Rationale

Talar neck displaced fractures have been historically considered surgical emergencies due to their frequent association with peritalar joint dislocations or subluxations. It is also believed that early surgery will decrease vascular impairment and subsequent risk of osteonecrosis.1 However, given the high‐energy characteristics commonly associated with this injury, soft tissue conditions make immediate definitive fixation challenging and significantly increases complications.2

Clinical comment

Even when displaced talar neck fractures are considered to need an urgent surgery, there has recently been a trend toward performing a closed reduction of the fracture‐dislocations and wait until soft tissues are in a good enough condition to perform a delayed final open reduction and internal fixation (ORIF). There is a need to analyze which treatment paradigm has better outcomes and fewer complications.

Available literature and quality of the evidence

This search produced no systematic reviews or randomized controlled trials. There are five retrospective studies (level III). Whenever possible, these level III studies will be used to answer the question.

Findings

Lindvall et al. compared different aspects of 26 talar body and neck fractures (8 body and 18 neck) treated within six hours from injury or after six hours and found no difference regarding American Orthopaedic Foot and Ankle (AOFAS) score, nonunions, osteonecrosis or post‐traumatic arthritis.3 Sanders et al. review 70 cases of displaced talar neck fractures and although they did not list the detailed times in which surgeries were performed, they stated that surgical timing showed no difference in the need of secondary procedures.4

Vallier et al. reviewed 60 displaced talar neck fractures. Although the numbers in the study were small, no correlation was found between the timing of reduction and the development of osteonecrosis.5 Despite this, the authors advocate for urgent reduction because it may help to preserve any remaining blood supply. Once reduction has been achieved, a delay in fixation could be done and potential complications derived from severe soft tissue injury as skin necrosis, wound dehiscence, and infection could be avoided.

In another more recent cohort, Vallier et al. reviewed 81 talar neck fractures. This cohort had 2 Hawkins type I fractures, 44 Hawkins type II fractures – 21 were type II‐A (without subtalar joint dislocation) and 23 were type II‐B (with subtalar dislocation) – 32 Hawkins type III fractures, and 3 Hawkins type IV fractures.6 Treatment consisted of emergent closed reduction for dislocation patterns. Irreducible dislocations and open fractures underwent definitive surgical treatment immediately. From the total cohort, 46 (57%) were treated with urgent definitive fixation and 35 (43%) were treated with delayed ORIF. They found that emergent closed reduction within 6, 8, 12, or 18 hours did not correlate with osteonecrosis and the time to definitive fixation did not correlate with avascular necrosis (AVN) rates. Actually, patients who developed osteonecrosis underwent ORIF earlier than those without AVN (1.7 days vs 4.8 days; p <0.001). Authors believed that this difference might be attributed to a difference in the severity of fractures in both groups as there were more open fractures in the group that underwent urgent fixation. They declared that their analysis did not account for that potential confounding effects.

In addition, even when prior studies have suggested no association between the timing of definitive fixation and osteonecrosis,3,5 none of those studies specifically included the timing of reduction. Because of the small sample they were unable to determine an association between the timing of the reduction of dislocations and the development of osteonecrosis, but they stated that achieving an expeditious closed reduction is mandatory.6

Similarly, another study reviewed 106 talus fractures and fracture‐dislocations and found that there was no effect from the time since the injury to surgical reduction on rates of AVN and posttraumatic osteoarthritis.7 However, all these studies are retrospective and have relatively small sample sizes, so statistical power to reject the correlation between complication rates and surgical timing is limited.8 In spite of this, these series consistently show that displaced talar neck fractures might not need to be treated as surgical emergencies. However, if dislocations are present, they must be reduced even if this requires an open reduction.

Resolution of clinical scenario

Even when urgent reduction and definitive fixation has been advocated for talar neck fractures, current evidence suggests that there is no difference in AVN rates, post‐traumatic arthritis, union rate, or AOFAS hindfoot scores. Moreover, it seems that urgent open management gives rise to concerns regarding wound complications given the often severely traumatized soft tissues. With this in mind, in this case it seems reasonable to perform a closed reduction and, if congruence of the subtalar joint is restored, wait for the soft tissues to recover before performing the definitive fixation.