Management of Avulsion Fracture of the Talus Over 1 Month
For avulsion fractures of the talus that are over 1 month old, CT or MRI imaging followed by surgical excision is the recommended management approach to improve functional outcomes and reduce persistent pain.
Diagnostic Evaluation
Initial Assessment
- For patients with persistent ankle pain after trauma, especially with point tenderness over the talus, radiographic evaluation is indicated 1
- Weight-bearing radiographs (if possible) provide important information about fracture stability 1
- Standard radiographic protocol should include anteroposterior, lateral, and mortise views 1
Advanced Imaging
- For avulsion fractures of the talus that are over 1 month old with persistent symptoms:
- CT without IV contrast is recommended to determine extent, displacement, comminution, and intra-articular extension 1
- MRI without IV contrast is particularly valuable for assessing:
- Associated bone marrow contusions
- Osteonecrosis risk (talus has tenuous blood supply)
- Associated soft-tissue abnormalities 1
Treatment Approach
Conservative Management
- Conservative management is typically ineffective for avulsion fractures of the talus that are over 1 month old 2
- Patients with untreated avulsion fractures predictably have poor outcomes 2
Surgical Management
- Surgical excision is the recommended treatment for symptomatic avulsion fractures of the talus that are over 1 month old 2
- Surgical intervention provides significant functional and symptomatic improvement for patients with persistent pain 2
- Arthroscopically assisted reduction and fixation may be considered in specific cases to restore ankle stability 3
Outcome Considerations
Prognosis
- Prompt diagnosis and appropriate management yields reliably good outcomes 2
- Delayed diagnosis and treatment leads to poorer outcomes, though late excision can still provide significant improvement 2
- Risk factors for complications include:
- Displacement of the fracture
- Delayed treatment
- Associated injuries to the ipsilateral foot or leg 4
Complications
- Untreated avulsion fractures can lead to:
Special Considerations
Anatomical Factors
- The talus has a tenuous blood supply which can be affected by fracture displacement 5
- The posterior medial tubercle of the talus is a common site for avulsion fractures, often involving the insertion of the posterior talotibial ligament 6
Imaging Pearls
- The Broden view (supine flexed knee view with 30-45° internal rotation) may be useful for specific evaluation of lateral process fractures of the talus 1
- Avulsion fractures may be overlooked on routine radiographs; special attention to areas of tenderness is recommended 1
By following this approach to management, patients with avulsion fractures of the talus over 1 month old can achieve improved functional outcomes and significant pain relief.