A 55-year-old male patient presents to the emergency department after an injury to his right foot while stopping during a motor-vehicle collision. The patient is unable to ambulate due to severe right foot and ankle pain. Radiographs demonstrate a type III talar neck fracture with a simple fracture line on the medial talar neck and a comminuted shortened fracture of the lateral talar neck. Which of the following is the most structurally sound fixation strategy?
-
- Single medial approach and plate fixation of the medial talar neck followed by closed reduction and lateral lag screw placement A single approach to the talus is associated with an increased likelihood of malreduction due to inadequate visualization of the area with the highest level of comminution.
-
- Closed reduction and percutaneous posterior-to-anterior lag screw fixation Anatomic reduction is paramount to prevent failure of fixation and an avascular screw. Given the comminution of the lateral talar neck, this may lead to shortening of the lateral column and malreduction of the fracture.
-
- Single lateral approach with closed reduction and percutaneous screw fixation A single lateral approach may allow for visualization of the comminuted segment of the fracture, but it prevents full visualization and confirmation of anatomic reduction of the fracture.
-
- Dual incision approach, lag screw placement for the single medial neck fracture, and lateral plate fixation for the comminuted lateral neck fracture The quality of reduction is one of the most important influences on long-term outcome with talar neck fractures. A dual approach should be used to avoid malreduction. Screw fixation for a comminuted talar neck fracture may be associated with shortening and malreduction of these injuries. Plate fixation is associated with a low rate of hardware failure or loss of reduction.
-
