Working Diagnosis:
Osteochondral fracture of lateral talar dome with associated high grade ATFL, CFL, and deep deltoid ligament sprains.

Treatment:
The patient was made non weight bearing and continued immobilization using a CAM walking boot while awaiting appointment with orthopedics. The patient subsequently underwent arthroscopic debridement and repair using osteochondral allograft transplantation.

Outcome:
The patient was able to begin physical therapy two weeks after surgery, but remained non weight bearing for four weeks post-operatively. After completion of physical therapy, the patient was able to return to full activity and participated in the spring volleyball season.

Author's Comments:
This patient had a Stage IV Ferkel and Sgaglione osteochondral defect. Radiographs are frequently normal with osteochondral defects of the talus. This patient's persistent swelling and pain four weeks after the initial injury, in addition to the lucency noted on x-ray at the lateral talar dome, was suggestive of an osteochondral defect. Osteochondral defects can be associated with a traumatic injury or microtrauma over time [1]. Lateral osteochondral defects typically occur after trauma and have a lower incidence of spontaneous healing than medial defects [1].

Editor's Comments:
Osteochondral fractures, also known as a transchondral fractures, are bony injuries to the articular surface of a joint that damages the cartilage and underlying subchondral bone. These injuries are often related to acute trauma but are often missed initially as the ligamentous sprain is evaluated. This case highlights this fact as the initial presentation to the athletic trainer was diagnosed as just a grade 2 ankle sprain. Early identification of these lesions is vital as they can lead to early degeneration of the joint, especially in weight-bearing joints. Diagnostic imaging plays an important role in identifying these lesions. According to studies, only 69% of osteochondral fractures of the talus are revealed on plain radiographs [2,3,4]. As such, advanced imaging modalities including magnetic resonance imaging (MRI) and computer tomography (CT) play a major role in identification of osteochondral fractures of the talus. In one study, MRI was found to have a 95% sensitivity and 100% specificity for osteochondral fractures of the talar dome [2,6]. In other studies, both MRI and CT have been found to have a high specificity for identifying osteochondral lesions of the talus (96% and 99%, respectively) [2,5]. MRI has the additional capability of detecting associated ligament and tendon injury as well as evaluating the stability of the osteochondral fracture. Both of these factors play an important role in determining appropriate management. Treatment of these lesions is still a topic of debate with many factors helping to determine whether non-operative versus operative treatment is indicated. Maintaining a high index of suspicion and utilizing advanced imaging modalities, including MRI and CT, can aide in early identification and treatment of osteochondral fracture of the talus.

References:
1. Steffes MJ, Szatkowski J. Osteochondral lesions of the Talus [Internet]. Orthobullets. 2021 [cited 2022Mar16]. Available from: https://www.orthobullets.com/foot-and-ankle/7034/osteochondral-lesions-of-the-talus.
2. Pedersen ME, DaCambra MP, Jibri Z, Dhillon S, Jen H, Jomha NM. Acute Osteochondral Fractures in the Lower Extremities - Approach to Identification and Treatment. The Open Orthopaedics Journal. 2015;9(1):463-474. doi:10.2174/1874325001509010463
3. Bohndorf K. Imaging of acute injuries of the articular surfaces (chondral, osteochondral and subchondral fractures). Skeletel Radiol 1999; 28(10): 545-60.
4. Pettine KA, Morrey BF. Osteochondral fractures of the talus. A long-term follow-up. J Bone Joint Surg Br 1987; 69(1): 89-92.
5. Verhagen RA, Maas M, Dijkgraaf MG, Tol JL, Krips R, van Dijk CN. Prospective study on diagnostic strategies in osteochondral lesions of the talus. Is MRI superior to helical CT? J Bone Joint Surg Br 2005; 87(1): 41-6.
6. Mintz DN, Tashjian GS, Connell DA, Deland JT, O'Malley M, Potter HG. Osteochondral lesions of the talus: a new magnetic resonance grading system with arthroscopic correlation. Arthroscopy 2003; 19(4): 353-9.

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