What are the next steps in care for a 13-year-old female with a recent lateral talar avulsion on her right ankle, sustained 3 days ago, who reports minimal pain and can bear weight?

Management of Lateral Talar Avulsion in a 13-Year-Old Female

For a 13-year-old female with a lateral talar avulsion injury sustained 3 days ago who reports minimal pain and can bear weight, the recommended next step is functional support with an ankle brace for 4-6 weeks combined with early exercise therapy to promote optimal healing and prevent recurrence. 1

Initial Assessment and Diagnosis

• The patient's ability to bear weight with minimal pain suggests a less severe injury, but proper management is still critical to prevent long-term complications 1
• Lateral talar avulsion fractures are uncommon injuries that can be missed on initial assessment, potentially leading to persistent pain and reduced function if not properly managed 2
• These injuries may be associated with inversion ankle injuries and can involve the lateral process of the talus 2

Treatment Approach

Immediate Management

• Apply functional support in the form of an ankle brace, which shows greater effectiveness compared to other types of functional support 1
• Avoid immobilization with a cast as this results in less optimal outcomes compared to functional support and exercise strategies 1
• If pain or swelling is significant, a short period (<10 days) of immobilization with a rigid support can be considered, but functional treatment should follow 1

Exercise Therapy

• Begin early exercise therapy focused on neuromuscular and proprioceptive exercises 1
• Exercise therapy initiated early after injury has established efficacy in:
  • Reducing the prevalence of recurrent injuries 1
  • Decreasing the prevalence of functional ankle instability 1
  • Promoting quicker recovery and enhanced outcomes 1

Pain Management

• Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain management as they reduce pain in the short term without significantly increasing the risk of adverse events 1
• Note that NSAIDs may potentially delay the natural healing process as the inflammation they suppress is a necessary component of tissue recovery 1
• Acetaminophen (paracetamol) is an alternative that appears equally effective as NSAIDs for pain management 1

Follow-up and Monitoring

• Re-examine the patient within 1-2 weeks to assess healing progress 1
• If symptoms persist beyond 2-3 weeks despite appropriate management, consider advanced imaging:
  • MRI without contrast or CT without contrast is appropriate for persistent pain with negative initial radiographs 1
  • These imaging modalities can detect occult fractures, osteochondral injuries, or soft tissue damage not visible on plain radiographs 1

Special Considerations for Pediatric Patients

• In adolescent patients, it's important to rule out growth plate injuries which may present similarly 1
• Talar avulsion fractures in younger patients may heal well with proper conservative management if diagnosed promptly 3
• Early diagnosis and appropriate management yield reliably good outcomes, while untreated avulsion fractures typically do poorly 3

Prevention of Recurrence

• After the initial healing period, implement a graded exercise regimen with proprioceptive elements such as ankle disk training to reduce the risk of future ankle sprains 1
• Consider continued use of semirigid or lace-up ankle supports during physical activities, especially if the patient participates in sports, to decrease the risk of recurrent injury 1

Warning Signs Requiring Urgent Reassessment

• Development of severe pain, inability to bear weight, or significant increase in swelling 1
• Signs of neurovascular compromise including coldness, numbness, or tingling 1
• Failure to improve with conservative management within 2-3 weeks 1