Talar Neck Fracture
Classification systems
- AO/OTA grouping for the talus
- Descriptive by displacement, comminution and associated dislocations
Mechanism
Forced hyperdorsiflexion of the foot drives the talar neck against the anterior tibial margin — historically the aviator's astragalus, now most often a road traffic collision or a fall from height. The talus has no muscular attachments and much of its surface is articular, so its blood supply enters over a limited area and displacement progressively strips it, which is why the osteonecrosis risk rises with the Hawkins grade.
Age considerations
- Paediatric
- Rare; the thicker periosteum and better vascularity give a lower osteonecrosis rate, but the principles of urgent anatomical reduction still apply, and growth disturbance is an added concern.
- Young adult
- The typical high-energy patient. Urgent reduction of any dislocation, careful assessment of the soft tissues, and definitive anatomical fixation through a dual approach are the standard of care.
- Elderly
- Uncommon; poor bone and comorbidity may shift the plan towards primary fusion in a comminuted unreconstructable talus rather than fixation with a predictable failure.
Management options
Urgent reduction of dislocationshowhide
Indication
Every Hawkins II, III or IV injury — the dislocated talus threatens the skin and further devascularises the body.
Implant design notes
No definitive implant at this stage; a spanning external fixator or a well-padded splint holds the reduction until definitive surgery.
Approach
Closed reduction under adequate anaesthesia and muscle relaxation; open reduction without delay if closed attempts fail.
Steps overview
- Recognise the dislocation and treat it as an emergency — document skin and neurovascular status
- Under general anaesthesia with relaxation, apply traction with the knee flexed to relax the gastrocnemius
- Reduce the subtalar and tibiotalar relationships with directed manoeuvres
- If closed reduction fails, proceed to open reduction immediately rather than repeating forceful attempts
- Hold with a splint or spanning frame and elevate
- Obtain cross-sectional imaging and plan definitive fixation once the soft tissues allow
Notes
Delay in reducing a dislocated talus risks skin necrosis and worsens the vascular insult. This is the part of the answer that must come first.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Open reduction and internal fixation via dual approachshowhide
Indication
All displaced talar neck fractures once the soft tissues permit definitive surgery.
Implant design notes
Small or mini-fragment screws, or a mini-plate on the medial or lateral neck where there is comminution. A plate prevents the varus collapse that lag screws alone cause across a comminuted medial neck. Screws should be countersunk and avoid the articular surfaces.
Approach
Combined anteromedial and anterolateral approaches — both are needed, because a single approach cannot judge rotation and varus of the neck. Protect the anterior tibial and extensor tendons medially and the superficial peroneal nerve laterally, and avoid stripping the deltoid ligament vessels.
Steps overview
- Time surgery to the soft tissue envelope; keep the limb elevated meanwhile
- Supine positioning with a bump and a radiolucent table
- Make anteromedial and anterolateral incisions with an adequate skin bridge
- Expose the neck from both sides, preserving the deltoid ligament and its blood supply
- Reduce anatomically, correcting varus and rotation with both approaches visualising the reduction
- Fix with countersunk screws from anterior to posterior, or apply a mini-plate for comminution
- Address associated medial malleolar or body fractures and confirm subtalar congruity
- Close carefully, splint, and keep non-weight bearing while monitoring for osteonecrosis
Notes
Varus malunion of the neck is the commonest reconstructive failure and causes a stiff supinated foot. Watch for the Hawkins sign — subchondral lucency in the talar dome at six to eight weeks indicating preserved vascularity.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Name the blood supply: the artery of the tarsal canal from the posterior tibial artery, the deltoid branches, and the artery of the tarsal sinus — and explain that displacement strips them progressively.
- The Hawkins grade correlates with osteonecrosis risk because each grade represents more vascular stripping.
- The Hawkins sign — subchondral lucency in the dome at six to eight weeks — is a good prognostic indicator of preserved vascularity, and its absence is not proof of necrosis.
- Use two approaches; a single medial approach cannot judge varus and rotation of the neck.
- Preserve the deltoid ligament — its branches may be the only remaining supply to the body.
- A dislocated talus is an emergency reduction, not a next-morning problem.
Sources for further reading
- Rockwood and Green's Fractures in Adults — talus
- Standard operative orthopaedics textbook — fractures of the talus
- Regional anatomy text — blood supply of the talus
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.