What are the initial management steps for a patient with a mildly displaced fracture of the lateral process of the talus presenting to the urgent care setting?

Management of Mildly Displaced Lateral Process Talus Fracture in Urgent Care

For a mildly displaced fracture of the lateral process of the talus presenting to urgent care, the patient should be immobilized, made non-weight bearing, and promptly referred to orthopedics for definitive management. 1

Initial Assessment and Imaging

• Physical examination: Assess for tenderness and swelling on both medial and lateral sides of the ankle 2

• Initial radiographs: Order standard ankle radiographs including:

  • Anteroposterior (AP) view
  • Lateral view
  • Mortise view
  • Consider Broden's view (supine flexed knee with 30-45° internal rotation) which specifically helps evaluate lateral process fractures of the talus 1

• Advanced imaging: If lateral process fracture is suspected or confirmed:

  • Order CT scan immediately to determine extent, displacement, comminution, and intra-articular extension 1
  • CT is the first-line advanced imaging study after radiographs for fracture assessment 1
  • MRI may be considered if associated soft tissue or ligamentous injuries are suspected 1, 2

Immediate Management in Urgent Care

1. Immobilization:

   • Apply a short leg posterior splint with the ankle in neutral position
   • Alternatively, use a walker boot (e.g., VACOped®) 3

2. Weight-bearing status:

   • Instruct patient to be non-weight bearing with crutches 1
   • Avoid prolonged immobilization to prevent deconditioning 4

3. Pain management:

   • Implement multimodal pain control approach 4:
     • Acetaminophen (1000 mg every 6 hours)
     • NSAIDs (e.g., ibuprofen 400-600 mg every 6-8 hours)
     • Opioids only for breakthrough pain if necessary

4. Patient education:

   • Explain the nature of the injury and importance of follow-up
   • Instruct on proper use of crutches and splint/boot care
   • Advise on elevation of the extremity to reduce swelling

Referral and Follow-up

• Urgent orthopedic referral: Arrange orthopedic consultation within 3-7 days 5

• Treatment plan: Final treatment will depend on:

  • Size of the fragment
  • Degree of displacement
  • Extent of articular involvement 5, 6

• Treatment options based on fracture type:

  • Type I (large, single fragment): ORIF (Open Reduction Internal Fixation) 6
  • Type II (comminuted): Fragment excision 6
  • Type III (chip fractures): Conservative management with casting 6

Complications of Missed Diagnosis

• Persistent ankle pain and reduced function 5
• Subtalar joint instability
• Post-traumatic arthritis
• Nonunion or malunion 5
• Loose body formation in the sinus tarsi 7

Follow-up Care

• Clinical and radiographic follow-up at 2 weeks and then at 4-6 weeks 4
• Monitor for:
  • Maintained alignment
  • Signs of healing
  • Complications such as delayed union or non-union
  • Post-traumatic arthritis
  • Persistent pain or instability 4

This fracture is commonly misdiagnosed as a severe ankle sprain due to difficulty detecting it on standard radiographs 3. Maintaining a high index of suspicion for lateral process talus fractures in patients with lateral ankle trauma is crucial for proper diagnosis and management.