Summary Talar neck fractures are high energy injuries to the hindfoot that are associated with a high incidence of talus avascular necrosis. Diagnosis is made with radiographs of the foot but frequently require CT scan for full characterization. Treatment is emergent reduction of the talus following by internal fixation in an acute or delayed fashion. Epidemiology Incidence common most common fracture of talus ( 50%) Etiology Mechanism a high-energy injury is forced dorsiflexion with axial load Associated conditions ipsilateral lower extremity fractures common Anatomy Articulation inferior surface articulates with posterior facet of calcaneus talar head articulates with: navicular bone sustenaculum tali lateral process articulates with posterior facet of calcaneus lateral malleolus of fibula posterior process consist of medial and lateral tubercles separated by groove for FHL Blood supply talar neck supplied by three sources posterior tibial artery login to view 5 more bullets anterior tibial artery login to view 1 more bullet perforating peroneal artery via artery of tarsal sinus login to view 1 more bullet Classification Hawkins Classification Type Description AVN risk Hawkins I Nondisplaced 0-13% Hawkins II Subtalar dislocation 20-50% Hawkins III Subtalar and tibiotalar dislocation 20-100% Hawkins IV Subtalar, tibiotalar, and talonavicular dislocation 70-100% Imaging Radiographs recommended views AP lateral Canale view login to view 2 more bullets CT scan best study to determine degree of displacement, comminution and articular congruity CT scan also will assess for ipsilateral foot injuries (up to 89% incidence) Treatment Nonoperative emergent reduction in ER indications login to view 1 more bullet short leg cast for 8-12 weeks (NWB for first 6 weeks) indications login to view 1 more bullet CT to confirm nondisplaced without articular stepoff Operative open reduction and internal fixation indications login to view 2 more bullets techniques login to view 4 more bullets complications login to view 5 more bullets Techniques ORIF approach two approaches recommended login to view 2 more bullets anteromedial login to view 3 more bullets anterolateral login to view 2 more bullets technique anatomic reduction essential variety of implants used including mini and small fragment screws, cannulated screws and mini fragment plates medial and lateral lag screws may be used in simple fracture patterns consider mini fragment plates in comminuted fractures to buttress against varus collapse postoperative non-weight-bearing for 10-12 weeks Complications Osteonecrosis 31% overall (including all subtypes) radiographs hawkins sign login to view 2 more bullets increased risk with increasing degree of initial fracture displacement associated with talar neck comminution and open fractures recent studies have found a significantly increased risk of osteonecrosis with the presence of subtalar dislocation and/or proximal fracture extension into the talar body delayed internal fixation is not associated with avascular necrosis associated with a dual-incision approach Posttraumatic arthritis subtalar arthritis (50%) is the most common complication tibiotalar arthritis (33%) Posttraumatic arthritis may necessitate fusion surgery Varus malunion (25-30%) can be prevented by anatomic reduction treatment includes medial opening wedge osteotomy of talar neck leads to decreased subtalar eversion login to view 1 more bullet weight bearing on the lateral border of the foot