What is the management plan for a patient with an acute mildly displaced fracture of the medial malleolus and a suspected osteochondral fracture of the lateral talar dome?

From the Guidelines

The management plan for a patient with an acute mildly displaced medial malleolus fracture and suspected osteochondral fracture of the lateral talar dome involves further evaluation with a left ankle CT to confirm the extent of the fractures and guide treatment.

Initial Evaluation

The patient's initial X-ray has already been performed, which is in line with the recommendations for initial imaging of patients with acute trauma to the ankle, as stated in the American College of Radiology (ACR) Appropriateness Criteria 1.

Further Evaluation

Given the suspected osteochondral fracture of the lateral talar dome and the presence of a mildly displaced fracture of the medial malleolus, further evaluation with a CT scan of the ankle is recommended, as it can provide more detailed information about the extent of the fractures and potential involvement of other structures 1.

Treatment Approach

The treatment approach will depend on the findings of the CT scan, but it may involve surgical intervention, such as open reduction and internal fixation (ORIF) of the medial malleolus fracture, and potentially arthroscopic evaluation and treatment of the osteochondral lesion of the talar dome.

• The use of 3.5 or 4.0 mm partially threaded cancellous screws or tension band wiring for ORIF of the medial malleolus fracture is a common approach.
• Arthroscopic evaluation of the talar dome can help confirm the presence and severity of the osteochondral lesion.
• If the osteochondral fragment is unstable or displaced, it may be fixed with bioabsorbable pins or small screws, or removed if fixation is not possible.

Postoperative Care

Postoperatively, the patient should remain non-weight bearing for 4-6 weeks in a short leg cast or removable boot, followed by progressive weight bearing as tolerated, with physical therapy focusing on range of motion, strengthening, and proprioception exercises.

• Pain management can include acetaminophen 1000 mg every 6 hours and NSAIDs like ibuprofen 600 mg every 6 hours for the first week, then as needed.
• This approach is recommended because medial malleolus fractures often require surgical fixation to restore ankle stability and prevent nonunion, while proper management of osteochondral lesions is crucial to prevent long-term ankle arthritis and chronic pain, as supported by the ACR Appropriateness Criteria 1 and other studies 1.

From the Research

Management Plan for Acute Mildly Displaced Fracture of the Medial Malleolus and Suspected Osteochondral Fracture of the Lateral Talar Dome

• The patient's left ankle X-ray shows an acute mildly displaced fracture of the tip of the medial malleolus, which may require further evaluation to determine the best course of treatment 2.
• A suspected small osteochondral fracture of the lateral talar dome with adjacent tiny ossicle fragments is also present, and a left ankle CT scan may be necessary for further evaluation 3.
• The presence of tiny chronic ossicle along the posterior aspect of the ankle joint and soft tissue swelling about the ankle should also be considered when developing a management plan.

Classification and Treatment of Medial Malleolar Fractures

• Medial malleolar fractures can be classified into different types based on their morphology and location, which can help guide treatment decisions 4, 5.
• The classification system proposed by 4 categorizes medial malleolar fractures into six types based on the recurrent patterns on the coronal and lateral view of 3D maps.
• The treatment of isolated medial malleolar fractures is still a topic of debate, with some studies suggesting that conservative treatment may be safe for fractures displaced ≤2 mm, while others recommend surgical treatment for fractures displaced >2 mm 2.

Importance of Accurate Diagnosis

• Accurate diagnosis is crucial in avoiding misdiagnosis and overtreatment, particularly in cases where extra ossification centers or accessory bones may be present 6.
• Foot and ankle surgeons should be aware of the radiographic appearance of extra ossification centers, including one at the tip of the medial malleolus, to avoid confusion with fractures.

Further Evaluation and Treatment

• A left ankle CT scan may be necessary to further evaluate the suspected osteochondral fracture of the lateral talar dome and to guide treatment decisions 3.
• The treatment plan should take into account the patient's individual characteristics, the severity of the fracture, and the presence of any associated injuries or conditions.