Elsevier

The Foot

Volume 19, Issue 2, June 2009, Pages 133-136
The Foot

Case report
Neuro-epiphyseal injury around the ankle: A case report

https://doi.org/10.1016/j.foot.2008.12.002Get rights and content

Abstract

An epiphyseal injury without obvious trauma is a diagnostic dilemma; in neurologically impaired children, the lack of sensation and repetitive trauma can lead to neuropathic injuries of the physeal plate, with bizarre X-ray changes; the problem is compounded by lack of awareness in the average orthopaedist, leading to treatment delays and unnecessary procedures like biopsy, or even surgery for osteomyelitis or malignancy, with increased morbidity and disability. We report a 12-year male child with myelomeningocele and neurological deficit; he presented with painless swelling and redness of left leg and sensory-motor deficit below the knee joints. X-rays showed distal tibial epiphysis plate widening and irregularity. A diagnosis of neuropathic epiphyseal plate injury was considered; the clinico-radiological picture only resolved after rigid immobilization in below knee POP casts and abstinence of weight bearing. Lesser changes were noted in the opposite side also. The injured physis displaced somewhat posteromedially over 8 months, but ultimately fused; contra-lateral changes subsided with partial physeal fusion. The objective of reporting this unusual case is to increase the awareness levels, and to report the bizarre radiological changes. Management involves non-weight bearing immobilization; diagnostic delays lead to more reactive changes with higher incidence of subsequent physeal closure.

Introduction

Epiphyseal injuries have been recorded since the advent of orthopaedics; although the patterns maybe complex, the mechanisms are now better understood and the treatment protocols well defined. Bizarre presentations of epiphyseal lesions nevertheless confuse the diagnosis, leading to management delays, preventable interventions, and ultimately poorer end results.

Modern medical science has allowed many children with significant neurological deficit to survive into older age [1]; orthopaedic aids have allowed ambulation with significant neural deficits even in myelodysplasia and after sequelae of spinal cord injury. A new entity is thus being recognized, namely the physeal injury caused by repetitive stress on a desensate limb, with poor neuro-muscular control. This injury may manifest as fracture, epiphyseal separation, neuropathic arthropathy or even a trophic ulcer [2] in the weight bearing limb. Fractures in children with spina bifida have a reported prevalence of around 30%, and they usually involve the metaphysis or diaphysis of insensate lower extremities. A few reports also describe physeal injury or fracture, but these are rare [3], and in most cases the diagnosis is delayed due to lack of awareness. Charcot-like fragmentation and bizarre physeal destructive changes (and adjacent metaphysic) induce diagnostic errors; unnecessary diagnostic biopsy may often be done with suspicion of osteomyelitis or malignant tumors, with increased morbidity for the child [1].

We report a case with bizarre radiology and diagnostic delays, referred to us as a possible infection; the purpose of this report is to increase the level of awareness about this pattern of physeal damage in general orthopaedic surgeons; the unique X-ray features and the management by non-operative methods alone is highlighted.

Section snippets

Case report

A 12-year male child presented with redness and swelling of the left distal leg of 3 months duration; he was ambulatory with bilateral ankle foot orthosis, although with some support. He gave no history of obvious trauma, and there was no history of constitutional symptoms like fever, malaise or arthralgia. Past history revealed a diagnosis of spina bifida being made at the age of 6 months; he was operated three times during his childhood. Surgery for meningomyelocele was done at 6 months of

Discussion

Physeal injury is the least common neuropathic injury; it may occur in children with lower lumbar neurologic involvement who remain ambulatory. Neuropathic epiphyseal injury develops because of accumulation of repetitive minor trauma in the absence of sensations and proprioception in skeletally immature patients. Absence of reparative process and self-immobilization because of insensitivity to pain are factors for development of this pathological lesion.

Alarming roentgenographic features and

Conclusion

The present case is reported to highlight the bizarre presentation of this rare clinical problem. In the future, with longer life spans of neurologically deficient children, more of these cases may come to light; we hope that an enhanced level of awareness would make earlier diagnosis possible, and reduce unnecessary investigations and unneeded surgical interventions.

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