First and second year — the floor first, then every step
A talar neck fracture threatens the talar body's blood supply: classify it by Hawkins from the joints it dislocates, and look for the lateral process fracture that is missed as an "ankle sprain".
Orient first
The talus has no muscle attachments and is covered largely by cartilage; its blood supply enters at the neck, so displaced neck fractures cause avascular necrosis of the body.
The lateral process fracture ("snowboarder's fracture") is small, seen best on the AP ankle or CT, and is commonly misdiagnosed as a sprain.
Subchondral lucency of the talar dome at 6–8 weeks (Hawkins sign) indicates preserved blood supply.
Acquire the study
AP ankle, mortise, lateral; Canale view (pronated, 15° tilt) for the talar neck.
The manoeuvre
Lateral view: talar neck cortex, the subtalar and talonavicular joints.
AP ankle: the lateral process of the talus below the fibular tip.
Follow-up at 6–8 weeks: the Hawkins sign on the mortise view.
What confirms it
A fracture line through the talus on CT.
What licenses you to exclude it
A normal radiograph does not exclude a lateral or posterior process fracture — CT.
The classic misread
Calling a lateral process fracture an ankle sprain.
Reporting the injury
Classification to use
Talar neck: Hawkins I–IV (with the Canale–Kelly type IV). Body, head and process fractures are described separately.
Measurements — and how to take them
Displacement at the neck in mm; articular step-off in mm.
What to report
Fracture site, displacement, comminution, each joint's congruence (subtalar, tibiotalar, talonavicular), process fractures.
How to report it
CT: "Displaced fracture of the talar neck with subtalar subluxation and a congruent ankle — Hawkins II."
What not to report
Do not call a posterior process fragment an os trigonum without looking at its margins.