Working Diagnosis:
Hawkins type II talar neck fracture-dislocation with apparent self-reduction by ambulation

Treatment:
The patient was instructed to be non-weight-bearing after initial visit in the sports medicine office. She was scheduled to see orthopedic surgery the day after her CT scan, but cancelled her visit. She eventually was seen in the orthopedic office 2 weeks later (6 weeks post-injury). She was noted to walk into the office non-compliant with the previous non-weight-bearing instructions. The patient denied pain at her visit and requested a doctor's note to allow her to return to work at a local fast food restaurant with no restrictions. Her examination at that time showed normal gait with no tenderness to palpation to her right foot or ankle. On range of motion testing, she lacked about 5 degrees of dorsiflexion and 5-10 degrees of plantarflexion with mild subtalar stiffness. X-rays at that time were stable with signs of continued fracture healing. After lengthy discussion of risks with the orthopedic surgeon, the patient was recommended to remain non-weight bearing for another 6 weeks or consider surgical fixation. The patient, however, elected to continue to weight-bear as tolerated with repeat x-rays in 6 weeks.

Outcome:
The patient followed up with orthopedics at 3 months post-injury and denied any compliant. She reported she had been pain free with all daily activities since her last visit. Her physical exam was normal except very subtle stiffness to the ankle in plantarflexion, dorsiflexion, and subtalar motion. Radiographs obtained at the visit showed a well healed fracture with no signs of avascular necrosis. Case Photo #9 Case Photo #10 The patient was released to all activities with no follow up needed unless ankle pain occurred. Now over 2 years post-injury, she continues to do well and denies any right ankle pain.

Author's Comments:
Talar neck fractures are a relatively rare injury, but they can have a high rate of complications. Hawkins type I fractures are non-displaced and have a 0-15% risk of avascular necrosis. Hawkins II talar neck fractures, like our patient had, have subluxation/dislocation at the subtalar joint and have a 20-50% risk of avascular necrosis. Type III fractures are associated with tibiotalar joint dislocation and type IV are associated with additional talonavicular dislocation. Type III and IV talar neck fractures have 69-100% risk of avascular necrosis. Due to the high risk of avascular necrosis with all talar neck fractures, standard care is for urgent reduction of have subluxation/dislocation and immobilization. Surgical fixation followed by a prolonged period of non-weight-bearing is recommended for all type II-IV fractures.

In this patient's case, the initial fracture was not addressed by the emergency room and the patient was not notified of her x-ray finding until she saw her PCP 3 weeks after injury. It is surmised that she likely reduced her own fracture by ambulation. Fortunately, the patient had a favorable outcome despite the initial mismanagement and the patient's non-compliance with non-weight-bearing.

Since the initial visit in the sports medicine office, the emergency room has addressed the system error that occurred when the patient was never notified of the official radiology report of her radiographs.

Editor's Comments:
This case illustrates the importance of reviewing outside radiographs in the sports medicine clinic. Patient had an eversion mechanism which is not consistent with a lateral ankle ligament injury.

References:
Hak DJ, Shishui L. Management of talar neck fractures. Orthopedics. 2011;32(9):715-721
Halvorson J, Winter B, Teasdall R, Scott A. Talar neck fractures: a systematic review of the literature. J of Foot & Ankle Surgery. 2013;52:56-61
Vallier HA, Nork SE, Barei DP, Benirschke SK, Sangeorzan BJ. Talar neck fractures: results and outcomes. J Bone joint Surg Am. 2004;86(8):1616-24
Vallier HA, Reichard SG, Boyd AJ, Moore TA. A new look at the Hawkins classification for talar neck fractures: which features of injury and treatment are predictive of osteonecrosis. J Bone Joint Surg Am. 2014;96:192-7.

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