Orthopaedic Case of the Month: Ankle Pain and Swelling in a 23-year-old Man

Abstract

A 23-year-old man referred by his primary care physician presented with a 1.5-year history of progressive left ankle pain and swelling. He recalled no history of trauma other than stepping on a horseshoe crab when he was 8 years old and having the tail removed in a local emergency department. He denied recent fevers, chills, night sweats, weight loss, or weight gain. Physical examination revealed substantial nonpitting edema around the hindfoot region extending up the distal 1 .3 of his leg. There was no skin discoloration. He had mild tenderness to palpation along the peroneal and posterior tibial tendons. There was normal strength and sensation in the foot and leg. No lymphadenopathy was noted. His laboratory values, including complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), uric acid, rheumatoid factor, and Lyme titer were all within normal limits. Imaging studies, including MRI (Fig. 1), CT scan (Fig. 2), and bone scan (Fig. 3), were performed. Based on the history, physical examination, laboratory tests, and imaging studies, what is the differential diagnosis? Imaging InterpretationSagittal T1-weighted (Fig. 1A), sagittal T2-weighted fat-suppressed (Fig. 1B), and axial T1-weighted fatsuppressed contrast enhanced (Fig. 1C) MR images of the ankle showed a T1 hypointense and T2 hyperintense soft tissue mass remodeling the undersurface of the sustentaculum tali. There was a small irregular central area of low signal consistent with calcification.Coronal ( Fig. 2A) and sagittal (Fig. 2B) reformatted CT images of the ankle showed an area of smooth osseous remodeling at the inferior aspect of the sustentaculum tali. There was a 7-9 4-mm triangular calcification adjacent to the area of remodeling.Radionuclide bone scan (Fig. 3) of the bilateral feet and ankles showed radiotracer uptake in the left posterior calcaneus.Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Neglected Foreign Body, the Cause of Navicular Osteomyelitis in A Paediatric Foot: A Case Report

“…Foreign body penetration injuries are very much common in Middle East region especially in children. Foreign bodies can be retained for a significant time before diagnosis, as high a 15 years [ 1 ]. In our case, the wooden splinter remained asymptomatic for three years.…”

Distal biceps brachii tendon repair complicated by a suture granuloma mimicking a soft-tissue sarcoma: a case report and review of the literature

“…14 The incidence of foreign-body granulomas after orthopaedic surgeries has been described to be 0.61%, and these have been reported as isolated cases. 1,2,9,10,[13][14][15][16][17][18][19]23,27 Few articles have reported on suture foreign-body granulomas in the orthopaedic literature (Tables I and II). [14][15][16]18,27 Morimoto et al 16 reported a 2-year history of a left buttock mass that rapidly grew over a period of 2 months after nonabsorbable nylon suture was used to surgically repair a hip dislocation 20 years earlier.…”