the neurovascular status was completely intact.

Plain radiograph of the left ankle showed a displaced sagittal fracture of talar body and medial mallelous fracture(Figure 1). The main fracture line of the talus appeared to be oriented in the saggital plane. CT scan of the hindfoot and ankle further defined the fracture planes(Figure 2).

After 7days of bed rest, icepacks, and elevation the patient was taken to operating room where open reduction and internal fixation of both the fractures was done. The poseromedial incision was J-shaped incision at posterior border of the distal tibia , curving below the medial mallelous. The posterior neurovascular bundle was identified and protected by gentle retraction using a rubber sling. The medial malleolar fracture was identified and reflected distally, thus acting as medial malleolar osteotomy for exposure of ankle joint.

Upon arthrotomy,there was postermedial quadrant fracture of the talar body with displacement of 3mm.In addition ,there  was small area of communition of the central talar dome.Multiple small bony fragments were found in the ankle joint,which was then thoroughly irrigated.The postero-medial quadrant fragment was then reduced and secured with 4mm partially threaded cannulated screws.The use of screw with a low profile head was buried to prevent any further impingement.The stability of construct was assessed and found to be satisfactory,requiring no further fixation.

The medial malleollar fracture was reduced anatomically and secured with two lag screws(Figure 3).The ankle joint was stable after fixation and dynamic screening confirmed full ankle range of movements.The wound was closed in layers and the patient was mobilised  nonweight-bearing postoperatively,with ankle immobilised in a below knee cast.After 6 weeks,the cast was removed and patient was referred for physiotherapy,with gradual initation of weightbearing.At 3months follow up,ankle dorsiflexion was 20 degrees and planterflexion was 25 degrees.There was 5-10 degrees eversion and inversion of the subtalarjoint. X-ray of ankle at this stage was stasisfactory with no evidence of non-union or avascular necrosis of the talar body.


Fracture of the talus are rare constituting 3-6% of all foot fracture and talar body fracture compromise 13-23% of talus fractures(4).Thus, fractures of the talar body only represent less than 1% of all fractures(5).Up to 1% of ankle fractures have a simultaneous fracture of the talus.

Talar fractures are potentially devastating injuries due to their inherent risk of long term disability from ankle osteoarthritis and osteonecrosis(7).The rate of osteonecrosis of the talar body is related to the soft tissue disruption of the tibio-talar joint, energy of injury and vascular damage(8).With comminuted talar fractures,osteonecrosis rates of 75% have been reported.

Sneppen et al classified fractures of the talar body in the following manner, according to rate of occurence(9):

1.Compression fractures.
2.Coronary shearing fractures.
3.Saggital shearing fractures.
4.Fractures of the posterior tubercle.
5.Fracture of the lateral tubercle.
6.Crush fractures.

They defined fractures in the saggital plane which occurred as a result of shearing force, as saggital shearing fracture, but they did not report the rate of occurence of this fracture independently(10).Thus we are reporting a case report of combination of fracture of talar body with medial mallelous,an uncommon presentation.


Talar fractures are uncommon and talar body fractures are rarer still.Complications abound in such injury and make it challenging to treat displaced intraarticular injuries.Open reduction and internal fixation in appropriately selected patient can be performed safely with hope of reducing complication/s.Adequate visualisation and preservation of a fragile blood supply necessitate medial malleolar osteotomy.Succesful surgical reconstruction can produce a pain free mobile patient with good range of movement.


1.Hawkins LG. Fractures of neck of talus.J Bone Joint Surg Am 1965;47(6):1170-5.
2.Haliburton R,Sullivan R,Kelly P.The extraosseous and intraosseous blood supply of the talus.J Bone Joint Surg Am 1958;40:1115.
3.Mindel E,Cieske E, Kartalian G,et al.Late result of the injuries of the talus.J Bone Joint Surg Am 1963;45:221-45.
4.Pearse MF,Fowler JL,Bracey DJ.Fracture of the body of talus.Injury1991;22:155-6.
5.Heckman,J.Fractures in Adult,4th ed.,vol.2,pp.2308-2310,Lippincott-Raven,Philadelphia,1996.
6.Niazzi,T.B.M.,Joshi,R.P.,Jonshon,P.G.Associated soft tissue injury of fracture of the body of talus.Injury23(4):280-81,1992.
7.Taubar,C.,Nof,M.,Malkin,C.The inverted Y approach to talus and ankle joint.Injury 16(1):53-54,1984.
8.Mckeever,F.M.Treatment of complication of fractures and dislocation of the talus.Clin.Orthop.30:45-52,1963.
9.Mindell,e.r.,Gisek,E.,Kartlian,G.,Dziob,J.M.Late results of injuries of talus.J.Bone Joint Surg.45-A:221-245,1963.
10.Thorderson DB.Talar body fractures.Ortho clinics North Am2001;32:65-77.

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