01Approach to the Critical Patient/attcp50

Immediate priorities

›Orthopedic emergency triggers

›Open talar neck fracture

›Emergent orthopedic consultation

›IV antibiotics within 1 hour (cefazolin 2g IV)

›Tetanus prophylaxis

›Fracture-dislocation with skin tenting

›Urgent closed reduction to protect soft tissue envelope

›Procedural sedation preparation

›Skin necrosis risk if reduction delayed

›Neurovascular compromise

›Absent or asymmetric dorsalis pedis pulse

›Absent or asymmetric posterior tibial pulse

›Vascular surgery consultation if occlusion confirmed

›Polytrauma assessment

›High-energy mechanism recognition

›Motor vehicle accident (46% of cases)

›Fall from height (43% of cases)

›Motorcycle crash pattern

›Associated injury screen

›Spine fracture (axial load transmission)

›Calcaneal fracture (Don Juan pattern)

›Pelvis and contralateral lower extremity

›If hemodynamically unstable, prioritize ATLS primary survey before orthopedic management

Monitoring and stabilization

›Limb monitoring priorities

›Serial neurovascular checks every 30–60 minutes

›Dorsalis pedis and posterior tibial pulse quality

02History/hx43

Mechanism of injury

›Primary mechanism patterns

›Forced dorsiflexion (historically "aviator's astragalus")

›Foot strikes rudder pedal during aircraft crash

›Dashboard impact in MVC

›High-energy axial loading

›Fall from height with heel strike

›Motorcycle crash

›Pronation-dorsiflexion combined force

›Produces talonavicular disruption in Hawkins IV

›Mechanism details

›Height of fall or speed of impact

›Position of foot at time of impact

›Use of safety restraints or protective equipment

›Ejection from vehicle

Presenting symptoms

›Acute symptoms

›Immediate inability to bear weight

›Hallmark of significant talar injury

›Severe hindfoot and ankle pain

›Sinus tarsi tenderness

›Medial ankle pain

›Rapid swelling and ecchymosis

›Medial and lateral periarticular swelling

›Gross deformity

›Medial prominence (talar body dislocation)

›Posterior prominence (tibiotalar dislocation)

›Functional context

03Physical Exam/exam60

Vital signs and general assessment

›Hemodynamic stability

›Blood pressure and heart rate

›Instability suggests polytrauma hemorrhage

›Tachycardia from pain or blood loss

›Respiratory rate and oxygen saturation

›Baseline for procedural sedation planning

›General appearance

›Level of distress and pain

›Signs of significant mechanism (road rash, facial trauma)

Lower extremity examination

›Inspection

›Gross deformity of hindfoot and ankle

›Medial prominence (talar body displaced medially in Hawkins III)

›Posterior prominence (posterior talar body dislocation)

›Swelling distribution

›Periarticular and diffuse hindfoot edema

›Rapid onset suggesting high-energy injury

›Soft tissue integrity

›Open wounds (30% of talar neck fractures are open)

›Skin tenting (risk of full-thickness necrosis)

›Fracture blisters (delay surgery until resolved)

›Ecchymosis

›Sinus tarsi ecchymosis

›Medial and plantar ecchymosis

›Palpation

›Talar neck tenderness

›Anterior ankle and sinus tarsi

04Differential Diagnosis/ddx51

Bony injuries of the hindfoot and ankle

›Talar fractures (non-neck)

›Talar body fracture

›ICD-10 S92.109A

›Fracture line posterior to lateral process

›Sneppen classification applies

›Lateral process fracture (snowboarder's fracture)

›ICD-10 S92.149A

›Frequently missed on plain radiographs

›Mechanism: dorsiflexion + inversion

›Talar dome osteochondral lesion

›ICD-10 M93.271

›Subtler acute presentation

›May be missed acutely on plain films

›Calcaneal fracture

›ICD-10 S92.009A

›Axial load mechanism overlap

›Assess Bohler's angle (normal >20 degrees)

›Sanders classification on CT

›Navicular fracture

›ICD-10 S92.259A

›Adjacent bone with similar mechanism

›Ankle fractures

›Malleolar fracture-dislocation

›ICD-10 S82.899A

›Lauge-Hansen pattern

›Ottawa rules applicable for isolated malleolar injury

05Laboratory Tests/lt34

Trauma and perioperative labs

›Core trauma panel

›Complete blood count

›Baseline hemoglobin for surgical planning

›Leukocytosis if open fracture or delayed presentation

›Basic metabolic panel

›Renal function for contrast and analgesic dosing

›Glucose as baseline and healing marker

›Coagulation studies (PT/INR, aPTT)

›Required if anticoagulated

›Pre-operative requirement

›Type and screen

›All surgical candidates

›Polytrauma patients

›Nutritional and metabolic optimization

›HbA1c if diabetic

›Poor glycemic control impairs fracture healing

›Values > 8% associated with higher complication rates

›Albumin or prealbumin

›If polytrauma or nutritional concern

›Low albumin delays wound healing

Infection surveillance

›Open fracture labs

›ESR and CRP

›Baseline for open fractures with contamination

›Serial measurements track infection response

›Wound culture

›Obtained in operating room at time of debridement

06Diagnostic Tests/dt96

Scoring Systems

›Modified Hawkins-Canale Classification

›Type I: Nondisplaced talar neck fracture

›No subluxation of subtalar joint

›AVN rate approximately 10%

›Treatment: cast or boot, non-weight-bearing 6–8 weeks

›Type IIA: Displaced fracture with subtalar subluxation only

›No complete subtalar dislocation

›AVN rate approximately 0%

›ORIF indicated

›Type IIB: Displaced fracture with complete subtalar dislocation

›AVN rate approximately 25%

›ORIF with urgent reduction

›Type III: Displaced fracture with subtalar AND tibiotalar dislocation

›AVN rate approximately 53%

›Orthopedic emergency

›Type IV: Type III plus talonavicular dislocation

›AVN rate approximately 48%

›Tri-articular disruption

›Highest surgical complexity

›Hawkins Sign

›Subchondral lucency in talar dome on AP radiograph

›Assessed at 6–8 weeks post-injury

›Indicates subchondral bone resorption from viable bone

›Sensitivity approximately 100% for preserved vascularity

›Specificity approximately 58%

›Positive sign implies low AVN risk

›Revascularization present

›MRI not routinely required

›Negative sign (absent lucency)

›Does not confirm AVN (insensitive for AVN)

›MRI indicated at 8–12 weeks if sign absent

›Reliability reduced in smokers (JBJS 2024)

›Talar Neck with Proximal Body Extension (TNPE)

›Fracture extending into proximal talar body

›AVN rate 49% vs 19% for isolated neck fractures

›Higher collapse and nonunion rates

›Identified on CT preoperatively

MRI

›Indications for MRI in talar neck fracture

›Not required acutely in the ED

›CT is preferred acute imaging modality

›MRI adds little to initial management

›MRI at 6–12 weeks post-injury

›If Hawkins sign absent on radiograph

›Early detection of AVN before radiographic collapse

›T1-weighted sequences: decreased signal in avascular bone

›T2-weighted sequences: bone marrow edema pattern

›MRI AVN findings

›T1 hypointensity in talar body

›Indicates loss of fatty marrow signal

›Predicts osteonecrosis

›T2 heterogeneity

›Active bone marrow change

›Presence of Hawkins sign on plain radiograph makes MRI unnecessary

›ACR Appropriateness Criteria Level of Evidence: Expert consensus

CT

›CT as gold standard for talar neck fracture

›Indications

›All suspected talar neck fractures

›After closed reduction of dislocations

›Pre-operative planning for all displaced fractures

›CT superiority over plain radiographs

›Plain radiographs: sensitivity approximately 77% for talar neck fractures

›CT: sensitivity approaches 100% for fracture detection

›CT defines displacement, comminution, intra-articular extension

›ACR Appropriateness Criteria: CT usually appropriate for suspected talar fracture

›CT findings that guide management

›Degree of displacement and angulation

›> 2 mm displacement typically indicates ORIF

›Comminution assessment

›Medial column comminution associated with worse outcomes

›Subtalar and tibiotalar joint involvement

›Essential for Hawkins-Canale classification

›Talonavicular joint involvement

›Identifies Hawkins IV pattern

›Associated fractures

›Medial malleolus fracture (common concomitant injury)

›Calcaneal fracture

›Canale view (plain radiograph adjunct)

›15 degrees pronation, 75 degree cephalad beam angle

›Improves talar neck visualization on plain films

›May reveal fractures missed on standard views

›Technique attributed to Canale and Kelly, 1978

Ultrasound

›Ultrasound role in talar neck fracture

›Not a primary diagnostic modality for talar fractures

›CT and plain radiographs are preferred

›Ultrasound cannot visualize cortical detail reliably

›Limited adjunct applications

›Vascular assessment when Doppler needed

›Confirm dorsalis pedis and posterior tibial flow

›Guide aspiration of post-traumatic hemarthrosis (if needed for comfort)

›Point-of-care ultrasound in polytrauma

›FAST examination

›Intraabdominal hemorrhage in hemodynamically unstable patient

›Not targeted at talar injury

›Venous Doppler post-injury

›DVT detection in prolonged immobility

›Tibial vein thrombosis assessment

07Disposition/dispo32

Admission criteria

›Mandatory admission indications

›Displaced talar neck fracture (Hawkins II–IV)

›All require inpatient orthopedic care

›ORIF typically performed 7–14 days after injury (after swelling subsides)

›Open talar neck fracture

›Emergent operative debridement

›IV antibiotic therapy

›Fracture-dislocation

›Even after successful closed reduction

›Requires surgical planning and soft tissue monitoring

›Neurovascular compromise

›Vascular surgery involvement if needed

›Polytrauma

›Trauma surgery admission

Discharge criteria

›Conditions for ED discharge

›Hawkins Type I (nondisplaced, confirmed on CT)

›Neurovascularly intact

›Reliable patient with social support

›Splinted in short leg splint or boot

›Strict non-weight-bearing instructions provided

›Urgent orthopedic follow-up arranged

›Within 5–7 days

›Sooner if any concern for displacement

›Discharge prerequisites

›Adequate analgesia achieved

›Crutch walking instruction provided

08Treatment/t89

Acute pain management

›Analgesic options

›IV opioid analgesia

›Morphine 2–4 mg IV every 4–6 hours as needed

›Hydromorphone 0.2–0.4 mg IV for renal impairment or morphine intolerance

›Ketorolac 15–30 mg IV once

›Avoid if renal impairment, bleeding risk, or perioperative period

›Controversial long-term (possible impairment of bone healing)

›Acetaminophen 1000 mg IV or PO every 6 hours

›Adjunct to reduce opioid requirements

›Safe with most comorbidities

›Regional anesthesia options

›Popliteal sciatic nerve block

›Highly effective for foot and ankle pain

›Duration 12–24 hours depending on agent

›Bupivacaine 0.25–0.5% or ropivacaine 0.375–0.5%

›Saphenous nerve block

›Covers medial ankle and hindfoot complement

›Often combined with popliteal block

Closed reduction of dislocations

›Procedural sedation

›Ketamine 1–2 mg/kg IV

›Maintain airway reflexes

›Contraindication: uncontrolled hypertension, raised ICP

›Propofol 1–2 mg/kg IV titrated

›Rapid onset and offset

›Apnea risk requires airway management readiness

›Reduction technique for subtalar dislocation

›Medial subtalar dislocation (most common)

›Longitudinal traction on heel

›Plantarflexion then eversion to relocate

›Post-reduction CT mandatory

›Posterior talar body dislocation (Hawkins III)

›Urgency due to skin tenting risk

›Traction, plantarflexion, and anterior translation of foot

›Post-reduction management

›Short leg posterior splint in neutral position

›Immediate reassessment of neurovascular status

›CT within 2–4 hours to confirm reduction and define fracture anatomy

Open fracture management

›Antibiotic prophylaxis by Gustilo-Anderson grade

›Grade I (wound < 1 cm, clean)

›Cefazolin 2 g IV every 8 hours

›Duration: 24 hours post-operative

›Grade II (wound 1–10 cm, moderate contamination)

›Cefazolin 2 g IV every 8 hours

›Duration: 24 hours post-operative

›Grade III (wound > 10 cm or heavily contaminated)

›Cefazolin 2 g IV every 8 hours PLUS

›Gentamicin 5 mg/kg IV once daily

›Add metronidazole or penicillin for farm/soil contamination

›Duration: 72 hours post-operative

›Wound care

›Saline-moistened gauze wound coverage

›Do not attempt primary wound closure in ED

›Tetanus prophylaxis per immunization history

›Urgent operative debridement and irrigation

Definitive orthopedic treatment

›Hawkins Type I (nondisplaced)

›Conservative option

›Short leg non-weight-bearing cast or boot

›Duration 6–8 weeks

›Serial radiographs to monitor for displacement

›Percutaneous screw fixation option

›Some surgeons advocate to prevent secondary displacement

›Decision made by treating orthopedic surgeon

›Hawkins Type II–IV (displaced, requires ORIF)

›Timing of definitive surgery

›Delayed ORIF (7–14 days) after soft tissue swelling subsides

›Degree of displacement — not timing — is primary predictor of AVN

›Delayed ORIF does not increase AVN risk (JBJS 2004, JBJS 2014)

›Surgical approach

›Dual anterior incision (anteromedial plus anterolateral)

›Modern preferred technique for visualization and fixation

›Plate and screw fixation superior to screws alone for comminuted fractures

›Surgical goal

›Anatomic reduction is single most important determinant of outcome

›Nonanatomic reduction increases secondary reconstructive surgery rates

›Post-operative protocol

›Non-weight-bearing for 8–12 weeks

›Serial radiographs

›Hawkins sign assessment at 6–8 weeks

›If absent, MRI at 8–12 weeks to evaluate AVN

›Physical therapy

›Initiated after weight-bearing cleared

›Range of motion and strengthening program

DVT prophylaxis

›Pharmacologic prophylaxis

›Initiated after hemostasis achieved post-operatively

›Low molecular weight heparin: enoxaparin 40 mg SC daily

›Or rivaroxaban 10 mg PO daily

›Duration: until return to full weight-bearing or minimum 35 days

›Prolonged non-weight-bearing period increases DVT risk

›All patients counseled regarding DVT symptoms

09Special Populations/sp90

Pregnancy

›Imaging considerations in pregnancy

›Plain radiographs with abdominal shielding acceptable

›Fetal radiation dose < 1 mGy for ankle radiographs

›Risk-benefit discussion documented

›CT ankle with abdominal shielding

›Preferred over MRI acutely for fracture characterization

›Estimated fetal dose well below teratogenic threshold (50 mGy)

›MRI without gadolinium

›Safe in pregnancy at any trimester for AVN assessment

›Gadolinium avoided (crosses placenta, FDA Category C)

›Pharmacologic considerations

›Analgesia

›Acetaminophen: first-line, safe in all trimesters

›NSAIDs: avoid in third trimester (premature ductus closure)

›Opioids: use with caution, minimum duration required

›Regional nerve blocks preferred over systemic opioids

›Popliteal and saphenous blocks safe in pregnancy

›DVT prophylaxis

›Enoxaparin preferred over novel oral anticoagulants

›Warfarin avoided (teratogenic in first trimester)

›Multidisciplinary coordination

›Obstetrics involvement for all pregnant trauma patients

›Fetal monitoring per gestational age

›Timing of definitive surgery

›If possible, delay to second trimester for elective cases

›Emergency surgery not delayed for pregnancy

Geriatric

›Injury context in elderly patients

›Lower energy mechanisms may produce talar fracture

›Ground-level falls in osteoporotic bone

›Less common than in younger cohort

›Concomitant hip or proximal femur fracture must be excluded

›Fall from height in elderly may produce multiple injuries

›Physiologic considerations

›Bone quality

›Osteoporosis reduces screw purchase

›May require augmented fixation strategies

›DEXA scan and bisphosphonate therapy post-acute phase

›Renal function

›Creatinine clearance for contrast and analgesic dosing

›NSAID use limited or avoided

›Cardiovascular comorbidities

›Perioperative risk stratification

›Cardiology clearance if significant cardiac history

›Analgesia adjustments

›Opioid dose reduction

›Start at 50% of standard adult dose

›Increased sensitivity and elimination half-life

›Delirium risk with opioid use

›Acetaminophen preferred adjunct

›500–750 mg every 6 hours (dose reduce for frailty)

›Benzodiazepines avoided for procedural sedation if possible

›Prolonged sedation and paradoxical agitation risk

›Rehabilitation considerations

›Non-weight-bearing challenging for elderly

›Upper extremity strength and balance assessment

›Early physical therapy consultation

›Home safety and assistive device planning

Pediatrics

›Epidemiology in children

›Talar neck fractures rare in children

›Account for < 1% of pediatric foot fractures

›Cartilaginous talar body provides some protection in younger children

›Adolescents approaching adult injury patterns

›High-energy mechanisms similar to adults

›Imaging considerations

›Plain radiographs

›Standard first-line: AP, lateral, mortise ankle; AP and lateral foot

›Ossification centers can mimic fractures (os trigonum, accessory navicular)

›CT

›Essential for displaced injuries as in adults

›Low-dose pediatric CT protocols to minimize radiation

›MRI

›Preferred for nondisplaced suspected injuries when plain films equivocal

›Avoids radiation

›Better visualization of cartilaginous structures

›Treatment in children

›Nondisplaced fractures

›Short leg cast non-weight-bearing 6–8 weeks

›Remodeling potential greater in younger children

›Displaced fractures

›ORIF with smooth Kirschner wire or cannulated screws

›Avoid crossing growth plates with threaded implants

›Pediatric orthopedic surgeon involvement required

›Analgesia in children

›Acetaminophen 15 mg/kg PO/IV every 4–6 hours (max 75 mg/kg/day)

›Ibuprofen 10 mg/kg PO every 6–8 hours (avoid perioperatively)

›Intranasal fentanyl 1.5 mcg/kg for acute pain management

›Rapid onset, avoids IV access initially

›Procedural sedation

›Ketamine 1–2 mg/kg IV for reduction procedures

›Pediatric anesthesia support for complex reductions

10Background/b80

Epidemiology

›Incidence and demographics

›Talar neck fractures represent < 1% of all fractures

›Uncommon but high-morbidity injury

›Young active males predominate

›Mean age 32–37 years

›86% male in large series (Vosoughi et al., BMC Musculoskeletal Disorders 2021)

›Bilateral injury uncommon but possible in bilateral axial load

›Mechanism distribution

›Motor vehicle accidents: 46% of cases

›Falls from height: 43% of cases

›Motorcycle crashes and sports injuries account for remainder

›Complication rates

›Avascular necrosis (AVN): 25–31% overall

›AVN rate increases with Hawkins grade

›Hawkins I: ~10%, Hawkins II: ~27%, Hawkins III: ~53%, Hawkins IV: ~48%

›Posttraumatic arthritis: 43–79% depending on follow-up duration

›Rate approaches 81% with > 2 years of follow-up (Dodd et al., J Orthop Trauma 2015)

›Open fractures: approximately 30% of talar neck fractures

›Nonunion rate: low but increases with comminution and open injury

Pathophysiology

›Talar blood supply

›Predominantly extraosseous blood supply

›Medial malleolar branches of posterior tibial artery

›Artery of the tarsal canal (posterior tibial artery)

›Artery of the tarsal sinus (perforating peroneal and anterior tibial arteries)

›No muscular attachments

›No supplementary periosteal blood supply from muscles

›57% of surface covered by articular cartilage

›Leaves minimal bone surface for vascular ingrowth

›Blood supply enters talar neck and body from inferior and medial aspects

›Displacement disrupts these entries

›Higher displacement → greater vascular disruption

›Fracture mechanism

›Forced dorsiflexion compresses talar neck against anterior tibia

›Produces the characteristic neck fracture pattern

›Progressive energy causes subtalar joint disruption (Hawkins II)

›Further energy causes tibiotalar dislocation (Hawkins III)

›Maximum energy produces talonavicular dislocation (Hawkins IV)

›AVN pathophysiology

›Vascular disruption at time of injury → avascular talar body

›Degree of displacement is strongest predictor of AVN

›Timing of surgical fixation does not independently predict AVN (JBJS 2014)

›Revascularization can occur even after confirmed AVN

›44% of AVN cases revascularize without talar dome collapse

›90% demonstrate < 25% collapse (J Orthop Trauma 2026)

›Posttraumatic arthritis mechanism

›Articular cartilage injury at time of impact

›Avascular necrosis leading to subchondral collapse

›Subtalar and tibiotalar joint incongruity from malreduction

Therapeutic Considerations

›Timing of surgical fixation

›Delayed ORIF (7–14 days) is safe standard practice

›Allows soft tissue swelling to resolve

›Reduces wound complication risk

›Does not increase AVN rate compared to emergent fixation

›Level of evidence: multiple retrospective cohort studies (JBJS 2004, JBJS 2014, BMC 2019)

›Emergent intervention required for

›Open fractures (within 6–8 hours)

›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

11Patient Discharge Instructions/pdi34

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

12References/r48

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

Evidence & Review

Evidence & Review