What is the recommended treatment for a subacute nondisplaced subcortical fracture of the plantar surface of the talar head?

Treatment of Subacute Nondisplaced Subcortical Fracture of the Plantar Surface of the Talar Head

Simple immobilization is the most appropriate treatment for a subacute nondisplaced subcortical fracture of the plantar surface of the talar head to prevent articular collapse and promote proper healing. 1

Diagnostic Approach

Before finalizing treatment, proper diagnostic evaluation is essential:

1. Initial radiographs: May have limited sensitivity for talar head fractures

   • Radiographs detect only 78-87% of talar fractures compared to CT 1

2. Advanced imaging:

   • CT without contrast: Recommended for detailed fracture characterization
   • MRI: Most sensitive for evaluation of occult fractures with associated bone marrow edema patterns 1

Treatment Algorithm

Primary Treatment

For nondisplaced subcortical fractures of the talar head:

• Immobilization: Cast or fixed-ankle walker-type device 1
  • Duration: 4-6 weeks typically
  • Non-weight bearing or protected weight bearing status
  • Allows fracture healing without surgical intervention

Rationale for Conservative Management

• Small, nondisplaced, and nonarticular fractures respond well to immobilization 1
• The subcortical location on the plantar surface suggests minimal risk of articular collapse if properly immobilized
• Avoids surgical risks including infection, hardware complications, and anesthesia risks

Monitoring During Treatment

• Regular radiographic follow-up (every 2-3 weeks initially)
• Monitor for:
  • Fracture displacement
  • Signs of avascular necrosis
  • Proper alignment

Special Considerations

When to Consider Surgical Intervention

Surgery may be indicated if:

• Displacement occurs during treatment
• Articular surface involvement becomes apparent
• Failure to show healing signs after 4-6 weeks

Potential Complications to Monitor

1. Avascular necrosis: The talar head has better blood supply than the body/neck, but monitoring is still important
2. Post-traumatic arthritis: May develop in the talonavicular joint
3. Delayed union or nonunion: More common with poor immobilization compliance

Follow-up Protocol

• Clinical and radiographic evaluation at 2,6, and 12 weeks
• Progressive weight bearing after 6-8 weeks if healing is evident
• Physical therapy for range of motion and strengthening exercises after immobilization period

Pitfalls to Avoid

• Inadequate immobilization: Can lead to displacement and poor healing
• Premature weight bearing: May cause fracture displacement or nonunion
• Delayed diagnosis: Can lead to inappropriate treatment and poor outcomes
• Overlooking associated injuries: Carefully evaluate for concomitant ligamentous or other bony injuries

The key to successful management of talar head fractures is proper immobilization with careful monitoring to ensure healing progresses appropriately while preventing complications that could lead to long-term functional impairment.