Treatment of Suspected Acute Impact Fracture of the Medial Talus
For suspected acute impact fractures of the medial talus with possible remote impaction or avulsion fracture along the anterior superior talus, initial radiographic evaluation followed by advanced imaging with CT or MRI is recommended, with treatment based on fracture characteristics including immobilization for stable fractures and surgical intervention for displaced or unstable fractures. 1
Initial Diagnostic Approach
- Initial evaluation should include standard radiographic protocol with anteroposterior, lateral, and mortise views to assess the fracture 1, 2
- If radiographs are negative but clinical suspicion remains high (point tenderness over the talus, inability to bear weight), advanced imaging is indicated 1
- CT without IV contrast is excellent for evaluating occult fractures, determining extent, displacement, and comminution of talar fractures 1
- MRI without IV contrast is the most sensitive modality for detecting occult fractures with associated bone marrow edema patterns and is particularly valuable for assessing associated soft tissue injuries 1
Treatment Algorithm Based on Fracture Characteristics
Non-displaced or Minimally Displaced Fractures (<2mm)
- Conservative management with immobilization (cast or walking boot) and limited weight-bearing for 4-6 weeks 3, 4
- Regular radiographic follow-up to ensure proper healing and alignment 5
- Early diagnosis and appropriate conservative management yields reliably good outcomes 3
Displaced Unstable Fractures (>2mm displacement)
- Surgical intervention is indicated for displaced fractures to prevent long-term complications 3, 6
- Open reduction and internal fixation (ORIF) is recommended, particularly when the flexor hallucis longus (FHL) tendon is interposed between fracture fragments 6
- MRI is crucial to identify potential tendon interposition that would necessitate surgical intervention 6
Special Considerations
- Avulsion fractures of the medial tubercle of the posterior process of the talus typically occur after forceful dorsiflexion-pronation of the ankle 3, 7
- Avulsion fractures of the anterior talofibular ligament from the talus are extremely rare but should be considered in the differential diagnosis 8
- Untreated avulsion fractures predictably lead to poor outcomes with persistent pain and functional limitations 3, 4
- For chronic untreated fractures with persistent symptoms, surgical excision of the fragment may provide significant functional and symptomatic improvement 3, 7
Imaging Pearls and Pitfalls
- Talar fractures are often missed on routine radiographs; special attention to areas of tenderness is recommended 2, 6
- The sensitivity and specificity of physical examination are optimized if clinical assessment is delayed for 4-5 days post-injury 1
- In cases of suspected fracture, the Ottawa Ankle Rules should be applied to determine the need for radiographs 1
- For suspected posterior medial tubercle fractures, oblique radiographs with external rotation may improve visualization 6
- CT is particularly valuable for detecting lateral process or comminuted talar body/dome fractures that are difficult to identify on radiographs 1