A 23-year-old male recreational player presents two weeks following an innocuous inversion injury. He was able to weight-bear without difficulty, had very minor residual swelling and a near normal range of motion. He had an increased anterior draw on the symptomatic side. While he appeared to be progressing well an x-ray image conducted shortly after the injury showed a medial talar dome injury.
A medial talar dome injury is seen on a mortise x-ray view. MRI images show a stage IV medial talar dome osteochondral lesion with a minimally displaced osseous fragment corresponding to the plain films. A partial fluid cleft at its posterior margin and a mild subchondral oedema suggests an unstable lesion. The talar dome injury is on a background of a previous ATFL partial thickness injury.
Talar dome lesions generally involve either the superomedial or superolateral corners of the talus. Compared with lateral lesions, injuries involving the medial talar dome are less likely to be associated with trauma and are less likely to do well with surgical treatment.
Lesions can be graded based on their radiological findings. This can help determine the best treatment approach. Grade I injuries involve increased signal in the subchondral bone without any displacement. Grade II injuries have partial detachment of the osteochondral fragment. Grade III injuries are completely detached, but undisplaced, while grade IV injuries have a detached and displaced fragment. In very general terms, grade I-II injuries should be treated non-operatively (initially anyway). Higher grade injuries, or those that fail conservative treatment after 3 months, generally need surgical treatment. In some cases a diagnostic arthroscopy is needed to accurately grade the injury.
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