What is the treatment for a 2-day-old dorsal talus avulsion fracture?

Treatment of a 2-Day-Old Dorsal Talus Avulsion Fracture

For a 2-day-old dorsal talus avulsion fracture, the recommended treatment is protected weight-bearing with immobilization in a cast or fixed-ankle walker device, with the specific approach determined by the size and displacement of the fracture fragment. 1

Initial Evaluation

• Standard ankle radiographs should be obtained, but these may miss subtle fractures or underestimate the extent of injury 2, 1
• CT scan is essential to determine extent, displacement, comminution, and any intra-articular extension of the fracture 2, 1
• MRI is valuable for assessing associated bone marrow contusions, osteochondral injuries, and soft tissue damage 1

Treatment Algorithm

For Non-displaced or Minimally Displaced Fractures

• Immobilization is appropriate when fracture fragments are small, non-articular, or minimally displaced 1
• Protected weight-bearing with immobilization in a cast or fixed-ankle walker-type device for 4-6 weeks 1, 3
• Radiographic follow-up at approximately 3 weeks to confirm adequate healing 1

For Displaced Fractures

• Surgical fixation is indicated for larger fragments (>15mm) or those with significant displacement to restore joint congruity and prevent instability 4
• Options include open reduction and internal fixation or arthroscopic-assisted repair, depending on fragment size and location 5, 6
• Non-weight bearing for 6-8 weeks in a cast or fixed-ankle walker device following surgical intervention 4

Post-Treatment Management

• Active finger motion exercises should be initiated as soon as stability allows to prevent stiffness 1
• Progressive weight bearing after adequate healing is confirmed radiographically 4
• Regular follow-up with weight-bearing radiographs to assess stability (medial clear space <4mm confirms stability) 4

Important Considerations and Pitfalls

• Early diagnosis and appropriate management yield reliably good outcomes, while untreated avulsion fractures predictably do poorly 7
• Missed talus fractures can lead to persistent pain, reduced function, and potential complications including malunion, nonunion, or subtalar joint osteoarthritis 5
• Overly aggressive rehabilitation before adequate healing can lead to fixation failure 4
• For fractures that are diagnosed late (>1 month), CT and MRI are particularly important for assessment, and surgical excision may be necessary if conservative treatment fails 8, 7

Special Populations

• In pediatric patients, MRI can help exclude Salter 1 fractures that may not be visible on radiographs 2
• For athletes, particularly those involved in snowboarding (where lateral process fractures are common), earlier surgical intervention may be considered to facilitate faster return to sport 5