A 35-year-old male presents with a 6-week history of progressive ankle pain and swelling following a fall from height onto a dorsiflexed foot. X-ray imaging shows a fracture through the neck of the talus. On follow-up imaging at 8 weeks, a subchondral radiolucency is noted under the talar dome on the anteroposterior view. The structure marked **B** (Talus + Subtalar Joint) is the site of injury. What is the clinical significance of the subchondral radiolucency finding in this case?

Explanation

## Why "It is the Hawkins sign and indicates an intact blood supply to the talus" is right The Hawkins sign is a subchondral radiolucency that appears under the talar dome on anteroposterior X-ray at 6–8 weeks following a talar neck fracture. This finding is a favorable prognostic indicator because it demonstrates that the talus has maintained its blood supply and is undergoing normal bone remodeling, thereby indicating viability and low risk of avascular necrosis (AVN). According to Maheshwari 10e, the presence of the Hawkins sign at 6–8 weeks is a critical radiological landmark that predicts healing without AVN in talar neck fractures. ## Why each distractor is wrong - **"It indicates avascular necrosis of the talus and poor prognosis"**: This is the opposite of the Hawkins sign. AVN would be indicated by the *absence* of the Hawkins sign and progressive sclerosis of the talar body. The Hawkins sign is a sign of *viability*, not necrosis. - **"It represents a stress fracture of the subtalar joint requiring conservative management"**: Stress fractures of the talus or subtalar joint present differently and do not produce the characteristic Hawkins sign. The clinical scenario describes a high-energy talar neck fracture, not a stress fracture. - **"It signifies a Lisfranc fracture-dislocation requiring immediate arthrodesis"**: Lisfranc injuries involve the tarsometatarsal joints (between the midfoot and metatarsals), not the talus. The Hawkins sign is specific to talar neck fractures and has no relevance to Lisfranc pathology. **High-Yield:** Hawkins sign (subchondral radiolucency under talar dome at 6–8 weeks) = viable talus = low AVN risk in talar neck fractures; its absence suggests high AVN risk. [cite: Maheshwari 10e — Talar Neck Fracture, Hawkins Classification, and Hawkins Sign]