Talar neck fracture

Last revised by Joshua Yap on 28 Feb 2023

Talar neck fractures extend through the thinnest cross-sectional portion of the talus, just proximal to the talar head. They represent one of the most common types of talus fracture (~30-50%), along with chip and avulsion fractures of the talus (~40-49%). These fractures are commonly associated with subtalar dislocation and/or posterior body fractures 4.

These fractures usually result from forced hyperdorsiflexion of the ankle with associated axial loading. There may be a rotational component with hindfoot supination and impact on the medial malleolus 6. They are usually a result of high-energy mechanisms. There is a 20-38% incidence of open injuries and 50% incidence of other associated injuries 6.

  • Canale view: 15° internal rotation, with 15° tube angle from vertical (similar tube angle to an AP foot) better demonstrates the fracture 5

  • useful adjunct to plain radiograph to identify subtle incongruities and assist with pre-operative planning

  • undisplaced type I fractures may potentially be misclassified and the majority of talar neck fractures are not able to be classified according to the Hawkins classification 6

  • the majority of apparent isolated talar neck fractures are actually talar body fractures with extension into the neck 6

Hawkins classification 1:

  • type I: undisplaced fracture

  • type II: displaced fracture with subluxation or dislocation of the subtalar joint and a normal ankle joint

  • type III: displaced fracture with the body of talus dislocated from both subtalar and ankle joint

Canale and Kelly 2 described a rare type IV category which in addition to features described for type III there is dislocation or subluxation of the head of the talus at the talonavicular joint.

  • type I fractures: short leg cast or boot for 8 to 12 weeks, non-weight bearing for at least 6 weeks

  • type II-IV fractures:

    • initial management

      • urgent closed reduction in the emergency department with CT to confirm the position and assist with pre-operative planning 6

    • definitive management

  • hardware complications

    • loosening

    • backing out

    • hardware or peri-hardware fracture

    • infection

  • tendon entrapment or injury

  • risk of osteonecrosis increases with increasing classification type

    • type I fractures have a 0-15% risk

    • type II fractures have a 20-50% risk

    • type III fractures approach a 100% risk

    • type IV fractures have a 100% risk

  • post-traumatic arthritis 6

    • subtalar (50%)

    • tibiotalar (33%)

  • mal-union 6

    • varus mal-union (25-30%)

The classification of talar neck fractures was described by Dr Leland G Hawkins in 1970 1.

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Cases and figures

  • Figure 1: type 1
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  • Figure 2: type 2
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  • Figure 3: type 3
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  • Figure 4: type 4
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  • Case 1: type 1
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  • Case 2: type 3
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  • Case 3: type 1
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