Congenital Pseudoarthrosis of Medial Malleolus in A Young Soccer Player – Diagnosis in Clinical setting of Ankle Sprain
What to Learn from this Article?
Diagnosis of congenital pseudoarthrosis of medial malleolus specially in a confusing setting of ankle sprain
Case Report | Volume 4 | Issue 1 | JOCR Jan-Mar 2014 | Page 11-14 | Giuliano C, Fabiano F, Gabriele P, Giacomo P, Enrico S
Authors: Giuliano C, Fabiano F, Gabriele P, Giacomo P, Enrico S
Nicola’s Foundation Onlus, Arezzo, Italy.
Nuova Clinica San Francesco, Foggia, Italy.
University of Perugia, Italy.
Address of Correspondence:
Giuliano Cerulli, Orthopaedic and Traumatology Residency Program,
University of Perugia, via GB Pontani 9, Perugia,
report a case of a young female soccer player affected by congenital
medial bilateral malleolus pseudoarthrosis and os subfibulare.
Congenital pseudoarthrosis is the failure of the bones to fuse prior or
at birth. The etiology is still unknown, although frequency is high in
subjects affected by neurofibromatosis or correlated syndromes, so it
has been suggested that these congenital disorders may be the cause of
Case Report: Our
patient, a 16-year-old female, high level soccer player, was referred
to us following a right ankle sprain during a match. She reported no
medical history of tibia-tarsus joint injuries or disease. Pain,
swelling and functional impairment were noted immediately after the
accident. Standard radiographs in the emergency department revealed a
displaced fracture of the medial malleolus and the presence of os
subfibularis. The patient was transferred to our Traumatology and
Orthopaedic Department to undergo malleolus ostheosynthesis. Before
surgery swelling, functional impairment and intense pain at the medial
malleolus level were confirmed. However, there was no radiological
opening of ankle, instability or pronation pain; furthermore the
flexion-extension was preserved with slight pain. Twenty-four hours
later a considerable remission of symptoms was evident with increased
range of motion and reduction in the swelling and post-traumatic edema. A
radiograph on the left ankle to compare with that of the right ankle
was necessary to overcome the discrepancy between the radiological
diagnosis and the clinical examination. The radiographic results of both
medial malleoli were comparable although on the left the os
subfibularis was absent. Since the diagnosis of fracture by the
association between the radiographs and the symptomatology was doubtful,
a bilateral CT was performed. The scan revealed a medial bilateral
malleolus pseudoarthrosis and an accessory right subfibularis nucleus.
The patient was discharged from hospital with the diagnosis of “second
degree right ankle sprain in patient affected by congenital medial
bilateral malleolus pseudoarthrosis”. A therapeutic-rehabilitative
program was prescribed for the ankle sprain and unnecessary surgery was
avoided. After 30 days there was an almost complete remission of pain.
At a follow-up of six months the patient was completely asymptomatic and
gradually began competitive activity.
accurate history and an objective examination should be performed and
correlated with the results of diagnostic procedures in order to avoid
the incorrect diagnosis of a fracture needing surgery. The rarity of
this ailment and the absence of consequences on long-term function, show
that this disease does not justify sports activity cessation. Traumatic
events at this site must be assessed properly in order to avoid being
confused with malleolus fractures leading to over treatment.
Keywords: Ankle sprain, medial malleolus, pseudoarthrosis Introduction.