What is the diagnosis?

Hawkins 2 talar neck fracture

Image 2. Imaging series of the ankle with annotations showing comminuted and displaced talar fracture. Author’s own images and annotations. 

• Pearl: Hawkins Classification used for Talus neck fractures 

Image 3. Images courtesy of ALiEM by Mary Haas, MD

• Type I: Talar neck fracture [1]. One out of three blood vessels to the talus is affected, and there have been no reported cases of post-injury avascular necrosis [2]. 

• Type II: Talar neck fracture with subtalar dislocation [1]. Two out of three talus vessels are affected, with 42% post-injury avascular necrosis [2]. 

• Type III: Talar neck fracture with subtalar and tibiotalar dislocation [1]. Three out of three talus vessels are affected, with 91% post-injury avascular necrosis [2]. 

• Type IV: Talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation [1]. Classification added on with 13 year follow-up revealed 52% post-injury avascular necrosis [3]. 

The higher the Hawkins type, the higher the risk for avascular necrosis 

What is the mechanism of injury?

High energy impact (typically a motor vehicle accident or fall from height). 

• Pearl: Recent reports have shown that minor injuries such as sprains and slips during sports activities, particularly in the lateral or posterior process, can cause a talar fracture [4].

What physical exam findings are expected?

On examination, the patient will have hindfoot pain, swelling, and ecchymosis [5].

Which imaging modalities can be used?

Initial imaging with plain radiographs of the ankle, anteroposterior, lateral, oblique, lateral, and axial views.

• Pearl: Canale view on plain films better visualizes the talar neck fracture. It is described as angling the x-ray beam 75° from the horizontal axis and positioning the foot in maximum plantar flexion with different degrees of eversion, usually around 15° [6].

CT scans are used to assess for more talar neck subtleties. The imaging can assess for  fractures and associated pathology that can be missed on radiographs [7]. 

• Pearl: sometimes helpful to get 3-D CT reconstructions to view spatial patterns of the fracture and associated subluxation or dislocation [7]. 

What is the management in the ED?

Urgent reduction of displaced fractures and dislocations. 

• Pearl: Reduction to protect the soft tissue envelope and neurovascular structures [7]. 

When do you consult Orthopedics?

Emergent Orthopedics consultation is needed for open reduction and internal fixation for displaced talar neck fractures [5].