What is the management for a subacute non-displaced fracture of the plantar surface of the talar head?

Management of Subacute Non-displaced Fracture of the Plantar Surface of the Talar Head

For a subacute non-displaced fracture of the plantar surface of the talar head, immobilization with a non-removable knee-high device such as a total contact cast or fixed ankle walker is the recommended treatment approach to prevent progressive deformity and promote proper healing.

Diagnostic Considerations

When evaluating a subacute talar head fracture:

• MRI is the most sensitive imaging modality for detecting occult fractures with associated bone marrow edema patterns, particularly for persistent pain after negative initial radiographs 1
• CT without contrast is useful for evaluating radiographically occult fractures and soft-tissue abnormalities, with high specificity (99%) for detecting talar fractures 1
• Talar fractures are often difficult to detect on plain radiographs, with sensitivity of only 78% compared to CT 1

Treatment Algorithm

Initial Management (0-3 weeks)

1. Primary Treatment: Immobilization

   • Non-removable knee-high device (total contact cast or fixed ankle walker) 1
   • The device should accommodate any foot deformity safely and provide pressure redistribution
   • Immobilization of the complete foot and ankle is indicated to prevent progressive deformity

2. Alternative if Non-removable Device Contraindicated

   • Removable knee-high walker worn at all times with appropriate foot-device interface 1
   • Note: Risk of non-adherence may lead to development/progression of deformity and delayed healing

3. Pain Management

   • NSAIDs for pain and inflammation (e.g., ibuprofen 400-600mg three times daily) 1
   • Acetaminophen as an alternative if NSAIDs are contraindicated

Follow-up Management (3-6 weeks)

• Repeat radiographs to assess healing and rule out displacement
• Continue immobilization until clinical and radiographic evidence of healing
• Avoid weight-bearing on the affected foot during this period

Rehabilitation Phase (6+ weeks)

• Gradual transition to protected weight-bearing with supportive footwear
• Physical therapy for range of motion exercises and strengthening
• Custom orthotic devices may be necessary, especially for patients with foot deformities

Special Considerations

• Talar head fractures are rare, with limited high-quality literature regarding management 2
• Non-displaced talar head fractures generally have better outcomes than displaced fractures 3
• The rationale for immobilization is that mechanical stress plays a central role in perpetuating the underlying inflammatory process, which can result in progressive bone destruction and joint dislocation 1

Potential Complications

• Inadequate immobilization may lead to:

  • Progressive deformity
  • Delayed healing or non-union
  • Development of skin ulceration, especially in patients with neuropathy
  • Post-traumatic arthritis

• Immobilization devices can cause:

  • Skin breakdown (reported in 14% of people with diabetes treated with total contact cast) 1
  • Reduced mobility and independence

When to Consider Surgical Management

• Development of displacement during treatment
• Failure to heal with conservative management
• Symptomatic malunion
• Associated talonavicular joint disruption

While surgical techniques for talar head fractures have been described 4, the rarity of these injuries has precluded development of standardized surgical protocols. For non-displaced fractures of the plantar surface of the talar head, conservative management with proper immobilization remains the first-line approach.