Osteochondral lesions of the talus in the pediatric population: A practical narrative review

Osteochondral lesions of the talus (OLTs) in children and adolescents are a clinically important cause of persistent ankle pain after trauma and may also be present without a clear inciting event. Because plain radiographs may fail to detect OLTs or may underestimate their severity, modern pediatric pathways rely on magnetic resonance imaging (MRI) for characterization. However, conventional MRI may be inconclusive regarding osteochondral fragment stability in selected cases. In this setting, magnetic resonance arthrography may provide additional information, although pediatric-specific evidence is limited and its routine use is not supported. Nonoperative management is commonly used as first-line treatment for stable lesions in skeletally immature patients, but reported success is variable and often modest, prompting increasing interest in standardized conservative protocols and prospective comparisons. When surgery is required, selection among retrograde drilling, bone marrow stimulation, and fragment fixation is primarily driven by osteochondral fragment stability, cartilage integrity, fragment viability, and the extent of subchondral bone involvement. Assessment should also include ankle stability because clinically relevant concomitant ligamentous instability may influence treatment selection and outcomes. When ligament stabilization is indicated, minimally invasive arthroscopic techniques may be considered. Cartilage restoration and graft-based techniques may be indicated for large or cystic lesions, high-stage lesions, or revision cases, though pediatric-specific long-term evidence remains limited. This review summarizes contemporary assessment, imaging, treatment options, rehabilitation principles, and long-term considerations to support evidence-informed clinical decision-making.