Avascular Necrosis of the Talar Body Presenting with a Vertical Fracture and Dome Collapse in a Low-Risk Patient: A...

Avascular necrosis (AVN) of the talus is an uncommon condition, although it can arise due to the bone's limited blood supply and typically occurs following high-energy trauma or in patients with recognised medical risk factors. Fractures developing as a result of AVN, particularly vertical fractures through the talar body with early dome collapse, are relatively rare. This report describes a unique presentation in a patient without classical risk factors, highlighting delays in diagnosis and the complexities associated with management. This appears to be one of the few reported cases of a spontaneous vertical fracture of the talus secondary to AVN in a low-risk individual.

A 47-year-old woman of no significant medical background presented with an 8-week history of progressive left ankle pain following minor trauma during a holiday. Initial assessment in the emergency setting suggested an ankle sprain, but persistent pain led to repeat clinic evaluation. Radiographs demonstrated a defect in the talar dome, and a subsequent urgent magnetic resonance scan revealed extensive involvement of the talar head and body with a vertical fracture extending into the dome, early medial collapse, and marked surrounding inflammation. The patient continued to experience deterioration despite immobilization, with increasing functional limitation, including difficulty managing stairs at home. A follow-up scan demonstrated non-union of the fracture and progressive collapse. While advanced reconstructive options such as total talus replacement were considered, ongoing systemic barriers, such as funding delayed access. Due to worsening symptoms, she underwent open reduction and internal fixation of the talar fracture as a temporizing measure whilst access to definitive management was sought.

This case highlights the aggressive course that talar AVN can take even in individuals with little to no risk factors. Early use of advanced imaging should be considered in patients with persistent ankle pain when initial radiographs are inconclusive, as delayed diagnosis may lead to structural collapse and reduced treatment options. This report adds to the understanding of atypical presentations of talar vascular insufficiency and underscores the importance of timely recognition, multidisciplinary decision-making, and addressing systemic barriers that may delay definitive care.