A 23 year old male patient arrived at our emergency department after an acute ankle sprain with pain and swelling of the ankle. Injury mechanism was a supination and inversion ankle sprain when dismounting from his bike. The clinical examination showed a swollen right ankle with pressure pain over the lateral malleolus. Examination according to the Ottawa Ankle Rules demonstrated no other local pressure pain. The range of motion was significantly decreased due to the pain. Plain x-ray showed no bony lesions or fractures (Figure 1). The diagnosis of a fibula-calcaneal ligament lesion was posed and an ankle orthosis was applied. The patient was discharged mobilized with crutches under pain adapted weight bearing and heparin for thrombosis prophylaxis. Additionally he got analgic drugs.
Conventional x-rays antero-posterior (left) and lateral (right) of the patient after trauma. No fracture or osseous lesion was found.
After one week the patient returned to our hospital. He reported to be unable to weight bear and to have severe pain. The clinical examination showed a hematoma around the lateral malleolus.
An MRI scan was performed. The scan showed a rupture of the fibulo-calcaneal and the tibio-calcaneal ligament as well as bone bruise between talus and calcaneus. Additionally a line of the medial talar facet was found (Figure 2). Due to this finding we performed a CT scan of the right foot.
Several MRI slices showing the lateral ligament injury (left upper), the bone bruise in the calcaneus (right upper) and the coalition in the lower pictures.
The CT scan showed a fracture of a taloclcaneal coalition. This bony coalition was located between the medial talar facet and the sustentaculum of the calcaneus (Figure 3).
Two coronar slices from the CT scan showing the osseous talocalcaneal coalition with the fracture line (upper part), the lower part shows the coalition in the 3D reconstruction.
After this diagnosis we changed the therapeutical strategy to an immobilising lower leg orthesis. The patient was admitted to full weight bear in respect to his pain. The pain medication was addapted and thrombosis phrophylaxis continued.
BMC Musculoskelet Disord. 2013;14(111) © 2013 BioMed Central, Ltd.
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