Talus fracture missed for 4 months

Here is a report that my father typed up to send to different medical experts. I figured i would try posting to this forum as well. I also have x-ray and MRI pics online that you can look at. Any help/advice I could get would be greatly appreciated. Here is the summary so far:

Patient, a 21-year old, healthy male, jumped off a swing in mid-air on March 24, 2003, landing painfully on his right foot. An x-ray taken in the course of an ER visit (to an upstate New York hospital) was read by a hospital radiologist to show only a “questionable chip fracture of the anterior of the tibia.” The patient was referred to a local orthopedics practice several days later after being sent home from the ER with no cast or instructions to immobilize the foot.

At the orthopedics practice (March 27th), a physician’s assistant fitted the patient’s foot with a Bledsoe and had him utilize crutches for a little more than two weeks before telling him on April 14th to discontinue the Bledsoe and sending him to physical therapy. Patient continued to complain of pain when weight was placed on the ankle and in the course of physical therapy. Patient complained of pain, said he could barely stand on his toes, and walked with a limp, but was told by the P.A. on July 14th that this was normal.

Additional x-rays were taken on April 14th, May 5th, and August 1st, but it was not until August 1, when the patient insisted on seeing a physician for the first time, that a talus fracture was found to be present on each of the x-rays. The patient was then told to resume wearing the Bledsoe. An in-house MRI scan was conducted on August 6th and, following another visit on August 12th, a CT scan was done at the local hospital on August 16th. The radiologist’s report of August 25th refers to the re-identification of “the known fracture of the talus,” extending posteriorly and inferiorly from the talar dome, with the fracture line “still clearly evident,” and with “evidence of sclerotic change on both sides of the fracture line.” “The posterolateral aspect of the fracture line extends to the talar calcaneal joint and the posteromedial aspect extends to the sustenaculum tali.” There is a note that “there may be a free fragment in this region.”

Patient’s foot was casted in late August and he was cautioned to avoid placing weight on it. Bone stimulator treatments were begun on September 10th. A consultation was had with a local foot and ankle specialist, Dr. Michael G. McClure on September 23rd. After reviewing the x-rays and other imaging, Dr. McClure concluded that the patient had either a non-union or delayed union talus fracture and recommended the surgical insertion of titanium screws—although he expressed the fear that the patient was “fighting a losing battle” with avascular necrosis. However, since the ankle had only recently been immobilized and bone stimulation had been initiated less than 2 weeks earlier, Dr. McClure indicated it probably made sense to defer surgery for another month, to see if any healing occurs in the interim. He recommended that new CT scan and full-power MRI readings be taken in late October (with cast removed). He referred the patient to specialists at Johns Hopkins and Duke for further consultations.



My latest doctor reports a lession in the talus that is a few cms long. I am currently looking into getting treatment from a doctor at Johns Hopkins and from the fairly new Ossotron ultrasound bone stimulator shown to have good results in non-union fractures. Currently, I am just trying to see if it heals in the cast since I am finally non-weightbearing and immobilized for the first time since 2 weeks following the injury. I am using the EBI bone stimulator still.

I'd like to know what I can expect, any more information that you can decipher from the xrays (see link), possible treatment options that I should seek, best case scenario, worst case scenario, etc. I would be forever greatful for any help you can give. Thank you.

Posted By Evan Kamlet on September 30, 2003 at 14:51:00:

This slip-on device is a soft and stretchable Nylon/Lycra® fabric molded with a proprietary gel pad to protect the entire Achilles tendon of the foot by absorbing pressure and friction resulted from rubbing with the surface of the shoe.

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