What is the treatment for a 15mm bone fragment along the medial aspect of the talus?

Treatment for 15mm Bone Fragment Along the Medial Aspect of the Talus

For a 15mm bone fragment along the medial aspect of the talus, surgical intervention with open reduction and internal fixation (ORIF) is the recommended treatment to restore ankle joint congruity and prevent long-term complications. 1, 2

Initial Evaluation

• Initial assessment should include standard three-view ankle radiographs (anteroposterior, lateral, and mortise views) to evaluate the fracture fragment and overall ankle alignment 1
• CT scan is essential as the next imaging step to determine the exact extent, displacement, comminution, and any intra-articular extension of the fragment 1
• MRI may be beneficial to assess for associated soft tissue injuries, including ligamentous damage and cartilage abnormalities 1

Treatment Algorithm

Surgical Management (Primary Recommendation)

• A 15mm bone fragment is considered large enough to warrant surgical fixation to restore joint congruity and prevent instability 1, 2
• Open reduction and internal fixation (ORIF) should be performed to anatomically reduce the fragment and secure it with appropriate hardware 2
• Arthroscopically assisted reduction and fixation may be considered if the fragment involves the deltoid ligament attachment to provide better visualization and minimize soft tissue damage 3
• The surgical approach should be tailored to the specific location on the medial aspect of the talus, with careful attention to preserve blood supply to minimize risk of avascular necrosis 2

Post-Surgical Management

• Non-weight bearing for 6-8 weeks in a cast or fixed-ankle walker device 1
• Progressive weight bearing and physical therapy after adequate healing is confirmed radiographically 1
• Regular follow-up with serial radiographs to monitor for complications such as osteonecrosis, which can develop in up to 38% of talar body fractures 2

Potential Complications and Monitoring

• Osteonecrosis: High risk due to the tenuous blood supply of the talus, requiring close monitoring with follow-up imaging 2
• Post-traumatic arthritis: Common complication affecting both tibiotalar and subtalar joints 2
• Delayed union or non-union: May require revision surgery or bone grafting 2
• Collapse of the talar dome: Can occur at a mean of 10.2 months after surgery in patients who develop osteonecrosis 2

Special Considerations

• If the fragment is associated with significant comminution or open fracture, the prognosis is worse and more aggressive management may be needed 2
• In cases where the fragment cannot be adequately fixed or if there is extensive damage to the talus, salvage procedures such as total talar replacement may need to be considered for end-stage complications 4
• Weight-bearing radiographs during follow-up provide important information about stability, with a medial clear space of <4mm confirming stability 1

Pitfalls to Avoid

• Delayed treatment can lead to malunion, nonunion, or post-traumatic arthritis 2
• Inadequate fixation may result in fragment displacement and persistent instability 1
• Failure to recognize associated ligamentous injuries can compromise surgical outcomes 1, 3
• Overly aggressive rehabilitation before adequate healing can lead to fixation failure 1