Surgical Science, 2013, 4, 405-409
http://dx.doi.org/10.4236/ss.2013.49079 Published Online September 2013 (http://www.scirp.org/journal/ss)
Fracture Bilateral Talus in Children
Vinit Verma, Amit Batra, Pradeep Kamboj, Suresh Bhuriya, Raj Singh,
Sumit Kumar, Rakesh Gupta, Narender Kumar Magu
Pt. B. D. Sharma PGIMS Rohtak, Rohtak, India
Received March 10, 2013; revised April 12, 2013; accepted April 19, 2013
Copyright © 2013 Vinit Verma et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Talar body injuries are rare, particularly in children. To our knowledge, there has not been a single case report of bilat-
eral talus fracture in a child till date. We report two cases of fracture bilateral talus in children. The first case is of a
fracture separation of the distal tibial epiphysis and a fracture of the body of the talus with subluxation of ankle on right
side and a fracture neck of talus on left side. The second is fracture bilateral talus with epiphyseal injury of left distal
tibia. A minimal or undisplaced fracture of talus is less likely to undergo avascular necrosis than a displaced fracture but
even with optimal treatment, avascular necrosis may still occur. It is of prime significance that these fractures should be
diagnosed well in time to avert complications. Therefore an appro priate length of follow-up is required.
Keywords: Paediatric Talus Fracture; Bilateral; Avascular Necrosis
1. Introduction
In childhood and adolescence talar fractures constitute
one third of all tarsal fractures. In pediatric patients, talar
fractures are rare and account for only about 0.08% of all
pediatric fractures [1]. Fracture of the talus is through the
neck in about half of all cases. The usual mechanism of
this fracture is sudden dorsiflexion on a partially plantar
flexed foot that occurs due to a fall from height [2].
Skeletally immature bone is much less brittle than its
adult counterpart and as a result it can sustain higher
forces before fracture occurs. The talus is predominantly
made up of cartilage, giving it much greater resilience
than that of the ad ult explaining the rarity of this fracture
in children [3]. Most of the fractures will be in the neck
of the talus, as in th e skeletally mature patients, although
they are proportionally far fewer [4 ]. Posttraumatic com-
plications after pediatric talus fractures have reportedly
occurred more frequently after a high-energy trauma or a
displaced fracture. Avascular necrosis, arthrosis, nonun-
ion, delayed union, neurapraxia, infection and wound-
healing problems account for most of the complications
[5]. Talus fractures occur more commonly and with a
greater severity in older children. The older the patient is,
the more chances are, which shall require operative
management. There is significantly less risk of osteone-
crosis in younger age patients than in their old age coun-
terparts. The outcome is more favourable in most of
younger patients irrespective of the mode of treatment.
Although there is no apparent difference in the cause of
the trauma leading to fractures of the talus, adolescents
present with more severe fractures of the talus compared
with younger children [6]. The problem with paediatric
displaced talar fractures is not only incongruity of subta-
lar joint, but also shortening of medial column of foot
which results in hindfoot varus, forefoot adduction and
supination. This leads to an imbalance between the per-
oneal and flexor muscles [7].
We have reported two cases of fracture bilateral talus
in children. The first one is a rare combination of a frac-
ture separation of the distal tibial ep iphysis and a fracture
of the body of the talus with subluxation of ankle on right
side and a fracture neck of talus on left side. The second
is fracture bilateral talus with epiphyseal injury of left
distal tibia.
2. Case Report
A 9 years old boy presented at night to the emergency
department, with history of fall from a height of ap-
proximately 10 feet from roof of his home. He complain-
ed of intense pain in both ankles with swelling around
both ankles. Radiographs of both ankles revealed a frac-
ture of talar body with salter-Harris type IV epiphyseal
separation on right side (Figures 1(a) and (b)) and frac-
ture of the neck of talus on the left side with fracture tibia
(Figures 2(a) and (b)). He was immediately given plaster
of Paris back slab in neutral flexion at ankle joints with
C
opyright © 2013 SciRes. SS

V. VERMA ET AL.
406
(a)
(b)
Figure 1. (a), (b) Fracture dislocation of right ankle with
fracture of talus in case No. 1 (A-P and lateral views).
(a)
(b)
Figure 2. (a), (b) Fracture of talus and fracture of shaft of
tibia (left) in case No. 1 (A-P and lateral views).

V. VERMA ET AL. 407
elevation of the injured limbs and judicious ice packing.
The patient was investigated and was planned for surgery
on both the sides. The epiphyseal injury of distal tibia
(right side) was reduced and fixed with k wires. Fracture
of talus on right side was fixed with a lag screw and a k
wire and supplemented by pop splint. On left side the
talus fracture was fixed with two k wires and above knee
pop cast for fracture tibia after closed reduction (Figures
3(a) and (b)).
He was kept in plaster for 8 weeks during which time
he was not allowed to bear weight and had regular follow
ups with radiographs at our fracture clinic. He was then
taken out of plaster and physiotherapy was commenced.
The patient was kept non-weight bearing for a further 2
weeks, before being allowed to weight bear. At 4 months
follow-up he had no functional problems on the right side,
and at his latest review 26 months post injury he practi-
cally had no problem to weight bear and had regular
checkups with radiographs in our fracture clinic (Figures
4(a)-(c)).
(a)
(b)
Figure 3. (a), (b) Post-operative films of right and left sides
in case No. 1.
(a)
(b)
(c)
Figure 4. (a)-(c) Radiographs at final follow up. The im-
plant has been removed and sound radiological union can
be appreciated (case No. 1).

V. VERMA ET AL.
408
Case 2
A 7 years old boy was admitted to casualty department
with pain, swelling and inability to bear weight on both
lower limbs after a road side accident. The child and his
father were travelling in a bus on a seat above the rear
wheels. The floor of the bus had a bump corresponding
to the rear tyres of bus, on which both of them kept their
feet (Figure 5). Suddenly, the bus driver applied the
brakes to save a pedestrian. As the bus came to a sudden
halt, the child’s and his father’s feet pressed violently
against the bump in the floor of bus. The child com-
plained of severe pain and inability to walk after that and
was taken to hospital. The radiographs showed bilateral
talus fracture with associated epiphyseal injury on left
ankle. The ch ild was subsequen tly operated upon on both
sides with lag screws and k wire and a lag screw and a k
wire for left sided epiphyseal injury (Figure 6).
His father also complained pain and swelling in foot
and ankle region and was diagnosed to have lisfranc’s
fracture dislocation which also had to be operated. The
child was kept non weight bearing and splinted for 2
months after which he was ambulated. At last follow up
of 52 weeks, uneventful union had been achieved with
full weight bearing (Figures 7(a) and (b)).
3. Discussion
Fractures of the body of the talus in the immature skele-
ton are rarely encountered [8]. Less common is the sce-
nario where there is a talus fracture that is associated
with an ankl e fracture and dislocation in children. To our
knowledge, there has not been a single case report of
bilateral talus fracture in a child till date.
Talar fractures in children are rare because the talus is
predominantly cartilageno us, making it much more resil-
ient than that of the adult [3,4]. The authors have found
only few reports of talar body fr acture in children. Cases
Figure 5. The pictorial representation of the mechanism of
fracture in this series. The rear passenger with his feet on
hump on the rear wheel of a bus suffers sudden dorsiflexion
force when bus comes to a sudden stop resulting in the
aforesaid fracture.
Figure 6. Post operative radiograph of case No. 2.
(a)
(b)
Figure 7. (a) and (b) Follow up at 2 months and 6 months
respectively (case No. 2).
involving the talar body which were undisplaced have
been managed conservatively in the past with excellent
outcomes [9]. The concern with talar fractures in any age
group is that of avascular necrosis and consequent os-

V. VERMA ET AL.
409
teoarthritis. In displaced fractures of the talar body, the
risk of avascular necrosis has been reported to be about
27% [10]. The published results of fractures after fixation
reveal high incidence of both early and late complica-
tions, with osteonecrosis occuring in ten out of 26 cases
and full talar body collapse in five out of those ten cases
[11].
A major difficulty in management of these patients
remains the diagnosis. Forty-seven percent of patients
with chronic instability of ankle show evidence of previ-
ous talar osteochondral fracture on magnetic resonance
imaging, which had not been previously diagnosed [12].
Therefore it is likely that a significant number of talar
injuries may go undiagnosed. The clinical signs are vari-
able but can include localised tenderness at the site of
fracture, which can be associated with a decreased range
of motion, and in more severe cases effusion and crepitus
[2]. However it is important to note that there may be
little or even no signs. If there is any dou bt at the time of
presentation as to wh ether there is a talar fracture further
imaging is recommended. In case of late recognition of
talus fractures, catastrophic results may occur in the
hind-foot [13,14]. Hence it is prime that these fractures
be diagnosed well in time to avert such complications.
Following such intra-articular injuries of ankle joint,
good anatomical reduction with osteosynthesis when
appropriate are mandatory even in an immature skeleton,
in order to achieve a good result. Preservation of blood
supply is paramount. Removal of metal work is recom-
mended after there is evidence of healing [1]. Patient
should be mobilised early without weight bearing and
should remain non-weight bearing until there is evidence
of sound radiological union. It is now worthwhile to
suggest that looking at the mode of injury in this series
our public transport buses should be modified accord-
ingly or manufacturers should refrain from keeping the
seat near rear wheels just after the bump. It is suggested
that it should either be just below the seat or the area
should be free of seating to avoid similar injuries.
4. Conclusion
Talar body injuries are uncommon, particularly in chil-
dren. There exist significant differences in outcomes and
complications in adult and children. These injuries can be
difficult to be diagnosed and a CT scan or magnetic reso-
nance imaging may be required. If already diagnosed, a
CT scan is advised to clarify the nature of injury. A
minimal or undisplaced fracture of talus is less likely to
undergo avascular necrosis than a displaced fracture but
even with optimal treatment, avascular necrosis may still
occur. Therefore an appropriate length of follow-up is
advisable. The authors advocate use of non-operative
management in cases where the fracture is minimally
displaced or undisplaced and in cases where there is a
displacement, patient should undergo anatomical reduc-
tion and internal fix a tion.
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