Fracture-dislocations with skin tenting (within hours)
Irreducible dislocations
Neurovascular compromise
Reduction quality
Anatomic reduction is the single most important surgical goal
Nonanatomic reduction independently associated with higher secondary surgery
Malreduction > 2 mm coronal displacement worsens outcomes
Dual anterior approach superior to single approach
Better visualization of reduction
Reduces malreduction rates
AVN management after confirmed diagnosis
Protected weight-bearing
Prevents talar dome collapse while revascularization occurs
Serial MRI monitoring
Assess revascularization progress
Core decompression
Limited evidence; some surgeons use in early-stage AVN
Total ankle replacement or pantalar arthrodesis
For end-stage collapse with pain
Arthrodesis historically preferred but ankle replacement emerging
Evidence levels
ORIF for Hawkins II–IV: Class I recommendation (expert consensus, multiple cohort series)
Delayed versus emergent fixation: Class IIa based on retrospective evidence
Dual approach: ACEP Level C / expert consensus
Patient Discharge Instructions
copy discharge instructions
Talar neck fracture discharge instructions
Injury explanation
Fracture of the small bone (talus) at the top of your foot connecting to the ankle
Serious injury due to risk of bone losing its blood supply (avascular necrosis)
Your fracture has been assessed and you are being discharged with close follow-up
Weight-bearing instructions
Do NOT put any weight on your injured foot
Use crutches at all times when standing or walking
We have provided crutch walking instruction before discharge
Splint and cast care
Keep splint clean and dry
Do not place anything inside the splint
If splint feels too tight or too loose, return for reassessment
Elevate your foot above heart level as much as possible to reduce swelling
Apply ice wrapped in cloth to top of splint for 20 minutes every 2 hours
Pain medications
Take prescribed pain medication as directed
Do not take ibuprofen or other anti-inflammatory drugs without asking your doctor
Acetaminophen (Tylenol) is safe to take with or without prescription pain medicine
Follow-up appointment
Orthopedic surgery within 5–7 days (sooner if worsening)
You may need CT scan and possible surgery at that appointment
Do not miss this appointment — displacement of the fracture can occur
Return to emergency department immediately if
Increasing pain, numbness, or tingling in the foot or toes
Foot or toes turn pale, blue, or feel cold
Wound drainage, redness spreading from wound, or fever > 38.5 degrees C
Splint becomes too tight or you cannot move your toes
Sudden severe worsening of pain
Signs of blood clot in leg: calf pain, swelling, redness
Expected recovery timeline
Recovery is prolonged: most patients are non-weight-bearing for 3–6 months
Complications including arthritis and bone death are possible even with excellent care
Outcome depends on severity of initial injury
References
Guidelines and key sources
ACR Appropriateness Criteria: Acute Trauma to the Ankle
Smith SE, Chang EY, Ha AS, et al.
Journal of the American College of Radiology. 2020
CT usually appropriate for all suspected talar fractures
MRI appropriate for occult fracture when CT negative
Current Concepts in Talar Neck Fracture Management
Whitaker C, Turvey B, Illical EM.
Current Reviews in Musculoskeletal Medicine. 2018
PMID: 29974334
Talus Fractures: Evaluation and Treatment
Lee C, Brodke D, Perdue PW, Patel T.
Journal of the American Academy of Orthopaedic Surgeons. 2020
PMID: 33030854
Landmark studies
A New Look at the Hawkins Classification for Talar Neck Fractures
Vallier HA, Reichard SG, Boyd AJ, Moore TA.
Journal of Bone and Joint Surgery. 2014
PMID: 24500580
Displacement at injury — not timing of fixation — predicts AVN
Talar Neck Fractures: Results and Outcomes
Vallier HA, Nork SE, Barei DP, et al.
Journal of Bone and Joint Surgery. 2004
PMID: 15292407
Foundational outcomes data: AVN and posttraumatic arthritis rates
Outcomes of Talar Neck Fractures: A Systematic Review and Meta-Analysis
Dodd A, Lefaivre KA.
Journal of Orthopaedic Trauma. 2015
PMID: 25635362
Posttraumatic arthritis rate 81% at > 2 years follow-up
The Hawkins Sign of the Talus: Impact of Patient Factors
Griffin JT, Landy DC, Mechas CA, et al.
Journal of Bone and Joint Surgery. 2024
PMID: 38512980
Smoking reduces Hawkins sign reliability
Classification and imaging references
Talar Fractures and Dislocations: A Radiologist's Guide
Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB.
Radiographics. 2015
PMID: 25969933
Imaging-based guide to classification and diagnosis
Diagnostic Accuracy of Plain Radiographs Compared to CT Scans
Fereidooni R, Moein SA, Ayatizadeh SH, et al.
BMC Musculoskeletal Disorders. 2025
PMID: 41034813
Plain radiograph sensitivity approximately 77% vs CT near 100%
Rethinking Avascular Necrosis After Displaced Talus Fractures
Frazer A, Ndoja S, Grad V, et al.
Journal of Orthopaedic Trauma. 2026
PMID: 41589883
44% of AVN cases revascularize; 90% show < 25% collapse
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