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SplintER Series: Pedal to the Metal

Posted by Justine Ko, MD on

A 32-year-old female presents to the emergency department with right ankle pain after a high-speed motor vehicle accident. On exam, she is noted to have ecchymosis and swelling over the distal foot, and pain with ankle dorsiflexion and plantarflexion. An x-ray is obtained as shown above (Image 1. Case courtesy of Dr. Charlie Chia-Tsong Hsu, Radiopaedia.org, rID: 18235).

What is your diagnosis?

The patient is diagnosed with a talar neck fracture. These fractures are associated with high-impact mechanisms and account for nearly 50% of all talar fractures [1]. X-ray is a good initial imaging modality for these injuries, however, CT should be considered to better assess the articulating surfaces of the talus.
  • Pearl: To aid in viewing the talar neck, a Calnale view can be used. The x-ray is taken with the ankle plantarflexed and pronated 15˚. The beam of the x-ray should be angled 75˚ from the horizontal plane where the foot lies [2].

What is your management in the Emergency Department?

Management depends on the type of talar neck fracture. The most common classification system for talar neck fractures is the Hawkins-Canale classification:
  • Type I fractures: nondisplaced fractures that usually only require splinting and non-weight bearing status.
  • Type II-IV fractures are displaced fractures with an associated dislocation that requires an urgent reduction in the Emergency Department
    • Type II fractures: talocalcaneal dislocation
    • Type III fractures: talocalcaneal and talotibial dislocations (Image 2)
    • Type IV fractures: all talar articulations are disrupted [3,4].

Image 2: Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 84976

  • Pearl: Most talar injuries are usually caused by forced hyperdosiflexion of the ankle. They are often associated with other injuries and frequently present as an open fracture [1]. A detailed secondary survey and skin exam should be performed on all patients.

What is your disposition? Do you consult orthopedic surgery?

For Type I fractures, close orthopedic follow-up can be arranged after the patient is splinted in a posterior mold splint. Given the association with high-impact mechanisms, type I fractures are rare. Type II-IV fractures require orthopedic consultation and urgent reduction. These fractures are associated with an increased risk for osteonecrosis given the disruption of the talar blood supply with dislocation [1].

Resources & References:

Looking to brush up on all things ankle-related? Review the 2 minute ankle exam and the approach to the traumatic ankle.

  1. Shamrock AG, Byerly DW. Talar Neck Fractures. In: StatPearls. StatPearls Publishing; 2021. Accessed June 19, 2021. http://www.ncbi.nlm.nih.gov/books/NBK542315/1.
  2. Melenevsky Y, Mackey RA, Abrahams RB, Thomson NB. Talar Fractures and Dislocations: A Radiologist’s Guide to Timely Diagnosis and Classification. Radiographics. 2015;35(3):765-779. PMID: 25969933
  3. Dale JD, Ha AS, Chew FS. Update on Talar Fracture Patterns: A Large Level I Trauma Center Study. American Journal of Roentgenology. 2013;201(5):1087-1092. PMID: 24147480
  4. Alton T, Patton DJ, Gee AO. Classifications in Brief: The Hawkins Classification for Talus Fractures. Clin Orthop Relat Res. 2015;473(9):3046-3049. PMID: 25586336

Author information

Ko, MD, CAQ-SM

Assistant Professor
Department of Emergency Medicine
New York Presbyterian-Weill Cornell Medical Center

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