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Avulsion fragment in ankle (talar neck)

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Last October I suffered an injury during a gymnastics floor exercise. I landed short causing my foot to be in a very hyperflexed position. When I went to the hospital they took an x ray and it showed that I had chipped some of the bone off in the talas bone and so had floating bone in the front of my foot (avulsion fragment).

They sent me home without a cast but with crutches and said I could resume my gymnastics in abot 3-4 weeks. After 3-4 months of not much let up on the pain I went back to the hospital and told them that I still wasn't able to do my gymnastics.

I had an mri scan which again showed the floating bone and considerable swelling posteromedially where the tendons were still inflamed.

I then underwent an injection under controlled ultra sound into the tendons which made no difference at all to the pain. Just a few weeks ago I had another injection where the floating bone is which again made no difference to the pain.

I am now desperate for this pain in my ankle to subside as it is affecting my work and my gym as I have een forced to retire after 18 years in the sport. It is beginning to get me down and I really need it sorted. Would surgery be the next option. I would really be appreciative of any advice on what to do next or any other treatment options to make it better.

Thanks
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replied August 12th, 2011
Especially eHealthy
apalmer8,

Sorry about your injury.

An avulsion can be from two different things. If you plantar flexed the foot (toes pointed away from the knee)) then the avulsion fragment was probably pulled off the bone by one of the ligament. If you dorsiflexed the foot (toes towards the knee), then the fragment was probably knocked off when two bones hit each other.

They have different surgical treatments.

In the first type, the avulsion fragment can be excised and the ligament reattached. In the second, it is a little more involved. If the fragment is small and does not contain a lot of articular cartilage, then it can just be removed. If the fragment is large (with articular cartilage), then it may have to be reattached. Also in this type of injury if there has been plastic deformity of the cortical bone, that would have to be reconstructed.


Unfortunately, the injection around the avulsion fragment did not give you a lot of relief. So operating on it may not either. Usually the surgeon looks for relief with the injection before trying surgery in that location. But, not always.


Also, you have to remember that surgery is controlled trauma, and itself can cause problems. Unfortunately, the ankle range of motion needed for gymnastics is well beyond what is considered normal ROM. The ankle also has to be able to take a lot of impact stress in gymnastics, and often after a significant injury, it just doesn't get back to its preinjury status.


You should discuss your options with an orthopedic foot and ankle specialist. you might try to find one who trained a lot in the sportsmedicine aspects. But, you are asking a lot of the ankle. Hope you get back. Good luck.
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replied January 9th, 2013
i rolled my ankle a week ago, i just had an X,ray and it said i have avulsion fragments off the medial aspect of the talus, can you give me a little more information on this injury please.
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replied January 10th, 2013
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peth,

An avulsion fracture off the medial aspect of the talus means that you have an injury to the large deltoid ligament. This would usually still be considered a sprain. The deltoid ligament has two layers: the superficial and the deep. When there is an avulsion off the talus, it is the deep deltoid that is affected.

To do this, you must have rolled your ankle "outward", or also called an eversion injury. This is the opposite of the way most ankle sprains occur (inversion injuries, or rolling the ankle inward).


Usually, this injury is treated like any other ankle sprain. In most cases, the avulsion off the talus is a small fragment. Thus, only a small portion of the ligament is torn off of the talar attachment. But, there may be more injury within the ligament itself, which would not show up on x-ray.


Thus, the usual treatment for this is RICE: rest, ice, compression, and elevation. If the patient is very tender, the use of crutches may be necessary for a little while. In significant injuries, it can take some time for the swelling to go down. Also, since there has been some tearing of the tissue, and avulsion of the bone, you may have some bruising. In some cases, the bruising may be quite extensive and take a long time to go away.


Once the acute stage is over, you are usually placed in physical therapy. Most of the time, you can do the therapy on your own.

You will need to do range of motion exercises, followed by strengthening exercises. The best range of motion exercise is to write the alphabet in the air using your toes. By tracing the all the letters of the alphabet, the ankle will be put through all of the motions of the ankle.

As to strengthening, the best thing to do use something like the TheraBand system. If you Google “TheraBand exercises for the ankle” you will get a long list of links to videos and articles on the use of the TheraBand.


So, at first, you will want to keep the foot up in the air. Use some compression (ace wraps or compression hose/stockings). Ice for the discomfort and swelling. Use crutches if you cannot walk without a limp.


If you have any questions or concerns, ask your orthopedic surgeon.
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replied January 9th, 2013
Hi Peth,

I am by no means a medical professional, but having experienced this injury myself I am able to provide you with a little information.

An avulsion fragment is where the force of the injury has pulled some bone off your talus on the medial aspect. This will mean that your will have fragments of bone in the surrounding soft tissue.

In my case the fragment of bone was at the front of my ankle. Due to the fact I was a gymnast at the time, my ankle was being put under high stress, and so even after the swelling had gone down and the injury should have healed, the bone was being forced into the surrounding tissue and catching causing pain, and decreased ROM.

After months of pain and the injury seemingly not getting any better, I had a steriod injection in the area, which seemed to calm everything down, but only for a short while. The pain came back in a matter of weeks and so it was decided to exise the bone through an operation. When the scar and swelling from the operation had healed the pain had completely gone from the area. There were unfortunately other complications from the injury so I have to have further surgery in the near future but thats another story.

How has your consultant decided to treat the injury? Have they discussed with you what will be next? I was not put in a cast or anything as was able to weight bear as soon as possible, presumably because if everything settles down properlly and you are not aggravating the ankle as I was, it can heal fully with no complications.

I suspect that as it is so soon from your injury you will not know whether the fragments are going to cause you further aggravation or not.

Good luck with it all! and be sure to come back and let me know how everything is going. If you have any more questions or would like any advice just let me know and I will try to help as best I can.

apalmer8
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