\

,
JAY
Foot &
Ankle
Pearls
BlellABD I I A Y. D P ~ I F.\ CFAS
Professor of Fool and Ankle Orthopedics
Temple University-School of Podiatric Medicine
Oirector 01 Foot and Ankle Surgical Residency Program
and Medical Education
Graduate Hospital
Philadelphia, Pennsylvania
HANLEY &. BElFUS. INC. Philadelphia
publisher:
HANLEY & BELFUS, INC.
Medical Publishers
210 S 13th Street
Philadelphia, PA 19107
(215) 5467293, 800962-1892
FAX (215) 790-9330
Website' hnpJ/www.hanleyaodbelfus.com
Library of Congress Calaloglng-ln-PubllCalion Data
Foot and ankle pearls f edited by RIChard M Jay
p ,cm.-(The pearls series)
Inc!udes bibliographical reieref'ICes and
ISBN '-56053445-' (alk paper)
1. Foot-Oiseases-Case studies. 2. Ankl&-Oiseases-Case studIeS. I Jay, Richard M
11 Series
, Foot DlS8ases-diagnosis-Case Repor1 2 Foot Dlsease5-(jjagnoslS-Probiems
and EXefClses 3 Ankle tnjuries-dlagl'lOSls-Case Report. 4 Ankle Injuries--<liagno5ls-Prob!ems
and ExercISeS 5 Foot Injuries-diagllOSls---Case Repor1 6 Foot Inluries-<tlagnoslS-PrOOlems
and ExerCIses. WE t8 2 F687 lOOt 1
RC9S1 F66 2002
617 S'8s-21
2001039937
Printed In Canada
FOOT & ANKLE PEARLS ISBN 1-56053-445-'
02002 by Hanley & Betfus, Inc. All rights reserved No part 01 thiS book may be reproduced,
reused. republished, transmitted In any form or by any means. or stored In a database or re-
trieval system without written permission of the publisher
last digit IS the pont number 9 8 7 6 5 4 3 2 ,
CONTENTS
"alieni
I. A 43-) Cllf-Old \\ oman with a painful and swollen grcallOc ........................... .
2. A 43) car-old man with constant heel pain ........................................................... .
3. A 24. ) Car-old man with a crushed foot ............................................................. .
A 56-)car-old \\ Qman Yo ith :.hOOling posterior heel pall!... .................................... .
5 A 63-year-old woman y,ith insulin-dependent diabetes and non healing ulcers ... .
6. A 46-year-old man with a cyanotic hallux and fifth toe .................................... '" ..
7. A 46-year-old woman with a hoI and s'WolJcn fool ......................................... -.... ..
8.
A 22-year-old man with pain in hi s third IOC ....................................................... ..
9. A 33-year-old wi th a painful right ankle .................................................. .
10. A 56-year-old man with a traumatic injury to hi s unkle ........................ _ ............. .
Page
1
3
5
7
9
"
13
15
17
20
11. A 44-year-old wilh right foot pain of insidious onset ................................ 22
12. A 60-year-old woman wilh a continually aching arch........ ................ 25
13. A 52-year-old woman with a painful bump on her foot . 28
14. A 71 year-old man with an itchy. scaly rash on hi s upper and lower
extremities and a lesion on hi s right fOOL......................... ...... .... ... ..... .... ...... 30
15. A 51 -)car-old man wilh chronic diabetic fOOl ulcerati ons ..................................... 32
16. A 74-year-old man nonlIaumatic heel pain .................................... .. 35
17. A 52.year-old man with an 8-month hi story of a fOO( ulcer . ..... ......... 37
18. A 13 year-old girl wi th lateral foot pain ....................................................... _......... 39
19. A 15-year-old girl with pai n in her second toe ........................ ......... -'2
20. A 13-)car-old gIrl wilh a painful fOOl ................ ...................... 44
21 . A I-' -year-old boy wilh severe fOOl pain caus ing him IO cl".1\\11 ......... .................... -'6
22. An 8-year-old girl with nightly heel pain ............................ . ........... ..... 48
23. A 19-month-old girl who is unable to walk ........ ...... .
50
24. A 6-yearold boy who walks wilh flal feet.. ............................................................ 52
25 A 58. year-old man with complications after anhroplasty ...................................... 54
26. A 19 year-old man wi th a soccer injury 10 hi s right ankle ........ ....... ..... ......... 56
27. A 14. year-o ld boy wil h an internal rotat ion injury to hi s anlie ....... 58
28. An Il -year-old boy with arch pain ..................... .. ........................... 60
29. A 72-year-old diabetic woman wi lh a plantar ulcer.. ............................................. 62
30. A 65-year-old. insuli n-dependent woman wi th a painful ............................ 65
31 . A 23-year-old woman wi lh excruciating foot pain after a mOlorcycie accldent. .... 67
32. A 34-year-Old woman with higharched fee t and ankle pain............................. .... 69
,
,I
1-'.
-'"
_1 5.
J6
37.
18
.\9.
"".
"'
42.
\11 I t .)l:ar "M girt a toe ...... .
\ man .... ilh per:'l,!.::nl ankle pain ....... .
-\. -l6)car-old "oman ..... I[h a lump on the top of h.::r foot ..... .
\ m.1Il l\tlh a painful. JI'iCoton.:d gr.:::lIlocnail ....... .
.\ '6-yc<lr -olJ .... oman ..... Ith Idl lordoot paIn after a jog ........ _ ... _
.\ 61 -}''::.1r-olll man .... jlh !>Ollllssue at ank!.: and heel
\ m:m "'Ih a p..1mful ankle .............. _
\ !l-)ear-old .... oman II IIh a painful rom
An l:I.l-)c:ar-olJ man v.lth paintul hallu:>.
\ l>o'omCtn .... ,Ih a r:ti-.ed mass on her 'iCeond t<x! ............... .
C01'<nms
12
'"
76
78
80
82
84
86
88
90
"'
\ 2-1'.::ar-oI0 girl II ilh ('Ill! -.tlcrely flattened fOOl 92
'".
.\ lxJy .... ilh a pamful right arch .... , ................. 94
"5
A JO-Yl' M oltl man WI [h a clini cally deformed Ide foot and ankle_.. 96
"0.
A ... ar -oIJ niliner wilh per\i)[enl :lnkl c pain ..... .................. ....... ....... 98
"'
A 511-) car-uld \.\(JIIl.U1 \\ i[h <;c\crc. Tn'urring foot pain ...... .. ................................ .
oll!. A IO'ycar-oIJ hoy .... I[h a limp ......................... .
49_ 1\ J-yc:l r o!d boy .... i'h bowed legs_
100
102
104
,0 ,\ 12 yeilr,old hoy .... lln p:lIliful. achmg 106
51 A 5,).:.,r old boy WI[h persist<.'lIIldt fOOl pain..... . ...... _ ...................... 108
52 A 6,)ear--oIJ gi rl .... ilh di!>Comfon in her hands and f .. 'Ct. .............. ... ............ .. 110
1\ ... :lr-1IId.moln \1 Ilh .1 , ti lf hilllU\ . 112
54 A 52-).:ar'll ld .... 011 ... " \I nh hurning pam 10 h ... r forcfoot. ....... 115
55 A .l().ycar-oIJ mall \I uh J progrc!>!>i\dy flattened roue .. fler a mlllor jail .............. 118
56_ A 14year-old boy \I I\h pain in his knee ......
57. A 27 month-old gi rl \lho is unablc to \lJlk . .... .
58. A l:! -},c,lf-tl IJ buy .... ilh a painful and s\lollen ankle .
59. A J 7-)"' 3rold hoy \I ilh "red. 1> \\oll.:n toe
60. A 41 -year-old \Inman with a d,lrkened Ilnd painful [oc .....
61. \n S6}car -1IId m.m .... ll h chroniC fOOl rain .....
II:!_ A IO .. e .. r-oIJ boy \\lIh a painful. '\\lJllcn fllol.
(jJ A _IO-) ... ar ul<l man I-I- I(h painlu l. 1\ ann. 'pfl'aJ ing cellulit is "flhe leg .
(.14 A diabcllc man \\ ith a foOl ulcer
65. A 55)car-old nMn I-I-lIh fc\er . crythem;l. :tnd purulent drainagc from
th.: fight Ie!!: .
66. \ .n yearold \\.oman with a cold fOOl ...
67 A 50-)-car-old pb} ... r \I i[h acute l'alf pain .
121
123
125
127
129
UI
134
136
U8
I,,"
143
,"6
1
CONTNTS
, II
68. A man with painful thigh muscles ....... . 148
69. A ))-),cllr-old "om.1n with ht..',d pain .. .. .................................................................. 150
70. A 4O-)car-old diabetic man with a persistent ulcer ............................................... 15)
INDEX .............................................................................................. ........................ . 157
CONTRIBUTORS
Richard M. Jay. O.P.M. . FACFAS
Fool and AnI-ie Onhopedics. Tl!mple Unh.crsily-Schoo] of Podiatric
Philadelphia: of Fool and Ankle Surgical Residency Progrnm and 1I.k-dical Educa-
tion. Philaddphin. Pennsylvania
The Crllduatt Hospital Fool li nd Ankl e Resi dency Progr am
Phil adelphia.
Jeffrey Deloit. OP.M.
Shunt! Ho!la\\dl, DP M
Robert r-,kCond,ey. [) P1\\.
Michael Ra) no. O.P.M
Brian Rei!. 0 P.M.
Thomas Lmdmo. O.P \1
Dawn 0 P.1\ 1
Barry While. DP \1.
Jodi Schocnh.IU', D_Pt>.1
;,
PREFACE
Fool (/lid A11kle Pf'orls 11> the latest \olumc in the highl) popuJJr Pearls Series. , This book
is a compiilltlon of interestmg and challenging C:1!>CS secn at Ihe GrJdu:ue Uospital in
Philadelphia, and II pro ... ides valuable infonn:ltion nOI readily av:ulablc in siandard h:xtbooks.
Each case unique and illustrulCS one or more or thcrap.:ul1c confronting Ihe
dinician. II is also "intcracthc" in Ih'lI the reader. based on the information represented
.llly relating to a pain loyndromc). is asked to make a diagnosis. The IS later revealed
and discussed. and aspeCts th<lt are especially importam arc caplll rcd und lislcllIII Ihc end of
each case as "Clinical Pearls:'
r ha\ e Ilvililcd Ul}self of the expertise of [he Gradu:1lc FOOl and Ankle surgical res-
idents. as they a keen anll observant eye for interl'sli ng and:lre among Ihe bright-
est and energelic I know. II .... nalUr.llto ask Ihem for help in pUlling to-
gelher this hook. Thanks to Hanle) & Belfus for allo .... lIIg me 10 reprint a few cases from
RIrf'wll<u%gy I'l'arls and hl/l'C'liflfls Disease 1'('<11'15.
Enjoy!
Richard r.,1. by. DPM. FACFAS
EDITOR
PATIENT 1
A U)t'ar-old ,", omlln wilh a IJ3inrui and swoll en greallfle
The palient Pr<'!>CrlIS .... ith a 3,"ay of pam aoo .... elhng m lhe Icfl big (lJt JOim She "11
huns 10 Cltn h:l\C= the Sheeh touch ffi) toe - The patient demes any hisl0r} of trauma to the left rOO(
. .nd ,hOlt she her primal) 00.:101. ""00 .. "tI on illdomdhacin 50mg BID. When relief
had not been obtained:! d:I.)"s later. cam!' 10 the emergeocy Jcp,'lrtmcnt for The patient
1\ without a \ignih,anl p;bt mel,heal
Phys;(QIExaminulio,, : Vital nannal. Generdl mild /lOnna!. Canl iac:
,<'gular role. no ClleSI. de:!f breath sounds. Abdomen' '>Oft. 1l0nlelldcr. E'lrenuues: palpable
pedal put..es bllJlernlly: a w,ollen, reddened, tender left 151 MTP JOInI of the left foot ..... ;'h 1+ non-
pUli ng NeurologiC: iniacl.
Luhoralory Findings: (He willi drffcrenlwl; \'; Be 13.30011 . ..1 (-WOO- IO.OOO normal); I) mpho-
les :'i(lOO/ .... 1 (100()....4"OO norm;ll). RlluiQgraph of left fOQ{ ('\Ci! hguI"I:J: erosion of the I1rM metatarsal
he;ld wtlh bone exhIbIting martd sign. Serum normal. ESR -'5 mmlhr (increased).
\rthro.:entnls !If len ht MTP JOint : incre;lscd WBC. spt'Cific:dly ncurrol'hils 85 {0-:2-' normal):
m"nosodium urate and display a ncgau\c birefringence under polarizing light
lTucroscopy).
QUfOftioll: What )"ndrome explams thIS patient's ami S)
Owgnosis: AculI: gouty anhritis
Discussion: Gout is a disorder of pUrine me-
wbolism characterized by hyperuricemia and
deposition of monosodium urJte crystals in joints.
Allacks may be precipitated by trauma. surgery.
fasting. infection. and medications such as diuret
ics. Gout is usually monoarticular and predomi.
nately affects the joints of the lower elltremity.
spcdfically the 1st MTP joint. This disease is
widely dispersed among many races and has a
higher incidcrtee in men vs. women typical ly Over
the age of 30. Women who are affected are usu-
ally postmenopausal. The between
the selles is belie\'ed to be due to the action that
estrogen plDYs in promoting renal excretion of
uric acid.
Pathogenesis in\'olves uric add. ei ther from in-
gestion of foods conwini ng purines (e.g .. shell
fish, beef. alcoholic bevernges) or endogenous
synthesis of purine nucleotides. Humans lack the
enzyme urica<;e, which ollidizes uri c acid to allan-
toin. Under steady-state condi tions. renal ellere-
tion is the mDjor route of uric acid disposal (ap-
prOllimately two- thirds). and bacterial oxidization
of urate into the gut accounts for the remaini ng
one-third. Two factors-either alone or in combi-
nation- contribute substanually to the hyper-
uricemia of gout: increased uric acid production
due to an abnormality in the metabolism (HGPRT
deficiency), and diminished uric acid secreti on by
the kidney.
The pathology of acute gout arthritis involves
urate crystallizing as a monosodium salt and over-
saturattng joint tissue. SodiUm urate becomes less
soluble at lower temperatures. which may explain
why the urate crystals predispose to deposition in
areas such as the toe joints and earlobes. The urate
crystals initiate and sustai n intense attacks of
acute inHllmmation because of their ability to
stimulate the release of several inflammatory me-
diators.
Signs and symptoms include redness, heat.
swelling. and tenderness of the affected joint. of-
ten with prodromal irritabilit y and a sudden onset
of pain in the early hours of the morning. The pa-
tient typically remarks Ihat it huns to e\'en have
the sheets of the bed touch the area. Serum uric
acid levels mayor mlly not be and often
there is an increased serum WBe liS well as an el
evated ESR acutely. Radiographic findings are
usually nonnal at this stage, but may demonstrate
soft tiMue swelling and joim effusions. Definitive
diagnosis is established by arthrocentesis of the
joint and synovilll Huid analysis. The presence of
monosodium urate crystals thaI are needle-shaped
and display negative birefringence under polariz
ing light microscopy is definitive. AI$(!. synovial
fluid leukocytes are elevated. with a predomina
tion of neutrophil s.
Treatment consists of the orlll administration of
NSAIDs. such as indomethacin. up to 75mg sus-
tained-release BID and/or colchicine. Colchicine
is II very toxic drug with GI effects such as nau-
sea, vomiting. diarrhea. and cramping when ad-
ministered oraily. it nas been suggested mat II
prompt response to colchicine is diagnostic of
gout. However. note that other arthropathies also
respond to colchicine. Also. if it is started 24
hours after onset of an attack. the response can be
variable. Other treatment options include an lOtra-
art icular injection of coniosteroids, administration
of ACTH. rest. and elevation of affected area.
In the present patient, a treatment course of
colchici ne provided a marked reduction of pain
after 5 hours.
Clinical Pearls
I. III acute gouty arthritis, ESR and serum WBCs are often
2. Presenceofneedle-shaped monosodium urate crystals with negative birefringence
10 synovia! aspirate is diagnostic,
}, Acute gouty arthriti s usuall y is monoanicular and is by prodromal im-
mbl1ity
4. It affects more males than females over the age of 30.
REFERENCES
1 t, ... tbllClicr Kl . 8",un ... ak\ E, Wit_ 10. cl It HlmS(,"'s Pnnciplc' of tnlCm:lt Mf"<l"'''It. f"<l . N . .... York. Me.
O"'''-H'I1. t998.
2. Klippet lit, WcylUld eM. Wonmann RL (cds)' I'nrll<' 00 1110: RIIe"m,ue Di'IC4$C'. t tlli cd. GA. Anhriu. FOII_-
I>on. t997
2
PATIENT 2
A 43-year-old man" ilh constanl pain
A 4l-)car.-old man with a :!. to Jmonth history of conStant left plantar and lateral heel
pam. He relates that he has c;t(pericnc('u intermittent fool and bilateral knee pain for Sur-
gical nrthrm.copy ",as performed on his bilater-JI with mild to pain relief. However.
pain in the lefl heel has persiSled with both ambulmion and nonwcighl-bearing .. md has become mildly
progressive,
Ph)'sical Examination: Temperalurc 98.6
e
F; pulse 711; 16. blood I SOISO.
HEENT: nonnal. Lungs: de:!!. Cardiac: reguJ:lf. Abdomen: nomcllder. Skill: normal. "ith healed
:lJ1hroscopy portals on the left and right p:lin on palpation of plantar medial
and !nler.u tubercles of left c3!cancus. and on laternl uf lert e,lleaneus: nomender plantar
iascia: manual muscle testing uf lower norm,ll.
Laboratory f ' illdings: eBe wi th differential: nonnal. Chemimy profile: normal. Lung function
tests: normal. PT/PTT: nomla! . CholesTcnJl: 109 {120-199 nomla! I. Palholog.v: Gross .pe.:i men -2.5
x 1.5 X I em aggregate of yellow bony MICfOs.:OPU: ,pedrncn-cystic v.ith dense.
h)alinized wa!ll;ol1f3ining area of bony som ... hemosiderin pigment deposition . .'ll1d areas of
Increased vasculari ty: sUIToul1di ng bone sho .... ed fauy replacement of marrow. Inwgmg: Radiographs
of right foot - no osseous pathology: len fOl)t r 'oCe lenligureJ- large intm..cakanea! bone cyst uf the
body. wit h well ... in:umscnbed borden;. MRI of leff foot righT figurel-int ... rosseous Significantly
l{lbulated calcaneal bone cysl v. ilh marled increase: ill imensity. indicall\e of high Huid COlltell\
0 11 TI,weighted image: signal imel1si ty comparable to fat and adjacent intramedullary
ho_,!, ... 0!' .. '.! ! .... ..
Question: What is the most lilely cause of the palient', heel pain?
3
f)iullnosiJ: hpoma of the calcaneus
Dill;ussiofl: [nt raosseous lipomas of the cal-
caneu are ntremcl} rare, They an: com-
monly found In the 10 .... 1.'1 e"remlt) than the up-
per ('''remll) The bones mot often affe(;ted are
the nletuph),scal regIons 01 long bones such as the
femur. tibia. ,md fibula. Irregular bones such as
the ho .... e\er. can be affected
TIle percentage of all bone tumors occurring in the
fOOl is less than 2q.. The maJOnty of intrnosseQU5
lipomas of the calcaneus are t)' pically found
within the central portion or body. Though un-
common. the dlagno'iS of calcaneal bone cyst
should bo! In the differential diagnosis
of luyplcal heel pain
The diagnosis of calcanl.'al bone cyst is based
on lhe p;lIlcnt"s hiStory, cli nical findings, physical
lind radluloglc c\aluatlon. There arc many
different of lied pam, Note that the ac
cllrate diagnusis of itraosseous lipoma can lead to
a pruper and effecti\e treatment for Ihe patlenl.
The patient was taken to the opemting
room. and an biopsy was pcrfonned
through a curved lateral Incision over the calca-
neus. A lateral conical window .... as created o\<er
the urtderlymg c)-slic lesion "1Ih a sagittal saw.
1be hpolTUtous lobular mass was remo\ed en toto
and scnt to pathology for frozen sp: imen deter-
mination and histological e\aluallon.
lbe scleTOlic ..... all of the cyst .... as aggresshely
curclled, 1be void was filled .... llh ground down'
mi .lture of autogenic Iliac bone graft and allo-
genic conic:ocancellous bone ,raft chips because
of the large sile of the IntfllOSseouS delicti. lbe
lOf'Ilcal ..... indow was replaced and sured with an
orthosorb pin. Closure was then po!rformed in $C-
quenllal fOllihlon.
The pallent was immobilized for approlli-
matdy 6 "ceks in a cast. and then ,i\en a cam
walker. ProgressJ\ e .... elght-beann' began at ap-
prollimalely 8 we<:ks, and at the 3-ffiOnth follow.
up the patient was almost lOO'l> pain-free In his
left fool. He relurned to full activity withoot lim-
itat ions. only occll'>lonally ellpcriencing discom-
fort in his Ie-ft knee 3nd fOOl If swelling occurred.
Clinical Pearls
I. There IIIC SCleral hypotheses, bulthe troe elJology of an mttllOSscous hpoma is un-
.... n
2 The pain of mtraos5e()US lipomas can vary from Intermlltent to constant. dull
aching. Upon palpation there may be tenderness in the In\ohed bone. and symptoms
rna) 1.m fOf )ears,
.3, MRI and IT SC3n can be elttremely helpful in outhning the borders or the leSion
nnd determining tIM: of intr.lOSstOu$ Invohement, They can also be \ery userul
when planntng the surgICal ucislOn of tJM! lesion.
4. There IS a risk for pathological fracture of the calcaneus ..... hen a large lumor or in
tfllOSSWUS C)st IS preSCnl. Therefore excislonaJ bIOpsy wilh curettage and bone grafting
is of len recommended.
5. 11Iough the lcston IS bentgn. th<: POSSIbility of mahgnancy eXISIS. either as a pri_
mary bone tumor or a secondary area of melastases-esptl.:lally if there is cortical ero-
Of eXp3nsi\e destruction of surrounding tissues,
REFERENCES
I Ik""lt'n \t J .. """.\M
1" hputtla>; Ra.l,oloj!>< ond nIIln,"au"". 1t:oJ .... t<.>iY 1()7 ISS-IOO, 1m
.1 S ti, ..... "ooA. <I at tnlr"",seoo.lipo" ... "fthtc.l<a .... u. J FUOI AnUt 1114\ 381 .184. I99L
4
PATIENT 3
,\ man "-ith a crushed fool
-\ man rekues a history of ha\'ing hIs right fool crushed in a h)drolic Jack.lift 2 days
19O ... aI TIll! patIent had immediate pain and swelling and sought treatment through em-
1"10) htalth. \4herc rc:\ealed no frocturc:s Of dislocatIons of the right fOOl. As pam and numb-
the patient sought additional medical advice.
PhYJical Examination: \ ilal signs; normal. General. mild distress. HEENT. nonnal. Cardiac:
fl:gul.l.l" ratc_ no munnur;. Chest .... kar breath Abdomen: !>Oft. nontender. nonpal-
I';lblc DP puh/;' "'llh a palpable posterior tibial pulse on nght: 2+ oonplmng edema to the medial fOrl:-
(,lQt and an-h area. (\Iends from arch to hallux and fiT'Ol lnlcrspacc. NeurologIcal: decreased
(["'O-polOt dlscrinllnallon, sharp and dull) dorsally. toes to ankle: all extensor tendon func-
tion Int:ICt. hut II1freased pain wllh ROM of to!! extensors.
La/mrntory Fj"dillgs: of right f(lO(: increased soft tissue densi ty; flO frnclUres or
,h,IOC3tions
Q"t)/iU/l: What this p3tien,s signs and symptoms?
,
{)iagllosis: Cumpanmcrn s)ndrorne nght foot
Discussioll : Companmcnt syndromes of the
upper and elltremltres are
complications of troUnia. Eighty peru:nt of com-
partment syndromes Ol'Cur rn the lmo.'cr c.\tremlty.
from trauma. OIher etIologies fracture.
musculoskeletal surgery. hematoma. and infection.
Early sIgns and symptoms are: pain (usually
OUI of proponron to what is expected for the elin-
i.;a] 5itual1on); Increased pam with Sln:tch
of tendons m the suspected an:as of disorder-the
ostc:ofascial compartments; the presence of pulses
or. in sc\ere or advanced cases.
follo .... e..! by h) and anes
thesia; pink (normoal) capillary refill; and de-
creased sc:nsallon m the dismbul10n at the po"te
nor !lbial . deep peroneal. or superficial peroneal
ncr>es \1.1 t"'u-point discrimination. lighl touch.
and pm prtck. Note that the mOSt reliable indica
tor of the \yndrome an mll11Compartmental
pressure > 30 mml lg as measured by a Wicks
catheter,
Compartment syndrome with increa,<;ed
pft'ssurc causrng increas.t.-d pressure on the
\t'ssel This leads 10 increased \enous pres-
sure. a decreased arteriovenous gradient. and
overall decreased local blood now and oxygena-
tion. After approximately 30 mrnutes of ischemIa.
part-Sthesla occurs. Withrn 2-4 hours. functional
occur in the in\olved muscles. resuillng
In paresIs In 4-12 hours. IrTe\"er<;ible muscle de-
terior-Illon bcgmJi. and In 12+ hours. contractures
form. After 2" houro; marks lhe onset of m)oglo-
binuria. '" hich. If unrccoglllleu. can lead to a<..'ute
renal failure.
Tllnc IS of the e'-"CllCe 10 lhagnosrng and trea!-
109 compar1menl syndrome. IlS lhe late scquel3C
are permancnl dysfullI:tlon and dl sfiguratlOn
r reallnent of removlOg all casts and
un:s;,mgs and kpmg the hmb at hcan le\e1. as
ele\3lton create\ more iscncmia and interferes
'" ith \enous return. II)dr.ltion is also Importanl to
help counteract the effects of m)oglobmuria. In
scvere. pmgressi\e compartment
gical decompression is rndicated \ ia either a )in-
gle or dooble rnci'lon that ..rdc:qu;ale de-
compression of the Il1<'dial. interosseus.
and lateral compartments ('iCC figure).
In Ihe presem pallenl. a wrgical incisional re-
lellse of the medial and central .;:omparrmcnts re-
!t01\Cd the )'nurome.
Clinical Pearls
Remember the 7 Ps: pain. paresthesia. paralysis. p:lin on ROM. pulses Of
and pml.
2 Companment pressures > 30 mmHg are diagoostic of compar1ll1<'nl syndrome
J. Do not elc\ate the Irmb in quesllon.
" H)"dnlle tnc pallent to pre\enl m)oglobmuria and acute I\'nal farlure.
5. The btM treatment of compar1mcnt \yndrorne is fa)CiolOmy.
6. Late-stage findings are drop fOOl. <:Jawing of toes, .urU sen-loOry nllu i-..:helOlC
chan!!es
REFERENCES
I E. n"" ... y M ,,( FOOl !lI(\nI Il.hi"",.. \tt). '" W
.
MIf"'''' M 'I"' .. of "'mpanmc:m 01 111<,,,,,, CIon Onllo. HI. 1"'11
6
PATIENT 4
A 56-) ('lIl"oold "ORlan wilh shoot ing posterior h('('1 puin
A ... oman ... ith a j-month hhl(lf)' of JIO"lenor '"penor righl hetl p3Jn. [ni
nail). she' noticed ,harp. r illn 1ha1 remluing. but 11 10 ap-
proJtlmau:ly \-4 ... ccks alter Ill<! on.el 01 initial mplOIl't'> [rrilJling pain. s",clhng. and leBde:mess are
present ",uh boIh .tmbul.ltlon ami noolOoeighl-bearll1g. but are especially uggrJ\Jtoo ... j[h octivlljI. lbc
pJllcnt d.::nie\ :Iny prt'tlpJlallng JCllvi'y ()f history of trauma 10 the area. Con..crvalive treatment ron
oLmll.mHamm;Jlory medi(aliun. tllt-rapy. (am'" .Iller. In..J ..... I[h minimal ",hef of
,ymptoms
Physical xominatilm: T cmperalure F. 74. 17; blood prelsure 145180.
HEENT: n\lrmal. l.ungs: .' !car. Cardiac: regular. AlxIom<!n: nonlcntler. Skin. norrn:ll tnlure!turgorl
ternpernture. pain on l'.ilp3tion of po)t.:nOf l\)pcCI of calcaneus and
tendon Jt us mscnton; )lightl) pruxun31. p3lpable oss<:ous PrQlubernllee on superior po!i terior
,urface of right nontender plantar or plantar rnedialtubcrcle of calcillW!us: no of
crepitus 011 ROf-l uf fight f\chilies tendon. but posltile Ji.>Comlon on dorsiflexion 3nd plnntarflexion
.If fight mliltual mu..cle of lower extrernlly - dccreased pl:lntarflexory p<)\\ef of the right
all other mu..clc grouP) nomtal
l.ooorolQry Radiographs of right foot/ankle Imld anhntic changes t11 ankle 'WIth tao
lar hppiug. deneased calcalt<:31 meltll31l0n angle .... tlh mild prominent posterior caka
(Ilaglund,dcfomllty/. prominent plantarcalcane.d f-IRI of right foouankk (see figure): lack
. J! humogenkuy \'-Ith multiple intrntendinous 'plit.,,: I11tratendmous flUid .... Ithm Achilles tendon
through multiple Oil D,iJI of T!-.... eightcd image; mcrc:3;,cd thickness of AC"hllles tendon
.md decreased signal int.:n,lly .... Ithill the tcndon approximately 2- 5 crn from A(;hliles msentunal area
.. n TI ..... eighled linage.
Qut!rio,,: What IS thl: moSI likely cause of the palienl"s posterior heel palll?
1
IJillgnllsis: Chloni(' lem!on rupture with minor IIJglullu', uell>mnl)
Disrussiun: Ptxlenor heel pain can
man) entities. Ro:trocaleaneal or retro-
oorslhS. Haglund's deformlly. Achilles
tendon d),)funC"lIon or rupture. retrocakancal
'pumng or enthe<;()p;lIh). and possible fracture
... re some of the ITl(){e common 111 the dif
fercnhal diagnoSIS. A thorough history and phys-
ical. as as plam-film i1Idiography. bone scan.
and MRI can help )OI.If differential.
1be dlagnosts of chrome Achilles tendon tt'ar is
based on the patlCnt's sympl:oms. the: physical
.:\am. (Illd. man) magnelic rewnancc imag-
mg. lbcre are >,Cleral hypotheses regarding the
of Achilles tcndon rupture. Some of the
morerecogOlzed etlologles that haw b..'Cn linked
to the indude intr.llendinous steroid injec-
ticms. mUloid degcneTat10n and microu:ars wnhin
the [endon. ph)'sicaJ traming .", ithout
proper ""armup. chronic tendinous inflammation
or and re[Jl)Cakancal
\.\hen the diagll\)';ls uf chroniC \chille) [enOOn
rupl:ure is thoe ma.k. the mo.t then ,m-
plement a tre:ltmcntl'UUN. Cunsef\;;[lvt: therapy
I) often emplo)\',j tlf)t. con'Nmg uf a LI.Unbllla-
tiOll of NSAIDS. n:\1. ph)'lcal thempy Csu...h ..
prorn<Kcptl\t: e\erci..e). ullr:t-
sound. ice. "hirlpooll. JoCl'Ommodaule paddmg.
hcelltfts. and fUrll.:tl\.lnai If cnfll,cnatJle
care is exhausted any relid In
sympl:OIIb. then inten'cntion i) usually IIn-
dertaken. Surgical lre!llment ten-
don repair. and (If
C.1k1l10515 and at,) bon)' promil"ll!n(s as deemed
appropnate. VanOti.'> tt'(limquc, and post-
opcmtil'c protocols th:u mH( hcen e!>l .. blt,ho..-d;md
n:lillt.-d olt:r the }ear5 h.I\( effe-ctile.
In the pn:ent ,J IC])3If lit the
"as performcd. ulonll Willi a re"'::l1l1m Of1hc: rt:lrO-
ealcllneal spur She he,dt:,j \Iocll. and the pam
re\Ohed.
Clinical Pearls
I . There ure many regarding rupture of the Achilles t,ndon. hut the true eti -
ology IS unclear
1. lbe Icndon I) dlftcrem fron1 OIher tendon, 1II!>Cl1l1llllnlO the footllccau'>C
Illa.cls a s),nol'ial sheath. It has a paratenon
J. The Ach,lIcs tcndon has an area of decreased vascularity. lno""n lIS tile ..... au .. r-
This area IS approllilnaleiy 2--6 cm proximal [0 the 1II ..... 1110n .lIld is
panicularly IUlnerable to rupture
4. MRlls u..efullll delenmnlng Achilles tendoo p.llholv8Y. pal1ll'ularly in the
a.llal and v'e ..... s.
ConSC'f\-aulc therapy of len falb loallel-iate the S) "'"h lhfl)fIIC
,khllles tendon ruptures. Surgical mtef\enliOll may be 1leCCSS-af)
REFERENCES
Clomcnc 08. IF_ S""", GW Mh.Jlln >tJJd po<nlmdon,,,. EclOlojl)o.md UuC"..nl A,m I M<'d
!'N-ll!-'. t98J
, N. T""" \. C"PI,'OG ten<l;", "'",un: ,n .thlcltll ""I ... hem,>!,), ,of IN Inul" ,,,,'"" ,,,.,,,k J r ...
. 1101 t 1'A1
A <;UlJf'" f" .. ,hronk- I,h,tle-!; I I'ooC SIll1 .UO 1) .!<I.11OO.

PATIENT 5
A " oma n "il h insulin-dt'pt'ndent di abetes and non-healing ulcers
A 6)-)eaHlld .... om.m rn:Sc!nls with multiple small ulcerauons on the dorsum ofller "ght foot. lbe
Oases of ,.,.. ulcer; are Ik!crohC surrounded by pen .... ound hyperpigmenlcd 5Clcrollc plaque. 11lc
p3u",ru a long history of non-healing ulcers on the dorsum of her right fOOl. AI age 61. an erythe-
matous p:lpule in IhiS same area. lbe lesion remained relatively stable for 12 months, but
Ilkn began [0 erode and become Inflamed. and she ooled purulent drainage from [he penphery of the
k)lon
Physitai ExaminQtion: TemperatuTC 98.9" F: puh,e 82: respirations 18: blood pressure: 188189.
'ilun: otherv.-i..e nomlal. nonnaL Lungs: ckar. Cardiac: nonnal. Abdomen. nonlender. Lower
",,'remit),: lion palpable dorsahs pedis pube on the right foot. all othcr pulses weakly dIffuse
no, ... d entire dorsal aspect of right fOOl: necrotiC base of ulcers. fibnnou5 lOoound edges.
(lCnwound hypcrplglllcnlcd sckrouc plaques 5urrounded by 1'1) thcmil (sec flgure).
IAoorQtQry f'i"di"KS: WBC 11.000/ jl.1. hemoglobin 10 gAll. HCI 26.9%, p)3tclclS ]00,000/1-'01.

the etiology of tho: ulcen?

Diagnosis: Necrobiools Jlpmdu;a dlabetirorurn
Disc:ussion: hpoidica. at:I:ording
10 ,"luller and Winkelmann. IS a tk'gc:neratile
e..sc of dermal o:ormcclile tissue characterized dln-
ieally by an inHammatory, pretibIal. sdc:rodcnna
tOllS plaque: thai is of len associated .... Ith diabetes
mellitus. Nt"CtObKbls lipoidka is nol dim:tly
lall:d 10 hypc:rgI)C1.'lTUa. but rlUher IS a result of de-
pol>lts of immunoglobulins iInd complement In the
ICSSCJ .... alls. L'lIman and DahJ suggeSt thai the
pathogc:ne:sis of necrobiosis is an immune: complex
lascuhtls. nus is supPOrted by Handelsman ..... 110
beilCICS thnt agJ)l:Oprolem isdc:poslted in the blood
leMel .... aJls and bel .... c:cn the collagen bundles. WId
Ihallr1lUrna often determines the site of necrobiosis.
Pathologio:al findings of mdudc ill-
defined areas of fibrosis associated with granulo-
matous inhltrnte .... Ith and plasma
cells. Histologically lhere is palisading of hislio-
C)[C5 aboullhe ncx;roblotic areas. especially in di-
abo::lle who are more likely tu hale mli-
mal thickening and perivascular fibrosis of the
middle and lo ..... er dermal vessels close 10 the:
nCC"rOOlOIic areas. Deposition of fal is lllso seen in
till: necrobIotiC" areas.
Necrobiosis lipoidica usually begins as an cry-
papule or nodule. The leSIon becomes
a wuy. or )ellowish-red sclerotic plaque_
The: eentrJ.1 ponton uf the leMon shghtly
-.caly, atrophIC. and <In,j uk-crntion may
develop The most common locatiun for nc:.:robi-
olle lesion) the pro:llbllli region. "They may also
be mamfe:sted on the thighS. poplittal areas. and
dorsum of fcel and arms. The tend to be
multiple. bllalcral. and 1\IiMiiagno.
sis can occur because of lar1allon III size.
locallon. or IIIflummalUf) dcgener.ui\"e thangcs.
1be diffcrenual of necrobiosiS IipoidiC"a
should irx:lude granuloma tmmdart.
dc:nnalltis_ posltr1lumallC fibrosis .... llh lic:lIl(J\oidcro-
mc:um;lloid el)'thcma loourntum. ec-
thyma. nodular pannlCulllis. and
Treatment of till; Ie)ion is quite controlersial.
Howe\er. most agl"L'C Ihal although this lesion is
cummonly 5C:cn in dlaixtio: pallencs, complete
control of the dllibetes docs nOl nffecTlhe course
of lite lesion.
The pn:se:nc patIent had necrobIosIs lipoldica
dtabeticorom thlll secondnnly infecled by
r11Cthycillian-resi"lant Srllphvll)("'}("1 liS IlIIretlJ.
The p;llicnt undef"\\cnl a pophlcal-dOfiJlis pedIS
byp;ns to lIlcrealoC blood How to lhe inloh'ed area.
The ..... ound!; .... en: debndl'\llntmoperalllely. and a
rull eoun.e of Vancom)cin .... a) lbe
pallenl .... enl on to heal
Clinical Pearls
I NecrobIosis hpoidica occurs in both dlllhellc and nondlaheuc pllilents.
2. nOl directly related 10 hypcrgly(:Cmia.
J. SpontaflCQus rcsolUllon of lesions can occur after lears of
" NecrobIosis is most commonly foond in lhe: pretibial rcglon: no .... clcr. II can oc-
cur on the ThIgh. popilleal fossa. dorsum of fOO( or forcaml. and Olhcr areas.
REFERENCE
Campbtll DR D,"""".; .:asculu d,,,,,,,,,,,. In Ff}U""'11! "The Ihgh F_ In 1n4bcles ".'" y, ... Chun.h.1I1 "
,n lllOOt. 199(. lIP 11-38
10
\
PATIENT 6
A -'6year.old man \li th a cya notic hallu'I; and firth toe
A -l6-)ur,old man prC'>CnlS '" nh d hl)IOf)' 01 locrea".ed of the hallux and the fifth
1< 11: pl:mt .. rl). locrea.'>tu w.clhng. ,m.! Cr1IpllOns Clf mulliplc bullae. The p;Ltlcnt has a long hiSIOf)' of
and alcohol3busc and renlly hvmg III an unlicaled. abandonc"! hoouloI:. He ",as brought to
Inc by hi.) IfIOtiwr for of .... nh '>Cconu:lry bXh:rial Infecllon on his
t- uuocks and b.i:lteral thighs_ l1le pallelll had hi" third and founh 10.::.<.10 frostbltc 3 )'ears earlier.
Physirul EXQmilltltiQtI: Temperature 100.6' F; pul"e 65; re"pirohon" 15; blood pressure 100/68.
1)),,111: large erupnons of herpes zoster clfeeling multiple on the back. buttocks. and po!;IC'
flor thighs. HEENT: norm:!l lungs: dear. Cardiac: normal. Abdomen; non-u:nder Lo ....... r e.\lreml l)' :
puhes palp;lble III ami jXblerior liblJI ;lrlail's; haliUll and l:nera! digits cold, .... ilh
pedJI et.leuM: lIlultlple bullJe \\ 1111 dear lhlld pl:lmarly Ilnder .. hgns (<.et' figurt); de-
epicritic, :Hld
Lo/wrOfIJry f 'il/dil/gs: Wue henmglobin I I gld1. Het 29,9'iY, plmeletl> Un,
nal)'\I): Ilormal.
Qnutil/ll : \Vh,1I Ihe l'linlogy of Ihe pedJI prc\l'llt;uiou'?
II
f)isC'unio1l : FruSIbue Hn mJul) Ihal
ffllm c\lJOSlng the bod) 10 [empo:ra[ures 01 0 de-
gltts or colder: pcriphl!r.ll fn.-cze 3\ IhI: (d-
lular le\el, Ha)cset OIl suggcst that thi s leads 10 in-
flammatIon. lree radical - induced damag.'.
\3S<;ular dcficlclK'lcs. platelet fUllCllon abnormal-
lilt'S, and l<.I:hemlc-reperfusion mJury.
The of ffO.'itbllC: has been 31-
tnbuted 10 1110 0 dtshncllTk. "('hanisms according to
Weatherl y- Whllc e:1 al: III cellular demh that oc-
3t the: of e\pusure, aod (2likterioration
and 1k."'Cl'O'\is attributable: to Ikrnul
Ischl:mia.
Clmical of frostblle bc:c-n
categonled according to Murphy c::t al mto four
f-'i rst-flcjtrH pn:.ents with a
ccn1fah/ed ..... hue plaque that is numb and sur-
roundcd by erythema, injury
bliqer ""ith a clear or milky nUid Hnd
rounded by el)thema edema, Third-dcgret'
injUry is charJctcTlzed by hcmorrhagic blisters
thaI result m hard. blad CM:han. 2 weeh IJte:r.
f-' ourlh-dtj.: rl't' InJul) produces cornplete neero-
)t) pnd loss. HOllc\er. thiS !>taging doc!> nOI
hl:lp In pn.-dtcting the: ellcnt of lis)uc loss.
R.tdiogrnphic imaging can aid thc ph)siC"ian in
predtctlng the: IClcI of demarcation or tissue loss
Pl:un r'3Chogrnphs can demonslrnle soft tissue
' ..... elhng In early stagcs. and osteoporosis and pc-
nO'>ltliS III latcr stagcs Gr.tlioo SU"CStl. that ane: -
riography can demonslrnte the sto ..... mg of now
and OCelU'IOOS Ihat oc.'ur. but docs 1101 ndequately
danfy the: lelcl of injUry Bone: scan. according to
[La ..... l1. has no ..... the imaging
'itooy In lhe: first few da)S of mJury and can be
useu to gUide a surgeon and allow earher debride-
menl of d:unag.:d areas. HOlloc\er. 11 does oot
"clearcut"' k\eI uf deln;lIT.tI1I1Il. \IR .tn-
glogr.l phy b.:cn <,ug1!e-red IU .tIU m the xo:u-
nll:y of dctemllntllg the Ic\ cl of demarcailon:
no ha\e )ct publtshed.
AI:curdmg lu \hlrrh) CI ,II. there are t hrl'4!
phases of t n'lll nlt'll l lor fro,tblle. Fi.-.;t. in the
prethaw ph:I...e. II I) Impcrnule IU pnMed area
Invohed from rllo.:chanio:allTauma or from slollo .. d
relloannlng In tho:: .... ,uod phJ;,c:. re ....... mltng. II is
imponant 10 mpldly rcllo.ulll the: areas,
Placing the: Imohed "l""rnille' III .t 40- 1042-
degr waterbath IIolth or bela-
dille fur 15 10 JO uunute) i, the he!>I IIoJy to ;JC-
eomplish thi S Ac!i\e moIton of thl: lIl\olled
parl al'-O recommo: mkd.
MeCliule} 1.'1 al hale re<,omrnend.-d a pltOl."Q1
for the iinal. P'I"nh.tw pha,c. l'aranlOunt arc , up-
pres, ion of 1000al "nu ) ,ternle Ihromholane. ade-
4ume and prevenltOn of infecllon
Ibuprofen (a 1Il111lluor \l lthromoounc)
and aloe \crJ (a lopi,'al antllhromoolarl!:). cum-
bined II ith p"llIciJliu nnu a 'tleh ru.
lnpel1l1i)lhnc" lIn nnpr(l\',' t"Mle De-
bridement of clear IIhi(h represent ,u-
perlictal tnjury. can reduce fUrlher COntllCt II tth
the high lel'(1.. of I'n"taglnndm 1-'2 throm-
A2 III the: e\ uua\(. IIcroorrhaglc bltslel");
that represent dam:!ge to the Jermal plelus may
benefit from 1I,pITatlon: ho ..... e\cr. many belle\e
they )oould be left Int tlCt
The current patient pre)t."nted 1>1.'1\;1"111 dolyS after
InJUI). thus lbe prethlw and r.tpld TCIIoanmng
phases could nO! be Ultllated. Ilts clear blisters
IIoere debnde.:l. and Mllee f'TeH'nlion \If Infernon
IIllS 1I priOTIty. be ..... as pl;!Ctd on The pa-
llen! IS sch..'tIuled to( follollo-up ap-
pointments to wat,h for Ic,el tlf lIeman:ation.
Clinical Pearls
Management of Injury IIlciulle:
Protection of the inlolved area prior to rc ..... amung
Rapid re ..... armmg III -40- !0 ...... lICIO.llh II Ith h(\J
eh lorophl,nc or betadlnc for IS to lO minutes
Tnple WI[h ibuprofen. al(>I.' \cra, and pcllluitin
2 Bune \('an can atd In ellrly delennmatl(1n ofthc Ie_dot
.1 Complete: dernOlrcmion of the in\oll'cd cltrer1l1ty , houlll be 3('411Ired t"oI;inre ..
llcbrldcmcnt is all\;mpled - bamng of infl"Cl1on.
REFERENCE
W",hhum II .. ,, "'lui IS II. h"" 10 1""""11\ ... !>;n ( .. J \kV
12
I
PATIENT 7
i\ -Ui- )l'ar-old ",oman ",-ith II hot and "' ''''ollen foot
\ -I-)O:.lrolo.l \lum.1Il pre..enh to rhe cmcrgcn.:y \\ nh a fro. hex, and fOOl thai
(;Iu'lRgl'io!-r p':IIO. 'ihe that (ncr the coot'< of7 dilYS the fOO( oc-came masSl\cly edem:uous. red.
"lIoJ \l'r) lO..lrrn She .knits any hi,tory oflrauma.lbe patient has a p:L>1 mo;:dlc;i1 hl)IOr) .. ignificant for
in,ullllpo.'nlkm and h),pcncnsion.
Physical Examination: Tcmpernlurc 97.9 F; 63; rcsp,ro.lIJO'iS 16; blood preS5ure 100,56.
nvrrn;i.1 IIFI,NT rl\,mlal . Che\(. clear. CaJ"d,JC: normal. AbdOlllcn n\lnlcn<kr. LolOocr
!101I p3J('.lble Jor)3h) pedi, an,j posterior tIbial on lefl fOOl secondary 10 maSSI\C edema. audible
\\ cth Doppler; leu fOOl "'.1m, III cmnpar;"on wi th conlralalcral side: grad<: 2 pi ning edema from distal
left (O\){ 10 1l1luJk Ihml of Iellieg. Skin: IJrge bullae on plantllr distal 1eft fOO( from 3
!(I 'i. )IOJ II Ie,iull with Ik;mllrrhagic ct!ntral area lit .. r\a! 2.
l .lIoorulor), Fi lldillgJ: \\ B(' J J.llOOhd. JIg 12 1. Ikt 29.-'. platelet 200.00011oL1. Uri ualysi.'>: 1I0r-
,n,d.
Qllu rirm: WhJI" the ellolugy ut thi, loot dhonle(1
\J
OiognQsil': Punctun: l'ooumJ ",uh lorelgn body
Oisru!i!iO/I: A \.mely of r"rl"ign NlI.hc\ .11'1.'
eo>rnmoo follo\l In!: ot pUrlI.!Un: \\Ioul1ll Sennll\
can dc\l!lop If Jnd
IreJ.lmrrll not ('Oll1phc,l1ions mot)'
ioclude epl<lemlOl<J mdu
.<.eplK gJugrene. "-'p"'.
and possibly IlKS of limb or hIe
DiagllOl>ls 01 torelgn body Ix made \llIh
cardul :lI1d e\Jmlllalion. RaJIQ-
graphic e\alu3tlOO .an all metal fragment'
anJ mOSt glm rcganJles.s oflea!l comcm Tandberg
l'OflhrmcJ that JI1 \ i'lble r.ldIOgr.lphil-ally
because the density 01 the gJas.-. t!reater Itwo thJI
of the IISSue. He ,Iudled 66 of
and concludc.>d that hea ... y metals or pigment.'!
are not requH't.'<I for r.l(hool'xlIY \eroradiography.
ultrasonography. Cr. and r.- IR IIlIJglng he hdp
ful In (jetinmg 'mall .... of
Delection of ""nod .... llh ,ranu.lrJ ra<.ilographs i)
llifficullo SluJle, by Charne) und Woc,nt.r lom
pareJ lhe U!tC of <;mndard radiopaph) :IOU xerora
uio!l;mphy. The resull, of Charney, worl.: cumra
dieled IhJI uf PO'l lIun ul Ihe fragmenl
I'o;lS delefll1m ... d 10 be Ihe nx", llI1pOl1anl f;lltor
for \I'Uaillallon. Wood " ho.' .. t ..... -cn with "RI.
Th ... Inflammatol) proUUlL-J by the body
In 10 lhe foreign wood frngmenl loCen
easily on T2welghtcd image".
!be lI .... t ... p IfI management of foreign bodi ... s
is oflhe agent. ThiS can bc:: ac
compli'hcd JI If tilt- w,'und .. uperliclal.
Of In lhe opcrnlmg room If The punc
lure tracl \hol,lld be reopened and All
dc\'ltalilo!d aJII..l foreign bodlC, Ix reo
mo\ed. It an .. b"'"Cl>!> pre"..nt. m':I'lon
and drJlnage JfC reqUIred The area \hott ld then be.
\r .. )cd .. g.lIn 10 J"tlre JII fmclgn
I'o ... re relll(J\ed Pall.: thc wl)lHld 10 31101'0 drainage
and jlfC,,:nt premJlU1l' dOlol,lfC. Cultures be
.n tnc time of 10 lden
til)' the Jgem and .. lIow for proper se
1 ... .:1100 "I .. oublouc therap}.
me , .' .:ond 'tep I, the JpPrOpnatc 30-
"biOl"'""!o I,lrml hnal culture can be obbHlcd.
1IIl)'4 common mfC.'\."tj\c Jgenls m a punc1ure
wound \I lIh cel luhll' .. re SIO/""/U(on IIJ IJIJ'''US.
alph .. hcull11)'11<. 'tll.'l"'("'-"( .... onus "fH
({"mudIS. &1 hI nthl" . uli. and f'rel,ls. The mo;,t
lOlllmon found in purx.1ure ,",oonds \I Ith
I .. f'lt' udomlJll(l! Cera
lolin. :Jmpililllrll,ulhJ.:larn.lIcurcillirlicl3VUlanic
und. Of .:Jmuanl)llll lor puncture \louno.!s associ
.lled .... ilh Cellulin, all.' l\ .... ortlll\l;.'llIkd. If OSk'O-
m)dilis i, SU'IX, ... IL'<I. t'Clt:llidunl: or cil'rofloxocin
Uft! .:JKlices.
In Ihe I'fl.'<,enl p:ltient, embeuded in tl'K:
b:lt: of tho.' \llllllld prClb..'d J<'cply to lhe dorsal sur
f'Ie'" "I Ihe fOll t \n un...:c .. , \\-It) plamarly
lrum the <;ccnnd mctalan.alto the hlth The patient
,Ianeu on empiric 3nllbloun (In,!CCled cefa-
zolill .U1d rnctronlo:uolelanu t;lken to toc operal-
109 room I\}I' imrne\ll.u,;- illl.I'lon and dr:lmagc. AI
the lime of <urgery. a small plt!CC of glass 1'o3S re-
IIItl\ed tfflm II!.! W{)JJnd Tl\I;.' urea \las paded
open. and the pallem receJ\ed dressmg l'hanges
lYo 1I."e a d"y. Her r.: uhurc camr bad..
/01' IJegJtJ\ c (multl.drug
ft!""lantl Jnd cnteIlJC(x,-.;j 1lw: p.lllents anubl
wert' l hangfillO lanllll1l)Cm fOl' a 2\1.:.:1:
l'OUr.t:. Shc ",cOl on 10 healuOoI.'\entftt1t).
Clinical Pearls
I. Once the of ..... Ith pulll.ture \I,lUnd n\;lde. tile treatment
be sw 1ft
2. Supertil"ial De lre.ned \I ulll0l:31 .... nulld l;lft! Dc ... p \I.llmd, be
completed ... d IIl1d (.II.'bride.l When 10 doubt. open It up
, Ihe I'o\lund to a ('kart \I<'lual
4 Pn!\ em con\Jucr on.: do!><." of tet;UllI' Immune glohulln I,'r all ""und, thm
.1rt' 'lI'PI(:iou, nnd not de"n
REFERENCES
OS. J-\. 31 r<;"nn"'IJJI" In I'" lI.oJ""".I,I" ... r"f'h; J Foot o;;U'I
-,q.
FltllI"lllid K. (" .. an J ... "I the 'J ..,h Ion"
} 1 .. h.uo>On P P\.cli<lomr.>na< ,"(e.1".",.,. Ii>< t."" !"'".,rut< .. "uh<l,. J -\.\1 \ I '0 I 'J I'lloR
4 J.....q>h WS Ibndbuol "I 1_ .. E""',,,,I\ Inl ... ,,,,,,, 'e .. y, ... l . (h""h,1I1. "" .," ..... I<NI,
"
PATIENT 8
A 22-year-old man with pain in his third toe
A 22 )car-old man preserus .... lIh p.:lln in his left third digu. lie was JumpIng off a dIving board
he fell a In thIs (IX UC had pain immediately following thiS senslll lOn and had difficulty
ntO\ mg the toe The p;i!lCnIIS heahhy, wi th 00 past metllcal hlstOf)'.
Physiral Ezaminu#an: Temperature 98.6
G
F. pulse 65, rcspml.tlons IS, blood preSSure 100168.
1.U',"crc'trcmny: puhes palpable hlialcrally.lefl third digl! slightly edematous and cl)lhemalous: pain
Oil palpallQn of dl!olal aspe.;1 of thu'd protlmal phatan,; p'lln \10 Llh range of mOllon of pro\imal mler-
phalangeal JOm ..
IAOOral()'J findings: WBe 5000/ .... 1. Hg 16. Hel 36.9, pl atelets 3OO.00011J.1. nonnal.
QIltstion; \\ etiology orlhe patient's pain'!
"
Diagnosis: Enchundroma with pathologic fr.:Kture
Discussion: An enchondroma is a lumor Ihat
Jelctops in the medullary cavity and is compo\c:d
of lobules of hyaline carulage. The neoplasm is
usually In the third to founh decade of
life. I! is seen equally In men and women. Solitary
cllI:hondromas are usually asymptomatic and arc
therefore a\i an incidental finding on
radiogrnph or bone 'I(::ln. Resnkk sugge,1S Ihm
pam assexiated with a ran be suggestive of
malignant transformation - a Ihat is
more commonly noted in the long lubular bones.
According to a study by Aratil et al.. enchon-
dromas repres<:nt about 3% percent of biopsy-
analyzed primary bone tumors. Resnld. and Marco
et al state that approximately 40-65% of solilary
enchondromas oc::cur in the hands or the feet. It
\lne 01 the mOSt common tUlnors found In the foot.
Arata ct al. however. that the most CO\11-
mon ,ites of in\o!vcment in order of decreasing
frequency are diaphysis. metadiaphysis of the fe-
mur (4D%). humurus. libia. and shon tubular
bones of the hands and feel. less common si tes
include the ribs. radIUS. hbula. ulna. and pelvis.
Some enchondromas lead to osseous c\panslOn
(ellChondroma protuberans) Ihat simulates the ap-
pearance of an osteochondroma.
R"'OI"!;I..yili .. ,,., .... "j" .. iIViI. "'" lk.."..,i; ..... ""; oy ....
et a!. reveals a wcll-dellned. medullary lesion wnh
stippled (alcificallOn. a lobulated COntOUr. and en-
dosteal scalloping. Lesions may demonstrJte corti-
cal e:l:pansion and pathologic fr.ll:ture. MRI rel'ca!s
a v.cll -cin:um'>Cribed oilow signal intensity
in TI -welghk'd and of high signalllltensity
in TI-v.eighted .mages. Calciflt31iulb may appear
as regions of low
Most enchondromas of
lobules of hyaline- type cantlnge. They also con-
tain calcIfied regions in V.hlCh the cells may ap-
pear degenerative or necrotic.
Marco ct al slate that enchondromas in the
small mbular bones of the ;Ind feet rarely
trnnsfoml into which are the
usual of malignancy. Maligmmt transfol"
ma\!on is more lIt..dy in enchondromas in the long
tubular or tlat bones. Indications of malignant
Iransfonnation include an enlarglllg radioluccnt
area. cortical pathologic fracture . ..oft
tissue amI disappearance of prcC\isling
calcification.
lbe present pallent ;,ustain,-'d a pathologk frac-
tun: ofa previously undiagnosed ellChondroma. He
was taken to the opcrntlllg room v. here the d01>U1
of tile third phalan_t "US p.:netnued
by a curette. The ellchondroma was evacuated and
sent for frozen SlXtion. whk:h demonstrated a be-
nign tumor A burr was u"cd to re-
IIIU", ""Y ,elll"ullug ""J.IIi:'.'" ur ii"'liULlj .. IL'
mor form the inner lining. The oone was
and packed with oonicocancclloliS bone chips. lOe
patient wem on to heal UIICIentfully.
Clinical Pearls
L Enchondromas are found equally in men and women. generally in the third and
fourth decades of life.
2. Enchondromas are most often a;ymptomallc.
3. These tumors are most commonly found in the hands and feel. bm are abo seen in
(he femur. tibia. and humerus.
4. Enchondromas that are pamful or 511Stam a rracture should be biopsieJ to rule out
malignant
REFERENCES
,\"''' MA. JA_ Dahlin 0('. P,uOOlogl<' froclul"C .krnugh tll>rom>s t 11o,,", hili f,lA

M:uw RA. Gnell. S. d.1 ('",.IItage Illmor<. F.'atu"lIOf1 ond Irralm<nL J Am Amd Or1ho :!I1)(1
_, R",""k CS. ("'1M AM ., at C."" k.""", ('00<:11"..", ""lto . .-h"ndom,. onJ e",oondronu._ Sk.t Radlot
t81 t ) 66---#.1. 19'1'1
16
PATIENT 9
,\ J3-)t'Clr-old "oman with a painful ri ght lmkle
\ .U-)o!ar-old .... oman ... Im it chid l'C)Jnplamt of pam on the hucra! aspect of her right all-
kle. The 1"31n h:b been pre'"'-'nt lor "bout l ...... "CKs and had:l relamcly acute Ol1sel. The patient. woo is
.1Il aVid ronFlCr. thaI \hlS In the middle of a to-mde run III hen began to c'perieoce Hsig_
nlh..:anl p:un" III her I)tlh:r :lillie. WhKh pn:\cmcd her from the run Currenlly. she is unable
I<l run be<'ause [he p:;in is [00 intense during e.terci..:. The patient's past medical history is unremark-
.ole. and her only om! COlllra..-eplL\eS,
Physical EXQ",;,wtion: Vllal noona!. Skin; mild l(X:ahf.ed edema allalcrnJ right ankle; 00
or opc:n 1e\ion_ pre'ot'ol. tendcmess on palpation of nghl lall:r31 malleo-
aod nghl u:nJcrnc.s un palpation of peroneal tendons. posterior to rightlateraJ
ROM n,lrmal ri!!h! anll.'. \lll-lalar. and midmr<ial joulis; temJcmc\s on againSt o:.o:r-
of sullialar JOint No onhopcdlc malalignmcnt noted.
l .Ilborafory /-"illdillgs: Radlogr.lphs: IIU occult fractures or other kSlons of distal right
III-ula. MRI diqalthird ur right nt-ula included bulh a lino:ar decreased 011 TI-\\Icighted im
Jge and a locali1cd In\Clhlt} 00 T2 in area.
Qlle'fitm: WhJII' the hkdy GIUS(: of the paticnts righl pam'!
17
l)iQgnusis: Stre., tlf nghl 'Ibula
IJiS(uss;on: Stre.)S al\: fairly l"Qm-
mon dlnk:!l enlillCS in podi:um::
prlKuce They art" grncrally Ihr result of
a repetnl\('. amount of lo;,(] on a
bone The load. I'.hich repre'oClIIs abnormal ",,-rrs.o;
on lin ott\(1'" nonnal bone, can tIC a re,ult 01
grouoo reacti .. : or t.:-nMOO from
lendll)ous IIn(] ligamentou5 lm: .. :hments. Sunllar
In outcome but different in in_ufficiclk-Y
fnlol:tures. I'. hlch relate 10 normal pl.ll:etl
I.IflO1l au 3ln'0"'lIal bone. fracture"
are <,een in p:lII':OI, I'.llh <nlcomala-
cia. ul'iea.e. anu Oll1o:r mc::labolil: bone

Stress fnlol:tures can be !ittn In thr
.:akllll(uS,fibula.libia. femur. nal ICllIar. <;e ... mlOld.
.md of In.: luwerc\trtmlly "fill, fre
'-Illl'nlly. In loOlllC b . of Ihc upper
IlleY generally occur in lhe ph)'sicaHy :lellle.
in nmners. 10 the
of .Ires. The mosl COlllllllm
factor is tmming error: for a slgnltkam
10 tmming diqance"Of a ue,'reuse in inter-
\als bctl'.e..:n long runs. More 1I11ens.:: al-
l()'.\'s I,uk: tmlC for.he .. rfcrted bone to adapI phys-
IologIcal!), 10 the Increased pla<:ed upon
u. OIher (a.,"toJrs are nglu running surfac .... ,. puo..-
gear. lind poor phY',eal fitness. AnatomiC
rnalalignrnenl) su.:h .." lillib kngth di.)Crepaoci.:".
h)perpronallon. and riglu l'8\'U, fL'C1 may k'3lI
to _tres.s
Diagnosi s can at be a dlflicuh problem.
but )Ill n, and are helpful. TIle
p.:llll;'nt'S u.ually mdudes an 00-
'01:1 of I'.hlle tminrng. TIk" pam u,u-
all)' refie\i:d with of .t<:li\it) FUI1h.:r
'-IlIt'SlIonlng of the pallen! may unLOler re.:ent
Lhanges in IfUlIllnJ! habits. sULh.:ls higher mileage.
different runnmg surfaces. or new Phy\-
Ical e,(IUIl may reveal an abnunnal gail. pam un
palpation Over lhe anee'led and locahO(ed
warmth
Coniinnallon of .. fr:lctur ... r ...
18
'-IUU\" a raul{,,\!raph. bone <;can. or MR[
,tre" IrJO.:ture, may Ill'" appo:ar on '(-my. os
'<Ou, eh.mee' fl"luire 1-3 weel) to register on
film, r.lllillllrJphlc 'Igns IOcludc penoslea1
re",-llOn. a break m lhe bone anWOI'
:I flXJ.I.lrc..; 01 Stre,) fr.IClure, wllhin the
.:OI1I.:al ponU)n ,)f 10llg bone u,ually II pe-
rcaltion: In lhe por1l0n.
I'.hil:h maJe ut .:afll:dlou\ bone. lhe) show a
....:lerotlt line.
1111 J ,u'pKiou, dm",al prescnlallon
bUI no e\ldetto.;e I)f ,Ire" fractllrt" "n con\enuOIllll
,ra), require more and 'pecific
Bone \Can .. Rmaln;1 I)oou ,'pIlon for<.hagnosing II
fr:tcCUfC. The-y :lre highly sen'lche for- bone
lurnover and are poSll1ve long before :In '-ray .
They 1'.111 .hnw I n IIKrea ..... u ,)f upwli: in the
of Ille fnldun: Bone i.Ift' sen.itile bUI
not 'ped!ll' fur fm.:ture. IlIId rewlts could
be uu.: to 1lI"ltgnam:y Jnu bon.: infecnon.
MR! hlh h.!come ,1 morc popular modality for
'Ire" frocture. In tile pallent,
MRI , ho ..... n Oc..:au .. e of her :ouft ti s"ue symp-
10111'. IIIduulng penll1Callendonills, which can be
ruleu OUI u'lng Ihl) modality. In Ih'5 case. the T2
"ciBhled nn .. ge \ hlll'.etl intensity
wlthlll II!.! nllull;lI) l: .. of the tlbula, and the
Tl linage a lme of hypomlcn-
wllh a l"rtl';JI break," the same: area
TreatnlCIU 01 IS mucb easier
"hell an l."arly .!t;lgno .. " "made Early on. si mple
may gl) a lung" ay 10l'.ard refienng lhe symp-
toms I'.lIh 11:1.' and N5AIDs. can be:
,uflici':111 to .. 1I0v. the bone IU heal. If a later diag-
i) maul'. ImnlOblh/allon of thr affected area
ilia) be rl'qulrc<i Some bonc) affected by it stress
fr;!ClUre lila)' requll\" mol\" ilggressl\c therapy.
,UL'h .t>. ,uI'gIGII (i(allon. hecause I)f thr,r poor
healing ablhl}. Ihc'>C Illlludc Ihe ba)<! of the fifth
rnelalan.al. Ihe- and Ihe loCliphoid III the
hand Onl'e lhe trndure 1\ II is im-
perahl': fOf til<! ,llhkte 10 change the training
habn, Iholl I;..t! 10 ,m, fr.tClUre
Clinical Pearls
1 Radi ographs rna) be negauve immedIately following the injury. Tl'oo to thn..-e
". ... "5 later. a rca..'lion may be visualized
2 Bone so::an senSI\I\C. bul not
J MRI 3 hm:ar dC'Crrasc in on TI and increased mlenSlty on 1'2-
weighted images.
REFERENCES
I .\.t,8I)Ue r ..... 'Nn'o IIhthkln J 'Ird 191.1
2 ....... u \1. S2fTuns OJ. R"'nd 0 Map'", ... In\OS'''i III "'" ....... r.an.al >ltUS flOlClVfU. J Fool Surl 27;
17171,
T..u1lWll IE. eI 01 lo .. nm.mll) ,Ire" fIOlCIU' .. ,n athie,,,, Ph)' Spon> Mcd II: 198\
y, ,t ..... E Kw. f SII .. ", !""Iure, \n ..naI"" of RIoI.lK>k>gy 91 441-&6, 1%9
19
PATIENT 10
A 56-year-old man wilh a traumati c 10 his ankle
A 56-year-old man presents 10 the emergency department (ED) Imml-diJlcly "olio .... lAg a traurnanc
iocKient to hiS right ankle 1be patlent .... as ... alklng on the .... ft lk \I hen hl'1 righl foot hlt:l ele-
\lllOn In the sidewalk His .... as body propelled fOf"\ll'arti while hi ... fOOl remall1<."'d planted, Ilc i ... currently
unable to bear ... eight on that fOOl. 1be patient's medical hlslol) is nOOCOnlnbulory. but he men-
tion a nghl ankle 40 )cars earlier
Physical t:xDminalian: Skin. moderate ... elhng: no e\:ch) Mu\Culrn.lelctJI: pam on paJ-
pllhOn 10 :lnterior aspect of nnl le jOint. \\ hieh (.'tended 10 bOlh malleoli; pain on :mcmplctl mnge of
moIlon Due to scn:nly of pam, lalar t ilt and anterior dr3\\cr tests not po;:rformcd.
Laboratory "'indiogs; Radiographs: mcreas.:d soft [iSSUe dcnsuy ::u umcrior of ankle
JOmt. :\\ulsion off of lateral malleolus; incidentul anterior ankle joint tlrthnn, with forma-
tion. No fractures to unlde. no osteo.:hondral nOllced. and no joint m
Ilood alignment. and medial clear space nomlal.
COl/Nt!: 1fle pati ent was placed in a compres)ion and told to take Ibuprofen for the
pain and infl,u!1mahOn, He was also informed about the prinCiples of rest. and ele-
vutlon. Finally. he was ghcn cf\Jlches. with the direction to be nonwclght-bcaring until follow-up
appointment wi th his podiatrist The patient ret utrn:d 1.5 weeks larer usmS crutch He ad-
muted to removmg the compression 2 days after ib appliculion due to di..comfort . AI Ihal ume, he
had swellmg alki ecchymo)is about the joint. mostly laternl. l11ere w contirlilation of pam on
ROM of the JOint and With supi nation of rllt: subtalar Joint. An MRI was ordered.
,uRI f ";fld;flKJ: ]>anial tears of antenor and posterior talohbular with jl.Jlnl effusion
Ihrough these defects. Calcaneal hbulnr ligament could not be on any of MRJ cuts. and C\-
lcnt of p:uoology could not be appreciacoo. DeltOid hgamenl5 Inlact; no abnormalities of tlbl(){alar and
sublillar JOints.
QI/t!stio".- Whal is the best treatment apMn for thiS InJury?
20
AIISWtr : of bone Heel.s and rcaUachmenl of IigamerHS
Disl llSSioll : Ankle Ir:lUma, which displa)s as
anlle pam, edema. and enh)rllO'>rs, very com-
mon Swdit'S have shown Ihlll up 10 32% of pa-
tll:nts wlIh IIIIe11l1llnkie trauma have recUITt'OI."CS:
thus. lhere is II need fIX' late11l1 ankle stabilization
and Al'.areness of the :angles formed b)'
the onenlallon of the ligament!; and their relauon
to the ankle and subtalJr JOmt crucial for
understanding the- rnhamcs of ankle spr:l1ns.
As lhe rOO( JTlO\e!O through its range of motion
,junng gall. the ootenIX' talofibular ligament IS
mosdy used to m\'en.lon I'.llen the anl.le is
ploot1tfkxed :and the hgamen! is parallel to lhe
libula,1becaleaneofibuillf ligament. bemg the only
[ateral collaleral ligamenl to pass lhe ankle )Omt and
,ubcalar joml. hesl1C'arl) parallel 10 IhesubtaJar joint
Jl(is and allol'.s mollon in the . ublaJar
JOim. llIc mol'!,: Ihc'iC.' Jrc 'Pf"llned. lhe
I'.ealer the) bcconK:. and the)' Will not be able
'ISt1he forct.'5. commg ;J(.llh_ tho.:: mille Jnd
jolnts, Jlltrnoperame rcp"lr requil\-d for
currence of ankle ;,prams and a \ingie traumatic
event oblrter:llrng lhe anJ.le )OlIIt hgJrnems,
In the pre<:nl p;!herH. ;rnhrmcopy ,hol'.ed
acute 5)llOvi u,> betl'.<.-en the! mferi(lr tibial
and the lateral c:anil:rge damage
I'. ithin the right ankle )OU" The anlcrior tJlohbu-
lar ligament of the 1:l1er,l1 :lIIkle Jvrm l'.aIo partiall),
10m, anti the cakanNI houl3r Jnd Il(hlerior fibu-
lar lig:amc: nlS could not be I 11Iere I'.erc
avulsion fractures off of both the .IIIICflor 1"lofibu
lar and calcaneal fibular li!!arnenh The avul...ed
PieceS of bone were removed. 3nd lhe ligaments
reaUached PEo,\ .llKhorl
Clinical Pearls
When examining patrents wilh nnkle injuries, I:lke e\tm !IIlle 10 ('Jrcfull),
OIze Ihe ankle ,IOmt for ligJrnem lears and frJctures. /\1'>0 perform .:ompkle ,'\lll!lin:l-
lion 1o rule oul any fr:rc!ures or dblocalions,
1 R:KhogrJphic evidence of bone Inferior to rhe Imeral IS fughl)
of alulsion fractures in the about the anlle ,101111
3. :"IRI are completely :!Ccurale and should not be: the unl)' mod .. l
ilY used for diagoo\ls Take mto accOtlm the of injul'\, the dinrcal hndmgs,
and the radiographic \tu,jies to help eorroborate your findangs.
4. If surgery is needed. antrnoper,llil'e visualization of the injuf) the be"t \1<3)' to
make your tinal diagnOSIS_
REFERENCES
t U;w,1\on W 1M Sm'blrOm procfduR ror l..reral:WJe lfI$w"h,> Foot I J: 17 1'1'1.1
! PedllWO \1 In' .... _ inUrN OIff=mw Wagn<ISl" "" ...... of the !" .. rnun:, anol f"'l-pr<:"'t .,.,Jy. J f""1 'i<uJ
!6(2) 1m
21
PATIENT 11
\ "".) l'ar-old woman with rij!.ht foot pain of insidious onset
\ lO.oman to office "1[11 a complaint uf pmn In the of her
nghl fooclor J pcnuJ of 2 She relates a !I01fIt: .... hat Ofl)et. .... cll as radiauOfl of pam
(l{ .. hng[lIlg 1010 her thud and fourth toes. The p:l.In IS generally whlie the pa_
llen! " IUlIbul;.Jling. ,lnd 11 better \\ hen She .... as seen al an emergency dcpanmtnt ap-
prmim:ud) :2 ,",eeb prior. "uh '\e\en: paln in liM:- (00/ talco:u that [!Ole n:\ealed
no lkhlrtlut) "golh.-anl for !kpre))lon. tkr onl) mc .. h,'ahon Prozac.
The alkrgu; to codeIne. p!:m liin. and sulfa drogs. She denies tobacco and alcohol usc.
Physical ExuminutiIJ n: General: no apparent dblrt"'-S. LOlltr C\lrcnuu<,s; bilmeraJ palpable
puhes; nunnal l.!plll.!ry refill lime; no a1em:. of the ngll l fOOl. Slin: no open normal
rolor no cl)lherna. palp.1lion of nghllO<)1 !;3u<;Cd pain between 2nd
lind .Ird IIICIa1<1l'>ab Jll>! proxlm,t! to mct:ltarSOll heads. I1ldulIlng into 2nd :lnd lrd [;lteml com
of medlJI and I.!lera] foOl c:Ul.>Cd pain III second IIlterspaee; p;rlpaiion bnse of 2nd meta!anal
(Ill.! pl<lntarlle\ton 01 joim al,o caused pain. Neurologic: decrea*d So.!nSlll10n 10 light touch
and pam Jlong tmeraJ ,l\peel of 2nd digit :md medial of 3rd dign.
Laburatory Fimlil,!:s: RadIOgraph t r..:e figure) and MR] of right fOOl bone defeci at b;rsc of
ond meilltar.nl. rabe motion \lhcn pUllhroogh !tOM under f1uom..copy: ...:leroM.-U bone ends ck\cI-
l'pmg:1I of \clond metalnr...:.1.
QrU'!iliQn: What i\ the lause or cauo.es of the p3lient"s
12
Diognosis: tl/i:I,m;)lna lind frJcturc nonunion of 2nd metatarsal
Discussion: 1be lIIiu(llllllpn:ssion on first
.lImmng this p.1tt('nt led !he physician 10 lean 10-
wllI'd D di(lgnosis of neuroma of!he 2nd Interspace,
Howe\er, palpation of the 2nd mellimnaJ directly
te\eaJed pain that 'Was more consistent With a stress
or occult fracture of !he 2nd mcllItarsal. lbe Hay
of !he fOOl demonstrated a sclel'Olic area and a pc-
nosteal reaction at the base of the 2nd
Because of the possibdllY of a coocomltanl fleU-
roma. it was decided that MRI would be !he best
dJOICC to \isualize both !he neuroma and !he
met(ltarsal fraclUre, 1lle showed Increased
\Ignal IntcnsllY .... "hlll the marrow of the 200
metatarsal base on the Tl-weighted image and an
cnl(lrged mterdiglllll IlCf'le m the 2nd Interspace,
With over 2 million bone fractures in the U,S,
each year, there is abeutS% Incidence of nonumons
.md even more delayed unions, 11lere is 001 a dis-
uoct line clinically and rndiographtcally that delin-
c(ltes a nonunion from a dela)ed union. Generally.
the diagoosis of a delayed union is made ..... hen a
!racrure has not advanced at an average rate of heal-
ing for a pru1icullr type and location of frocrure,
This time fl1lIl'le is usually J-6 months, but is ,ari-
.. ble dcperxhng on !he bone and type of fmerun:. A
nonunion d.agnosis reqUln:S evidence either clini-
or on x-ray that healing has ceased and union
a..:IUSS the fracture SIte IS highly unhkcty. The FDA
has funher classified a IlOIIUlllon as a froctun: that
has failed to completely heal after (I mmimum of 9
months. and healmg has 001 progressed radiograph-
k;ally for a period of3 months.
Dc:13,)ed union and nonunion can be due 10 both
local and systemic factors. Systemic f3CIOfS in-
dude the patient's nutritional status. acll\lI)
lc,el. and even tObacco usc. Yo hich has been
10 ha\e a \ery detnmental effect on bone
healing. Local factors Indude mOllon lithe frac-
ture site. madequate fiulIOII. open fraclures. com-
mtnllied fractures, and blood supply.
Nonumons have been divided into two Iypes
based on the viabllllY of the fracture ends, is
the hYl"nuscu/ar (or hypertrophic) Iype, in
which the bone end is \'Iable and capable of heal-
ing. This IS different from the al'aSCu/or (or at-
rophiC) type, which has a nonviable bone end and
no chance of btelogic reaction, Hypenrophic
nonunions can be fUr1herdivided into the elephant
fOOl, horschoof. and oligotrophic types. and avas_
cular nonUnlOIlS are scparated inlO the commin-
uted. looion-.... edge. defect. and atrophic types.
These subdivi sions an: based on the blood sup-
ply-or lack Ihcreof-suppl)tng the bone ends.
Tre(ltment of delayed unions In mosl cases can
be as simple as immobilization of the fracture
fragments. Electrical sllmutlllion 10 accelerate the
union has become popullr when immobilization
IS insufficient to !;onlplete the consolidation. 1be
placement of a bone stimulator causes a steady-
state potential around the bone fragments, with
the elC'CtronegD.the side stimulating ostcogenesis.
Nonunions require a more (lggrtsSlve treatment
protocol because they huve lillie or no chance of
healing due to a dysvascular state Such treatment
is gcnerally surgical in nature, Because the bone
ends are dysvascular. they must be resected and
then rigidly fi'tatcd to have (lny chance of heating.
The repair gCllCral1y requires some type of bone
grafting to mllntain the length of the repaired
bone. Bone grafting techniques vary greatly (e.g. ,
inlay bone grafts, onlay bone grafts). Once the
procedun: is completed. the repaired bone must be
completely immobilized. and a bone: stImulator IS
used to hasten consohdation This procedure can
take up to 4-6 months for romplete healing.
Tllc I1R:scnl patient underwent surgical
lion of the dys\3SCular bone ends: a bone graft
was placed betwccn the two ends; and !he
was Immobilized With imemal fixatlOll. She was
placed in a below-knee !;asl and was instructed 10
rematn non-Yoelght be:ll1ng for a total of 6 weeks,
The patient wenl on to heal uneventfully.
lJ
Clinical Pearls
A nonunion Ch,It:kll'nzed b)
A hone defe... 1
False mOllt}fl
IIf bone:: ends
Rounding Lind nUhhroomlng of bone
Scaling t,r oono,: with bone.
2. Contrnindicauons 10 the lI'<! of In the In:almcm arc"
S) 00\ ial
AEFERENCE
Bone gap grcutcr than half the diamc1tr 01 tile bone
Bone gap grcbTer [him I ell1
l'ncontrollablc nlotlon
S"S""'- CT Pnn<:.pIt ofrrOC!u .... In'" C ......... Uo.-t n (il.
PATIENT 12
A 60-year-old \\oman wilh a conlinually aching nrch
A 6O-)(,3r-old .... oman .... llh a complain! of lenJcmc,\ In the Ilwxh.al :bJlCct of
her right alllle: for a period of J mOlllhs. The pain occasiQllally r.Hlialc\ mill her fOOl. and gen-
erally increases 'While ambulating and during prolongw pcnods of ao.: tl "II}. She relate, I\oJ ;mlecetknt
trauma that led to the Ollset ortOc pam Further questioning re\'('als Ihm ,he a Hal-
lenmg of the arch O\cf.he past 5<:\o:ral rnoruhs. There has been IlO Ire3UTlcniio dale. e,\:ept for acetll.-
mmophcn for tnc pam, .... hKh providc:o.llinlc relief. Pasl medical h) percclI_n,m and octd
reHux; medications included mdoprolol and omepralole. She no \..00 .... 1\ drug alkrglcb. ,,00 her
ollly previous surgery I'. as right fOOl hUIl1Onel.'lomy \\ UhoUl
Physkul Exomination: General no apparent Lo'ol<er E'trcmitk" p,llp"ble pedal pubes
hilaterally: normal capillary till time. I' nh mild edema alOI1S /llt.'\li.I1 ;"IJCU 1'/ rl1'ln Jnlle. 'H,in:
no ecchymo)is, 110 open lesions; color, turgor. and normal <.on,ujerJble tcn
derness along of posterior from just behind medial m:illeolous to It5 III nJ' lcular; nor-
mal ROM III ank"lc Joint and :Ind midtarsal joirlts; llIanual !!1u...:1e rCh'akd "II groups
full strength. e.-.:cept some weakness of fOOl and pain on il1",'Iioo. forefoot
(In rearfoot. especially on right foot. hed r!.;c with inability to lip un toes. Neu-
rologiC; all nuaCI; neguuve Tinel's sign in tan;al tunnel
LaborofQry I-'ilrdi/lgs: MRI: thid;:cning of tibialis posterior tcndon: In,reawd 'l!!n;11 Lircumfer
cntiall)" I'llh tendon shealh effUSion: mlratcndino1l5 Mgnal. Radlugraph, jI,ltcml _jc .... ,
hgun:l: loss m longitudinal arch ..... ,th fin;t ray dc.alus and in cylml line: "11 phllll"rlle,ion of
lulus, caJcanl;'al Inchnallon approached parallel I'clghlbeanng surface. no {NCO.ltlhnll(
Qutstion: Whal is causing thl;: medial ankle pain'!
zs
/Jis(ussion.- Po,leTlor Ilbl .. 11 PTllcndon d),,-
fUII<.lIul1 ha) dl;lf"u".-J Imm.'tlc4ucnlly over
[tie pa<:,[ '<!\era1 II lO.as lorn-
monty ,IT at urnkrui .. gnoscd.
J\ Ia'cot )urgt' III publl,hed aRlde, about thiS rJ,,-
urdcr Icd 10 mtlrc re.u.ly r ... -..:ogIUlII>n of its 'IOS
and ...
The leodoo\ lII .. m IUncllon I' help and
,1<110.' rearfonl C\el">IOI'I U(1'110 heel ,Irile during the
,Ia",,<" ph3)c of g311 \<:, IItt lout IntO
ffill.hlaocc. till" [cnuon helP'> Io.:l the rnldlJI">31
JOiol ilild Ilc.-gtn, 10 (.IlI";! ,ublalar JOlnl
m\cl"'lion III lilt! pha-.e of
lile lendOI1 JCedemle\ jOmt lO\el">ioo
end. In hl-cl hl1 So. 'Impl) pU!, the lib-
ial rendon I) Ihe maIO imener ollhc (out .!nd I'
largel) n:' lltllhlblc for nMintaiulIlg,l/'l;h height.
Theft' h;IS bc:en ,orne luntmvcT.y 10 the
.. e of IY(' temJ<>1l dy<t'undlon It generally In-
\'ol\e' a ,,' the lemh'lI from a multi-
tude 01 calh ut "hll'h I'> u"uaJly
torilll In 11;ltlll\' Stlme ,trucHiml
.riune f>T in ,OInt-IIl.llIun. "hl,h 111.1) le.lo 10 PT
I ... ndun u}',fundll.n mduue;,ll1 a,'ce"o!) icu-
lar. rlgio or tle\lbJ.: ftlltfoot. and eljuLnUS. Thc..e
dl"(lrtier... :\lul1!; '" uh ,\ lone of c
as.:ulanty wllhm the lendon bc:t"een the me
dlDI m;dlculu, JIKI the tend"n 1I1 .... rlll'n.lead to.k-
gCl'Il!falioo IO.lthm the tcmJf>n. ,h the tendon de-
geocrolc, II to \JowJy elong;l.Ic and
elcnlUal1y lo ... s
of the peroneus bre-
III gam 1}(.I\;.rnlJgC' and l.":llI..es of an:h
height and n1lulaT'I.J.I JOint break.
.lI1d \lagll18
ha\c b\.-co proposc.! for lhe ortlle de-
formity. Siage J is ':OlblOcml .m a'o)mptomallc
period. durll1g IO.hlll! the patient has nothmg nKlre
than .111 under!) 111& ,trouural or anatomic abrlOl"-
mill II) Ihat prc ... him or her 10 the
men! \'If PT tc-nuul1 d),fulldion the pallent
progrc<,.>C, inl<) 2 )mprollis JCldop thai
tiling them ro )"ur olhc .. S)mp!ollb mdudc len-
dlnlli,. ",)me dlu't!lII hchll1d the m<"diaJ mJl!co-
hi". ,Ind oi 3 11.11 fO{l1 "donmly. The
rJhcnl 10.'111 halc lendemc<,s along the course of
IOC lendon. Inm uf Ihe f\ln:fuut. and far!urc
10 li,e up on the on one )Ide.
j is simriar III 2, but With 100ft' dis-
..rblmg ') and grc:mcr tkgener.lUon w IIhll1
the tendon [e.g. Ionglludll1altcars or partial rup-
ture.'. Finall}. 111 Iage '&, the pati<"nt begms to ex-
pcnen.:e 'Joint ooaprallon nod funcllanal disabil-
Ity.
])iagnosi ... can generolly be malk from the pa-
history Dnd a good dinical c(arn. Radi-
{'un he u:.clul III :1:;1,(:S5 JOint :l(!3.ptallons
In laler .. of and III\' useful m sur-
gical p[anmng The MR[ become a useful 1001
10 the p;lrhology withrn the deter-
mrning IO.hcthcr a blmple tcnOl')nOHIIS Of
... belher the plogresr.cd to mid
Ical"> ,md partl'IJ roplUre." MRI also
may aid rn wrgical plannrng.
TI't';Urn<:m IS generally on the of
O}'tunction. [l.111d I d) srunnilln In wme pa-
\tents can hr IT\:lHed embCr. The underly-
abnormalrlY musl be {'on-
trolled to further of Ihe
ddorrmty This IS genemlly accompllsheo IO.llh
<.t.'In<: t)-pe of orthotic wuh II high degree of
NSMDs and ph),sicalthef'Jpy rna)
h:ne ...ome benefi t as lO.ell. 011(;1."
progresses mto the laler bcCOlllCS
lhe onl) option Surgicalll1ler.entron (sec
iigure) 'lam with direct tendon rermlr aod pro-
gre ... 10 t<"mlon and lillally 10 bony re
COlbtruchon. inc[uumg calcaneal and
subtalar procedures. lO.uh the lasl
,t<:p being a triple
Earl) aod ac{'Ul'lltc diagnosIS IS par.i/nouni to
pre,cnl progression of deformi lY into (he latcr
Mages of pclenor tiblallenoon Tbc
pTt''iCnt pallent had oirecl surgical repair of the
tendon. A b)'OO\cctomy was perfor'!11C<l along
wllh repai r of the longlwdinal Icars Ihat lO.ere
found IIlIr.toperoli\cly. The p3l1CI1I "'<1.> Immobi-
lized in :I \hurt leg for a period of 4
llJX'n rcmuvnlof rhe lII'1. 'he pro\ided {'us-
10m-molded onhoses. and healed uneventfully.
Clinical Pearls
1. In the carly stages of postenor tibial tendon dysfunction, plIliell\s describe II.n a.:;:he
along the InneT si de of the foot. \\tuh II. moderate amount of warmth between the malle-
olus and the naVicular.
2. When looking directly at the fool from behind, yuu wtll notc the 100-many-toes
Sign - the fool is abducted. and the loes arc: St."Cn Imernl1y.
3. The paltent has difficulty stamhng on the toes and usually is surpnsed not to have
flOuced tl eltTlier.
4. Simply reSIsting aclilc inversion In the nonweighl-bearrng posulon usually elic-
lIS pam along the PT tendon.
5. MRI can soow intrasubstancc: ICars even 10 the carty stages,
AEFERENCES
ROWIIbn, ZS. CbtUQ, Y <If tho poslt'lOI' "b.a) CT:ond MR\ "l1h ,u ..,aI COIT'OI<II ..... bdlOIocy
169 229-11S. 1988
:' SancInl OJ, 0 "asnonot to!:IIJI\;\I'U ,mo.gln. In the fOOl and anI.k J Fool SUf, Z8 '70-}TI, 1989
27
PATIENT 13
\ Sl.}ear-old woman wi th a painful hump on her fool
\ ""oman presents with a painful bump on Inc dorsomcdial asp"1 of her nght foot. It
has been present for many years and h3.'> grown slightly during thiS lime: . bul has ne\er been parnfuL It
is no ..... especial!) uncomfonable in Ughl shoe gear. l1lcre has bc .. en no trauma 10 the fOOllh .. , could have
k-d to dc\C'JO['m<:nl of the bump. The patient has changed shoe gear In an otllcmpt 10 accommod:lle the
lesion Sit.! denies the pre!it'nce of mhcr SOfHI5SUC m,u)('s el'iCl%here on hl.-r bod) There is no signifi-
cam medllill the paticrn is IIQIlaking any medl!:auons; and ha. no I.nulO. n drug aller-
Re\ lew of S) .. ms IS ncgall"c for fc\'!:rlchllls1nighl sv.caIS. recent .... clght 10S5. cough and short-
ness uf bremh. nausea/\iomiting. and diarrhea or consti pation.
Physira/ Examinlllion: Pedal pulses: blialcnlJ palpable. Var.cular' .;apdlal') rclill normal.
Skill : riO euema. norrn,1I temperature. Palpal ion firm ,!lid fn:ely mo\ubl.:- ,lppro'timnlely 3 cm X
I em. on dor.omcdLul aspo:ct of right fOOl; locution JUSI latcr..L1 10 libLali, ,Lnlcrior Il'l1don I nOl wLthm len-
Lion), no fluLd within mass.
l. abQrtlwry f"i lldi " gi: RuJiogrnph (righl fool/: ,"clling over
concll of mCtal lll')al and medial cllIlciform nUac!. "Llh no periosleal rC:lCllon or no
]iculion wilhm
28
lJiJfussion: TIll, is a common soft-ti.s:.ue le-
'1IJf1 that hm. abo been referred to as a derm:llofi-
broma or sclerostng hem:lnglom:l. It is most com-
monly fou[l(\ on lhe lo .... er ulremllY and has :I
hll!her H1I:idcnce in .... omen. It usu:llly comes :lbotll
.. fler some Iype of tnl"llXUOtiS Ir.auma; some ha,e
proposed tMt an tn.\oeCI bile TIl<! lesion
gellCrtllI) is a firm papule or nodule ... arymg in
from J 10 10 I:olor is qUlle \ariable.
A -.ome .... hal pathogllOmonic SIgn of a der-
matofibroma i, the dimple .. ign . When
Ihe le)lon I) Mjueezcd bet .... een the forefinger
.tnd Ihumb. a dimple is produced
In the center of Ihe This dimple caused
oy the lelhenng ()f Ihe lesion 10 toe o\'erlying
epldennis.
Generolly. lhe lesion cauo;es no that
would I"l-qui rc Its etcision. and il frequenlly re-
gresses tn sileo In those rare cases .... pain is
per..btent. lhe lesion can be
The present patient undelVient an ucisional
biopsy. The lesion was cuised In I()(O and sent 10
pathology ..... here 11 was re\caJed 10 be a fibrous
This large requim:! a
,km Hap closure aller (\cislon. due to the redun-
dant slin Ihal remained followmg us remo ... al.
Clinical Pearls
I. 11 1)\101:) c:m be confu..ed .... ilh melanomas bet:luscoflhc in skin color.
2. III>lloc)'10mas arc:1 \'ariely of dermaTOfibromas. "hich Dr\: mlcly malignant
The trentmCII1 is eu"ion.
REFERENCES
'k(jl.mry EO. 0' 01 (lfFOQt N B>.Ittmon:. W,lh..m .t \I, ,ll,fIS, 1991
A W,M""I R \I"""Jlel'lnl <>f r ...... ,,"". Pnm C.", 27\21
\\..uIlK\ Tu"",,", O,,, .... tMS1td
!.w ttl 1:I;tlllmort'. W,lh:um & \\ . Sal",.,.".... 1992
PATIENT 14
A 7l -)ear.old man an itchy, seal}' rash on his upptr and lower extremities
and a lesion on his right fool
A 71-)car-old man .... uh a medICal history significant for chronic lymphoma
presenu 10\ ull a dry. scaly. red rash on both his upper and lower ext remities. face and trunk. The: patient
recalls the rash hegmning 3 )'cars ago. but tnen disappearing al lhe cnd of the summer, [t returned I
)Cat ago.
Physirol Examination: Vital signs: normal. General. no distress. HEENT' connenlng of facial
featUre!. Cardiac: reguillf rote. no murmurs. Chest: clear breath sounds. Abdomen. soft. nonlender; r<:d,
raised. scaly plaques. EXlrcmlUes: more plaques: bullous leSIon al nght medial arch. Neurological: In-
tact; no focal deficlis.
LAboratory Findings: WBC 12.800fJ.l 1 (normal 5000--10.(00). Buffy coal (abnormal circulat-
Ing T -cells), Serum chemistry: Increased LDH isoenz) mes 1.2.3. Chesl x-my: hilar lymphadenopathy,
Posi tive for human T,lymphotroplc \ irus (-I).
Quu tiQ1I : What syndrome thiS pahem's Signs and symptoms'!
JO
Mycosis T-cel! Iymphomn IcrCLJ)
Discussiml: MycOSiS fungoldl's or crCL is a
malignancy of CD4 helper T .cclb [h;1I u<'UJJJ)
!lr.;;t manifests in the .. km. The process
the entire Iymphore[icular and
the lymph node .. and IIItl'mal org<lns become 111-
volved in the course of the Epidemtolog-
ic<l!ly. this disorder hm; a 2: I male 10 female r:l1io.
and the age range is 5-70 years with t) pical onset
III the 6th or 71h decade of life. The C3usame
agent is believed to be the hum3n T -Iymphotropic
virus ( HTLV). which often is not easil) detected
initially.
The patiem l)pic<JJly reports on$<: [ oflarge. pru-
ritic. red. and scaly plaques perh:lps as recemly as
I month. bUI also as long as several )cal"l. ago.
These plaques. which are round or arctfonn-
shaped. can be: mndomly Llistributcd ovcr the en-
lite body. Peri phernl lymphadenopathy IS oftcn
present. and many times the p:ltient has preceding
diagnoses such as PSOriasiS. comact dcnnat itis.
and nummular dennatit is, Chest x-rJy reveals a
hilar 1)mph3denopathy. and hem:l1ologlc eX3m
,hol'.s eo,inophiJia. aud wac
(!O.OOO mI). Serum chemistry m-
creased lactme dehydrogenase isocnzymes 1.2.3,
CT scans are ht:lpful Wi th more advanced
,tagt:S of the disease and may aid in
rt:troperitoneal node. in patients wi th
,kin inlohement. lymphadenopathy. or tumors
ufthe .kin Dlagnmts II! the early stages is often
pr..,blematll:. nnd hl-tnlogic cOllfirmntion may
not b<: possihle for despite rcpe:lted biop-

of di,order includes:
I I ) I'. hich are T -cells with hyper-
chromatic. irregulaT-\haped nuclei. in the epider-
mi, and dcrmh layer.;;: 12) microobscesses in
the epidermis with ;:eHs: and (3) band
like and patchy in{iltrnl.' in the upper dennis
tending into ,kin Monoclonal anti-
boil) techniques ar ... u:-.o.:ful. myco,is cells are
llcti-.me(i CD4 T hrlpn cells.
The course .JIIU prognosis of the Llise3se is un-
predictable. hill the .ur. ivai r<l1 e generally de-
if tumors and Iymph<ldenopath) are pres-
cnt and more Ihan of the skin is

Tremmcnt for is stage-
uepcndell t. In the prc-CTCL M3gC. with an
Ihhed histOlogic PUV 1\ phQ{ochcmo-
therJPy the 010, 1 cffcClht: tremment . In the
hi;;tologlCally pro\en pLllllle without I)m-
ph.Klcrnopath). PUVA photochemOlhempy IS also
the mcthod of Choice. For the extensive plaque
stagr with muhipfe tlIlnors or in the prescm.:e of
lymphodcnop:lthy or abnonnalclfl;ulmingT ..cells.
electron beam pl us cheTIIOlhernp), probably the
current cornbiuatJ;:)II.
Clinical Pearls
1. lJiopsy with hl.lologic eV:llnation mayor may IIOt give the diagno"is of cutaneous
T-ccIlIYn1phoma ini tially.
!. Look for hilar Iymphadcmopnthy on x-ray.
3. On physical exam. look for pcripherallymphndenopathy I'.lIh red. r3hed. round
to proritlC pl3ques .
.J, exam will I\:vcal mycosis IT-cells with hYpo!rchrom3lic. irrcgu.
larly shaped nuclei).
REFERENCES
I hllpalfll. T Color JnJ S)OOr'" "I elm".1 DI'''''"I"I,'lty \,.I.J ..... " \I,'Gt." 11111. 1'J'/7
Glusac E, eI aI CUIJ....,..' T .... ..,u n.,rm,lol Cli" 17111. 1999
31
PATIENT 15
\ 51-)car-old man with chronic diabetk fool ulcerations
\ 51\'(.Ir-ol<.l man with a 3-month hislol) o!ul.:crat,on at ItIt :!nd wbmetatarsa.l. The pa-
I,ent thaI JI[ ... r v.ea. ing;lJl ()ld pair of shoe;,. a callus fonned and Increased 10 an
ukcr The- p.llltnl \3.\10' h,) prim3J) care ph) ,.cian. IO.-ho then referred him 10 the v.ound tau eellier. Past
mcl,':::It h,\lor. '\ "gnllllam for d.3beh!\ mellitus.
l 'hYfI('oJ Exult/illa/ju"." \'ital >!gns: nonnal. flO !tEENT NeAT Cardiac: reg-
Ul-If fmc \\llh"Ul lI111nnur.;, ('he,\. clear brCi11h sound,. Abdomen \Oft and IlOnlen,jer. Euremiues:
"111.111. I"n,hmg uker:lIiun of :!nd ,ubmeUitanal. wnh yellow. roul.smelling drainage. mostly fibrous
b:be. ,mu rim: palp;ablc pedal pube, bLiaterally: decTea5ed prolecme IoenSDllon [0
Semmc, Wcm,lem 5.07 monoulamenl from toe, [0 midfoot.
l.ooorlllorJ filldlllgs: WRe I ..UOOffJ-L Radiographs of nght foot (see iigure): seelero-
'I' and I},!, of I,t ,,110.1 1m.l mctatars,d heads .. wIth bony eroSions and loss of archi tecture; probi ng soft
h"U{' Ulu'f Ilelow Illetataf':ll on lateral view; no cmphy:.cma evident.
Qll rV;/JI/: Whdl :Ire ,.ome HCJ lmenl options for this pat!ent?
32
Diagno5is: Osteomyelitis of the :!nd
Vi5ClIssion: Ostt"om)eiitis of the dinbctic
foot oft.:n a .hallenge to tre:.t :l(ld emJicilte.
cnuSt' peripheral vascular usually coex-
isting. With compromised circulation. dclhcry of
antibiotics (ABX) to the ,llffLoct.:u llJ\!a
may he null. Theretore. al1.:-mJ!I\c m<!lhods of dc-
lih:ry must be emplo)ed In I'no. Buchholz and
Engclbrt.'t:ht lirst descnbed the use of ABX-
Impregnated ct:rnt:nt for the treatment of infe<:tcd
total hip This techmque wus modi-
hed by Calhoun Cf alln 1994 to the form of ABX
fX,l:rmlt h}lrnethacrylmc (PMMA) heads on
glcal wire for the treatment of In the
j,chemk- foo\.
Commercially prepared ABX-Impregnated
P"" 'IA are not ;j\allublc in the U.S. mainly
bccaue of Ihe lack of complctt'd .;hnu:al
I/owt'\t:r. most prepare thl'lr 0'" n ABX-
Impregnated beads Intr.lopcrathd) Pr.,' IMA is a
,om pound to cement Ihe component s in
placc dunng anhoplasty surgery. The ABX beads
are fabricated by implanting antlhlotlc pov-der
1010 PMMA ct'mt'nt ,11 J rmill of TyplcJlly.
P\1M,\ c.,rnent IS to -I(,h packeb. and
tu ;Ivoid e.\ees, waste. half of the packal!e can be
rnix.,d "'l1h the approprime r.ltio of ABX Too
mucn AEX Inc bends from nardenlng.
whereas 100 little ABX limits the effectivencss of
beads.
Choice of ABX depends upon the lype of O1i-
,robiaJ infl!>.tion qbpeltcd. such
lL' aoo tobramycin are the
mOst widel)' ued. dlle to the e\tenslI'c research
;nailable on these ABX. low mcidence of reiu:tion.
11T1.l3d _pe.::trum uf ;Klivlty. :Ind l1cat stability.
PMMA C('nlent hardens via an exothermic reac-
lion: Ihcrcf0rt:. the ABX must be heal ,table aoo
WJter .alublc. When possible. choice of ABX-
impregnaled beads should be directed per culture
and ensitivity. Olher ABX choices iBCludc cefa
n.lin. ticardllin. piperrillin and doxycycline.
Antibiotic be;ld) are fabricated intraoperatively
by mi( ing phamlnceulical.grade, powdered an-
ubinliC and liquid rJlCthJymethacl)'l:lte into a
putty-like Next. while' tile PMMA
mixture is soft. small beads or pellets approx-
imately 3-7 mm in diameter an: rolled. The beads
arc Ihen placed on surgical wire or
nonabsorbable suture Ino. 10-15). The beads
harden in roughly 5- 10 minutes via an exothermic
reaction-therefore. the surgeon work effi-
ciemly. Following debridement and excision of all
deVitalized <;oft tbsue and bone. the string ofbcads
is placed loosely into Ih., \'oid of the ""ouoo. either
buried or left with one bead exposed
\ ... -.: figure). The ,kin then dosed primarily.
T)picalty the stri ng of beads IS left in for 2
weeks. if the need to fill 3 dead
space or if ri.t.. of a second procedure to remove
tht: beads IS not 3dvisable. Ihe beads can remain
pt'mlanently without causing ad\ersc effccts.
T\\o ",,<'eks i, the period within "'hich the beads
can be "'ith minimal granulation
o\ergrowlh. Note thai tht: beads ,,an be removed
In 1010. or inched OUI one at a IJlne as the granula-
lion tissue riiis Ihe wound. iilhe wound cannot Oe
primarily closed. an occlusive film dressing can
be employed to fonn an ABX bead pouth.
The benefit of this procedure is the ability to
achie\e high of ABX concentration at a lo-
cal while a\olding systemic tOllieily. The
closed space is a requirement 10 obtain a high. lo-
cal concentration of the ABX. The ABX is then
rekased into the wound by diffusion. Elution of
the ABX is greatest within the first 48 and
then tapers down O\'er the nell! couple of months.
l)etectable levels of ABX ha\t: been recorded to
beads impl:lIIted over 4 years.
JJ
Small-SIZed beads t_l--7 mm Ihameter) arc Ideal
Ixx'ause Increased IIrea a large per-
centage of ABX [0 be relea."Cd at a qUicker rate.
ABX-impregnated PMMA beads a"old
effect.'i and toxicuy. 1bey are espe-
cially u)trul "'hen managmg patients m "'hom
achlt:\mg ther:lpeutic tiSSue of ABX in the
foot difliClI Il . as those WITh dla[x- TcS mel h
1115 or infmpophteal occlushe anery.
In the pre...ent pallent. rest'(tloo. biOPSY. and in-
sertion of antl blotic' Impregnated beads wcre used
[0 erodlciJ.te this osteom)ellllC process.
Clinical Pearls
I. Use heat-stable. po",dered ABX and liquid PMMA cement to prepare antibiotic
beads f\. h ... ABX "'ith cement 5:1 respecti \ely.
2. Make beads:loo uS(' surgical wire or nonabsorbable
suture.
3. Close the pnmanly. or u.-.e occlus[\e film dressmg o .... er u.
4 Beads can remain permanentl y without ad\crse effeets. or can be remQ\ed.
REFERENCES
SL A8X''''1"",n.lIcd boll(!, Pru-I I 0.-.110 R :!O II "", l-"H. 1991
2 H.nry SL Lli "'BX tr..",_nl fOf of onhooic ,"foons Clln Pharmolunclln 29(11 36-45. I99S.
\ RoWe. R . 1 al "'"ub,o"" beads 'n Iht Irt-Olmoni of DM peiliIl U>ltom,).htl> I Ankk: Su 1201--) 30. 21100
PATIENT 16
,\ man wit h nont raum:llic hl't' l pain
A 74-)ear-ol.J man pn"\CnI" '" IIh a J-"'ed.. uf righl n.:c11"31n. He n. .... CI\ mg 3. ) I{'mld
H1JL'Clion from pnrn:!!) ph),.cian 2 .... eeh ago. \\.-hieh diJ offer \Orne relief The pallenl de-
.;.;nbc' SC\crc pam o\er lhe .:ouplc of da}s. incrca'>ctl ""llh and he \lear.; his dress
He has obtained onl) minimal rellcf from alll iinfl..unrnalorics. lie .my lr:lUma [0 the area.
" hysical E:rami"ation: Vital ,ub1e. HEEr-.'T normal emll,le regubr r:llc :Ind rh)lhm.
these. deaf. Abdomen: bemgn. Skin oormal . t\CurologKal motor ,mJ <,e11'<l1)' II1t .... l, LOlloer
II)': palpablto pulses: mi ld tenderness", uh palpation of plantar malia! tubercle of rit/hl heel. neg-
au\e dlioComfort along plantar f3;'(13. pam with 1Tl\.-QlaJ and lateral rompre')lOn of calcaneus,
Ill' tenderness noted to lII"t:rhon of A.:hillts tendon. negauve 'Lgn, ide nee of cr)locma, ec-
,h}LnmL), or
Laooro/Qry Findillgs: (' Be: IInrnml. Unc acid: 5 mgidl RheLL (ll;l[uLd Radl'
ngraphs: .:alcancal TIght foot; negative cortiu! or b..J1l)' <"_mpllon T ,<)9 bome
hee figure): IniCILloCl)' Increll-!>Cd actl\ ity on :lllthrec wllh1l'l the Tighl heel
QII H tiOl /S: WhM IS the C:IUse of pMicnI's hl>t: 1 pam? the TCLomll1cnded tTCatment.
JS
nghl calcaneus
OiJr/IHIO,,: Ir.jC!llrc' of the fOOl are
Ill.llnly Ir ... .Ih/N lU th .... 2nd and eaka-
'11K- rn...'1:hanl",n 01 InJur)'. \\ hlCh IS commOn
to all 'Ir':" " I."ue'\lle repctithe force
latlfue .100 eH'llIuJII) llle
I>od)' rt"I'IOn .. b (0) rcpclltlle b), la)'lflg
dO\l n 1lC\I ","'ne along 1M hnes of
Ill\;l\'ihal 'Whllh can li.ll..e up to 2 Voet:M. If
Itle rep.-tulle: ton.'e dunng thts proces:..
th.: bod} d,l!,', nflt ha,( a .:hano:e: to lay do\l n new
trabixulae. and faIlure The pnmanly can
",,'UOth "'all\ \I Ith a rompre,slon'l),pe
l""'llCmJlcul.ir 10 tile trabecula
tinn, :11 Iho: Jllflction of Ihe hod) and [lIberOSII)
TIll' not .lpp.:mn\ on radiographs
1,11\111 2 \lO:cl.., from d.lIe ot inJul).
(,(lu"dcr Ih .... "t , Ire's fraC!urc Ifl an)'
pilt/em th.lt prc ..... 'WIth heel pam. Patients usu
.lUy pre,,,nt \11th ptllnt tcnJem .. to tho: plrl1llar
l:!lC.in .. u" ,md IIc'Crlb.: pain Ihm increases
lhmughout th .. dOl)' 1'II .. n .iggmvated by lack
1,1"'u,,hIOmUI1Ifl ,hO( gcar pallen!;;
rcl,U .... 1 re .... nt hi,tun" (II bcglOnlnl1 a runmng rou
III .... ur \I .. g'lI n A of metabolic dis
0.',1"", mlluduH: o'leomal.lcia. 1m
p.;rfelIOl, <;<.'ur\y. Paget's
.. h!oCa-c. llt-r,,"' and ... 'cn meulffiltOld
a p.''' ... nl to !.k\ .. lop '\I(ess
tradur ... ,
.III! ,)111,'11 . Imllar to plOintar
001 p.m,'IlI" ,I,) 1)<0[ (L>mpIJ ln po.:!'t
1!t'\la ratho:r, pJm \I tlh contmued 1lC-
11\11) The dmll'JI hndmg is ';e\erc pain
WIth lateral comprt'5sion of the calcaneus and
minimal tendeme\, of the plantar medial tubercle.
Plain radiographs appear nunnal 3t the onset of
'mpioms. The most userul dIagnostic modalilY rs
a three phase Tc99 bone scan .... hlch shows focal
uptJke \I Ilhm the calcaneus as carl)' as 2 da)'s (01-
low1l1g (mc-ture An MRI may also be helpful,
of marm ... edema (decreased sig
nal mlenSII) on TI ... elghted unage).
The earlier the pallent presenlS for trt'atmenl.
rhe beuu he Of ,he responds. An mjeCl10n for
plantar )hould I'lc avoided If there is any
of fracture dut to dcla)ed heahng
ur avascular necroSIS of the calcaneus. If dilg-
oo:.eU early enough, a stress reaction rna)' be all
that is present. The'ie palle"'s respond quickl), to
I 1 'Wech of nonweightbearing WIth crutches.
cast. and gradual return to IlCtivit)'. Onct a de-
finllive flltigue fracture has been diagnosed, am
ple tmlC mllst be ll,\'cn to allo\l for complete heal
Ing. Idcall),. a leg Ca51 and removal of
wCIghl-bc:lf1ng unlll Ihe fr.lcture is oontender
\It:eksjIS the treatment of choice. A
c.:Im walker and an ACE bandage may bt used for
imrnoblli/atlon if lhe pallelll is oolllbk to main
tam oon-\lelght beanog
TItt! present pallent wa) pllK'ed m II. below-knee
casl for a tOlal of6 'Weel..s. He \las 10 i't'-
mam oon\leight beanng for Ihls lime \I Ith lhe aid
of a rolling walker After the Clllol was removed.
Inc: pallenl IIlCrt'ased ilIChvit)' I-I e
remOilned b)'mptomauc and \I.:IS able 10 rt'Ium 10
nonnal dad)' IK'liI'IUe5,
Clinical Pearls
\ fr.l\;\ure m.:l)' present 10 plantar facltus. bUI the pallent
" more: tend ... r on lalcrul compression.
II II .... , .. i, any \u,ptcion or fracture. a corticosterOid injt:clIQn should avoided .
. 1, ,j !xllle \l:an or \-lRI if the paticnl 'itatc5 that pain throughout the
d.1V . Ultl rher ... "point tenderness and pain \I Ith or Ihe: calcaneus,
4 \ three I'h;I"-I: bone .l<:an inneo ... d uptake in all three \llIh a
,t((" tr,,,,tur ...
\. ... rrndures includ ... imnll/bllil..ll ion wllh a
.Hld nwll .... ,gllI fur at k!:hl 4---6 \\' ...
REFERENCE
("I P,.".. ,( I, ... w", tn,lrCou,"", L<:<, .13.611. 1<184
J6
PATIENT 17
\ mall" ilh an 8- mont h history of a fool ulcer
A 52 ')C,I( "Id man I' JJrnluetltQ oo..pll..ll because of nn ulcer under the 11111 metatarsal head of
,he nl!ht 1001_ The uln'T ha.. t>t-t:n pre-...:nl for 8 momhs. It is ,IPPfO'{unarcly 10 mm In
J':prh mill 01 unJ<"nnmmg . .Il1d til<: "outld 1\ 1 x 9 mill The pauen1 rece,\cd "L-ekly m:;'lImrnts
In a y"JI..IHi.:Jre f;luluy_ con'.'led of a \ ariel)' of woun..t-CMr prOOU(:1S. shasp dcbndement.
Ind JClt'mrn .... j.III\C "nd tJft1o ... ,ling ,hoe .. .\11 oflhe.:.e .. "erc in healing the ulcer.
lie J 1)'P'!.2 Iluh J .>,(I-ye:rr hlSlol') ofdill!x:tes, IIldudes l\1.:ohol abuse and a 3-
11Jd: a-dOl' ;Kldllllon. He "JlIergic to penu;: illin. Cunem nK'dlclitlOns Include gl)buridc:. 2.5
mgda): llprorloul.m. 750 1118 b) mouth. '\\ICC dally; chndam)cin. 300 mil by mOlUh. elcry 6 hours.
1'II.vsicaf I;'.ramillulioll : .... ell-noumhed. m no (hSITC)S Temperature
'J!!.I! 1'. pul ..... re'p,r"t,u,,,, III. bluod 11070 III the supine: posilLon. Slm: ulcer under 2nd
1111"1.1131';11 h''II.I III ngh! 10uL hone no ,'gns of cell uht, s and (mmmul o;.cruu) dmmage. Mus-
'irenlllh 515 !II "II di.'<!p tendon normal. Neurological: IOta] sen50ry
["" uf righl r')o.'1 wilh 07 Semml.',-Wein'll.'l li monulllarncnt
l .. flfmralQrv filldill}:S: wile 49001tJ.I. ISO mgfdl. ESR 52 mill/hr. lIellloglobin 13. 1 gldl.
hel ,l7 Ii'"',. R .. of nght foot-IQo.s of portion of 2nd head:
111.'\.\ I'onl' fllml.llipn r,ee Three-phaSl.' bone senn - lncTCll.)Cd uptake in delayed
pha'ie ullnJ Jnd .'nl JUl.'tah,,,,,h. nu Olher not .. -dy,llhm foot or unlle. arterial blood
Ilow IrIpha,il' .... ,I\C l(IIm, ,II dor,,,li\ pedis. posterior tlbml. and poplncal arteries: pressures
,,(70 mlllll)! ,n ..... 101." and I J{) mmHg at anl le-bmchi31 mUc' 0.9
"
Diagnosis; O'tcQrnyeliti& O! thl! 2nd rnelat:lrsnl
Discussion: Cer1ainly a bol'lC bIOpsy and Lul-
tun: is the gold in the di.lgnosis of
toomyelitis. gh'mg the ab!.olute infonnatlon rlt:eded
for further m::atrnenl. In the patient. the
pathology reparl reveal<-'<I rnul1iple areas of plasma
cells, ostCQnecnhis. and IIlnammatory responses
consistcnt with osll'Omycli tis. The dcmincraH:tation
process confirmed the presence of Ol>tCQmyelitis mi-
croscopically, The microbiology results of the borre
specimen revealed Swp/ryll)C(}Cnu IIIm;,us. which
was methicillin-resistant.
The patient underv.'ent ;l pro,imal
tarsal amputation and received a 6-y,eek wurse of
IV through:1 Hickman. lie .... kept
oflloaded during the entrre postoperative course.
and upon complete closure of the wound site, he
wa.o. fi tted wtth a mold<::u shoe and too:: filler.
This fonn of osteom)elius tends to be chromc.
"(be patient did nOl Iii the illness pattC'm.
oot rather had a localiLoo di"<!ib<: Persb-
lentdmi llage may be the only finding from a
troct. All too often. the patiem Ignores this
finding. or the prtKtrtioner the potential
danger. Rarely the patient fed painort:\en.>Ct:
until the area be..:OlllCs superficially 111-
f;..'{'lcd. It is not until the radiographs reveal the typ-
ical lindings of thickened. scle-
rotic bonc with areas of radioluccncy and areas of
p.!riotium thai the alarm IS <;QtJndcd,
i\ radLcal npproach is critical. as local amibiotic
or IV therapy usually unsuccessful. Inadequate
treatment lea\'es a low-grade infection thai per-
and may il1lo infectivc process-
v. hich ag:un is treated inappropri3lely. In the pa-
tient described here. the 2nd metatar;al head is in
a destru<:th'e radiolucent ph:!'<\!: if follows
chromC' nature, a layermg of eburnmed pcriostium
Will dc\elop. fe,ull ing in a of the 2nd
mctata!';al With a and Iramfer of weight to
the adjacent rnetmarsal heau. Thb !lrca will then
bre:lk open into another ulcer. further complicat-
ing this diabetic p:!tienCs ambulmory
Clinical Pearls
I. As imparl:!n! us it to reC'ogni7e and diagnose early. tt more im-
portant to the crcallng the mfcctlon early in the
2. Bone cultures via an adj.ta:nt or of the bollC in t, irnp;:m-
tL\'e for a complete diagnosis.
3, In a diabetic patient. if bone is for any period of lime.
should be at the top of your differential list
REFERENCES
M.:Glaml) E. Banh A. [)o" .... y M .. bo<'" ofl'oo. SU'l<ry. 2nd cd. \lD ..... ,!ljJm, & W,lk,,,.,
t992.
2_ LS. McKuLnd lB. RISley TS fOf mf""LK)n Of gang ........ ,n pJI,.,nl5 ""h oj,>be1N
"",tllm, Ann Slllg DO 826.1<149
38
PATIENT 18
A girl \\ilh lal eral fool pain
The pallcn! 1'rt")I.'lIb \\ Ilh complain'" of [eft foot pain of apprmim:l.ldy 2-)car dur.nioll_ There is
10 hl'lory of IIII'l1Umali..: c'en!. The pain primanly 3\ the Qf the foot. worse
.,1 Inc end 01 !I'M! 0.1.1)'. and h .... h .. 1 by The child Ihal O\(:r the pall! J months
the pam h3) IncTca-cd. and It not rclielN b) NSAJI)... She unable 10 p,inIClP:UC In sports and
"JIlIIOI for .Illy Inng J',l:In.:('\,
/:'xaminlll;un; GCIII:r.lJ: 110 welling of kn foot; lender at Jllicrol,j[cral .J)pecL Museu-
lo,ke1clal polin on anlle sllbtaJar mO(ion limited; clcr-;ion pre<;ent: perone:!1
[clloon) 1101 In no 13't'ml leg p3in. joHlI ROM unauamable. Glilt gastTOCne
<'l lll' I.kmun_tr:ncJ b) IlmllJIIDn of at al1kle .... hen leg h c'tended on thigh (in-
J(ll'!ltl""un .... hen leg lle\cJ on thigh): longitudinal medial :tf",h With abJuction
<II fnrcfoot
/.(looraIIJry fjll(ling$: RaJi(lgraphs: AP and lateraJ-b.!akmg of talus amI narrowmg of subtalar
"ant.'atl.'r \.1cdi.ll uhliljlll."t:Jk:meonavicular buny bndge, Ham,BI.',nhe - middll.' and
f"" ll.'nor facet- nl ,ubullar Joint, par.:lllcl \0 one :\nuther. CT M:<l1l jsec figure): bony bridge between
;ll1d ,\ IIh no in jOints.
QUl'lfiQlIS: \\ hatl}pc uf coalition I, Whut IO.-ould be an aceel)I;lbJe atl\'( course
"I
Diseun;u,, : In yoonlll"hlldrcn. the com-
mon IOf i\ lhe IXhle
oflhe suhfalar JOinl. MOOI1i7.Jlion oflhe
.:ook .... -ed JOint. ralher Ihan a fusion. is common
pr.ILIl(e III the lhemp) disorder. The: rcle;hC:
oflhe can lTJ()(ion 10 the rear-
fOOl. Onl)' IIvhen the fool matures (16-18 )e;m of
age) 0fI<: con"der any pe of or mul-
Ilp1e JOint fUSlOO\ lreaunent usually
fails In the treatment of cakaneona\icular (C-t.:)
bridges, Succe$s is reported I" hen resecting thi\
bndgc In til.- )oung . ...,;tI\<: child. Sublalar
IlOl nece\s.al) <:ven m the presence oftalar beal.mg
In a child III nh cakmK'ooa\-icular coalition.
HO\lc\cr. In the a<luh. the prognosis IS lIIorse If
t;ilar prcM."nt 'iimple re\oeltinn of the ("-
N m the adult an<l replacement with I"ax or sil-
Icone. or mterpming the bell)' of the e'ltcn-<)rJlg-
Iturlim bre\is. not moblhzatlon
The )oung child more ;tctl\e and it b possible
that this elplalllS the higher ralc of I\'SoI'C-
lion m ,hllJren
The dlfhClli1), und the ':omplil'dtlon Ihat
I" nh the )ounll child and their complalnl of
pai n to the re:ufOOl IS misJI3gnosis and Inappro-
priate trcJlment Without proper uf
lhe rtarfoot. you Cllnl10t tre3t this condition. cr
has cenalnly hel","'\! to the diagnosis of osseous or
narmlll malulons. bul lIvuh the aidof MRI )'OU can
IlIOlale lhe e"<:let poSllion. thielncloS. and length of
lhe fibrous bond to any of lhe joints. When the
JOint IS restnf;ICli amlthe m.dlarsal JOint
1{bo:J. ghding motion. lhe 13lu5 51arts toolemde
the na\.cular aod talar Ixakmg results.
When lhe coalition i, prescnl 10 a childs early
dc\clopmg the adpcent JOmt changes as
I"cll. the future anhntie changl!S and adap-
me changes \lipping and Jamming of JOmts}. an-
other phcnomcoon oceu", a ball and soclet anlde
(IS a eompcnsatOl)' response to the re
Stnlll"l.! IIll'1lotl uf The JOmt. The tibial pla-
fond concave. and Ihe dome appcnn to be
lunvo;:"< and ball,h"p.:d; 1m- joml now IlCCCph tull
III UoolflClKlIl. ptal1lJ11luion. inlersion .. Ind
..
CI'cr.ion .\nklt 'tnt-llil), I' "I "_l.II\.WC\Cf. 11111.'1'
The fUl.llI) HI d Idl!!u, 1"'-"'IIK)fJ I '\Iter tU'loo.
this IS the to fClr tilt!
not rronool1l."cd_' It lhe poun "e"remt'. U,t lhe
foot in ,Iight pmnJII11n -do llI't In\ett .. -\ pt'rioJ of
numobililJlion I J f"! IIlJ) be dllemptcd U)-
ing this "hort leg \lJllmg Cbl Reo\. iet' . trla Jnli-
inftammatorit:) nuy 1\;\\(, a pn""\e eflet 1
In the agin!! ,100 the I"no de\clop,
the cool ilion laic. the re_ult WIll not Ix the hal!
and -.ockel ankle hili ,10 anlle \\-tlh ...
Jl.1ln1 In thl' a p,mtJIJr
is reqUIred A, I" ilh lI1any "h,IJhood condllion).
early recognition the need for radicJI.
complication-prone procedure, The' 111"'1 ",Clur.e
of treatment I' athe m<'an) .... '!X'" or-
Ihotie \lould be to!.:rateJ JnJ all{l\l the 1001
10 pronalc Omtl forcloot \0 .1)
not to drtle the tiN :lIfccling the mid-
IlIrsalJlllill Do not pmt the fOUl in
3, Ihi, \1111 :.1101" too 1l11llh 111.)tion to the
forefoot down II Ihc IllhJt,If'J) IIlUII(ln in
erea., ... d. pain II ill be Inc"n:.llc',1 the hl.'el
Iu the \tn!IM:_ .11:(('" it 'lin ,ubtJlar
jOm!. When .;ubtlllJr JllUlt nl(>[I"n I' lc,m't,'d and
the miJta"dl JI'"1\ 11"'""' II' ml>\lon. the
la)us ,tnns 10 merrille lhe n,.\ilul"r. dnJ till.tf
btaktog
When all ,"onloCfIoJII\(' Ilep" fall. lon<'ldcr
Sigmii<'lInt relief he okained by re-
..... of Inc lo,lituon ,\ Id}t:r ,lr m"tcrid)
III the ca!cart\.'On3\Mll.tr 'P.'lC to ,IVOIJ :t
rence, Re<oe,'1 tht' bar. and int<'rpo"< the t:'tensor
dlgitorum bre. I'
The pn!'>t:nl rat lent failed all C(ln'iCT'<att.(' mea-
sures. She undcrwenl \urglcal rt..et:IIOD of the ,"al
c:tllC()na\if;ulJr w:thtlllfl. \\ollh Il1IcTfJll,ition oftl'M'
e\ten-.or dlgltonutl breI''' l1Iu'iCk, ,\ gastrocne-
lenglhening \\oJ) al<;(l pi."rfOmlt."(j\ 'hon leg
cast \\oas applied IXlIloperntl.ely for a pcnoo of 6
After rcmo\i.l (II the the p .II1l.'nl III ...
placed In She now
joy, 1m \1,.\1,,(, duldno(l(i ilnd pn",,-ip.llC_ ltl 'oC'
eral .... hool 'l"lrh
Clinical Pearls
I ,,, quite nnponJnI If a IImua!lon of O1ll.h;u,\:11 JOUlI lnotion is
1l()'J in h,dn "I .m .K'.:.:pt.Jbll ,UlIOUnll,f rrarfOOI me)llOIl. then ..:on.iuer
nt."\lIl.l\'I,ular ':Nli'lon
After .:111111..11 tlk mt'Jial oblique radiograph is ley II parallel
"f the JOint and e..l" ldenhheJlion of signs.
_1 If 111 u\luhl..111 \IRI ,"III nie .. l) fibrou" aocl os...:ou" uniofb.
" lhe CT i, mlhl .... hen ttl.! I:hild is older and an UllIon ;s _li)PCCled
,'ll.'f" hhn,lU'
If a ...:,'<lrWlry \!'hlrocnemlU" equlnu, del clops be.::IU ..... of lho;> abducted posmon.
l,,".,.lcr a hl .... ' r.lI...:d nnhoill.' If the ",gnific;lnl. pcrh.IJh kngthcn thc tendon
.n 111.: um.: III n: ..... lII"n
REFERENCES
(;''fI",I<J'' .... S .... .. "I..r ",,,huo/l IrU'N b) ",,,,,,-,,,,,,.lJ\d oj ,he
," n,,,,,I. J 11,-", 1.,,0' \ 71
Il (,I,tr,., fl. \l,n",., S. 'm.n 1'\1 CumplllerllN 'oo""ll,.pn) ,,f'.L!o.;ak",,,,.l ur.:al m"hIlOll. FOOl An .
It I'!M
\1."' .... 10. \1 \,1>0, \1 T ."",,1 ,', ... 1"".,,, '1"1>(,,, M., fOOl J 80M Jo,n. SUfI! /lotI.\ '176-984. 1'l8J
PATIENT 19
}\ 15-}ear-old girl with pain in her M'Cond toe
A 15-}car-old girl ",uh leC! fOOl pam nocar the tOt'. Tht pain bt.-'Cn prc<;enl for
I )tar ShI: flO hl)lol'} of trauma. and describes the pam as a dull ao.he that has bC'cn gtl-
WOI'S(". She also re\eals that lhe pam \\<Iio:n .... (J.!'> hlgh-hc:elro ,hoes.
Physical Examination; MlISCull))keielaJ: exqumtc IIIC:I;lIJNI \\ nh il,..,ion and
tension of left ..ceood tot; on palpation OH:r dorsum of 2nd mtmIOlT-.orhalangtal.lO'nl. (,.
IrtlTle pam on forcible compn:s.sion of phalan_, base 2nd head Gal! pallent
places majOrity of her "Clghl on lateral aspect: forefoot Inverted.
IAooralllry Findings: Radiographs: AP view (M.'e tlgurc) - n:lIIcninjl of nk!I:lI.m.al head and
Juint widemng wllh a central depression: lateral vic:w- dcflln hc"U.I1CCI.: region ",uh
slight beaklnl!, and OMcoph}tic fragment i1C<lr JOlI1tlc\cl.
Qutstions. Whm b your first impression? What arc your surgical
42
Discussioll: A plau'lbll! Ihl!Or) fur lhe falluT\!
"plphy,,, Il) heJI I' C"n',I.mllOnJ-
I'I\')sion UI1!(\n anJ poor \!oou.:hondral
u"llieallon are ('l)Ii'I .tnl lr.!uma 10 an
ImJnillurl! e[ll l'h) 'I' lile rn':.'(h,lnKill 1."1-
fom I!\o.'noo lhe ftllm '1lIe J'kll'mal Mallon
.LOOullhc .u11,-uIM ,urlJ<.r and rrplacw
b) Jil\.,\;l..:ol1lpr .. "um If Idl un..:hc:,lL-.J oler the
thc jOmt "'ill I>t-.:ume ngld. rainlul. aoJ.
''l'i t,'o;lflhnll,
R'l(hngr:.rhM:;lJl). the.- nlO.\t ntwiuu, IirKlmg b
'" l<.knms: uf lhe: JI"nl 'j'bll! '" IJemng \).lUr-.
lhe \.IC'Cl .i ller \yl11p1ol11 on.)C1 Wllh pro-
J; re""lon of 11K- 'lmUlllun. the of the
chondrnl bone "no.! the lI)O;:wlaf'1kl1 h<!ad
Ilatten, In lho: a .. hilnlCU In lhe ohJcrehlld. rhe
".:hermc cplph}<.o:al bunl,' .Lud anl(ul:'lr (;antiag'"
\lcalcn and The bont" crem\!"
wuhm rh ... Jnlnl. .unl 100>;.: M i ... , appear.
wll h re,ulmm P;1I11 II " IIO! unu",,,1 tp st. ..... th ...
Imgm,.-nts In lhe JIll'o.tI 01 Ihe .tom! \(X1l'C
fhe lea)1 1f:IUnlJII,' and (el't ainly tho:> 100,1 ,lIn-
"lti mor)' cnt,lIl, rCllll\\,tl ut the fragme nt .
Re.>edlng the of lhe mctata00tl he"u
.lHu\I .. for in .. 'n:: J'<!.t of mullon Rt'-
,'(II('n uf lilt- pW\lmJI phJlan, ha-.e .!"ulm
.. the mctatar-.al ht'aJ and usually n::duccs
the.- \)<mptom, In lime, h()IO. ..... "r. ""lght as \\.dl as
00 the "un'Ouoomg heads will
incre:bC. a Irslon,
PcrfOr::lIl11g the ,>ubdlOnJral ,urfaer by dnlhng
an opuon .. ider ... d carly in thedeH:lopmc:nt
of Freibergs. Pertelratlon IhrouEh the metatar:o;al
hea.!. nrnJ mctatan.al \haft cau!>eS in-
crea ..... d bloooJ to be the aspect.
It may be aUI i->able to con.llk'r an O)tcolomy to
reJhgn Ill<! mclal.m.al hNd Thi ' "'ould eliminate
the direct ,'ompre"lun on tn.: heJu from tile plan-
tar In alidillon. rotating
the heau effects a decrease in the force
from the phal:mJ(
10lnt rl'Ol ... dufl:s ,houlJ be avoided
ill children: If polin i. ,'gnl!i cJI1I . and
the damage 10 the articular port",.n c"cnsi\e.
}U-U may be led 10 the nlCt,ll:lr,orhalangeal
JUlnt completely ur palllUll y nrc nOI con-
tr'JIndicaled. Pain wilh thi' ddon"'ty is c\houst-
iug 10 the </11,/10 the p:lrcnl'-: II all d".; has
fa iled . then thh rJdic;'l1 JPpf'iI,"h I, fI.'Ctlnul1t'nded.
Inthe prc<:t:nr pmlent, rhe treJlmcnt radical
due 10 tile damag ... to the ar1Kul:u- sur
f.",e
Clinical Pearls
I .Irl} (e("gnIlL"n "I' r rcibcrg', Infra.:tlOn i .. p..r .. mount Ofi\oodinl,! the jOmt \\.ilh
u.. ... hil .. prul'cJ
!, An tlr1hnllO: .:pn,tru,:I .. -d to m:llnlam.1 forcfou( ... a" IIIelllh forefoot
III IIh ,I nll'.MIIIO allo\\. lhe lnu metalJr-.al to drop. jamming of Ihr lorWnU 101:.
'. Con"der nn e,lrly on til<! Tll'd o(the.- nl('latar.a1 to locrcao,c
J,>f'oln"'''UIi. Thl> " ",mllar 10 a Vvaterman pflXedure. and \\"111 inerca)oC moIlon.
REFERENCES
1I,,,,,l R, <'t F .. ,!>tr\t'_ unnd.d.,J U'atIrn;[ Onho>ped"" II IQlIR
J 1"",.1", I', hau" (}.d."-...t",, '00 cd 51 l Oll", Mr). M .... h.
Or.M.ul J r"" Ch,IJ, 1'0001.00 'I." Y"ll. R.,,," 1'1"'" IW!,
Ud,,1 II. LIM> P h",hrr_', .t,,.. .. .,. F,,,,, Anlh: Q..I IO!. 1"81
k,nnJ.J f' t ,"',. .. R o."''''''''''n"".''I'''''y ,n Ji",.", \nlle" l:!i)..!\1 IY!!')
\1",,11,," I' 1.",.11 .LI'" r . "."" I Jonoo",..,J" ,. Ill] cJ Phd"""lpl" ... I 'rr'''':w. 1"""
\1".",1 "III<_"''''' I fr'<>'''"'I(' ,nf'",-I .. " on .,hl"., \'" J \1,'.1 211,11 l"",IWI
PATIENT 20
A gi rl with a painful fool
A 1-'->tar-oIJ girl been complaming of pam In her left fOOt for _1 home
did !lOt pro\ Ide :my ';gmlicanl relief Her chief complamt aunc p;lin t<xaJiloo the
me. larsi and p.lln correspondmg [0 the course of the peroneallcndons along IhI! blerJ] ofhtr left
fOOl 1be lerl IllOR than righl. Pia) ing t"pe..-Iall) the problem. She
.... lIen .... Jllmg ool'l!fool. The p:llienl\ 1'''''' m ... 'thl'.I1 hl'ln!) unrcman.Jble
Famll) hblOry IIlcludcs maternal talonavicular and symptom:t!l': ,um,II.lr walilion.
Ph),Jicol EXQmin(l/iQn: Pedal pulses: steady and palpable Skin: normal. Neurologic: nonnal.
General. rcoarfoot I'olgus hilmernlly. \\ uh forefOOf perpendi<.cular to re:lrloot: .:qumus bi-
Imemll),: "Hid hullu1 alxlUclo lal!!:us with of JOII1I :'\11<j conlracted dig.
liS '\\0 through live MUM:uloskelctal: htp. lnc.!. and nk1c JOlint ROM normal; wbmlar and
midtarsal JOint ROM rc\trictcd bilaterally; muscle strength nunn.11 and '} Gall an
wlglc c cycle.
l.abvratory " ;lIdjllgs: Radiographs: "YI1("tO>IS :Jill! cun!tllon: 1.llar
bcakltlg: n:," o", Ing of postcrtor tul!xalcancal roundillg ollat"ral of talus; nllddle \ub-
!alar joim obll lef3lton on lmeml view: asymmetry of :lnlerior fa..ct uf ,ubl.llar joinlill oblique;
halo dfed M:lerolic rim around sustentacul um 13111: irregular Jnd h>ll) l'(Ii1llJ I 'ur/'li:e
fQUtldmg coali tion: 110 distinct conical margins: -.ccond;Hy uegcnCfllltle JUIIII and b.l1l-and
sodel ankle (BASA] JOIII I (:.ee 11gure).
Cfmrst: lnlllalJy was ghen a perone .. 1 IlCr'lC block \O.llh \O.hllh relieved a per-
oneal 'pasm. Subsequently a SinUS tarsi injection was adminiqcrt:d With hdocaint. mcth}lpn.'<i.
m;.oIOflC.w mglml. mglmJ. and D Unna btlOt \OoJ' applied. TIle rati..-m in-
to walk", Ilh !;RJu:hes. llOIl\O.clghl-beanng. After 3 mOlllh) of con...: r\"3!1\C !hempy. ,he IS \tlll
e'pencncmg Mgnificanl pam while walking.
I ,,1,)l1a, and coal uion
f)isrussiOl'; \hN oflhl' pallcnl's dls-
""nfun .... ;1) by a limilal10n of motion.
I he UlI),1 (omm"n pre ..... mJl1on of
1000JI t ... o,er the cooli tion
';Il'. enhancffi by Jl,;1I\ it) ,md relieved by immo-
I>Ili1.llloo or !e\!. 110 .... e\cr. the pam to
J proximal JOIn!. In Ihl) u .... a", the subtalar
I',int Pain i\ deep ..... "hln the SinUS tarsi.
,nd a I,f joint and midtarsal
tolnt range: ot motion IS ..:hamo.ten,lIc_
Perone:!-I 'p.1(m m,,>, p"'\eni . bill fIOl ncce5-
,.Idl) Peronl,".ll 'pol-,m i, frequently found in me-
d'JI lalul:ak.Irll'.11 th ... most common
tarsal coalition. III which Ihere: i\ a restricllon of
motion on the medial aspect of the: JOlllt. but not
laterally TIllS uilimaldy leads to a calcaneoval-
gus deformity. With a decrease in the medial lon-
gitudinalllfC'h and abdu..:tion of the forefOO(,
With most coohuons. lTIOIion I) 10 the
adj:llXmjomlln thiS p:lltent,the lTIOIion was picked
up by the ankle. Since this was un carly-onscl syn-
oslOSis.. the talar OOITl(' began roundmg to mate a
ball-and-'iOCket ankle. This dc\eloprnent mcT'east(j
in\ersion and e\c:rsion.1lIc 'iOllluon 10 the pallent',
persistent pain was a derP-SC:lll'd heel !.eal to
'- emilie mcrea.sed front:li plane motIOn of the ankle,
Clinical Pearls
Early IJt:nll hc'a\l\1l1 ofn \\. ith protection oflhe pro.\imul Jtlmt5 decreases
the ..:han.;e 1)1 JOint as the cheld grows.
2. In eMly of JoiI1l<. lhe rc"riction of mOlion only increa.'>Cs pro'lmal Joint
mutlOll ,\I .... ... the 1I1lide for the poten!!al dc\dopment of ba!l -;md-MlCket
JllIlII lIillll1allOn 01 n1l>tl on ..... Ilh:l resultant mcrease motion pro(imull y).
REFERENCES
C" .. dIIlR EI ...... \" flt 1J I'.,,"ful H",f.u "".'IItbry to W>oal Cion Onbop r77!>4 I<iR3
0. ...... ) 'is r .. "'I,-.... I",,'<1 In C\,mrroht-n.". T.\lbool,. m Fool Sur,.!), Vol I 8all""""'. '" ,II",,," &. ""I .. ' .... 1\192.

I., ...... <;",IIc..I1' V 01,,11 L'1 ""';" N T.on..d .'(),Ot",o ... An tn>If\IC11O/1;1J Ie"." J FON
PATIENT 21
rJII.:n! 1\ a ,,;hi ld until rc..:cntl) he pla)cJ JII round Qlerthc
I months hc ha\ been complaining of pam the I.lt.:ral J'p"LI of nghl root.
l.m no long .. r ptay .. n)' When he h:Jli l>ecn for J hmg pt:nlld In.: l>Jin" \() uuen<.e that he
bt:glns [0 era",,1 Upon he points dl ..... "'lly 10 the arc:1 of lhe taN The 01 ICC and
a IlIm_lcruiJdl allll mflammalOf) drug offered him .,"Ole relief . \n m.:t in ...... rt he pur-
abo ha) ,Ollie .... h:lI mlligal<'u the paIR
i'hy(ica/ /::x(1l11illutirm: Genernl ",crall health leI)' good Luwcr C\lfcnllty _ 11I1ll1;tlion of mid-
IJNII am.! >ublalar mollon: mudemte of right hJOll'ompnrcd h) kf1. N':11/1)\ ,I'oI:ul;lr norm,1I
Gall ,IJIlCI."-righl rOOI abdlil led .... Ith 10\5,)1 JlIo:<.hJllollglludUHd Jflh aOOl.'ler1ed he.! llo
JlO,ilioll. gJlt -CMI} ht.-ei-("lff with lIl.lrked oJ f,ll)! 10 kg,
Labnralf)r.v fi"dinKs; ("-"e I,lter.d \iew ellmg,llcd
of ,:aicancu ... ,'gl1. medial \lhliquc \'I"::V. o.:ak,ln<.:u_ and n3\ h.ul.tr In close
bone, appear 1IIIIIen(.'(I '" IIh IrT('gul ar. tn<ji,ltnd <.:oniull '"rtn .. f" IRI Lh'lnccU on
thc T2.",cightcu Imagc_
Queu;lm; What the I,leliho()u dd(>rmily '" III require intcn--cnllon'?
...
I'lno'a: llurI} -hH' po:rc.:ru of .oft ..:ah:nn,::ouilvi..:ulnr..:oahtions eventually require surgery.
Di)'C/ISSioll : Pilin h 8 willmon finding In
cundilion . .lnd " u<' lIally in uns.::t fol -
lowing <;ome re.:.::nt Illlivity or trauma. Lim!tution
uf .. ubtul3T nnd midr:LI"al Joint motion is an obvi -
l"IlI1ical findll1l! . The jomt
li mited In the direction of II'lver;ion, with greater
limitlltion if peroneal mu.>!:le <.pasm is present . Pa-
ti.:nb may with a \algu, defonmty due 10
intense toni..: pewncu, brevi s which is
'Imply a rncchani,rn 10 limit painlul mver-
,ron Inv':f<;ion and c\el"ion of the midtarsal joint
imlucc pain Wllh 1II1l;:, thc valgus ddorrmt) be
lomes more n gld TItere arc. ho"'e\er. re-
roned cases of SP:blicity of I'Iher than
the peroneus brevis and of a v:ml5 position of the
hed In patients ",uh calcaneona_ il' ular l'Oalitions
Pain is Isnlat.:d to the midtrmal joint re-
;Ion. and th.: child point .. directly 10 Ihe area of the
tarsi, Wilfllimitatioll of midtarsal and sub-
t Llar Joint,. the foot to in the
Jlredion of alxiuClion and c\'crsion. The pl'r-
,'n..:al, ,horten up due to thl " compensutcd
I/, 'n An} attempt to in'ert or the foot
,rC:lles extremc pain. Unfortunately. a peroncal
'f1;lStic flatfoot often di.lgno<'l' d inllppropnately
(a!canCllU3vlcu!ar coaillions are usually lden-
utiable on the medial ohlu,IUe VICW. Thi s C<XIlIlion
l}picall) appears :is a J cm .... Ide bar bridgrng the
!,.lP normall) fllUruJ belween Ihe calcaneus and
IlJI u: ular A "pseudocoalition" to bon)' over-
l,lp can the false unpresslon of a
icular bar. making 1\ ncce,slIry 10 obtain ,cvcral
oblique at anglClo to differ
b..:twecn positional artifact and t!lle coal; -
In the C:b<: of a fibrous or cartilaginous cal-
canconal'tCUlaf coalition. the will be
mllTe diffi cult. On the later:ll view. an ..:longated
process of,he caJcalleus. known as
the anteater sign, may he seen. The calcaneus
and navicular are clo.",r than nonnal on the mcdiul
oblique view. and the bones appear flattened with
irregular, cortical surfaces.
MRI virtually eliminates the difficully in diag-
tissue. and the physician wiUt
an advantage .... hen he or ,he suspects nonosseous
coolitions. AllhouJ!;h relatively invisible on con-
vemional radiogruphy, fibrous or cartilaginous
union, can be confinncd with the use of MRJ. Ra-
<!iographs and cr have not proven reliable in the
Identitil'ntioll of fibrous latloal L'OOJitlons. ac
cUr:llely and reliably indicotes fibrous. cartilagi-
nous. and O<;!>(,OlI S coalitions of the lJloca1caneaJ
and joints. and is useful for de-
Irt:ting the prescnce of ... llng bars. MRI is rec-
ommended with suspet:t..:d lJrsal coalitions when
radiography and cr are negative.
Early intervention is pat'Jmount. Young chil-
dren thut with rntar beaking secondary to
compensation respond favorably to resection of
thc ca1canconavicular \Ofllissue coali,ion. When
beaklng is in the older child or young
adult. rs Icss favorable. and a lriple
is gen.::rally necessary,
treatment is nill1cd at restriction
of 5ubtalar and midtarsal joint motion to reduce
patn. This may be accomplished tllrough the u10e
of shoe modifications, onhoses. padding. or cast
ing. Physical therapy, a11li -mflanllnalory medica-
tions. li nd local )Icroid injcctioll into thc aTCa of
Ihe coulition may be used as lIdjuncts. Although
the may resolve for a time. they may
recur m the fu ture, requiring repealed casting or
cvcn wrgical Intervention.
In the preSCI1l (Xlticnt. a resection was in-
evi table. and the child was then maintained in un
orthosis to minimize midtarsal motion.
Clinical Pearls
the nmltarsal joint by stabilizmg the hcd wi th your hand. maintaining a
neutr:ll prn>llon. the foot and then repeat rn a pla11larnc)loT) adducted
lJOlo ill On Two !lungs lldppen .... rlh a cualition. palll cli clied o\er the tarsi. and a
limllation of motion noted.
2, MRI Tecomm.:nd thc be,1 dlagnosllc aid for a sus pectcd coal ilion,
REFERENCES
MS Tar..J <"",h"on, A ,urgl<;at J Am !"tldi." Me<! ,\ '''''' Rt 181. liiIIl
f'a.. huJa SD. b y RM TKr<aJ "", II1 lOn Eliot",) d" gnQiis. alKl r",.rmenl J 1'001 SUI'(! :!9'474 19'Xl
3. Penman MD. 5J T"","Jcnahl lO"'. J I'O<X 19811
PATIENT 22
An girl with ni ghtly heel pain
A hcallhy. :lIhlelic llule girl of :.e\ere nght f<X11 ram ,It the en.! 01 lloe \1;,y 00 in the
middle 01 tho: night. Ikr that 1I11o.1l.es in Il.'al'$;h [he entlfe 10104 p.unlul. l1w- p;lm has
been pn:Jo<:I\I for UH:r Q ffiOmtu. and h"" been in II .. ftIunJ Ih..- lo\\cr .. "!.Ie
and heel. lbe lamll)' ()oclor :mnbuted tilt: paillto IrKreJ..-eu 31.11"11)' and "grm>'UIl! p.un'_ rh.: glrl"s pe-
dmtncmn ad\ , ..... 11 the parCIII-S to tall' ocr 10 a poUl;Jtri_, for unhNK d,c' i,c, 111e J,.:yj,e, her
no relld. and ,he ":1) referred fOf a -.e.:uoo opinion
The plIllcnt'S plI;,II1l\.\.l!cal hblol) I.> "uh no hl'["ry u! Ir"UII1.I. <;1\.:
crease In pJln "" hen "'plnn
Ph),sil;Q/ f;;.ram;nntion: (knernl: ;md guarding Jwund _ubular )'IJU1I. phi' JClre:!!>!: in
total ROM: right l'alr mu;.cle Ohilmcr thnn OPI'O\lle <''l:Ir.:rrrny I .. I.. t'lclall'(lin
locahled to rtght arch ;Lnd heel are:1 borh medlall} :m.llatcr.ally; III,) I'Jm upon p.N.:ri"r
of nor upon dOl1iillexion of ankle, Sl.. in: no "11-11' mfl;LrnmJirlln ,'r edema; \"l.Cular
supply to fOOl
LaooraI/Jry f i m/illgs: R.I.liogr:lph (see tigure) lateral I1l'a'I"", hal!) .Ir.:a I em In di
ameler. rc\!lng inferior alld po,tenor to the su, tentacul um t:llr, :I,ial 'Iell \111' lakaneu .. , \lrl'cued 0 de
jo!rees 10 , urfac<'l findings, wllh Ihllo loe:u,-.J l < III 11"1'111 laleral wall of
the c;rlcaneu" reehnO:\lum bone )CJIl. f!)l.'alare" 01 III r ... ot nght
calcarteus. immeJiate and pcNln.reclLon Images-focal area ot m<-rt";\sed 'n of mid
right calcaneus; images - increased activi ty in this region CT den,it) In 'lIfl'I!rinr nUr!!in ofnghl
.... ", ",01,,, I"' ........ } ,n ."ft'<inr
DiscI/Him' : .... honJnm. \m: rroclUrc.
.,Il<,> "Iami- Cenu,h"' \\. and BmUie>., are
b) (he r.l!.i iogl'apnll Radio-
. 'lUdic, I\;J\( rllJ\l-d to be 11l1.' \'ah,able
Ji;ll,!no<,tK 11101. NJllhc h..,)'. 1r.lb:ular pattern of
tw:me In Ihr )"ung (hdJ lhe Ie-
",10 uirtkuh ,,\ lo,;;lIe lkre '>hould be a d.:ru.e.
...:ie'(lII( rim ' UOl.lUnd.Ilg the Ie,ion. 100. is
",,, '111..111,'\1 In tho.' \.:r)' )OtJ ng child \\ nh an
o.k\doplng k" .. n " he rim not
. 'rp.:ar until ]..,e IJllhe Ie'l('n\ m:I/UrJIIOTl. '" hen II
" l>eing \;l.,,,:ul:lrl y ll>illpi'e"'....-.J II 1000'il l,U In lhe
'f"lIlg) Ill.! k'lun Il'II.re,l!K!' In ""Ih
p:i lll bu, dIx\ "'" mno;ohdJ.c a o;o..lerotlC
run .tbt..\U' Ihe ,'cntral llc . r rll.!u ..
i\ddillonal .,tud,c, are rccommt"nucu III
"rc .... lI!i ng .... nh ,hi, \;I!<ue bUI dassk
pam. 10 ,' leMl y l<.lcntif) a ''''pecled lesion, Nur-
m.llly. ehildn:n .10 !IN ha\( p.lIn. If pain h pres
,'n,. il lllli'llK" l'on"dcrt'd unh! a hrlll.!i
:, 11.1111,' .1 t\ IC'1<)II rn.IY he Ic .... alcd III the
.-mu. al, "ll1lleJlm .... or ,u)'peru,leal bone, While
all will demons'rllle II radiolucent mdus wnh m
rim. cancellous ond )uhpcrios.eal bone
leSIOns an: more difficuh to diagnOSo: as these fea-
lUre'S arc les pronounced .
In tn.: atypICal ,ituatton. the nidus IS not sur
rounJed by M; lerOli", bone. "'hoch males It espe-
cially dlffkult '0 ident ify .... ,.hm .he complex ra-
diologKal :lnalomy of the JOinls. This KCnario
uf.en leads 10 mt'5diagnosll> and delayed definime
trC:lIrT1CIlI, Misdi agnose) mdude IXISHnlumalic
5)'00\"1115. rheuma,old .mhrms, and c1len hysteria .
In ma"y cases. pallellts undergo unnecessary
treatrT1Cnt. 0) ImmublhlaUOn wllh plaMer.
use of crutches for an e'!lended pcriod of 1IrT1C.
join. IIIjCClions, anhroswpy. clen
anal)sil>.
In lhe pn:scnt palllllI. a cr oh.:.ined, and
the oSI<:oid oSleoma was Idenllfied and surgically
resec.ed. A bone graft was placed m the
The paticm wa.' placed III 0 beluw-knee CIlS! for a
perioo of 6 .... ceh. She \\1,'111 on '0 heal
full y,
Clinical Pearls
I';un I,.he mlhltmponant due: c-hlldrtrl do rI'" 11II\"" /HI/I/ unli'Jl IIi,.r,. IS (/ lillUr
.fa "" .. 1lI Whcn in oouhl. checlll OUI. Do nOI assurT1C h)
1. It thele of an O'o leoiu in a )ouog pa.ienl .... ,lth pcrl>t)tenl. un-
d,Jguo...:u J<lltH raID. r.t<hological exammalion. bone ...... 00. ond cr ,hould be rcpe:.,ed
I le.tr .tiler the ,)[1""'11\ 'Imptoms. 'mce the m,tial ncg:ui\c findings may be po'llI\e
.II J 1.ller ..wr.: Bune -.o.lIIlIgr.lphy and IT a,d ID .he uiagnom. &:IIl"graph)' oJenllhl"S
lhe J/lnl,.! join', .1nJ (T in locahzing the precise IUITlOf ' lIe_
REFERENCES
lIu .... \Co II< I>< Tuq .... r","'",..n'.;wI 1'.-01"'-"''', 200 cd Ph,bo,klflh'" W B s ..... nd<" . \I<,o')
J., RM ... ,I .. ",m:,\J , .... J Fuol 2'J ,Y'l([
JF ,n ,''''' t.i"'l""''' """ ..... n' of ",ICOI<! 0'\It0ml or !lw Ialu> 1001 "' ...... In 178.

J .. l 0 1<>11 Ih .. "" ..... 1.1 s."",.r>J I,,,nl 41h ed, V. 8 .... ::II
PATIENT 23
A 19-1IIolllh-old girl "ho is unable to W:l lk
A IQ-Illonrh-old girl I> prc,.:ntcu for cH.lulllon of:1II ulht .. ble gait upon <Lmbli ialion. The IXlrent,,'
concern i, a tendency that ha, .:vidclH 'liKe the child b.:gan 10 walk .It 9 months
orag.:.
I' II.ysirul Examinatioll: GlIit abnormal gait: heel, dunng <,min.' gail
cycle: '" h<'n heels cam." do\\. n 11.1 ,upportmg ,urf:n:;: knee, Wt:11l into genu re<:ur\':ltum.
Ncurvlog,,: : no dcl .. y In no dch.:it: IIOl11lailur <.''11.1'111,1, cong ... nl1al. net rdatC'u to ,my
Ilt'uromu,cular
Trt (J /lne/ll COli ne: Serial dONne.ling ca"ls \lcre In an :Utt'rnpl [0 reduce the bilah:ral
.IOU gt:nu recur> alum. The O.Sb "i;'re applied HI lnce <:,[(' n"l011. from the [III:' to the prm.lmal
thigh. "ud ,hJlIg.:J wcckly for J " -I>.cd. GraJu"l1y ,lu"III .. , ing tht' fOOl to Jt'ue:l,... Ihe plan-
larflcxlon m the ,lIlkle reuuced Fullowing ea,1 remu',II. ri:Ju,'liun ut Ihe Jelormily
I>.as maim3in.:d. Ankle Jorsiflexion to 15 d.:gr.:e, . ,mo.1 Ihe h,ld a remarkable abll-
il) 10
6 alter Ihe eaSh hold been 1\'1I10't'0. the the ,'hllo.1 10 ha,e ,;ome
I.hfficull} I>.alklng. aud wllhlu J few I'.ccb she haJ 10'1 ,,11 ani lily hl 'Ianu Mraighl. 111e g.:nu reeurva-
lum relurocJ In cnmlJ('nsalioll (lIthe .:qUlllUR. rh.: dlllo:.l elenlU.llly ,I"rleo:.l )eamllg -0 far forv.ard in an
enor! 10 "alanc.: th,,[ )he I'.oulJ f:llI. In" )hon lime 1'..1, unable \0 '!.Ind or I'. :t!k.
I'.JS anJ th.: need for ,\dlilks ten(lon-lcnglh<' lling pnxedure \\ a,>
\fleT I month of c",tin1:! no ImprovernC'nt of Ihe ':<jUI!1US "'as ob,crveu. allJ CJSimg \\ as dll'l"olllln-
ued. A \\ lIh the child ... pedl:J\ncl:J1l rclealed lh"l he IOU hm! not .Ill) Il"urologic
abnormalin.:s or J.:\dOpmenlal J.:lay. \\i Ilh IhlS confUSing picture 01 conllnual .;omr:lc!Ure 01 unknown
origlll. addillonal were prior 10 the lenJu A(hllle, lenglhcnmg.
IAboralOry"-i"di llgs: EMG nerve wnuul'lu)II wlll!,'itic,: no nene re,ponse: mo-
tor nerve in uppt:r and !o",er e ... lrcml t il.') slo\\cJ; -.e1i'Or) act ion potclihab Jlmini,hed m am
plitude. With prolonged laleney \0 penk. ,\ IRl 01 brain Cr::!'\\CIgllled ,,"nonnal U1erea-ed sig-
nal in ,upratCIltOri,11 "'hilc mattcr bil:Jlcmlly. o..lipi IJl region great<'r thall from,,1. Enlyme
ar)lwlfalase A deficiency
QII Hl i(lII: What I' } our diagno,is'/
50
r.kta.:hroIll3I1c k llkod)' Slroph) fMLD)
OiS('UHiofl: The lme mfantile fonn of MLD
'''-'jl Ill S rn,idiou,ly bet"'een the Irft.t and !SeCond
,.-ur. II a.-. an llutO'>Omal recessIve
ilai l Pallent, for this allele ha\e a
ahS<ol:e of ;uylsulfal:lM' A aCllv!!y.
"uh lhe Jb-.cIlCO: of Ihl ' enlynK'. cercbrosi.Jc sul -
1 .. 1t: oc-.;;umulates 10 the ly'M:1wmes of different tis-
,llC,_ including the hH:r. gall bladder. and
'..hlte mailer Dehcleocy 10 the :lC!L\"lly of thIs en-
lhe hcal-lahlle component of cerebroside
ulfalaloC. has been established as the primary en-
IVmJIU: abnomlJhty In MLD.
The Jch.:ie!li.) h n1(>';t fn.:qucndy lk'!TIOIlSlr.ltcd
,n unne. and cultured ti-
"'001.1515. but I, also !.c. .... n In <;erum. kidney ussue.
,!lid botl(' marrow i'll0I all of th.:loC IlS,ues are
h) lhe abnontlal amoullI s of ,ulfatidc.
hlltlhc "'hIll' malleroflhc IleI"\OU'i ,,)'Icm docs Icnd
!t) toe danMgl-d In fact. It the abnonnaJ accumu-
j.mon of \\ Ithrn the ollgodeoorughal and
cdl .. cell foulld 10 the myelin
,heath) an.! II!.- metabuhl' faIlure of cens that
]lrt:Ccde :md til<: that c:tll">e demyelin-
,{,lhon. breakdo\\11 n.'sults from a defectl\"e
rcsorptlonof cercbrol.idc .. ulf .. te. whlch !s necessary
for the :Ilion 10 grow. AJdlllonally. e\'en after maN
nt). C'nlymaue lallure 10 II1Clabohlc this lipid can
pre\cnt normal of lho: myelin sheath.
Early on. mOSI p;lllcnb appear normal clini
cally 3nd n.c::umlogically. Then progreuI\e men-
Ial regression, loss of speech, ala.\ ia. and mUSl.:le
he<:ome eVident . Genu recurvalum sec-
ondary to cqUlnU defonmty is often presenl, and
achild woo has already learned 10 y, al k. slmrlar to
lhe one presenled. becomes in gall .
The chIld .... uh lhe Ime rnfanllie form usually
does no! survIve beyond lhe I1rSI Jec::tde. Central
and penpheral dcmyehniuuon
and dcgrudallon often lead to a \cry debilltalrng
and most of Ihese chIldren contract fa-
181 re'piratory infections,
In Ihe present pallcnt. EMG lilldrngs .... ere con
sidered to be with a demyelinating ncu-
ropmhy, MRI findings wert' With
These findings, coupled with the
dlsco\'cry of A deficiency. pomled to
Ihe Thi s final of metachromatic
pro\ cd co be fatal.
Clinical Pearls
.\ c(lmplete Ilt:urologlc eumlllUllon is impen!llve \\hen any I(' ndon
patholog) that exhibits (' uher a or ftaccidity.
1. ..:haOl.!(' III gar t. or posiuon after the child has begun 10 '" alk is a car-
dlluli Ilt ,lIT1C I) pe of degradauon of motor fuocti on A complele I'et.jUlml,
REFERENCES
, .. It'l .. hn-.n.ot .. Ir-talc .. h.ln,....y A .a. ... "'pilfl or.dllld .. ,ill OIl""",""" J fOOl Anlr. SwJ.14 206-207,
, .. ,
"ok>do, Elf 'kl ... hn.wn..I .. Itulo,-""rophy....r mulIJple ,ulf.u-... dclklt""Y Sulblodc tn S.,.. ..... , CR. 8c1lllic1
AL. SIY .... I), 01 l.-.hl MDlecul ... B_, oIlnhmlCd 0..., ..,. lid Ntw \"en.
, .. "
"n'''.... "I ,nf".>u1c """",hruma .... by bono m:>m) .... Ne ... En,1 J ' led
.I1.IIMI
51
PATIENT 24
A 6-) ear-old hoy "ho \\alks \\ith filii
A 6-,C:ilr-old 00) .... -en for- .:\aluaIIO[} of I k bl,:('n \\ 1111 bilat-
eral ,1lki1k[US. Pnor treatment of '>erial for l( 1< .... :1.", ,honl} .after
bmh. follolOoL-d by Lorre..:tilC: untd age I! months. rarl'llh kd Ih.u Intlal..lf'U' .,.JJu.:tus
ha:. Impro,ed \Incc blnh; holOoC:ler. lhey about rhe i't'IJuall.t.',,,nnu) !"1It) .Jeny
ItUII thelfioCh,kl had any fuo.:llllnal probh.m\ \ lalemJI family III"ltll) h PI"illl'" hlf Inh'Cm. \\hi.:h ... 35
Ul:aled .... ull a BrOl>' ne bar Jnd LOffi.'CIIIC: ,hoc,
Physical .ruminutiU1I : anaiy,IS bilateral Jetormu" .. , ,,;Ul\;C po;l'.lhun 20"
evened 1 forefOOt adJu.::led on rearfoOl. itgureJ. IM!;<' pr,'uunC:IIH' b.lk' 01
prornmcllcc of t"l.lr head: rTK>d ial arth th.dcncd 'N.th ,:.lllll' ho.'IlI \ l us-
linlltJlLon of lli'r'>liJc\.on m :lillie III ooth llltt "''llen,j,m ;1i,,1 11 .. \."n
IA ooru/Qry fimli/I gs: .Ingle:> .'\5 dq,:rec_ U1 the po-
SlIion, lPh:rul of nalli.::ulur from t:lldr hc,.J: ,,,I,.h'd.,lll 'II m,'"uar.,II, at Lis-
franc's Jo. n! ... nil !alM 151 rnctatar.,tI angle mcJIJllv: I.lteral I,d, ... ,.k.lncal angle
wi th lallh 011 C:lIc:lIlCll_': incllnallOn parallel III ,m
Quts/ j QlI : What i\ }Ollr.::unn'm in 3 child wilh T(,(:IlITCI\! IllCI'lddlldlh \
Diagnusis: Re) ldual metatarsus aJductu$ and secondary Cl.jUlnUS
Disrussion: The posit ion of the navil'ular 011
[110: lalar head should bC' talen into consider.lIion
... hen ,jetenmnmg a surgical versus conser,atllc
"pproach. A laterally posi tioned navicular demon-
.trates subt:dar pronallon. "hile a medially POSI-
11uned navicular on the talar head IS seen II.-ith tal-
IPO:S cqUIllOvaruS lind cavus rOO( deformi ties. This
t) pc: of supmated position has fO be
-.cparatcly lind is usually seen wilh a forefoot ad-
JU<:IUS deformlty_ lbe radiograph will fCveal lhe
nJ\ kular posItion on the talar head. When reduc-
.'II!- the metatarsus adduclus angle wl lh trannerse
pl,me abducuon, an abdut10f)' fon:e may be eA-
,;rttd at Chopart's articulation. If a lattral devia-
tion of the nDvicular oa:urs dunng thIS cast re-
JUCllon.ta5t ther.IPY should tcase. With tootinued
lrnnS\crse foree and mldlarsaijoml abduction, 1he
will be D rectus foot at the upcnse of a
prunaled fl alfoot.
TI.e cakaneal cuboid relationship is to
OctCrlmll( the or of fortfoot 00-
ducluS. Forefoot I' ;1 I.Oflth\U<: Ikfollmty
produced by mldtar..aJ JOint ,upin.1tion MOUnd the
oblique m plantarnc'ion. Jduu..tiOfl.
and in\crslOfl of the furcfoot. For\!lOtlf addoclus is
t\ ident With an addoctl'l.l p!NIIOI'I of the cuboId on
the cakaneus. On the radiograph (If an adducted
forefoot, a line frum the throogh the lat-
COIl surfao::t of the cuboid Je\Iale5 m the direc;lion
of adduct lOfl. NormaJl) 1\\.0 lille'do not con-
lergt. An adducl ingline
SUpmal1O!1; an abducting Ime mld-
tarSa.lJOmt obhque aXI> pronallon. ln the 1'fC'oI!11CC
of abductIOn of the cuboid [mldt:m.al JOmt prona
tion). It J.:fomuty "Ill rlCeil to
be addre:ssed more rlllhcally and
In the present paticm. a ,on-.cn ,1111': tr.:atmem
was planned with the u.,.; of a J)"nJmlc. 'llIblhz-
ing in!>t:rt. This urthotic managcd hIS prob-
lem by limiting pron,ltor)
Clinical Pearls
Total reduction of the mc!ladductus c1efonni ly means nOl Jusllhe reduCIIon of the
forefoot at LisFraoc's. but also prevention of pronation and the delelopmcm of.m ('quI
nus. AllI-ays reduce the defonni ty early ami maintain In II high l1angc in<oert 10 prevelll
lrans,'crsc plane.
2 Equmus is d.e great deforme! of the foot. Com.ider Icnglhenlng proce<iure'. it
essary. 10 Incn:ase dorsiflcllion and !hus prevenl secondary pronallon
AEFEAENCES
byRM.John_M IlwTmImetWmIi..sductuo C"",,IIIPOOwryJ_l no-I!,
KIte JII Con..,.,w 1 Bontloon' 5.urJ 49" 1%7
53
PATIENT 25
\ man .. ith complications after arthropl asty
\ 'tll-}c"r-"klllloln .... h .,tlrrun.:tl 10 the ho,pll .. 1 \Oolth II of a ,uff. painful first
1Tlt'1311U,-oph .. l.ln!='::I1 r 'IT!') yllrll ",rrlle hlOl. ,0Ild1ll011 h .. J bI.-en m.my yean. but
rho: pam hi."I:om.: mNt: ,nlen...:. -m.: panent um.!':!"'':"1 an 01 the first MTP jollll.
II nil II lOla] pc large Imp!;"n! I Ie t.lkrnll'<lthc \urgel). and dul not Oc\clop IIny
II<' ",:1, tl,UO ... ed \o.{elly tor ,1b"';l"\illiUfl lind no complications
()I:;(lItn'd .luTing rhl) pcriw
T",o .Irtcr the til.: pall ... n! relumt;U '" Ilh [he complamt thallhe operated MTP joi nt
hall , .... ,'lIcII. Warm "ater ,,'OIls ",cre pn:.\CTlbeu. ,lInng wuh ampicillin for II 10-
day pcri()..1 1,)11('0 .... ing thi' rherap}. the mHamrnation tlccreao;ed. Iloy,evcr.lI monlh later. tlk: palient rc:-
tumed to Ihe ,kl'.lnmO:: nl \\ IIh a Tl,',l. hut. w.ollen tin-I \lTP jt)11I1 and cd!u!iti.
pru.\irnaU} tu Ihe ,rnlde. nle JIICd!Y admittcd to the
I'lr,Vsi rllf t:xamillllliVlu; 11111/<1/ I\-ITP Joint 10' nmgc of mo-
lion: Ill} hmh plantarl1cxinn 3ml Pal1'3tiOl): prulllLflcrKe: .J<lIl1t pamful m
and upon m<:re:l\Cd rm1ll011 /''''10' /'n.llOI't'rmil" Ski n: )lLgh! edemlt. Prllp,lttOn: nlong MTP
JOIO! at '1\c: Jr,lillllLll ,ofH i"n.: rna,. un m,,:ulul ll 'p<:>:t of hN MTP JOlnl of riSht fool.
l.ublJrnwry filllUIIXf: Inilllil fOllo' nnm,)I-'uIS 3nd of fiN MTP
Jom\. II nh mild h,IUtI' ,Iblfudu ddonTlIt)": n.teoph)"tcs ,md lurge 00fS.l1 letlge on tllteral
111'\\ 1.41/" f'rIHo/It"r(//IH RodlUgrJph, Inght IVOI/: marl ed I'e..orplion a\ pru,im:ll phalangeal ,hllf!;
m,nked peril"teal !\'u{ lion m tH'1 ,haft and head. I-' Ilhi n .hali and botlC at area
ilf lOtJI nnVI,m!
QUtl/iollS.' WI!.!! " !ht- rill)\! lilt'l} JI:lgllO,i,'! \Vhal otht:r can pre...em .... lIh the above
tiOOIll$'!
--- .;;;;;;::,.. .....
J)jagnusis: 01 [h.: flr'!ot mct:U<lNlphalangeal Jornt with foreign body rea':lion
l)is(IlSJiun: Silicon \llnually men: 110,,-
.:\ d. [here I) al\\.a the posslblitty ot fureign ma-
adhe.nng to the implalll after autoda\lmg.
rhe panK"utarmaneron lhe linl
lroln drapes or po,,(\er from thocn
[r.lpped in the medullary .Ind .-an L'(Incei\-
,bl)' louch ofr a forel!:n body reaction When the
nplant is in pl.1o.-e. there b a Ullntnutlon ofthc \35-
. ularsuppl) to the area In contact With till: implant.
With the <kt;rea!oe m blood \olume. n is under-
.Iandable that then: "III be a .kI:rcaSl: In the 100ai
action m thaI untl area. Along the ,arne
II Ik'S. ""e why there IS a preUlkl'lion
\)! bacteria the Implant Slh! or met"pI!YMS. In the
metaphysis. there a nonll:!1 510" ing down of
1>1000 at lhe JU\lanlelaphyseal halrprn tum. This
,Iuwrng a til <,ellie m
and .-auw "111'1 a
,).;clusion uf the and
tmally mafTO"
TIlere is :11-.0 the JlIl'>lhlhl} ofnva.'>Cular necro-
.1\. becausc loops adj'k.'CIlIIO the ('plphy-
".11 gm"lh plmc.lre br.lnLhe, of
the nutncnt anery, Undemandmg "e can ap-
predate lhe great n,k uf:ln
,)r unprediclable Infa:linn
In IllO!Il noncon1anllnatcd ,urgical "ounds. lhe
Kute Inflamm.l1ory re:w.'tiun and recog-
1i /able tissue n.pair commences in 3 10 5 days.
Surgical wounds Ihal bL-colne (ontamlnaled.
or those that con tam a foreign matenal nOl eltmi-
nated b) the a,:ule 1n1lammatOty process. manifest
a chrome mllalnmatory reactlOil.
Mononudear cells arc 1he predommant cells of
the mfl"mmatory reaction. 1l1ey phago-
C) IilC the remamrng foreign matCrtallhat the en-
zymes of the granuluc)lcs "crt unable to make
rolublc. If Ihe foreign matenal a chronic
Infbmmatory reaction b. !oCt up In whICh lhe
mononuclear undergo a pr(lhferation. These
macrophages are for the chronicity of
tile InflJmmalury re'pon'iC The) remain in dose
pro:c.imlly to the forel!!n fur as long as
1\ take, to ehmlllale II
The magnitude of a inflammntory reac-
lion depends on both the chemical and physical
re:lCI1\ lIy of lilc (aU'JIIIC mlltenaJ. Elery foreign
,ub,lanee. no mailer how IIlen. evokes an im-
mune A relalively men )ubstance such
as 'Ilicone, IIpon removal from Ihe budy. might
3) if 110 reatlll)ll had (lc.:urreU. HOwever.
on ml(ros(oplc Clliillllnnllon. a layer of molll)llU-
.. tear l' clls cOI'cred b) .lllun hbrous dis-
ccrmbl ....
In regard to the ph)'sl(al propenles of a foreign
that affed rea(I1\1l1), . bolh surface
qual1l) and mohlhlY are Important A
11'1:11 is )nlOl)th and immobile produces much less
fibrous pfillifl.'TJIIOn than one Ihal is rough and
subj<.'<'ted 10 motion.
Clinical Pearls
TinY panl\;lcs breal.. off an Implant" IIh "car or shear 100 Ithin ajOlnt
2. \IRJ moSI u>-elul to oJctennine the of shanb IOolthm lhe ,uITOundmg
JOmt.
3. Complele removal 01 the Implant be perforllll.--d and anublolll:S
lere.! rrollh)'laclll:ally
REFERENCE
,,,I we: InIlUu"'ll)mph.I<k-nopo.'h) onc, b,la",ral m<, ... , .... . ,10."01'1< 'nh'orlaoly F_" .....

"
I
PATIENT 26
A 19-)car-old man "ilh injury to his right ankle
,\ 19-}car-old mJn Mhl:uoed a rapid injury of lhe' right ankle ... hlle pla}'trJg wcc.:r.
He W3!. unable 10 conemue phi) mg I:>ecaus<: of pain and s ... clling. which d.!\clopt:'d rapl\lll o\er the IICJtI
hour The lInmwI3tc and radiographic )Ielded a diagno<-i) of a mOOcrate grade
II hg:lITM:n!ous of the righl ankle. lbe p:llienl ... as placed In with a poste-
nor splint, and given wnh for nOIl-"cil!!ht ix:arillg The: p:1In conllnued for ap-
pro\lrlI3td) 2 \lcd,s. and the jXlllcm fel! no beneT Ih:lI1 aIlhe' or orlgm .. 1 m:: .. umcm. III.' no" pre-
'>Cnts for aUJilion!l1 assistlln..-e.
Physical'::xaminulion: Pulses; not palpable due to massi\!;: ed.;:rna. Doppkr uOfS:l.hs
pediS and poslcnor ubial palen!. ROMlirnilcd and paintul In all planes of 1110-
CillO; no pain at mediJI ,md 1,lkr:l.1 m:tll.::oh . ..ever.:: upon grJ'iping Jnd fibula m:tlkoli bet .... een
hl'Cls 01 both hJmh oml '>quecling. ..... a.-. greater .... lth imcrslun tl!,1Il ,rnlle mll:rsion.
/ .afHml /(lry Fi lldings: Radiograph,: linear. nondl'pla.:cd fncturt' of tal;lr bod) e"cnding from
ankh: Juint UIIO po'terior facet of subtalar jOint.
QIlf'Sfi(m : What comphca\lOIl be Tllicd tlut 11\ a p:tticl1l y, It I! rt tular im,ture>
56
Answer: Avascular necrosis
Discussion: Talar rnIClUres are rehuively un-
,',lllllTlOn, bullhey can lead 10 potentially serious
Since (he (lIIlIS has no tendillOUsal-
Ixhmenls. and 7()1l, of its surface is covered by
..nicular cartilage. Ihc blood supply is extremely
I.:noous. As a reSUlt, avascular nenosis (AVN) of
the talar body is a common complication.
Although Ihcrc arc a number of classification
!.(ems for talar fraerures. Canale and Kelly Itt-
"mmend the Hawkms classification. This system
Jescribcs the fracture panem and predicts the like--
lihood of future complications. such as AVN and
postltaumanc arthntis. 1llere are fOUT types of
fracture with an Increasing fmjuencyof AVN: type
I has a 0--13% chance of developing AVN: type II
worse, at Type III has a 80-100'1>
,hancc. and type IV willgoontoAVN 100% of the
time. llIc mechanism of injury Involves a rnpid.
lorceful dorsIflexion of the fOOl against a stationary
ubia. causing impingement of the tlilar neck on the
tibidl plafond. Continued force results in medial
dorsal comminution. along with disruption of
Ihc talocalcaneal hgalllcnb and anklc: ar.d subtalar
capsules. As a re!.uh ul Ihll di,ruption. lhe alrcady
tenuous blood supply to the lalar body can be sig-
nIficantly disrupted. and AVN occurs,
The dIagnosis of A VN can be made on plaIn ra
diographic c\ aluation by the ab..cnce of the so-
called Hawkins sign. This sign. "'hieh Hav.lLns
descnbcd as bony atrophy found in
the body of the talus, a nomlal rcx:ti'e
hyperemic stale al 6-8 ",eeks foJlowmg these
fractures. Additional methods of evaluating AVN
include scimigr.lphy and \IRI
Once AVN has been diagno<.ed.lhe gool I) to pre-
venl talar dome collapse. AI..-conlmg 10 PL:nny and
Davis. il takes 2 year<i for a sclcrolic udus 10 reva.'>-
Wilh this m mind. p;ilicms be kcpf
non-.... eiJ!;ht bearing un that for 3n C\lended pe-
riod with the use of a patellar tendon brace.
In the present palient. AVN WllS ruled OUI by
absence of the Hll",kins on x-my. The lalar
fraclure was treated with a below-knee caSI. non-
weight bearing. ror6-8 v.ccks.
Clinical Pearls
1. CompltcalLons of talat neck fractures include: avascular (AVN).
nonunion. subtalar and ankle JOLDt posi-Itaumalic arthritis. slm and fl'-
teomyelitls.
2. The first clinical sign of A VN is imroctablc pain.
J. Evaluate for Ha ..... kins sign 6--8 wccks post-inJUry.
4 . Once AVN is diagnosed. the goal is 10 talar donI( collapse.
S. Revasculanzalion is enhanced by accurate. siable reduCIlOO of the fracture frag-
ments.
6. It takes approximately 2 years for a sclerot ic lalus to rc\'asclllartle
REFERENCES
1 GhoIan P. eI at Trellml'lII of'atar neck f..:tures. a,rucat """lu of J FOOl -\nlle J9j61 1t>"- YJOO
hnny IN. o.v,.LA flllClUl'CI and dllloca11011J of "'" _k lalus. J 20 1Il29-- 10)7. 1980
J. Thon1anorI 0 T.l ul fnICt\II"U Foot Ankle a,n 19Q9
57
PATIENT 27
\ I'&-)l'ar-old huy \I ilh internal rotation injur) 10 his ankle
\ \11.\ hv ... h <.Cell in lhe cnlergen.:y UepMllllf:nI \U'IaHlll1g.:an mtcmal llXauon injury
hI lhe n!hl ,!Oklo! hour. Inl1lJllf<'allnenl of ray). KC'. elc'OIuon. ban-
,jallt'. and lnufhe,. rtle p.l!ICIlL cold hi" had a ...... \el"<' and remam oon-
""eight fllf I \\o: ...
"h.vsicuf /':xflIllln(/liOIl : ,,"vllen righl .. , Mu,,,,ulv ... J..d':l,d p.lln on palpation of:1l1
.. rJI J'pc,! (II ;1111..1.-; neuro,,,,,-ular InlUd :IIW "nlrutln.,;;}I. tIl13t.'ralt)': all Lle ROM
11'-1:1"<'3',,-,\.1: !,Jin upon IllJnlart1C\lOn and <"<,,,,ion
' .uOOr/III,,'Y Fi"di"KI': a\ulslun .. 01 ubw on aI11er(>JXI\lenOr and Imeral
... " ,. er "JIl lIunhUlI, ulM tr,l<.;lUfe 01 10 IJ(cmUy 11lTllugil open
rel"(Juubr- .. h<!pt.-..l !menue F\ allJ:UII)I1 ,\ ,ji"pla.cd !) pc
III h.k.Ulre .'r;, Ju\t'lllk Ir.ll"Wre til Tdlau:>,"
Qrl hliVIH" \\ h.d I' ulitral ul t) or InJury" \\ hili i, Iht' m,h . Hlon for
"
1lUlI'trs: T rcatmcnt Jeperu.h lin th\' amount ot If > :! mm, is
DifcUHill1l: The of Ihe Ju\cnilc
Ir ... lUre olTllIau\ I' \'ill",r 111311:r:1I rol311un of Ilk:
hll. .1 ur U IIM:Ji,,1 rotallf'n 01 IIle: leg 0fI
1001. The tra<,.lure IragnlCnl I) ",ul<;ed
u' m tlk: anl('rolaleral a'po:1 01 tlK dl)1lI1 IIblal
by 11K anlcromlenor IIga
ICnt. '" hen an 1:\ll:mal rot"tlonal f(lrel: is applk'd
1,1 [he fooc alld by 11K (lpprn.lle m.,:.;ha-
The fnKlUre (ragment pmducalls roughly
'lu.uJnlalcral becau'IC the fracture hne runs
_"II), 10 the and clitJ. anterolatl:rall}. pro-
Jucing a Saller Ilam. III fra.:lUn: ulth.: dl'-
1,,1 TIbial
rrealmem 1\ on the al11f'1unl of
InCnt of the artKular .urfoce ,liter dosed ralocuon
I.:.;hmques arc 3l1cmptcd. Ir the ,epar;(tion is
,! reater Ihan t"'o millm1(.'lcrs, than
or llIM:n redudlon Yo 1m inlernal hlO1l{m is
("\;commend.'d. The prognO'>is u.ually i .. good If
.m"lomIC rcdU<.1I011 of the 3rhculnr IS ob-
t,lIl1cd. The m(Y.)t complication rcportt.'d has
1 ....... 11 pillI! Jnd .... 't;ondm) 10 articular joilll
,Ilo.oilgnuly fvllo\\ mg m;I(k'qua!c .. lo>&1 redu(uun
Initial lreatment of a or nliidly
Ju'enlle lrJttul'C ofTill:llIJ1 )hould con-
,1>1 of an al1cntpt III l'l'dUCIion and ploce-
mcn! In a tletO ..... tol,1 Yo lin Itle 1001 In Internal
tne"cion In lhe !Kute inJury, a hematoma bloc!..
, uh aspiration 01 the ankle j<>int i) performed af-
I",r appropnale ,km prc]hlrallon. "The f()O{ IS
,(; .. :.:d In full dor-.iflc'lon and abdUlkd "The
" c..:hanism is then 1'C'ersed ...... lIh ,our contr:aIJt-
erJI thumb appl)'mg to anlemlatcr:al
tibial alld franurc lr.lgmcnl. Whllt in\l:r
nally rotating the foot nn the leI!, m3mt:lIn axial
traction \naromieal I'l'tlu.;tion of the fracture
mandalOfy.lflhe fraclure IS displaced
more lhJn 2 mtllim.::tcrs, pcriorm open reduction
and Illahon When the fracture fragment
I' rotated. closed c:r.n be dlfricult due 10
mterpos,uoo of the perio"ellm and ankle joi nt

Surgical reduction an anterol:lIcral ap-
proach to the ankle JOint bo,:tYol!\'n and parallcl to
the e"enWl" digltonlnl [eOOOl1 and lhe
hbula. Take <;pi:.;iat III identify and D'old In
Jury [0 the laterJI .;utant"OllS brunlh orlhe superli-
peroneal ne .... e rite Mlperior eJltensor fClI-
na.;ulum h lhe fiN encountered,
When Ilk: peroneus t\'f1iu) pre;,cnt, the same
inlerval cnn he u..ed with mednd retrac
tion of the tendon the anlerolateral ankle
Joml capsule torn along wnh the ,ynde)mosis.
which call lead to mSlabililY between lhe distal
ub!a Rnd fibula Inspcellhe anklejomlto remove
3n) debriS \1\.0 lhec!.. the Integrity of lhe dome
of the I3lus,
Wi lh open :r.natOl11l1: redllCtron of lhe articular
Internal fixal10n is lhen u'>Cd to mamlam
Ute ""01TCC110n. lIl) recommended tnat tnc IntcrnlU
ii,allon be plact.-d p"r;;lklto the ph)'lC31 pialI.', but
If 11 is l1Cl:e,!iaf)' 10 cross the pltySlS, smoot h
Kirschner WII1'"S arc advised,
In lhe pall.:nt, open redu<.lIon ..... ;os nec-
essary 10 reduce the fl1luure, 115 dl"placemcnt was
more lban 2 mllllmelers
Clinical Pearls
\IICnlpt do .... -d redlKtlOfl ,,"h cQmpre)slon of the fragmenl Tu!..e CJ(C 110,)110 pro-
duce u prcnure necrml' ufler the cast has been apphed
2. Inform lhe pallent and family that surgical inre .... ention indi.::atcd If the
dosed reducllon f: liled nO( nppearmdiogruphlcallYI
1 Po,I-n..'du.;uon films are mdkatcd 10 che..:k the reducll on, If doubt rcnrallls, order
c-r
REFERENCES
"I.'gor H III "tlhr la,.",1 por''''" ,,/ 'hr CP'I,hy". ) 0" ... )om' \Uf u,.\
SII"'''' WIt. fI, .. ", R \d""'nh", I-l. lay 11M )u,eni., Ir ... 01 I,lIa", A J",al,,(>,al <p'ph)",.1 Irk,uI. J \m Pro,all
".J ..... ,,' '" '<)'.
\'ol"n""11 II) l,.tmln I Il>t ,""'mle 1II'<"1u " ,,/ r,ll .... CI,n ('nll"p 110 21 '1.
59
PATIENT 28
\n 11 .)t.'ar -old boy arch pain
An II-)ear'old boy complams of and mcrcasmg d.J.ConIIOl1 \\ hilt v.cJnng
His mC1l.l\cr ttim hi) ... allmg changoo. nnoJ he t"anOOI run ... ell Ik t\po:ri<n,t'(I occasional
turning in 01 his anlle) o,er the pMl lear wllh incrc:&)ing fn:qllE'llI.') "The f . .I(her and paternal
lUKle had problems \\!len [hey "cre boy). The l'hild i) now ..... en in the emergeocy tkpanmcnl
wilh a frJllureu met31:m.J1 He ,Ialcqhat II<' "'3) only lOoall.;m!! IOohtn he tell hl> fOOl "81\( way.
I'hysitul t'xumi,wtiufI: Gen.:rai 1' figure) .. kloml1lic) 01 both fecI. \\ nh Jimllauon
of IInlde dOfliifkl;ion: all toes contracted and cla\\t!d, G,lil annl) )j,' pallen! unJble 10 'oI-alk on heels
\\ llhou\ bal.,tnl'ing himself .... nil. mus.:lc "rcnglh of tibialis antenor nnd per-
one,\I) .... cal.. blt:lIcr.Jlly. Neurologic: ....:nsOlIIlJn. panlcul,lrl) vibr.lIor)' Hnd rcduled dl,tall)':
anlle relic, m)1 clkllcJ
Laborul ory Filldillgs: Ekcrrum)ogrOlphic Cllnduclion reduced number
01 motor unn UChon andllbrillar;oll polenh.tI,; IIlcrt'aseu proponl0n of pol) polentiuJs
and fll:.cinilml'l1l JlVlt:nliah.
Qllts/;O/I$: \\ hOlt is the of Ihi, hcrcdllar) pol) nCllfop:uhy? What nllcmmi\cs are u\ ail-
able to allow M.lbiltt)' I
..
I)i)'rllnion: The progno\ls fOf'
\Oouh the tntk!n100 of Ihi,
pot)'neumpmhy. 1ne inhcritalll'e p;lUem In
,'.lSC -cems 10 be dominalil. ullpl)"tnS a benef
Ihan if II \Ooell!
The lin.! IS 10 lOOlrol lhe: reilrfoot m\er-
'1(m PI...::ing fOf'tfool m \;'llglh the
\Upm3lory rQ(lllial .... ill Ihro"' the reari'OQ( into
fu rther IIl\er-.ion nk' ftarfout lall be ,>tabilill-d
\00 nh a IlCtltmt (t' to lock Ihe he.'1; the: .llkiilion
I,f a high-het'led .... 111 the
In the pre'lC'nI p:llleni. a 1:000\CfValll( Jpp!'Oiloi:h
mluaJl) 10 mJll;lse the p"IgI\';l>I>iOll O[ lhe:
<kfonnllY HOIO.(\<.'r. he did IlO( tolenlle the or-
IhmK1i. aod <,urgl,al ophnns \OoeTe el\ploo::d. 1bc:
surgical proc.:t1ure of plantar fasciol:omy.
Dwyer calcaneal O>.tOOlOlllY. ten.:loachlllt:s length-
ening. and Pfl"terior IIbial through the in-
10 tbe dorsUlll of tbe fOO(. 1bc: nexl
of 11 procedure to Inc great
10(. fir;t metatarsal O!>lcotomy. and If"a/li.-
Jeri of the tendons mto the ffiCtaLllSal
I1e('ks. The , ombm.3llQn of lhese procedures fC-
,III1:W the (a\lUS ..kfomlHY :md pm"'I(kod 11 polin-free
gait lbe ht:tl lIas reduced. and tbe ankle
-pr.uning was eliminated.
Clinical Pearls
A hlgh-lI.mged. IkeI' h.:el :.o:;,t .:ontrols the foot and can IImil in-
Juries,
2, ('Jr..' \lC "'hen all I\';lffool
will induce fUr1her Hllhe fool.
.' Th ... reM'lr1 III dl11dren Wllh IS a Inple Ilfthrode-
IO.llh early reLognirion ,',In b<! J\oide,J.
REFERENCES
1'ttWItk. N""rulon O,I;&nOO, Grune ai>d S'r.ul(ln, I
\!.<ibN)' L 8 ...... . "" o.".owy \1 "I Fuo< SurJ:tI)l.1r>d oJ R.Jr"""" . \10. \Oo,lllai'" Ik. ....
1...,1
Quill 'I, k" ..... P ,,' \I"",,,,,,", <-h" ... f'Ir..rm;r.. ........ .J . .>nd Ph).o.:>Iot!.ul "'_pn:I. s.u. ... ,\ ..... mJ<
1"'>1'1
"
PATIENT 29
\ n-)car-old dialK'tic woman a planl.ar ulcer
A 72-)car-oll.l .... ornan admlltcd 10 the ..... Ith a plantar ulceratiOll of the: lefl foot. located
below the 2nd and Jrd mClaUln.als. CelluhtiS on the great toe rrol.imally 10 the Jrd metatarsal.
1be pallent has been diabetIC for 15 )cars. and her diabc:h:s hl", been controlled ..... lIh 35 linUS of insuhn
NPH. She relates having a bumoot.'Clomy 25 )cars earlter
Ph)'sieai Examination: Lo"cr C'l.tremLl). femoral. popliteal. and dor.alis easily
palpable. 00 redness or calloused !l"ri .... ound with lh-charge at ulcer .... ound base
firm and pink. IO.llh gr:lnular consistenC)' . NeurologIc: no 10 Semmes-Wernsteln probe.
Laboralory ,.' jndings: Chemistries and complete blood counts (inctudlng controlled blood
,ugar)_ normal Temper:uure: 986
G
F. Culture and leSIS of ulcer: no gro .... th on three eon-
sa'uh\e R.lthographs 1M'\! figure), Jbnorm.lllcft foot - metatarsal., tapered absence;
lrst metaro.r..al na::k ab!>f;:!1L demlllCra1i7.lltion and desrruerlon of 2nd metatnrs.ll bone; lrst me!ll.tarsai
tlCad and shaft appeared "moth,eaten," IIh atypical configuration to tr.lbc:eular strocrures,
Questions: Whm the IOOSt hkdydiagTlOiiis bas..--don the rndiogrllphlc What methods are
used to confirm !he diagnosis? Ocsenbe the treatment Maging that may recurrence of the ulcer,
62
Diagllosis: O!.h!(Imyellll\
Disfussioll : O!.Il'Om}ciLlis iI!osocl:ucd with
penpheral dlscase. found frequenTly m
Ji abellcs or WiTh artCriosclerosis. IS a dl\-
.:.be of lhe elderly. 1be pallen! "" IIh v3..\.Colar m-
uflhe is mOM likely TO
.!elelop <bleom}eliTls from a of conllguoo"
infeclion. Small bones of the feet an' most fre
,/uentl) affecled. w Llh mited 1I1fecllon of SlIIlIh\"
i<or(J("CUS tll/("'IIl and entel"O\:oc..:i. \ , would
S)SlemiC are few. and local
'18ns
Lighllouch IS lho: pnm:u; .... n<;e that tho:
pallent 10 be aw..rc of and pn::lcnt Jr.:;b of im-
pending breakllown. Who.:n lhis sense is losl. ul-
..:..:mtion is HlCVlluble. 1berefore. quanllf)ing The
prcssure sense 111 a fOOl is crucial to lhe
": \J1II. The upllmal IHeLc of to
quanllfy light-touch sem .. 1l10n in d pinpoint dlstri-
nut ion aili'qnat<: for :Iwarene"s of impending
breakdown is the SemtTIC, Welll ,te ul iilament .
This a nylon probe. than a ball-pal III pen.
that cahbrmed to buckle III 10 grams of linear
pallent", , km- the amountllf
pres\urc for proK'{'Iile <;en"ation Ifthc
pJllcm camlOl f1 the probe bockling the
llll. then he or 111 .Ignlficum n\\': for the d ... -
I dopmcm of neuropathic woun .. h.
BiopslI':s and cultures lire nO! taken directly
lrum the wouoo (avlly. Wounds are (ontami-
n:ued. fbone culture and bone 'pecimen)
,tloold Ill! tal en from an adjacent. unmfected area
\ Ia a stparatc
,\tthe completion of the biopsy. the "oond is
then addreCd by surgical Too of len we
p<"rfQml local debndemcnt in the ofhce. remOl ing
onl) lhe oo_ious hbnn dnd tl"fOliC Tissue. Dol
lra"; ng de\ Ilalil.ed deeper Deep "''lCI-
of the de""ahud lI5.'>ue 10 mdude ten-
don. muscle. and bone is mandatory. Sharp dis-
..... "(Clion with II scalpel or w tth roulIg<"or<; of various
is helpful in n<"'-"rotic from he"ltlly
The roungeur I" pl:k. .... ...t undcmeatll
wound oo\:c. the h}pcrkeratotie and dellt:ll-
Iled tb"uo;: b
The I rst nWlIuar<,,1 head" tho! common
nrea for bre"ldo\l n I"h.:: lIonl1.11 foot has ,III ... ven
p,lltem of mution. IIlth n'LC. heel COII -
tncl - a genlle rolling ( not from the
outside to the of Ihe 1001 a, the fOOt
pronnlC\ through. with one bUlte bt:armg .... Clghl
that gradually to nnother bonc.
Contact C:bUng i. a way to plantar pres-
wre peal;., Of the ground reao.:live bul it
doe!- nOi \hi.'ur 'Ole Ihal "'hile the
caM m.lY be reduce upon remol31 the
patl ... nt hi) Of her dhordered galt pattern.
and the \rn:3r forcc\ return to another ul-
III the or adJli. ... m area.
01 the lI'>t head mu\,l be
wull f{"IR'>ight. UodcMand that the Irst
mct3i:m.al he..d t"W\ the m;IJOnly of weight at
and a re<;ccuOf[ 01 the rllCt;uarsal w!ll
.. r all of lOO we' ghl h) I"'" <tdjx"nt me!.;llal"'ials.
.n.: new p.:al on the !nd metalnn.aJ head
thl: In...rea..:u ,he3r w III lead to future callw.es
and the potemlal fOI" plamar Carry OOt a
logical ><ljllt."ncc when plauning ITK'tatarsal !"\:SeC-
lIOnS, aoo the JefomlllY in
Stagt! I. nle Itl lc..:ltu rnetatan..ll i) re<.e<:ted as
far pro.\lmol a, nccdl'"u. Ihe peak
that Ihe lIIillalllll: of Ihe ulcer.
Tht' uker I' and excised.
anu the pilleed (.n Jpproprimc <lnUblOlics
ueli.'nmned by bone
Stage 2. TIlt' patient rcmalll' roO'lofflo;IuC"d.
Snlinc drc'\ings. wct-Io-tlr)". are changed IWlce a
day. The dres,ings be pla..:ed Ikep IntO the
..... d wIJund cal it} .
Stage J. Wh<:o Ihc plantar 10.01100 has com-
plete!) cJo<ocd. the loreloot I) addresSt'd w IUt re-
gard to ,urglLal .. 111c fUfKuonal and
mtegrtt) 01 the forefoot 1\ paromount in
redUCIng the mk of futurc peal and
rclato:d [0 Rebalancmg is per-
formed by pallmelataNiI rather than a
or hoiatC' d met:ltar..al
The forefoot mechJnll:S ,Ire equally.
!"he \\ ... Ight -be"ring ,urf:..;c i\ ,pread OUI Imns-
\erscl y oler all hIe melatarsal With the re-
mmal of one mctatan,al. Will oc,;ur on
IIdjacC'nt mel3t:lrsals .
Stage -I. WiUt tho.: foot oow qnlLturJlly balanced
aOO uble to luncllon wnh equal welllhi distnbution.
Oftho<.c,can be u:.ed A tnple-lamlnale ortho!.es I\!K
onl) ocl"01l1mod.IIC\ tile fOl\1 hy mnlding Dild cush-
lOlling the Jhnormal rrnnueno:e\. bo.u also
,uppon, the fnot ,n II IIclural
In the prc .... 111 pallcn!. ,111 ul l\\lrlthtnK trcatlllcnt
p!'U1 \lU' tJk ... n t<l prevelll of os-
tCUIII)dllll I'rogre"loll 1111:. pl<ln inlolvcd surl-
,al debndemenl of lite bone lind ..oft tis-
)110:. The uker "'a\ ,urglLaJl) The !XItlCnl
....J, plal' ... J un J 6\\.<.'1:l l"ur-,e 01 tile ;lPpropnatc
IV Illctl.' rmmed hy the !">one
-111oe ScmltlC\ .... em'le;n htam"ni l:ot from Ilan...:n, Ol",a"..- m ('an Ille. II
;,I\()uld be In arTTl.unentotrlum uf JII .... prol""j'!f1 .. b
6.l
Wet \\1 tlry tlre"inS changes were perfomled
1\\ dall)', nnJ ,hi: !'Cmained IlOn-.... clgh\ beanng
on lhe Jffe,'tctl C\tl!':nl lt y. OIK:C the \\'ound granu-
1-lll"<l. the h'O:l\ "".1) rcb.danlcll "'lIh the use of an
onhosis to accornodatc the abnormal bony promi-
nences and suppan the foot In a neutral position.
TIle pallen! has now returned 10 normal daily ac-
IIvllies.
Clinical Pearls
Ne,er pcrform .... ah cultures of a wound: they IIt'e all contaminated. but not all are
IIltCl.tOO.
Bone blOJblcs and booc cultures arc the gold Mandan! in the diagl105is, and manda-
h:'''Y III up the proper course of anubiotic and surgical treatment.
REFERENCES
Ikll JA l.tth'Iuu.h. k,l,n. "",n, xmR'leS-We'/Uk,n . In EJ . Call ..... n AD.o.cc.m.n
\l. .oI,c.J" olin. H....u. 'hll ed. St lou ... M06by. 2001
FA. \lnIoll G. .. al\t \[N Cl.nicill n.elap"Uf"" COII>Kkf'UOM, Ind Unu,,1ol A",""Ii.
Ch..,\f, Cn.."",,\, IOJ7!
W.,,,".".n \IS The olin. ("h"'no<: Non Ht-.hnl Woo,,", Ptt,lIodc!ph , ft ()!; ptl.lll W""nO Cart' Ce ...
.. , .,\"',II,,'n.1 ,nJnuaL lW!
PATIENT 30
A 6S-)'car-old. insulin-dependent woman with a painful hlister
t\ .... oman presents with ::I painful "blister" on her right foot. She
that It appt"3red very r-Jpidly. :lI'IU has not 10 om! antibioncs and local wound ,are. 11
I' <luite painful UPOIl prt'ssun:. The worn:m is .... carlng and t>OCks. T1lcre is no history oflenglhy
\\Jlb or running rna) cnuM.'u the blister.
Physical EXQmillati(m: T 99,6
Q
F: vi tal ,r:lblc. General: aler1 and well oriented
III LO\\<'T e.xlr('[llIty: pt"Ji' allll poI>tcrior ubl::!1 pubes stead)' and palpable. Ski n
he!! 1igun,:): no [tophi': olher Iha.1l a 2.S-cm clj'thcma[oLl $ ring'" im a I-em central bullous crup-
W)Il, localed ccntrnlly 011 dor;um of right fOOl. Mus<:ulo:o.kclctaL urea surrounding raised m:tSs quite
tender upon palpation.
L{tboru/ory Findings: WBC 16.200/ fl-l: ESR 160 mm/hr: gluco<e 180 mg,d!. Culture
Iwm bullae: neguthe for aerobe. fungal. alld AFB.
Qllnl;on: What is )'our Ll!llLcal irnpre,sion?
DilJgllosis: P)OUeffl13 gangrenosum
Discussion: Pyoderma gangrcnO$um IPO)
was firo;! descnbed by Goekerman. and
O'leary In 19.\0 as a run:. reacme
neutrophilic PO begins as tender
papules or \esides. "",hich de\clop inlo p:unful
u\cerahons by induratIon and cry
thema.
p)oderma ulcerli may C1Ihlblt
pathtrgy ..... hich is an e)laggefllled response to a
minor trauma and can lead 10 of the ul
cefl:uion, pc; can be iatrogelllca1Jy IndUCed from
V8CClnaIlOl'l. In)CCtions. ,l/1od 1lIercforc,
surgical dC'bndemenl a direct cOnltlliodIC311on
In this condition.
pc; most commonly affccts the lo .... er e'lreml-
hCS, ho"",e\'cr,lherc an al)plcal form of the dis
case that i!l lnon.: prcva!.:nl in the upper
lies. head. and n.::ck. PO prlmanl) affa"ts young
to nuddle-aged adults and is 5Cen IlIQfC frequcntly
In women th.::n men
Diagnosis of PO. accordmg to BcnnclI ct .II.. is
a diagnosis of ;md there no specific
laboratory or histopathologic of the
ulceration will hldy cpldcmlaJ ulccratlon
wnh adJ;ll.:cnt cpldcmml hyperplasia. Dermal in-
flammatory and \cssel .... a1Js .... Ith fibri-
nOId /lCcrom arc alSO!oCCn hislologically.
PO can be associated .... Ith s)stemic dis-
eases. 'The Illefluure states thai Inflammatory
bowel disease and are the most com
monly reponed diJ.case a'>5OCiations. followed by
hematologic mallgnancy_ PO al.<.O been asso-
cl:lled With diabetes. SLE.IIIV. and m:lny other
coooitll)lls
The trc:lU1lCnt 01 PG has c\lcru.i,dy de
b:ltoo. TopICal thempy for 01lld conditions can
Include eonicosterold age-nb 10 the borders of the
hydro.col1old antlb3ctenaJ age-DIs.
.md aod elc\alton of the affted
limb. agcnts such as
Dapsone and clof:lzmllne ha\c also been used in
the treatment of PO_ The IImI commonly used
and succ .... thempy IS IIrJI corticosteroIds In
large Prednl'>llne (I 2 used for
moderate 10 '\('\ere PO. Ho .... e\er. doses of
prednisone can be a\.'companled by hy pertcnslon,
hypergl)cernia, and mCTl'ased sus
cepllbili ty to II1fection.
The prcs.::nt patien!', bli,ter e\Cntu311y rup-
lured lind de\clopeJ mto an ",[th sur-
rounding re\calcd no growth.
A biOpsy bion revt'nl<.'d dermhl inflamma
tory mfi1trOI(:S wi th hbTII10Id ne.:To"is of ,t'ssel
wlilb and t' pllJcrmal ulceration With adjacent hy
perplasia. A cour'\(' of locul .... 'ound cnre and topi-
cal to the border,,: of the was
imtimc:d. The leMon bc:gan to respond qUickly to
lhe:ropy. An Apligrafl allogeniC ,kin gmft was ap-
plied to the ba,<;e of ,he "",ound to mcrtase healmg
time and decrease ,,'oood L'{Jmmc:turc, '1lIe patient
had Immediate relief of painful After
a I mon,h coor..c: oflherapy. lhe .... ound "as 100%
epithelialized. She has had no recurn:nce of ut-

Clinical Pearls
Inlllal presentation of a pamfut. slerik noduk that e' .... ntually ulcerntes i .. a ke) m
the: I)f pycdenna gangrenosum.
2. When periornnng tht- It IS .... ise to collecl a tissue ..a.mple althe ,arne tlllle.
Try to IOcl ude the mnet surface of the bul!ae or tile base.
J. The heroorrh:tgic appearnnce is the sahent fealUre of the JI!>C.I!>C.
" Appearance a destructhe state.
REFERENCES
t II<:n""lI \11 .. J ... I."", J \1 JOIlU" JI . <I _I g .... ..,., ... l>u .. , A ,U' lIp.u''''" "t 1\ pICJt 400 l<'Im .. ",III an
pha,,", DfI fill'" 1" ","""""'" C.'" ","'<f'" (11 SII pallen" fmm 1"'0 ,n>lHul,,,,,, MeJ",n.c"'" II n 1(,.
2. Bun BS Th" c't11Io),y"tId I"'".'"",n' <>I lei <Ikon.. J SC M<d A",.>< b1-7f1. 1'1'1.\
\ ImusO.ColombC. \10 C. <I al .. Ied he.llnt: <>fpy",le""" 1r".'0,1 "Jlh .. .I.,n.tId ron
.. ..,.,,"an' 'hlhlU"""'rI'"'''''''' J "'In ,\,a.1 bI -6. :>00,
..
PATIENT 31
A 23-year-old \\unum \\ilh n cruci ating (001 pain after a motorc) cl r acridl'nt
A 23-year-old \\.oman alTlles al the cmerg(rK'y depannloCnI ambulance l:omplaiQlng of exCfU_
laung right fOOl pam. She hasjusl been In a accilkm. She "as hit head-on by another le-
hIde and a .\.Cleft' dONiHe",on IflJUI) 10 her righl anUe SIk- .Ibo h:b a mmOT IJeCralion to the
'..ce. but an} Other pain
Physical EXamillatiQn: \ lIal Mable. HEENT nonnal Car .. r .. gular r.llt and rhythm:
mild loch)canha.. Che!>1: dear. \bdornen. benign. 51.,", nurm;ll. no atlenn:l.lI(ln II' Neuro-
motor and :.cnj,Q1') intact. c'uremit} right ankle and foot In guankd of slight
planrarfluion; dONIlis pedis and ubial pul.'>Cs ,[rung. "IuI,Culo,kckt:l!, grt:M \I'I.cllmg ormid-
Juot and ankle." Ilh ecchymosis: marl:ed :Ioout anllt: JOLn! amI ,ubtalnr JI1Ln!. '" nh de-creased
ROM and crepitus.
Lnb6rolfJry F jlldjll gs: CSC: normJI. ,lull. ,pine .. md dJt.',t -nu
\nlle lateral view (see pmteriorly displaced. wnh l(aLlure- through nedc
of subtalnr jOin!: Jnkle and 1lI1ona\ L.:ular joim mlltl . nomllll.
Qm'sljolls: How thLs fmLlure classified'.' What LS tht: Ll10!>1 common
67
ViIfuui/Jn: The bone IS pnmanly can-
lCIiOlh. II IIh no mlhl,'ular origms or Insertions.
lind of Ilk: ,urface area IS co\ered With
1bcrdore.;l high percenlage of
fr.KlUre) are imra-amcular, and. due 10 the
h.'n1.lOU' blood , upply . necrosis is a
.::omn1<J{lI,OmpIiCalion
Thl't!e main brandies blood 10 Ihe
talus Ihe hbial. .Interior libial. and
peroneal arteries. The po)lenor Ublal artery is
further di ... ided illlo Ihe calcaneal. supplying the
poMerior wbt."rde: Jrtery of Ihe
pl)lng tht: budy; uml o.khoid. lilt me-
dial 'Ide of Ihe lalus. The anrerior Tibial artery
hran .. he\ inll/ Ihe medial tarsal. supplying Ihe
,upenor medlll neck: laleral tarsal.
Iht' talar head. and arta) of Ihe larsi.
.... hlch Ihe wlllr neck lind body I)
formed by ana\lOlll05i, bt!1 .... cel1 Iht: lateral
and pcrfnrallng peruneal
1bc IYPI,allalar 1lI;d: fr:k:lllre IS ,cnleul from the
<.lor..al nc.:k allll e>;'lts the tarsal carmI. II>hlch IS the
JX'I1lOn of the 1l!I:re an: t",o theories
as 10 the nlc. ... h'\n1'1lI ,)f II\1UI)' : II hypmiorsiflexlon
.. au;.cs TIl<! 1'\I.'I.k to Impatt against the anterior edge
(If the di,laltiblli. or the talu) aclS as a .::anule\er and
lilt> ned breaks due 10 bcl'\(ling fon:t's. 1lIe most
wiJcly d:l.)Slfi(auon ,y\tem for talar ned;
tmclilre\ I) Ihc one del.:lopcoJ by lla",kll1s In 1970:
Grollp I- undl)placed lertical fled.
Grou p II -di"placed frndurcs ..... l1h subl:alar joint

Group II I-dl,pla.:ed fractures II>lIh subl:alar
,l(JIIII and anLlc dl)localiOfi
Group IV fraclures "'llh subl:alar
]I.'In! . .lnlle:. and talonallCular
tal:lr neck rmo..lUres. except oomhsplaced.
requite open reduction With anatomic alignment
and Inscrtlon of a lag scrcw.
A ... ascular necrosis (AVN) is IIlely TO occur if
I ... o-Ihirds of the blood supply is disropled.causlllg
wcakenlng ofthc: talar trochlea. \\.hlCh IS subject to
collap5C if fu ll ",eight.beanng is aJlo",ed. The in-
cidence of A VN is around 4O'li> for. type II lnjuty
and 90-100% for type 111 and IV fractures. Radi-
ogmphic presentauon may occur at 1-' months.
appearing as II relallle IIlCrt.lSe In bone dtrumy due
to loss of blood supply and no bone resorption. The
surrounding bone becomes osteoporotic as a result
of reactive hyperemia from muma; diSUse is also a
factor. The presence of subchondral alTOphy (111-
ttncy) in the dome of the: talus on an AP radiograph
(H .... kil\!i ' sign) IS Indicallve of heahng and via-
bili ty The atrophy. which usually OCClirs a\ 6-8
weeks. results from disuse oSTeopc:nia and vascular
conge,tlOn. suggesting continUity of blood supply.
Tre3lment of A VN includes nonweilht.bearing
cast immobilization wi lh unatomic union for up to
2 years or anhrodesis. such as sublalar. tri ple. pan-
tular. or Ilblocaican.:al (Blai r fusion).
In the present pUl ient. an tlttremely consc:rva-
me approach was tuen. She wu cast for 12
weeks. and then used a Cam walker fOf] monlhs.
She was kept nonweight-beanng the enure lime.
No radiographic changes ",ere noted. and the pa-
uenl continued With the Cam walker (or an addl-
IIOnal 3 months. Her lalus did 11(1( collapse. and a
lrealment of c:JI.ternal liution of the ankle along
wilh pulsed electromagnelic field stimulation was
allempted. E ... i<!ence of rev3SCularil1llloo was
noted. and the patient undc ...... ent a pantalar fusion
uSing an Iliac graft to maintain loss of the extrem-
Ity length. These procedures were successful in
returnmg her 10 full mobil ity.
Clinical Pearls
fractures are lhe 'iecond most l"Ommon talar fraclure alld occur from either
a h) perdorslfle'ion or Ihe mlus acting as a cantilever.
2. The blood sopply 10 100 lalus ..... hlch IS \ery rich bUI eo\ lremely delicate. comes
Irom ,llIet' maUl "I.Iurce .. postenor IIbiul. anterior Ublal. and peroneal :merie)
.l Bawlln' ch,,/i c:ltion of tala I' neck comprise, four groups. based on in-
,h,I')I.all.jfI uf ,urmunding
" .\\ n>l.ul.lf l1('u'hi, th ... mosl U)mJllOn complication. II appears radIOgraphically
11 n:lmi\<,: iflcrea)e III bone densily.
5. 'ign is lIIuicmne of \iahility It pre\Cnrs 01 6-ij weds and uppean. radl'
-uhchoJluralluccncy.
REFERENCES
I Ca,,"'. ".Il, t1\ fr ... ,UA' ,.( II>< of "'" tll'" of 71 J !10M JOInc SU'l IiOA 141-1S6.

\U T Iv ''' .... , .... wrt .lnd ...... " "f l>a-CUW _""" 1I'00I Ankle Sur, 38il).IS4-t61.
..
PATIENT 32
\ \\ oman "ilh hi gh-arched and ankle pain
A \<:.t1 ... ,1,1 pn: ...... m\ "lIh 11,1 .. 1<:1111 Julie pain. Shoe rdolle) :lI;hlng pain in her l;ucral an-
1.1(> lhJ1 IItll"oCn, v. III! .>(;11\ ltv md of frequent anl>le "pr.lln, She )tJles 1hal she
I. .... 111'>.1)" h.....! \ CI) hl!:,h.ln..h<-..l and l,lLfricuhy weanng .::.:n.lln ,hQ<! gear rhe r;IIicnt denies
trJuma. hJ.' tn.:d prciJnm .. I.:.,I wilh hll ie rehef
Pllyrical F.xumilluIlOll." \ 'loll ,ign, _1Jhle. HEEJI,'T' noonal. Cardia.:' n.'gulJr rate and rh}- Ilim.
'k,:,t dt .. r .\to.lolTlcn Oo:nign <.,t.;in: nonna!. lk .. p h,'IlI,i\m I\'He\, decreased
\ Ibr.lIory ,,,n<, . II.IM. \ l u .... :ul."I...:ktJI, " ('{Ible. defo.>mlllY "11h planlarncxion of lSI
01 \\ nh re,.,[i\c of ante nor; of digits wi th h)-
le'llln'll PIP j<Jlnt; no of 1\0 tenuentc\\ ;llnng J.lIcrnlligamencs:
.. trnphYIlI po"tal"'r Ic!,
'"" bora/llr}' Fillrii llgl: (Be wi th ,!iff<'remi31 nonna! NcO'e .. ,-ell ... "lc, SO'1o de-
In muc"r .on,] "'::1",)1)' 25 m".ec . hUcncics .tela}cd. (..et: figure);
.. hn" lil'tl. wuh d"crgcnce uf l.itar III planl arfl e,i(ln, raklc.lk"nclll angle 0" on
\1' '-,ell
..
DistuS$;on; CMT .. h'>Ca..e I'" hert:dn.uy ITIO-"-
tOf lind .\I.!n\Ol) pcnrlM:ral ncuropath)' resultmg
from an abnonnalll) or m)chnauon II acoounb
for 'm of all h<.'rethtary neuropathies. Charcot
lind M:uie 01 france and Tooth of de-
\O.'nbed It "multaneOll,ly m I x86. Orlgmall} the
di.\.l:aSo! Je<.eribe<.l a.;, a pcroIX31 muscle :I.lro-
ph)'. but It t1ctennined later tltat tnc pcroneats
maintain rllOl!l of the:lr,trength until the laiC
orthe: di..e3Sc:
There are two of T) pc I or h)-per-
trophic C\IT 1\ the cla'"c pre'iCnlalion It L) usu-
ally llutuwmal oominam and b.!gms III til<: Ihml
decade of life. T)-pc I slowly, de--
rn)'chnauon and atrophy of nene fib.!r (au,ing
IllI.Xknlte Irllpalrmelll 01 muscle funClion. T}pt I[
or nonh) pcmophlc the neuron;11 fonn, I>. ilh
symptoms pronounced and occurring latcr III
life. Thc patllophysLology of the h)pcmophic
form abnorm,ll and molecules
along [hc nerve premature atroph)'. Thcre
IS II rem)c!m;Ulon ,mu onion bulb dfc(t lhal
enlargement uf rhe nerve. The nonhyper-
tmphic foml ,how, ,'trophy I>. Ith no el-
iue-nee of Ue1l1)e-llnatIOn.
Clinllal manife.talions IIlClude disml muscle
atrophy und wealne .. .. uaJl)' bilater.ll and
"ymn1<!trical-of the: upper and e:"lremille:;.
Muscle <k:genera1Lon a palle-m
1ne: muscles supphcd b} the tonge .. t :nons of tile
\CiallC nene affccted firi t, and lhe smallcst
mu\O.'!cs I1re lhe hDlloatrophy. Commoo
tation al!loU lfIeludes C3\O\aruS and c:qulno\aros
fOOlIYpe. conlraclUre of digits. drop fOOl.
andtor a steppage gall. The deformity
is due to of the anlenor and per-
oneus bre\ is, caUSing the longus 10 plan-
rarlln the: Ir'i' ray, resulting 111 a forefoot \algus.
The: remaining metalarsals may also be plan-
tarfle"ed, <;oft I1ssue at the:
JOII1l and do .... al sublu.\31ion
of the dlgllS, The unopposed pull of Ihe posterior
uagger.ucs lhe hUldfoOl larus. TlLt:rc: is
also wme kId of "Cnsof'\l \lbralOf'\l ""n>c:
and nrc hrst, -
TI1C Culeman u\.<:(l II) .!etemune the
fleXibIlity ollhe reMloUI \\llh u Irsl
70
ray A "'xxk:n blodl) undernemh lhe lal-
ernl border. ,md heel and rc"rl\lUI l,mnallon is
e\ If the rCdrloot 10 neutral or \ al-
lhen a Irsl ray prufedure "Ill redoce the
hindfoot dcfonmt)' lflhe rt:arfoot fails to a
mldroot or hindf\lot prOl..:tlure ",lIT"anled.
DIagnostic <tudies II1clude nene: condudlOfl \e:-
loenies, DN \ anal) ,I', and nene
Nene condlllllon ,In: often 5O'l Te-
doc'Cd 111 molO'- and sen<;()l) and
an: 10 three lime, nlOl'e than nonnal.
tonS"IS of ntr.l-depth
and
mil and ,tn:tchll1g treatment
call be: complex: thre.:: lIuc)tion. ,hould be
ans"ered before a proeedure: done,
I. What the motor of tl1\' mu-..:les .. round
the foot imd ankle?
2_ h the defonnil)' flc\lhle or fixed?
3. 1101>. is 10)) 01
rhe of ,urgit'al procedure depcrnls On
>our to Iheosc que,llon,. lhe ratlcnl', nge.
3ILdthc chief complJirH SlIrgK.LI <:lIlTecllon in-
dude, or anhrodesis of le,ser digits:
ool'\lfie,ory o,leotOI11IC, ul nLClal" .... als: p:roneus
longus or po,tenor IIblal te-m10n mldfoot
osteotomies or Japa)); ... akaneal os-
tCOlomy: or, for a SCH're a Dw)er os-
K'UlOmy, Triple anhrode<'b ,hould be used a
-.ahage procedure for a long-siandlllg, filed de-
fonnll), "L1h of hllldfoot
changes. 1lLe ke) to a procedure IS re-
loclllmg the cali;alll:us the: talus. causmg
\algus of the: hindfoot lind 3110"'lI\g the to

In the: present palle-nl. consen atilt therapy was
allempted. Custom-molded ortho..c:s con-
Structed with deep heel rups to maintain conlrol of
the rearfoot The forefoot rebalanced 10 :te-
comnKltiate the: fordoot The: pallenl had a
u...'CreaM' m latcml !lillie I'aln and de-
lILed any funhcr ankle 'prams III a 6monlh fol-
lo .... -up appolnllnent. C1l1111r1ll0U_ rnomlnnng for
clalual10n of lhl: progre"Lun ul the disc;ISC i,
done 1110nthly_ Alilii, tilll". ,IIC I' '1111 fUl1cliomng
\\ IIholll .JL(lluIl IY.
Clinical Pearls
ChafCQl-MllncTooth disease is a hereditllry. progresSI\c mOiOf and scnloOry neu-
ropathy Ihal ..:ompn..es 11 hypertrophiC type and a nonhypenrophlc Iype
2 CMT pro:-.cnts ..... llh a ca\"ovarus deformi ty. sensory controclUre of
dlglb. alld atrophy of lo ... cr muscles ("stork leg" appcarnncc:).
J. Both motor and conduction \cJ()I:ilic:s an: SO,," reduced.
4 l'.c the Coleman block Icst to delenmne the BUiblht} of the n:ar(oot.
5. SUTglcal pnnciples mdude cl.lfl'ttting ihed defonnllics. restonng muscle balanc-e.
and preventmg rurrencc
6. RadiographiC fealurfi inclu..!e dorsifluion and abdllCtion of the talus on the cal
caneus ("bullet-hole sinus tarsi"[. increaSfil cakancal inclination. and of
the bt ray.
REFERENCES
F ..... I'WI M PW"UI< Gru .... and Serllu"". 1'lSt>
! Quln P .... ofMtl ""'nl Oin ... a!. I'bY'ocOOt!l<al "'PC<:I\_ S..., 0..10. " .. ...
, .. ,
71
I
PATIENT 33
\11 girl 'nilh a
\n 11 girl "'lIh lund:rn "00111 .I!>normal I.)l>' .mJ, lI1"r,' 'f'CI.11 ,III p.un in her
n!!hl f'lUnh ['Ie, IlWlher Ih.J1 her u.lughlc:r been .,t ,h,'-.l1ul"It. ... "
grn\ .. h."tl .. ... c .. nn!,!. "11<:,1\;:0', IN .Ll'rru\lmJlct) .... .:cb t-. 1l),1 or hcr ,_ uo rh..' ,-COla vf
ltlt- fordonl. In .ttldnion. Ih ..... hild\ ;ldi'o"lIy len'll) nOIJbh d,""ftc,'-.,:.!, J '" i.lhe
gut', .llh ttlt" "'ell! , .. " .. xl 10 be.- arnJ dc:fOfmeU Ther.: lit} hl''''f, Ir rr."ITI .. I. med-
"-.II h"il'l> " ullro: 11\.111,,1;> .... _ Ilh lit. !..n., ... n .lrug I ,mli1 hi ",,1\ "I' ",II" I", po" I,' ''''(In
ilOJ 1lk:IIIIU __
I'h),sirul F.XlIInillDt;Qn: \ u.lI ourmal, Pul\C, pJlp.lt11c J'JI".lh. 1"'.1" .u.d I" "knnt I,ht;'ll
Ilu\lcr o:xm:rmlYI nomt:!1 rill _I.in 1..:'1<'11_: ,Iml IUT-
j!"r oHrnwl \ l u'l.ul,,l..clt'[al [t .... ,li,lo,:.III,'n,1 I[h ,h. p[ lilt 1,,,- milJ 1'>,
lateml hallu\ ",llglI' delnmllt) \11111 IIc\llllc rc" pl.IOII\' Iinnl..,1 pl'"11 ,r Ik''''1l IH)\I (II Jtll
IlletalM'-Oph.llangcal bll:llcmlly.
I .a/mrilfllr,. Fill dillgs: l',ec ,lIu!'! Jlh II1C[.I!.11 ,iI "I ht'llt bT n.) i"lIll
,:It.lOge, "I till llWtalar,oph.tiolrlgcal Joint.
71
(In(II\\i/JI'' IUd.,I.,r.,a "
d hI .111 ,1:.II'''d.,I.JI '.,I .... the
,J,I"'II " h.;",I,,,II;'- 'II II.UU"':
'I .,110.. ... 1. ItI.: tUnrlh
:>.1;,1;'1'-'11'11>11 .... " .UI<'," IIluh'pie mo:l .. l.mi .. ,I,
hll"Inll1:,: "III", "",1.,1.11,.,1, . hk' 10' prellM-
'I\, , ". Ih.: _,.d "".; "I lhe [1"1'-
"'II 1,1 ItI.: "1<-1"'.,,",,,1 \Olho,,,:::h Ihe
II.rl<lv.n, h.<, I-c.;n ;I''-'Io:I,,[t'd
",[h DOlI"" r ......
u"Ii_tn. 1',<,,,.1. _-\1-
'\lltlf""'" ruml'r', 'IndrulIlt.'. 11M'
"'1'111, J"."h"ll, ,.,,1 ",h<:r '}'h:11Ii.' J;";rJe,,
Ilr:"h"IIt'I"'''''''' ,. I,,",e ,n
i .. I1J Ill"" ,'Hen <0.;1'1'1" h,LlIe' J!h R",J,-
""rill,' I" .'\11,'''<'11 ,. II'"'' !H ,'''''llnn .m
"I Iii ..
In Ih( e."I)' .1,1',':. <'I pJII.:nh .In:
"laIlY,,'}I"I"UIiLlIt, Ih ... p"mary .;umplJIIII III
Ic' ",,!I"nl ",'Ik'n '''''llortl,' .111.1 IlMlly
11111';' fh<"<' ".111,'111, _II<' .l'Ir .,bOIl1 Ih':I T
'1'1,,:;11':'1'-'( {lI.kr I' ,11':lIh .)mp-
lum.. nl pam ,J1l\' ", pl'l:"ur.: Undtf
),IC<'nt ho:.IJ,; limit. ally \lnC may \o.:e
1" Tm'lIl"n III Iht; .... ' .lIe.C', 'Ofl
Jnd l.:nJun ,'I.'"l r.l<.lIl>n, I<:;IJ 10 aUUmonal dis-
"'''nlll'fl "" IIh U ..... or ,hue'
frc"lmenl 01 br .... hyrncl<lLlf',IJ m .. } IncltJde
(..re, ,,_ JfI OrihoUl
<.I,.miJut.: ... 3"""y (wm
h"<Ill<. Sho.: 1!car m .. t-.e mo<.llh.:d Itl .k;commo-
dale Ih( dOf", lI )' I()I:JIC\J <.I'!;I I [).;rlnlll'C neal-
ment rC:<jUtT':' ,urgl(.'JI nlrn:dnlf\ 1\1 lhe
.... II! .:,lnUm-H,rn. v.tli Iix- , hortcncd
.urt'l.,! 10
(;ufll'cd bflt(:h},mcIJIJT";" Illdudrng !xliI': gfllflS.
nlt.'"".I1,>,,l d"\f:Klhln ,\,leogl'n':SIS
"" Ilh 1,\.111(">11 d,:vl,'''',. ;lnd kndun lenglh-
I'mnt! ,m" , I. In pl,l,r) 1.'dlllh!IIC' III .,.!Jr ... ,. rhe
'>(\1 1 fl""C ,'\llllr:KI!\ll"
In Ih. rrr."eill P"lIl'llI_ LJIIU' dl'UJdlllll ((;al-
),11"'1') WJ' 1""1 hll 111 ... .1 hy knglhr.' nmg
rhe mCI"IJ lllf'IlJ. "c,UIIl!!. ,"ll\l!! ... lIe." ho, , V. ...... U
,hl' IWI' h<lnr.'
Clinical Pearls
Br ... hv"!,,t.I'''.I " III ull,'n cOII;:cn, "' !. Ih.'1 ,';'II'C' .L ,hnrlell.:.1
,'kI,II.,. , .. : rnc.
, BI Jlh)' -I"." I l'r,,j.}miIlJnrly LIUUf', in ""Ilh " :!5 I 1<'111 rI ... ,,\ "",t.:
1'.,,11'
l ( .... ," .. ,Unlpl.lIIlh I"\' ..... nt .:.U"I.' 1>\ 1',inlul
lhllr. ... , 1,1 J,"'" "hI .hue. '" (tit' delurr,lII)
I {,"" -, ' .. 111>': 1, ... ,IUJl<'nl IllJV b.: mnrt in 1>..1111'111'. hUI ,uf<!"JI
,. ., 11K' J,'IIIIII"C U\'_,!IllCII!
REFERENCES
Itt
rl",<;,,,,ol---l. '"
"'''''I-lI''1 I ... 'II'" , ,,<,.\ , I''''''
7J
PATIENT 34
.\ l5-) ear-old man "ith per'>islenI 3I1kl t' pain
t\ 2S-)CM-old man prt:\CIlI' \\ lIh a ."omp!atnl of p;:f'>I'teni IeI'! .. nlde p;Hn ol9-monlh dura-
lion. He that the ram de\cklpeJ IO.hlle hi: .... .is l':lrUClp.1l1ng In a l'C.:re.,tlonal fumoJIl He
denieS an) of direct U'aUlna to the area. Trcalmem "'1m Ice. 3!>plrm. :md t;Ompre'\IIC \Cl:.l:Ian-
dages has ofkrtd minimal rdll:f mptOfll'
Physical f;XlJmin(llilJf. : \lIal lIorll1.:11 Va'Cular" 2 4 do .... .. 10 pO_I"rior IIbl .! M-
bllalerall), Imm/i,u( C:llllllJf) r.:fill. epKnllc .. lIon In lo .... et m!aC!
bilalcrolly: negauI'c Tmers blgn on pen:u",ion of tibial ncr\e tt\ture and lurgl.r normal; no
edema or CI)\hema. normal ankle. and ROM. flO C\ ujencc: of pam
on 10IIlI IlItX)llil). pam \\ Ith a\.'tl\e plalilarflexiQn c\,: r.lon ; mild 1);lIn on palpatiun
01 left tcndun, m .... demtt." to )everc palO un p3lrmll(ln I:tcl\\t:en ,\chllic, and tendons,
poslcrolmo:ral tu the ,ut>ullar Joml
l-alHJratory ,.'j lldi llg)': Radiographs: bone to I,In IJteral VI<:\\ uf kft
fool.
QllutiOll: What the liJ..dy dlagno)ls uf thiS p<Lt\t."nt' s JlC""tcnt 3nJ..lc pam'
Dl'scussioll; Numerous bones may
be locaJo:d throughout the fnol. Of> trigonum is
.:m holll! to the wlus. lbe
talus has postenor tubercles. lTlI..""tiia] and lat-
In Mltnecases. the lilteral process rna} be eloo-
galc:d. In case II IS temlCd Sle!da's plUCeSli.
"\-lth o;c\ere ankle plantilfflellion. the lateral tuber-
de may also fr.lLture 'When impoch .. -d the
ubla aoo ... 00 thereby imlUlle an os
mgonum Dlfferentiallon of an Ol> trigonum and a
tratured latern] talar process can be difficull. A
fracture LS u,uall) ITIOI"e Lrregular in .hapc and has
,harp an os trigonum has
_mooIher bordel"l>. T)"plcally the os trigonum OSSI-
hes 8 and II lmd may be on a
btcml ankle radiograph.
Climc:llly, a pamful trigonum may present
"S poMerior :mllc p3in. which mcreases
V.llh LlctivLly. The flewr hallucis longus lendon
courses betv.een the: po'lerior talar and
v.hc:n the hallull is dorslflcltcd.thc pallent's p.:im
may be: reproduced. Ligamentous attachments
may also placc on the: arCLl. cre:l.Ilng p.:im
anklc OOr5II!C\IOn. Blomeehamcally. both
suplnate!.l and hypcrpronated feet can os
trigonum syndrome_ MRls and cr suns are aids
10 diagoosis
Treatment ilia) be COnSCOall\C. cOfLSISting of
IlOnsteroidal anll-JIItiummluory drugs. local coni.
costeroid mjt.'Cllon. alllie braces. orthotiC
deVltCS. andlor immobilization v.llh a below-knee
cast. If conservame treatment falls to alleviate
S) mptoms. of the os trigonum
may be
In the pmu.'nl. the 0\ trigonum was wr
gically c:,cised \ III u IIlcdllLl approoch
Clinical Pearls
!ngonulll ,yndll'lIlc is 11 condition of pain c:l:pcricnced upon irnwllon of an (1('-
c .. bone to the talus.
2. Clinically an os 1rigonum may lead to similar as that of a frattured pas-
terulaleral talar tuhcrt:fe .
.1 treatment be emplo}ed initially. If syntptOmS
cal UCISlon of the bone relieve symptoms
REFERENCES
I \lc-(jt,,1nI) ED.n at C"""""I'Io:ru.,,,, of Fool 100 cd. lbIumon'_ 'W,II_ & .... ,Ik,n>- 1\192.
2 \tOl'IIor FA ""'" ('> UlI<"'UIII ')Oldrumt JAm I'od.,..,. MsocI\3 197_1
7S
PATIENT 35
\ .J6-) ear-old woman wit h a lump on thl' lOp of hl'r root
r\ J6-yc r-oltJ. lltlio.:rv. II;(' health} wom.:m pro:"",nh \\ nh till,' .'hld "I J rJIII1Ul _ul t I I,
lump on the lop {.f her fOO(. She tha. the m.l.l., ,1pp!an:J .rrrrol\im:olci} .\ .... ed" ,I!:,) 0100
h,l) pr(l!Il'",\d} become larger Wearing caul><.', 111.. :r('.1...:<I polin .. oJ ,h"':"ItlI,'r1. With ",.<.: .. >","al
numbneb felt around hef digll' TIle pauem Jo:nie,.1 hl'u'r:< "IIf,IUln,1.
Physi cal .rmn;/I otitl// : \ Ilal blgns: I"I("!nnai. Put .... , 1. I 11", .... 11, .,n,,) f""h:rll>r h hl,11 hllat
cmlly. \\ Ilh Imm.' UtJrC l"apltlJty n:htl Ilu>,\-(r I: ," p'.uh .. "<;11_,.1,,," mIld ",I .. lcr
oUy: po,ih\c \ Ign \ltlh pen::Lls"on of JOl"'nl ltHJllcnu, Jlo!r'<'C tc,(UIl' Jod
turgor nomlJI. no cl)lhcma or euema: 2-cm diJlTleter. r.li .... J. IllJ" un d."".1 ... 1 ""f-"<."CI
of f1l,!ht 11IIJfOO{, underlymg .. ,t .. n-.or mus.:k lila" tn: .. ly mmablc ,nlJ IrJII,hu!1U"'I""
MU1>l.ulo,k .. k1;l1' ;1Ol..le. ,uht,d,lr. mldl,ir<"t. and ... "ph,I! .. nf!. .. ,tI RO'>.1 11",111,11. mi lJ 1'<"
<.klnnnll)' b.latcr:llly .. mu,de 5.5 btl,ucrJII\
LaMrl/ /vr} Filllli"RS: I\IRI (see li gure): 'ignJ.l <.hJ ng<'\ un.iI,:r <:\I".,'"r "IClh'f1111! !"on'vi .... nd
Ir.llc(. IIifO ,ublalLlI Jnuu. .,0 ... '
76
,,1ft k, i, ,]. rh.::, .,r" .ldllk.-J ." 111-
l.l il1ll1!! lllU"'I",h-.II.'.h;lI nk rodl Iluid ",thon ri -
Im,)u, 11,,",: "I ....... "I"n.ll ly. onu....:lc. bone. Of a
(. rtIl. .'!, I"h .. .. ) " U' U;l UV ,1,,; Uf' adJ3-
,:em t .... 1 1<"" 1 "f III Iln.il,n ,h':J,h, Jnd 1110;" ol ren
on Ir""ll1mi fl.'d _lI'':J' t . mgh ha'e
"I..., 1'k. '\: 11 (1.'1(,,,''] I,) .1' .},I<, r,,:ntendini
I" 'o('rI".I. I'r ",r 'h Th.' dc .... al a<f'i,'Clof
th,,' Intll I ' .1 .', >1111""11 1,'10.,;., 111111 1<'1' J.,\ <"Iopmen! of
.1 \lO! I1j! lit>il. ,lIItlll:!hl , 11<1t" p .. mJ" rlJ} an im-
1'''11;1111 1' .. 1.:
I r.:arn"" m "j !!,uuli " ,ndudc:s no,' t .lte ;brlta-
111111 . li t ,orll(."ll.' rOld. paddong. and
nul d .'lImp,,:,, '''n. au,1 'III I'll-,ll .: , .:i " on. Ganglia
,)mI'IOOl S
In the: pre .... nt pallent, Zlcedlc blOfl') .:onfinned
the: 11lo!: ganglion directly
und.:r lhe: u tl.'no;()f' digllorum brc"' ll l-.ce figure.
("pl. \\'lIh the: le3dlng Into the: \ ubt3lar JOmt
\..ee figure, bt'lf(lmr , 11k: lellol1 ':OI1l1nued to recur
de'pile .. \lihen the
1!anghoo \\,M 10t::II.-J ;m)und lhe: medial dors:aJ ,' u-
ncne, \\'hi.:h "a., dis<.ectal free and pm-
11k: h}pertrophiL bone mc:t3lJTh3t_
UlllClform .lOint rl.''\et. let.! 10 furttio..( reduce
IrTllallOll of the Ml:"a po'loperau\'d) 1n.c: pallent
6 \\,uh a negative

Clinical Pearls
\ Il ll<'n h'rnh nn an a...,,, of 1rT!1:l1 ion , JOint ,1( eOnneLll.'d to
.11<:,,, 1"11 ,11<",ll h
\ 1.'<.,111' ''1 i, Ihc do .... um 01 Ih.: fOOl, bil l ganglion\ l1Iay (1(;\-IIT an}\\'here
"n III" ''''' I
" ." pU,II UlI\ , mI(l IIIU} rd,c\c 'iyrnplvntS, bu. If ttic
['<-' .... i_' , ijl1J , re"lc, p,,;n t.!P;Clllllforl, perf(lrm surgkal
I Jro.! \\,.: U lIehnet.! thaI Irnlhlr.lmithllc wll hll1t llc;,oll U<,\UC
\-l'lrJu<' 1l " I ., tn'cats 3 ,11' amhcr ' C(,lored hqllld
REFERENCES
IL ,\s.
" .
\h \1. \I,c.!.'iIl"\',n ... ' rd ...:l
... ,", '.\ 11,..., \ " ,i "on" .:on!!
,\" \1
[) , .. ,"" l'I"'.o<klrt'\J, l.pp''''''W' ' \II,l ham, '" .... .!In )
77
PATIENT 36
A man with a painful. discolored great toenail
A 2b-)'ear-old man presents with a o:ompiaint of pain In his righl grealtoc. Ye.'>lenia} he played Ln
a long lennis match. during which he hold f;:Of1$lderablc: discomfort. He also relates that he .... as .... canng
iI new ""If of M\eakers. Following the match. he rl()(1ced di!oCOlor:all{ln of gre3110CIHlii along
.... nh P locahzed, throbbmg pain 1be pain became progreSS1\ely the 12 hours despite:
KC and ibuprofen 11 "as locall/e<! 10 the medial aspecl IIf the grealloe. and .... as Dggr.l.\lIled" uh ,hoe
gear and Simple ambulauon. The pauenCs p;aSi medical unremarkable. and he denies previ-
ous inJunc) 10 his feet.
Physical ExuminOlion: General: no lICutc distress: ",0:11 developed. v.cllnourished. Cardiac:
normal. CheSt: dear bilaterally. Neurolugic: normal. Lol'.cr ngh! hallux nlillth...roll)rc:d me-
Uiilll): mild t:f)thema alung 11311 m:lrgln Skin. no Up.'ll Vascular in-
tnct. Or1hopedlc: no gm,s dcfumll t)'. Musc:uluslelctal : con)ldcmble pain With palp3tion.
along proximal medial border of nni1.
Lohora/(lry Filldillgs: Radlugraphs: no evidence of dl,tal tuft fracture or as)('.ciatc:J fracillres.
QutJliOII: Whm }our dlagnosi) based on this chmcal pre,cm3!ion"
"
/liul!flur;s: Sut-ungual hern:uOnla
/);Jt'uu;nn: Subunj!ual re<ult
,.11" I'l:pcutl\ e J'i!,tul mi..:rotr.lUma Compre<;SLon
" rhl' n"'llbI..-.J bet .... .:.:n r/w naLlpl:ue and the un-
It:rlYLng 1l.,tall'haI:Ln, can damage nallbed aner-
Tho-re i .. ,I Jc:kl 'pa..-e b.!1 .... ..-.:n lhe
:;111 plale and the nail bI..-d :lIId malri .,.
. lhen fil,.. .... uh blood. Subungual
,,;.onUary 10 Ihr .. hemorrhJge can damage malri\
..:11\ :md the ,umlunllmg healthy nail bed. and of-
re n e\ treme p:lIn
Parients t) pLl.:aJl:- pre'>ent .... ,Ih a "wolkn loe
. .nd ,;ol1l"l:ul1I' LJlthn,bhmg ram loUowing a dig-
ItJI lIlJury The two common
Ire repellll\t Im..:rturaurna from such as
(c nnrs. and n cru,h-tyJll' InJury. The hemorrhagic
n.l il plnre (Niall) n'nlinn, Ihe diag-
,"",,. It I' IIllpt'rtill1l. hOI'CH'r. 10 ublam radio-
uf the dlgll "nee appru\lrnatdy 20-25/lt
'll ,ubungual Me a,\{x:i:lted With an
L1nderl) Ing ph"tJngeuJ fra<:ture
, ' rearmenr 111\'1111.:, drain;lge of rhe blood to re-
diKe ,uburlgu,11 pre,'ure Lnlolvmg
!.." than 1!i'i ,II rhc nail plarc!ln: u" .. :.lIy draml;d
.... irh lrephinarl(1n. Commnnly technrques in-
dude a heared paper.;:lip. an IS-gauge floCedle. and
J hand-odd tiectro.:nUlcry device, Once the plate
15 pl.'floCtrared. rhe blOtJd rol1ttuon is upressed
.... ,Ih ,lIght pre"urc. Tltc .Irea \houlJ rhen be
dcan..ed dre)"cd with a dry dressmg .
When the more than 25%
of rhe flad pIalf'. rhere an rncreased nsk of nail
b,:J laceration, In Ixr. 6O'l ofhell1atomas cover-
ifllllTllJl"( rhan 50<;' \lf the naLl plare are llS.'iOCiared
\lith nJilbl:d laceratr'm, that I'Cqulr'l! Il'palr. As a
re ... ull. "'omplete .I\ul .. ron ttl the
naLlbet.lls rl'\:ornmendt.-d in thc!>C m<lances.
of II .. ubungual hematoma is
qUick. and pamJc ..... fed Immc.-dlale
relief allli gern:mlly no1 romphcat ions fol1ow-
illS prompt drnmagc. l\utomatlc n;lIl B\ulston typ-
ically O<:lUr:. Within 6 \leeks, a new n:lil has
usually regrown "y () Without dy,rrophy,
In the pre .... 11[ p;(lICI1l. ;1110. 11 \clLlpel bl:lde w:u.
uSt..-d III a driJlIII!,! 10 drOlrl rhe hernarorna
ffllm beneath th.. nULl. The patlenl immediately
had n:licf pain.
Clinical Pearls
as'>OCi:lIed .... L1h :!O--.!54 01 'uoongual hematoma),
.! Nail bcJ I;..:erauons rnn ..., be consldeffii .... hen the hcmaroma m'ol\cs > .!S'l of
the naLi platc
1 Subung.nal hematoma) arc caused b) mlcmtrnuma anll b) IIIJunc)
.t Il andbeld c:lurery rs Ideal for trephinJlloo
Pn..rnp' r.lcrflmpre\\lon IS Important.
6 Ihulhrn<,(\n) muq be ruled our.
REFERENCES
\bL..t S r",u_ '" lho .... ,t .11<1 ",,,,,,.red 'Iruclurn tn McGl;anry ED R;mI" ". Do. ........ ) M r .. hl C""",,"hrn"'t
hooo/.. .,f f,IOI .uoJ I\lIl.It 21><1 >I. 8..t""""" . .... ,lha:m and .... t 'W!
p.,"l',,,n \ \I"tf,,1"II 1I "r ,,"'bma. Pnm :"IlI)()
PATIENT 37
\ 36.yearold woman with lefl forefOOI pain afll'r It jog
A J6-y.:ar-oIJ lo.omJn .... ilh 01 pain In .Ire .. IIi n.:t kit It"chll>[. She.' fiN had
d,;.romfOrl ill ,m';! J "cds ago follOll<tng:l JOg Wilh J The 1);.1111 mlllall) mllre of a gen-
.tehe thai .... uuJd and go .... jlh ller bUl II bo:.: .. m.: more mlCn!K' \\ ith
de'pllt reM, Pl'Ni,rCIlI c.Ii'-Comfort began ilfft-cllng 'Imple ambul .. lllln. 1110: p"UCIlI .... In
J local lkp,.lrtmcnl::! "<!eb ago ..... here .... ere r .. "d J' .,...,:"Ii"o: Sill.:.: !h.'" .. hI.' has
Ice hem. I'<dl J-'p,nn for p.:un ..... nhou! relld.
1be pal ient h;" 1'1gged ["II 10 three limes n ...... d forth.! p;'\)t } .. a,.... al." ... 11 in
crease In her Inlleage. lief medical hb:lOry is ,'gnlllcant tor hypcrtcn"ou .Ind ,:J\,ri. uker.llions.
She has no at tllllt: :Ind. besides the a'p'flil. i, unly fllPlO1 \l.
i::xnmilluti,JI/: General: lturnl.ll appo:: .. u-:ln(e. IIU I<:<.cm .... clt!hr Llfdia..: normal.
("he)I' eTA bllar.'rally, NCUIologK: no focal eN J: I:! Lo"t'r tlc"ble po:s-
caVilS fOOl r)jX' \\11111 mild equinllS bllaterully, \ IIt'rm,,] Skin, kft fore-
foot edema no tlpt"n t-.lu>('uh'"kci.:rnt nn [lam \\ 1111 d"r"rk1i,l'1 .111<1 plan-
tarfle'lorJ ,II \lTP joim; ItO pain .... !lh MTP JOIfII..:umprc"ion'dr,rr;1Uiol\: Mulder's
,igll: pam on p:llp:niun ,If (If Jlld mctatan.al .. h:,ft and ill 'nJ m.'I.It,II".,1 II nh plamar
til r\o wit h vihrutory .<lnnuIJrion of third mt' I.11,,,'al "I I,b\ ,\'U, dcfor
nllly noted
IAOONlloJr.y f illdillgs: Radiognlph t-.ee figure): c"ubernm txme p"'\H1l<L1 tu Jnalonllcal
rn:.k til 2nd mclalal',t1: imru":or1ic,llluccnC) medially: allgnlll<.'nt
..
Disc'IIHioll: w"" the hr'>l 10deS(ribc
'lll ... tM',11 1r.I..:tUrC". 111 '!bey WCn'Cflm-
KlHl)'..een 111 }<lung mliil"ry .... hll'h kd 10
IhI! Ie:ml "mm:h Tod .. }, lhe:<.e: fractures
(l,lUlly ft,uh UT>1I1 O\cru-< ,IIlJ.1It' '>I.'cn llJ(><;t rorn-
,.1(\1) in the km ... 1c alhkUl popul .. lron
WOmt'n .m' j(" .. Me 10 J.o""rb ,hock due 10 a
"ider pelli\ IC'ma \ara'!!cnu IJlgumJ and 2Y"',..
lIlu,dc 1ll,1'"', I hey al...o h.;Jle a lower bone
miner.IlJen'lty. e'pt"d;llIy I'O't meoopJu'l!. 1l1e
'(em .. le: athlcle: InJi.llor ,trc'>ll
e"IU1!! di'ollhl ......... IIllCI1\lorhea. '''let>[lI':nia.
Slnlllur.llly. "hlle a l'allh loot i, mort: hl.ely
hl leaJ to ;j Itbi;LI tr'lllUre. planu, reet are
tTlOrt r\"l)flC 10 JllCtllta"" .. 1 .u'cs, IrJetuTeS, Addi-
lion.1I1). Ihtl'<! Wllh IllCI .. I"nlh
\lonon', \"1>1. or dl.,.;r"'p:lm:y arc ;lIsa
,llm;r ... ,heJ mk IIIf>c:rrmn;)liun .... ell :1..' c[)n-
dlli()n, ,u,'h.J> h.IIIII\ IiUlllil' riglJu., con m..:rea.e
Ihe "n the 1'1 .,nJ mctal:u,:.l s. While
hn, rlml'K.en 1l11md w be: 3 '1l!l1iticarit risk
1:ldor. mO,llcellltal II n,:,lr fl"lOt grC'ater
th.1Il n de!!re..:, the n,k of J"lelupmg
meta'Jr.al ,ltl.''' Ir:tdure,. E\1rIn,I" ri,k t'Jetor\
tr:lInm!,! fOOtv.e3r. the .!\urface: or
terrain. anJ hlne"
NlIle.) IXnent Iltlllo;'.lIJI\JI ,Irt'\\ Ir;\I;tures af-
fect 2 4.1\ pl..:atJ> 111 lilt! du.-
tJI thirJ 'll lhe ,lwn, -\n exception 10 tlu, role is
<<lund III ballet Jal1<:crs .... h(\ \u_lmn proximal fr.lC
Illn" n ... ar Ih ... ',,('o"'nt.'t,.t;U'..a1 fI,int t!o<!l..'OnJaJ) 10
..... n f'Uim ... " rt1oL:n: " .. IMI .l high int.'i-
Ikn,,'e 01 IIlet;ll.n""t .tre', after hi
,u'gery IO;:'JlL.'lIJlh 1\",11..:(, J>fOo.;o;dure),
Radiographie31ly. of mClatarsai stress
fractures inUl3Uy appcar nOrnl3t PO>lh,e: findings
.) pkall) become apparenl b) J .... eeks. bul may
lake up to 6 A hneJr conieallucenl region
.... ith periO'<.eat and endoslcallhlckcn_
111 b. on in bone:. A focal !!clcrosis
I b;rnJ-hke of lrabulae) IS seen 111
metJph)'o('al OCone:. 1be golJ \lllndard for diagno.
IS a tTlple-phase bone Ahhough nonspe-
.:ifk. this leSI is \cry and is usually pos-
ili\e .... lthin 2+.48 hours ofth ... IIlJury.
n.e differential metatarsal-
gia, neuroma. IlCUnlt-, pre.Ji,locatlOn
eapsulilis, and bone lumor. A ('omple.e ..:linical
hl>lory and lhorough ph)slcal \IoLlI usually
lead to an approprlmc dlagno,I\. f>Io\t patients re-
laIC an insidious ons.cl of rain. '" Ith gmdual pro.
of Often. Ihere h an 3SMlCi-
m<.>tl recenl increa><: in On phYSical
e'(;un thc hallmark pinpoint lefldemcss. Fore
root eJema. pain \l,llh dorsifluion. as
"'cll as afl ifl;lbility 10 hop 011 lilt! affected fOOl arC'
findings.
Once a has been made. treatment usu-
Jlly with RICE pnnciples.
.:are willt immoblliZ;lIlon (<. urgical 'hoe), and par-
uJJ weigh! bearing (sof.en effcchle:, A gradu31 reo
tum to activity IS lery Importnfll. and s"'imming
of'en 311 \Iol1h any
fraclllrc, complclc healing will take 4-8 .... eeks.
In .he: pati('nI t1 \l,edgc ... as d15
pensed 10 off-load the: TIll!. approach
combmed .... I.h the: OIhcr cOrlj,t .... illi'e princ1ples
mcnliofled abole led 10 UTlCICfliful hcahng.
Clinical Pearls
NU1oL:t\ .... of froclures occur in the lo",er c\(rellluy
1. lite ,It ,In''' t"m..llIrc m IIOlliefl is 1-10 .nnes lhe risk in mo::n
!'.(Ilen" relate ;lfl1l1\j,hou<; (>lIse, of pain lI'ilh gradual progres,ion On t',-
,,"nll.III,'II. Ihe h.tllmilrl. plflJXIlllt tendt:mes.>,
I hllllJI r.l<h"graphs frcrtucntlyoo nOI n'IC;t! the fracture; JO-70'1-lIfe: flOTlnJI. Re,
IJI:'\! m,h"gr"ph. ,turin!! "eels 2 .' "III Te,,'al a at the Slle of.h ... froc
IlIre
fhe tlIJ)!Il\""L I!old "Jrllj,lrd!, n ITlplc'ptMse bone ..can.
f> 'gr;"lual (dum IO.'l'tivi!} I' 3 mu,11
REFERENCES
,,,,/<1
'I 1111. " <; ' 1lI< 1,>,1(,"',
"
PATIENT 38
" 61-)ear-old man with sort tissue masses al his ankl e and hrt'l
A 61-)l'ar-old man presents .... Im relati\ely painless soft tissue masses on the posterior aspect of
hiS left heel lmd ankle. He has a long-$I:lIIdlllg hi5\0I')' of 'i<!roposill\c rheumatoid anhnus IRA). Al-
though these nodules imual1y appeared o\'er 2 year.; ago, the) ha\c gro .... n during the past
J months. The patient ... as diagnosed with RA 15 )etLn preVIOUS. He .... as cffecmety ..... ith
NSAIDs for moM of thai lime, unul an acute rheumatoid flare pmmpu:d the adulllon of methotreute.
He has mall1l3Hlcd 011 a low dose ofmethoueule 17.5 mgt"eel). u,lth _moos NSA1Ds
Celebrel). The pauenl also relates re<:enl worsening of his gen.:raliJ.cd mommg suffness.
Physical Examination: Gentro!: ""ell developed. "'I'll ambubtory. IIEENT: ncBIl-
Ii'e for !>Clefllis, and thyromegaly: nLoct supple. Cardl(\(:: !lOrma!. Chest. clear bl1:uc:rally .
..... no fucal Jefect". eN =' - 12 inlacl. Stin: no Upper MCP , .... t'lling. mild
boutonnihe deformlltes digitS 2 and 5 bilalerally. Lo .... ernlremny: suf! I;SSU .. on pos!enor as
PCCI oflcfl heel and anlle measuring J.5 X 2 X I em and 2 x I X .5 cm. fespeclildy: no les.>Cr dig
11111 cOnlruclUres; mild bil:u,eral halJu.\ abduclo valgus deformllY. Vascular: nomlll!.
Loboralory f' itldings: ES R 32 mill/hr. rheulllatOld factor 704
nil evidence of calcuneal eTOSlon: mild )Om! space narrowing wnhoul erOl>lons.
Quts/ion: \.\ hat your IflagnOSIS. based on IhlS cllmclIl presen!ulton'
82
Diaglw.{is: Rheumatoid nodules
IJisrussiufI: R/K:lIm:llOid a chrollIc.
poJY:lrtlcular. sYJlunctric. lIInummalory di..eas..:
with a predilection for small pro\imal Cur
rently affecting 2.5 million this dis
strikes wome-n three timcs more often than
men. Although Ihe feature of RA is
Int1ommatory synovi ti s, multiple extra articular
systems can be uff.-:ct.-:d. [n general. the
number ufthese !;omplications IIh dis
ease severity.
The mOSI recognizcd skin in
R\ the rh<'umatOld nodule. These mx.lulcs u<;u
,Illy develop Juring an aClil c phase of the disease
and hale bi.-en I"I'ported to occur in 20-30% of pa
tients with RA Patients \Aha delelop rheumatoid
nodules commonly Itave severe RA, and almost
mlariably arc .-.eroposllive ( -t- RF).
Rheum:uoid nodules are usually hX:31ed m W
perficial 'lubl:utanCQus but can occur m
,kepcr structures ,uch as burs..1. jamts. lenoons. or
hglmem. lbcy are foulld on periarticular qruc
tures. exten:.Or lind mher areas suhjectcd
to m<.-.:hanl .. al pre"un.' Common liX:allons indude
the olecnltlon bursa. lhe the o..:cipul. lind
the AchllJes tendon. Th<::y u,uall)' pre..:m clillic:all),
.1' firm. flesh--coloreu. IlOntendcr. and freely
.lble masses. rheulllaloid nodules
Uf1: le<ions characteriz..:d by area:;
of centraJ l1C\.rosis. The periphery is compo>ed of
palisading and wi th chronic
Ulfl.lmm3tOI) infiltmtion.
The p.:lthophy,tology behind rhcummoid nod
ule, IS nOl completely IIndcn-tUCld. but a few thea
des hJ"e be..-n postulated: ( I) vll.'iCular innamma_
lOry chang..:, followed by (2) repetitive
rnll'rotrnuma, and (3) genetic factors. specifically
the HLADR BI 04 cllJcleS. Addition:llly, it is well
that methotreule. which has become the
gold ,talluard of RA thcrapy, can cause an accel.
.-:rah:d
TIle lhffcrenliai diagnosis includes ganglions,
tophi, absce.s. lind :O;3nthommosis. If after a
careful hi,lOry and clim("al c'(aminalion there is still
a queStion as to the diagnosis. llil excisional biopsy
can be pcrfonncd. Th" ho .... cvcr. is rarely neces
Although these nodules arc most commonly
seen Wi th RA. they can also be seen in Olherchronic
inllamm:ttory disorders as s)stemic lupus.
granuloma annuJan::. and necrobiosis hpoidica dia
beticorum. In Ih..:...e Ci\;.cs the history becomes ex
tremel), important in makmg a correcT diagnosis.
Rheumatoid nodules arc nontender and
often regress completel), wuh time. However,
the) can become sources of comillued irritation.
Complicntions. ,uch Olerlyil\g slin breakdown
\11th secondary IIlfecti on Jndfor undcrlyillg bony
erosion, can also OCCUT. Conservati ve measures of
treatment include aperture padding. intmJesional
'teroid and colchicinc. With the ability
to mhiblt giant cell formation, colchicine has been
found to gradu:llly reducc rheumatoid nodules. If
these conservative measures fail. surgical exci-
SIOn beCOnll!S
In the pre<;cnt p;nient, the nodules became quite
large and pain \IIlh all shoe gear. [t was
de('lucd 10 surgically excise them.
Clinical Pearls
I. Only 1% of al l rhl!umnluld nodule.> occur mthe fcel. Common locations are thc
olccranon bursa . .>acrum. and Achilles tcndon.
2. RheullIatoid nodules usulIlly imlicllte an advanccd disease
J Hi<tologic features a ,'cntml nrnmed by pall5ading
4. Lo<.al trnuma Clln be a preCipitating CICnt. Methotrexate maYllccclernlc nodulosis.
5. Nodules often regress or involute spontaneously.
6. Col< hllll1l.' may help thes.: gTO"lhs.
REFERENCES
Arnk""" R J!.lI<Unl.3I"id arthn,,, Pmnc. \In ,n.; Rt...uO'Ll'''' 1),,,,>=. II In l "'ll.nta. GA, Ar1nOIl> Founda1ion. 1'197
2 J. cl "1 Rt...um. l" ,.J dtlh""c J ,\In 1'" .. "",, M<"<l A,,,,,, 8.1 1:271l--275. 19'il
.... Tlnluln} . Rt...um .. ,,,,J NoJult of llx- FQ01 Mitt "PI"'''''''"''c' m"" .... lng an indcltrm,n.>\C..,n m ...... Sket Ra
d,ot n 437....1ffi. 19'l8
II ,It.,n" F. el al A" elc:r.u<"<l CU1.11l<'OU' noJ"I,,,i, ... 'ho",p) in p.ucnt ",un ,,,",,"m>la,d :IfIhn"'. J Am
''''.oJ DotTIu,,,1 l <q 11>2. t'l'lS
83
PATIENT 39
\ man "ith a painfullwl-Ie
\ m.m pr.: .... 'nh 10 lilt- d.:rmnrnCn!I"nl illh,:r h.1O 11d hy" rulll\.( H'
tw.;lc_ fie" c'!,cm:lllml' pmn ,>fthe ri!,!IUIOOf ,ulll ;llll.k .1/,<.1" till ,I" r,' h.::'f "ci}!ht on
tho! right I-I<: d,'l1ll', "11) ,'Ih.'( lornpl::unl Of arca ul I':'nd,'me,,_ Tile p.!1I,'n1 ,d . I", lh,t .... h.lt' he .... as
1M _,eppmg onto rtlt- (.Curb. a Ifillehn:! "I II'I'II"'"I.lldl :'()"ph .. trud.
IneOOhIJ..- '" hi' ,111\;'1.'. He .menlptelllO .... alL 011110." unallk hI pili I \ 1''' .. "" h, .. nghl
fUllt,ankk 110: IInmc.lI.ud) taleR to the ED fore"'JtllJIIIUl
l'IIYju'(11 Emmillfl/;on: afebrile Vit.ll .. ign,- I til .... r 11, ,\111.11 ckar
Cun.kll. rtguLlr \h,JUIIWII. IIOnlernkr. Skin: ,uperhclal "l1ra'!I'" "II bl,-r:.! ,"pt" I .. 1" Iq:. "nh
mild 01 lIu:J'.l1 h.:d and unlit:. Neurtl':lo.cutlr 'LIlli' IIlhll!. \111" p,"n "n pal-
polliO" IU 1.,ll'r,d Iq; "nd I11cJ" ,1 "illl mild ;w;,x. i.Ht'd p:""lul .1, I,,, ,111,11'. .j'l RO\\ of
right ,lIl ll.: . l<:I'I.II'JIU Oil palp;dlOIl lu righl rool: .. 1 .... 1 no p.un ,II k't"I PII ." PI'"""OO or
fibula.
I.flboru/u'., fi"di/rgs: 1111 U' ...... "II> 1, 11",I.'n. 11<1 Ita, IU,,, "I' .h,loc3-
{Ion ,IIIU, !lgurC\ Ir.ldUI'C \' I1h"11I Ji'I'I"C'l'n!llIl. In-
j;UlatIIHl. "I' <li,'al obliqut' ITI<'!dlJI malleol.tr rr.ll !UfO;: III nil",. \\'lIh n'nli.d .mJ pl.JnIM mi
grmln(1 1,1 Jr-I .. I fr,'!!lIwtll. IIlcr.:".,.. in medial clc,n ,P;ICL'
DiDgflosis: The mechanism was trauma (a direct blo" ) "Ithout any rOlallonJI
Discussion: Ankle InJurlcs are one of lhe
1I0S1 common InJuncs )Ccn In the ED Whelhe:r
'he injury is diagnosed as an anklc Spr.UII . stram,
fr.IClUre. or fraclureidislQl;ahOO. a thorough un-
.krscanding oflhe mechanISm of injury allow
the! c1illlcion 10 properly lreal lhe: disorder. Some
JifferellCe of opinIOn eXISIS as to whelhe:r ankle
InJunes should be .1:.rayed In the ED If there is a
possibllilY of a fracture or if the patient IS unable
[0 bear weight on the e"ucmity. lhan a radiograph
, hould be obLallled.
When evaluating an ankle fraclure. the physi-
mUSI elaluate boI:h soft tissue and osseous
Jcrangement. Having II ... orkmg knowledge ofthc
I, .. ,oologiul forces Ihat caused the fracture will
faclli lale accurate anatomical Joint restoration. In
the! preSt nl pallent. displacement of the medull
fraclUre und an mcre:tse 10 the medial
Spa.:e ltd to the decision to perfonn an open
reduction "'Ith flgid inlemal (OR1 F). The
OR IF was perfonned to regain st:lbilit y of the an-
joint and 10 anDtomu;:all y reduce the fracture .
... hile (l( the same time providmg the pallent with
[he best long-tcnn outcome.
The ORIF was done 10 hi s medial mulleolar
fracture only. 1bc decision loconservallvely man-
,Ige his high fibula fl1lClUre was based on the al-
ready neat-perfect al,gnmen[ of the fibulat fracture
fmgmenlS and the nQIIdiSruphon of the IlIIerosse<lUS
,nembrane and anterior Inferior tibiofibular liga-
rnent. This IIIJUry re'iul ted from a direct trauma!
blow to lhe! leg and anllc. The: high fibular
fmetul"!.: did nOl rcsuh from a I1ro11.'lllon (lTC'Cf"!Ilon
IIIJUry: therefore . .I. \l;rc: ... or re.
pair of the amerior inferior lIblohbular hgament
W:IS not mdicllled or
The medial m:IlIt'QI .. r (r:lI;lUre \I-IS With
t .... o 4 x -W mm. paml1d. parllall) lhreaded. :Ind
cannulmcd scrc ... s through a JIIcisJI)fj
o'er the distal 3Spl.'Ct of the IIbi .. under C-arm di-
rection {see figurel. Once (hi: medial mJ.lleolar
fraclure ... as properly reduced. the ankle mOrli;,e
and hbular "':1\" agmn n;IIIlJted under
i!.UOf'O!iC(lpy. The melltal "IMce reduced:
no tibiofibul ar lhaSlaslS was nmed 0f1 ankle
and the fibular IraclUI\' remJ.ined In e.1:cellent
alignment. 'The patient \1.1.) thcn Immoblli1.N 11\ a
Wcight hl:,III11J!. allJ ph))ical
therapy "'ere imtialeQ Jfter the I.ast ...... ,
81 approximately 6 "'ed;;,
Clinical Pearls
A high fibulllJ" fracture is usuully associated WIth an e\erslon or j"lron:llIon I}po.' of
mo\cmtm of the foot upon the leg.
2. Pro.1:imalfibula fractures typically halc an as:.oclatN amerior IIIfenor hblol1bular
ligament and IIIterosscous membrane rupture .... hlch are usually primarily repaired amJ
fi.1:3led With a tr.lnssyndcsftl()(lc. fully threaded cOrllea! screw
3. Medial malleolar fractures can be repaired percut:lneoosly ulldcr iluufH.'>(;oPY
guidance or opened and reduced wllh two parallel cancellous or p.a.rllally threaded ,;In-
nulated ..crews to Dnatomically aligllthe frac ture and 10 prelent n.)IDlIOI!
4 The focus on surgical correction of ankle fruclures is to th(' length iiI Ihe
fibula. assure syndcsmollc stability. and accurntdy realign the! 1Il0rll"<!
5 Osteochondml defects of (he talus oc.: ur with fr:KHlrcdl,llX:lI )"1l IIlJIIn."
about the anklc
REFERENCES
I 8ankJ AS. o....t>ey MS. MartIn DE. \llllu SJ VlcGt..m')'. Tc,,"'-"'" {I' .",,1 '\nU ..
PhiladelphIa. LippillCOl(. W,lham...t. WIlkIns. XXII
1. M,,,htU 101 Ho .. anl 8 . Sano,,. D. 1I.,...",k D IIlodiolog'" ... '''' ... DralO""''''- ,rn..o"nl , of " .......... '" 11"1<;mI.'" Jnd fro( I
F,..",u," aOOullhe . .... '" J fOOl SUrl Z8 114-17<J.1989
1 II:. G.....afr S. K. RQO.i B Charxrenstlalof optnl1""C ,uf"IUI"'" ""l'fruJ ...... Anlie-
fl"KlUru J Fool Ankle Surt .1014/ 356--36).I99t
85
PATIENT 40
A woman wi th a stilT. pai nful foot
-\ ! 1-)car-oJd, j..e he.dlhy prescrus wuh a .j month uf acute 1.:(1 rcarfOOI
pain 1be p.1\ICnl alw a (hronic Ji!>Comfurl III her left fool earl y chlldhoooJ: IhlS discom_
fon was rcnmlll1g In nalUre and oonprogn:ssi\t: umil rl"Cenlly. She tks.:ribcs her s)mptoms as a dull
ao,.'he wilh occasional of p<l11l. limit IM!r "cight-bo:aring acl;\ iti es. She de.
nles.illY history of trauma. but more adl\'': due 10 nUf'lng !Chool ro(atiuns and "auTessing
JUlies thl: '>C\o:ral treatment (OO'1,h!J uf plant:lJ' 111 Mrctching and
<; trengthenmg CU, [om-ntuIJed onhoiLcs. and NSAID thcrJPY ""thout an) ITl3JOf relief in
S) rnptom), Her cumhuon IS p.Htir.cularly aggr,lVated arter )lfCnUOUS Iln.d IS rchc\ed only wilh
IUllg of fest.
Physical t:xumillati/JII: IIEENT: normal. CheM. delU". Cardmc regular Abdomen, nomender.
51..1n, normal h:,turc.turlr0r no mIld pming cdem.t of lefll aleral rearfoot and
unkle. pam on pal!)'ltio" to left I(lter-al ntlufuOI. rearfOOl. und ank le: ROM of left an-
1..10:: nonnaL ROM of left .. ubtahlf Joint IST1 ) (kuea""d und painful on both in-
\ef'1011 and ROM of leu l11idt:lhal JOint mildly dL'Crea""d. bllt wtlhul.lt di scomfol1: lefl fore
fuot normal
1./I /wrUlIJry findill/p: Rmliogmphs: 1n<Xlemt,' dcgcncrJti,c l'hunges in STl . wllh jOmt \ pace
nafr{)\\.mg and SlI rrounding IllCrell'ed jagged appeanlJlce of suqcntacull.lm tali: midtarsal
JOi nt .:ongrucnt and ""']thUII! arthritic degeneratl o11 MRl lsce figu re): Increased signallJltensi ty on 1'2-
\\c.'ighlcu Imllge 1\1 area of 'lilli' larsl. rtlostlikcl) related to bone marro'" t.'dema defu(ing out from ad-
lat.'em lalu5 and IITegularny at al1lCu]atmg of ST1. particularly at middle (lICel. rep-
reo;entmg pr.-dommatcly cartilaginous L'ommUntCatlon "'d[h l>Ome IIlterposed fonnalloll on
TI .welghk'tllffiage,
QutIlio,,: What IS the I1IO,t cauS<! of the pauent's <k.'CI"Cased ROM alkl paIn In the rear-
fOOl'
..
DiQgnosis: Subtalar joint coalition (nmldle Facet)
Discussion: GenerJlized pain. dis(:omfon. and
,u(rm:ss in the hindFoot and lmklc areil has many
and the differential diugnO$is can be ex-
tensive. A thorough history and physical exam, as
well as the of radiogr.lphic modalities such as
plai n-film rndiography. MRI. CT scan. 3nd even
J three-phafoe bone SCan, can help narrow your
dIfferential.
Tarsal coalition is II foot condition in whi,h a
bridge or bar across two or more tarsal bones lim-
or eliminates motion between the Involved
bones or joint. The etIology of is st ill unclear. but
the disorder may be a..:quired or congenital. A
c03Jition can be a syndesmosis (a fibrous union).
.I synchondrosis (a canilaginous union), a synos-
to_is (an osseous union), or any combination of
the three.
Tarsal coalilion is sometimes accidemally
iound on routine radiographs. and the palient may
be completely asymplomalic. However. if symp-
toms are present They usually consIst of diffuse
pain, muscle spasm. and limitation of joim mo-
tIon. llIe pain onset IS Iypkally insidious, or it can
occur abruptly as a resul t of minor trauma. Symp-
toms are usually aggravated by activity and re-
lie\ed wilh rest. The symptoms of a middle facet
talocalc3neal coalition present as pain localized 10
the sinus tarsi laterally and the sustentaculum lali
medially. and as a significantly decreased STJ
range of motion.
Conservative treatment usually consists of
NSAlDs. physical therapy, injections, below-
knee casting, and ortholil: s. particularly those
thaI restrict subtalar and midTarsal motion. Or-
thotics are most effective when manufactured to
hold the rearfoot in a neutral or valgus position .
If conservalive therapy fails. then surgical inter-
is necessary to relieve symptoms. Sur-
gicallreatment essentially involves fusion of the
involved joint complex or resection of the bar
with or wtlhoul performing an adjunctive proce-
dure.
Clinical Pearls
I. A middle subtalar jomT (STJ) coalition is conSIdered to be the most common tarsal
coalition found in the foot.
I. MRI and CT scan are eXlrcrnely useful imaging modalities if there is a high sus-
picion of a tarsal coalition. especially when x-rays are inconclusive.
2. The symptoms of an SrJ or midtarsal joint coalition are aching lind stiffness. par-
ticularly in the region of the sinus tarsi or deep in the ST1.
3. Peroneal spastic Hal fOOl can be a sequela of a tarsal ..:oalilion. in which the rear-
foot becomes fixed in a rigid valgus position.
The results of baT resection are poor when degeneralive adaptations have occurred
in the area of coalition or surroundingjOl ms of the rearfool. A primary fusion of the STJ
or midlarsal joint may be necessary \0 relieve symptoms.
REFERENCES
S. McCar1hy BE. Menolic"..., S. O,SIU'U J C.karJeOJ\llv",ul..- bar 1\ "'trosptct .. sludy. J FOOl Ankl. Surg
.lO(-4}: 38J....389. IWI
2. SIoller MI; T""",I roaIll,on_A ,nrdy of "''11'"'' ""ull . 1 Am Podia" Assoc 64 1004-1013. 197.1.
3 SWlOIllk<.>ws.la MF. ScranlOfl Hansen S T"""I co.J",onl; l.oorll-renn ,""ull> ar i""kat u.c..-"",nl J Pnl .. " Onhop 1
2117_192. t98)
87
PATIENT 41
\n 8-1.}car-old man .... ilh painrul haliu'\(
An ciller!), gentleman prc's<:nls" uh painful ulcer.; (.n h;lllu\ TIle) lIa\ .. de-
\eloped 6 and are 00( responding to conser-alll'C trl',umcnl 1bt- p.1tll.cnl a of
dlabcu,'s. p:ripheral \ a...:ular di'>C:bC. coronary afh:ry JI\C'$C . hem
failure. and :llria] fibrilinllon.
"hysicall:.'xaminar;on; Gerlt"ral. ... ell nOllpp:lrt:m T.mper.lCul\' 1)8 2 . blood
1-10 65. 64. .. ms [2. Slm t;,.ee ligule,: tMas 01 right "'::COIlJ TOI: .tIlJ hallu',cf)-
thema of entire foo:lool. ulcer.; dry .... tlh a pale-colorcd granulo.1tion 100 ... flbnn c,llering on
th/:r.e .... ounds ..... hich measure 18 mm x 111m x J mm; lip of nght ho.lUu\ g .. no drflmagc.
fl EENT pupils J mm e4ual ami reactll.:: moist muwu, mcmbrJncs .... JCi1!IIi()n \Xoor;
ned, I'olchom or 1}lTIphadenupath) ('he'!: dear. CarJia.." n() Jugular reEul:lr
and _toile e)Ccliun mumlur. Abdomen bo ... ct _uuIKb. \\IIOOUt ortcn-
uer!1eSS; no Rf.'{"lUm. negative. wl1hou\ or ahnonnalily, Excrcmitles: bi-
1;1teml fCllIo;'11 and popli real \\ nhoul di\1:l.1 pulsts.
l. uiwr{Jlory F;IId;IIII5: DIp) ridamole 1\11 BI rest: anrero!tCplal Jefe,"c II Irh part ial (on-
IISCent "'Ich mYOI.ardial infarct. Nnninl:lsi\e \ul<l."ltlar te<;{lng; no lel1 po.-UI) [">I.'ppler \lave t"(lrm
Left ankle 'arm 0.56 RaJitlgmph .. no any cvi..kmc of o_lcol) 'I' or Ar-
tcnogr:un: at dl,c.lllcmorJI t>h:xbge JU'c tnlu!\'UI IOn; good !luw to oJor-
salis but no now 10
QutStiCH/ : What )our lllnKal
88
Diagnosis: Anerial oc!.:lusive disease
Discussion: Obviously. a bypass oflhe block-
should be considered. TIle question is what to
do with the fOOl in light of the patient's age and
medkal status. The patient was determined 10 be
JJI Anesthesia III aceordmg to ASA phySIcal
,latuS classlficallon reponed by Sakladin in 19-'1.
Cardiac cathetenzatlon pnor to any planned
,urgery was recommended. A femorul distal
popllleaJ re\ersed saphenous \em bypass groft,
under )pinal am:sthesi:l, is n:commended. This
procedure Will increa:.c to tilt: fOOl. but
will not revasculari;u: the dlglb. A plan for a Lis-
franc's pro\lInal amputatIOn should comldered
at the samc time the b) pass. 11115 "'111 e:lplun:
the best lime for II palent H':.lIoI:l and JJ1mimiZt the
nsks of anesthesia. 11Ie p;itcncy of the dl)lal arter
ies within the fOOl '" III diCl3le "hethcrlhc Lisfmnc
Ilffiput:lIlOn site !>hould be o.Il\tal or pro'(lmal
Clinical Pearls
1. Decide at the ume of revascularizllIion .... helher to close or h!a\c Ihe" amputation
Sltc open.
2. All too oftcn. the disral flow is nOI strong enough. and necrosIs of the nap clU)lng
the sile lellds to an abscess. Wllt:n in doubt. leave the amputation \I,e up.:n.
3. Leaving a "'OUoo open for delayed closure is a vluble opti on for the Wet
to dry saltne packing is advisable. Once the bed has granulated ,ufricICl1tly. the lIollno.l
can be closed, if complete closure not occur. consider growth fHUOn. to ;!c< ... lemlc
heal mg.
REFERENCES
DR OIab(hc; yucular .... In 'The HIp R"k RXJI '" [),.m.Ie' \tdl11u, N .... ' l'loul'I:h,JI L ..
(n,scoot, 1991. pp 1}-18
l P"uur M Amp!>1.aIlOll Io t ",le\:1_ '" thr d ..... "' fOOl. ell" On""" 2%1>11,10. 1\193
..
PATIENT 42
\ \4(1l1um IO.ilh a raised mass on her loe
A lO.oman prc..enb \11th 3 w,ollen around her right M'>:ond toe It has been In-
creasi ng in \;/.O: o'er IhI;: p!I$1 6 months. the pre\ ioos" lOoed:.s, [hi: mass pamful .... ,!h 3.!Tl-
nutation. The pallent canoot rttall an) of truuma or on an obJCcI. l ler p;lSI medical his-
tory is Ilnrcmarlabl4:. lor \Ii!!h[ She denies laking any medications. and IS In good
ph)'i;cal he,IIth
Phyrira/ t;:xumi"ut;on: GeneruJ: r,lls,''!,1 rllass on planwr of metatan,ophaJangca]
.JOint. measuring 2.'1 mm and I] mm height: firm and 11\1('1113111; not painful upon compression
bellO.ecn examlTler's thumb and forefinger: flO redncs).
LDborotory ,.'inding! : Radlogr3phs: swdJing Wilh no rn\ohcment.
IIr)[opmholog) bulbo.lu_. lobul.lr. gn!} mass from plunlar of nglll foOl \\US
be a II Ilh glalll cells anll ubundant kcrm,n .
..
Di ognQsi$: Epidennal inclusion cyst with foreign-body giant-cell reaction
Discu.rsion: Epidennal illClusion cySts usu-
ally occur secondary 10 tn;lUmatic implantation of
epidennal into dermal tissue. Once in the
deeper subcutaneous tissues. the epidennal celts
grow, producing a lipid- and keratin-filled cyst
that can enlarge and bel;ome quite painful and
sometimes infected. Epiderma! inclusion cysts
create a foreign-body giant-cell reaction: this in-
flammation may lead to the formation of a sinus
tract. When squeezed, a sinus troCI yields acheesy
ell:udate consisting mainly of kerotin.
TreatmeBt of this lesion is excision of the cyst
and sinus tract. Left untreated, a rare occurrence
of malignant transfonnation of epidermal cells
may occur.
[n the present patient, an epidennal inclusion
cySt developed despite the absence of a history
of stepping on a sharp object. Oftemimes these
lesions develop from repeti tive trauma. such as
with III-fitting shoe gear. as was the case in this
patient. Radiographs are helpfu! in detennining
osseous elltent. [n the present patient. because
there was no osseous involvement. the cyst was
excised. and she made a full recovery.
Clinical Pearls
l. Epidennal <.:ySts occur Sl:Condary to tr.!uma; wlIhout this history,
rule out ill-fitting shoes as etiology.
2. ElI:cise the lesion. as it is possible for these masses to become malignant.
REFERENCES
I (k!o<n:tLl J K.BlotlC bnal-!l """"noma .""n, from an .p,dermoid >ySI J Oerm Sur, On<o!): 310-t I. 19n
2. Polt.rGK. Wan! KA Tumon. tn McGlomry EO. Bonk. AS. Dowlley MS (cds)' .. booO: "fFOOI S"'1c/)"
2nd ed. Balm""n:. Williams and Wilt"". 1992.1'1' 1139--114()
.1
..
(, wUI,d" W;}\LJ,U;\Jl :>IU<K ;>JI' ,rll'\\ (SI!>I,lU;hIIP Jno,{ ",uI/M :fIW!ISIIIO
"\ ;lJnifl)
UOIV:>IPUIUI'I,1 IUJ;ll\lI puc IUJ,'lcII.WIIl UI p..,uihrCICUJ JU IlllJlpnllJ
-UO) IISm'JlI) IOU pi p q1lrl lI'UIl':.'I'<lq ;lull U\I,'lOPJ0.lIO 11:'101' ',ulci jO
-od IUJIJj;}\ 1111,.,.. ,numo" UI IUOJ;>JOI 1/11 .... JISue lu.>uU;)(U:IOlel p.hC;)JJUI
-Jop IIlI.'11l1 'UOI\"'UJCIUllld ICJ.""! '11:.1;)11'1 pur.I\' ;JlllpUC1' I iJOIIUYl/O'/
,I'
pull p.lpnpql! k.lOj.\JOI "OOJ)O P;!(\W 11'lurld IClP.ll.U IW lPI PIl" 4 JIlIC\ UI IOU) :i'UI
,e;>1 ';lllIull l r 1I01\;)!J'!oJt'" 10 UVI ICIIWI , III l.l:>q 41' .... toIl))O !>><is'll J'CIUtlld JO
V" ,UQJIOI)I 10. l;):ldw J,lUIIL un ;>_')U;.>Uttll(lJd ;)3JC-1 -j'1m311 ;)."0<;1 j,'jl 01 UI
puc dn ,I pur '11011 m'lIl <;J1!;>dllr JQOI Illau 1\!J....u;)f) :u8}lm'!"ll1x11"J!)i'lJ
p;lJmn.lJ pur. 1lI.xl.)J)0 l'''I ,,,-/1 SOIl IlI;>.));1 'IClWOU
;lIIIJ(lJaptlIMtPJ JtU - ;)lmb;oJc pur ,{lIo,Olllc.-i J;)'I\01 00 ;>\1111 U.llPI'II;1J;)I{J()o'l\)
:1111 :PIIII.lJlJIlIl "'liS -wOP 1<..111 \..1,)\ J;ltj ,(IIWCJ Jr-"II)I:1'I.I1 {q IClld
-SOlj III'W' Il Ul uu:;:Oll1nj P;OJ;1\1PP PIliP XU ,,'100) S;)IjIt>;)I,j1 urll) IU;I.I;lJJIP S'tOOIII,_ ;;I!,nCJ;I(j
-00;) J;JtjJ()w;>4J. )llOlllI:lu J;)I,j 10 OOUCn[Il\) Ull JOJ J:K/JOtu J:>II \q UI IlIlinruq" pIS PIO'JC;I\-':: \
WOJ !J,l ual1UII {P..l,)\.'W dUO \ll!\\ P!}I Plo-.m,l(-l \
17 lN3LLifd
Diagnosis: V<'rtical tOll us
Discunioll: The 'ynon} for HI1I1:al talus
,re: congeni tal pc, I mngenital flat
tOOL wnh mlonavicul<lr dislo'X<ltlon. :UllllOngenl
tal ngld rocker-bottom root. Th.: .:tiology is un
known. There a high im:iJcnn! in
:111.1 ncuromUM:u!ar
such ih lIlydomentngocclc. congcnrial dys-
pl:h!a of the hip. peNs. tri'\Omy 1J-15,
Olud Marfan ' s syndrome. BNh m:lles imd females
are t:"lliall) affe .. red. bot right fOQt is
<lightly higher.
The eonrlilion i<, cl,ISsifie(1 :le"'ording 10 mobil-
ity ,md pr.:.ence nllhe "bole I1m./l!]g,:
Groop I : fcetlhat cakarreol algns
rJulo,!!rJph to make tile
Group II: rigid fee!, 'l}melimt's part of a 'yn-
drume
Group Ill : lenieal talu, '" ilh trbom}
13-15 or IS
Group IV: lenreallahls "'Ith neum-
mus<:ular pmbkms ,uch ;IS blnd;l
An:llOmic:.lll). Ihe lalca1H;'!h i, in ami
with no anteflor l:lICKakaneal ;\nil-ula-
lion. The talus 1'; fixed in a lemeal poSItion. with
_,,,oci:ltect hI uf Ihe 100!ar head ne, k
The na\'klilar aniculale, I'. 'Ih Ihe JOl':lIl'one' of
the ralar neck. The llblunavicular and dursal
ligament) are c()mrJ' ted. prec:lud
Ing reduct ion of the nal'icular un the tJius, A (:on-
tm,'teJ eallancCK'uboid ligamenl for.:foot
a11<lucllon. and posterior cap,ule .lml
loim arc! <.ouftncted. 1>- lu.cle and tendon, of th..:
amcrior IIblal. <"Ien,or halheu, C.llenM>r
<liglturum l{mgll" peroneal. and ,Irt! .111
,,'ullu-a.: t<,d The posterior ubial lenJon \,,:11 as
Ihe peroncal V.'ndvn, anteriorly di,placcJ
Th.: tn:aunent go:<1 is 10 reduce and maintain
of the navicular and cal_
to the CaSling should be stancd 31
binh and cominucd for 3 10 4 momhs. 10 stretch
lire ,ofl In prepar.ttion for fUluTe surgery,
Reducing the talonavkubr will cJim
mate forefoot valgu). The fOOl is posilioned fOl'
caSt appliclllrOn by holding the forcfOQI in etjuinus
and \3nLS. The is 5upin3lcd and held in
and Inl-CrSlon.
Conservative trcmrnenl is usoalJ) unsuccess,
ful. c"peei.lll y Ii II is lale. Surgical proce-
indnde ,oft II s, ue rdeasc With posterior
tendon ltnglh.:nings (e.xlensor hal-
longus. digllonrm longus. per-
,)Ileal. and and tendon trans
('pl il ATT lendon). Thcse
may pfO\ide an incom-
plete of ddonmty, and bony pro
ceJurcs, inc!udmg of na\icu)ar. lale-
COlli). and .. oblal ar/lriple arthrodesis. have to be

In the pre.,cnl pmienl. the plan \\-":1.> to restore
Ihc bone and jOllll relati ollsillp. A Iwo-smge ap-
proach " 'as tal-en: Fil't. Ihe .: u ensor rligl torum
hrevi. was re!<eeted from ils origi n. and sinus
hlr,j Wi], Lcngllleninp w.:re per-
forllled on the tib.ahs anterior. e, tensor hallods
longus. amI elten,Or digltorum longo, . The talon
avieular joint was mobilized and marnlained \I ith
K,wlf(' fi.t;ltion. This poSition was held for 6
\leeks in ;In :lbol'ctheknee The second
\Iage of remo\'mg the pros and lengt h-
ening Ihe tendo.tchilles. The IIbialis antenor was
Ir3n,locmed .. m.! the fOOl and kg Ih'r.: nnmobi
lrl.ed. Aller caSI remul'J I. the <.hlld ",as main
lamt"d In " DSIS msc.n.
Clinical Pearls
Llrly re<.(>gnllion cal blnh) ul lertte:rll.llu, ,Titka/.
, Castmg be performed lor a minlmom of J Illonrh. EvclI irn com-
Ih .. dc("nnll), II '" it! TZunimilc , urgi"',1l pr{)Cedur.:, nccJed.
, Pinning the liN rol)" ,h .. illxjucllon ... nJ re;l\lgnlng Ihe (<110' , 1In pro'idc
j!ooJ reducllon ufthe delormity
REFERENCES
Ikn..-d \tA 'on,,,.J 1"lus (tin 1'w'.[I, IleJ 17,11 M'.
Or""ru"){ Slwrr.m! Ill'" 1"IIe p"Ih<,r"ol.:.1 In.>t,,my c'( PC' ,"Iil'" J R"'I<: J"lm IB, I 5.IA53--tbl.l'HI
"u".u- St R'n"y I'L. OM ,>I>"q"" !.Iu" ,\ I.lrth<,p:..JI.' TrJ"IoCr<p"""' I 1011. t'l77.
T ... lkJil'.</l cO<1'o' 1'<'" (}rrh<>p:d \ lin 'I/, ... h A,n.1 111
93
PATIENT 44
A IOyear-old boy with a painrul right arch
A IO)car-old boy presents with a pamful righ! arch. He sinned noticm, [he pam about 3 days ear-
her and feels most of it along the lOp of his foot. especially ..... hen he is walking or runnmg. There is
minimal discomfort at rest. His mother does not know of an mjury 10 the fOO(, but she Iw OO(iccd thai
he feels warmer a1 night and may be running a fc\cr. 1lIc child has noc been OU1 of !he eLI)' In 2 )'C3r:S
and plays locally_
PhY:Jita/ E.romination: Gener.aJ: essentially normal health. with no OI:her JOint or bone pam.
Temperature. 39.1 C. MusculoskeletaL acute pam o\er base of first metatarsaL mild 5\O.cllmg In this
area.
LoboralO,] Findings: wec [4.500/ .... 1. incll'a5I.'<i polymorphonuclear leukoc)les, ESR SO
mmlhr (normal 0-20). Aspiration In region of first metatarsal b;lse prn.UI\C for SlaphV/OC(KTII5 w/rt-us.
Radiographs, no abnormal Illes of fOOl; epIphyseal plates open with no signs of froctures ordl5tocation.
Bonl! Kan: increased uptake in nght firM metatarsal. with predominant uptDke In epiphyseal region. as
compared to len. unaffected side: focal increa5e in epi physis of nght first metatarsal proximally on de-
layed images (again compared to left).
QUtJnmf: Whm IS your diagnosis'!
lJjaNumis: Subacute cplph)'>Cal
IJjsl uuion: FaC'tors that inilucnce
(lfOttsses in bone include virulenct:
01 the bacteria. trauma creating a inJut)'.
and Ischemiilln tilt: bone. $llll'h)/Ot'O(,(USUlIrt'IU is
the most rummon organism so,',"n In Ilt:malOj!Cnot1!i
and S. been found tOM,e
a certain aftimlY for !he epiphyseal margins. The
111000 supply totile eplphy.scal cnd through a tor-
tUOUS and juwlposll\Ollal arte!)' that lli,cs off
I:>ronches 10 the and These
.mcries form let)' narrow aoo ITIOfe tOOllOU,'; IUm-
mg artenes. malin!! hairplll turns that "'lcnlUalty
,tow tnt: blood. is Mffil[ar to tnt: cffC\:1 uf a
high ..... ay mItICI1l8 the: 111 a tum: ttit"
tmfllc Thus, bactcna can lodge
Within the loops at the Junction.
The blood In the loops IS analo-
gous 10 the '-'Iuggi!>h flow in the: metaphysis, which
is the of lIoI;:ute hcmat(lgenou\ O'Ik'Omyditis.
lbc two COOOiliOIlS are qUilt: .Imllar m
11U1l. and m::atment ()epcndcnl upon the radio-
graphiC finding!>. If IUl;cncy IS seen In the bone
eoo., lleaT the epiphySIS. I;urcllage of lhe bolle is
iollie,lIed. Wllh the ab-..::nce of bone: changes. IV
:mtlblow: therap) atone is sufficient.
In lhe prt",clll pallent. IV eolt'ragc
Llentlo cradlc'ate the Infcrtlon.
Clinical Pearls
I. [n light I)fl llt: pam and lact.: oftraum3 in subacut.: is
Ill1ponall l to 'oCt up a dlfferclltia! wnh Ihe u'c 01 :>i-ray. C, '>Can. allJ M R[
2. Include the foliov.lI1g 111 )ollr differential diagno\ls: o'tcogenic \:1/'Com3. ehon-
droblastoma. Ev.lI1g\ sarcoma, boliC ey,1. UrOOie') and

1. Whether eurcnage Jnd JllllbiOlICS or a:.ok l'Our\C IIflrCa!ment .... Ith IS
Inslltuted. , tabillzallon of the fOOl parJffiOUnL
REFERENCES
Ltn. RI.1 Sulwio.UlC I"" JrO .. 1h In Iklu,'<li' ,,{ I"" (';"'''Ih ",.,t \. ..,00". It:. ,,",'I, 1.,,88
, LI.I><k""'-u", S AIc,ondtr II tnfI""'" 'oI,mut..l.tng """" t ............ \ , .... .... hallle Cit" Onhop 19J
, ...
R,,,, lRS. WG T,...I"",nl'>( _Uh:M.UI( '"'< .. In Jail .... 101111 b? 8 -U.l.
.,
PATIENT 45
\ man wi th a cl inicall y ddormed lert rool and ankle
'\ .. r-"lJ IT1.ln rreScrlls to the emergency department ..... ith a painful. edematous, chnlcally de-
fuoned left foot and anlle. He fell off his bicycle during a professional BMX (bicycle) race, and now
rel.u;:, a Tm:!,;hamsm 01 pl.lnlartlexlonlin\crsioo. He complainS of SI:.\cre pam and mild III
the rOt1l, Jnd I, un .. ble 10 bear any "eight on that side. The palienl has no complaints of head. flcd., or
oo..l pam and d("lllt's any IO<ili of consciousness or nausea. Past medical hislOf)' IS unremarkable. and
he '" onl) Ibuprofen on an as-Ileeded basis.
/'},.nkal Examination: Temperature 99" F. BP 134186 mmfHg. hean nue 68 bpm. respirations
IS. Gcncrnl' :Ikn and oriented 10 place. and time: .... ell developed, well nounshed. HEENT:
1Ic..K! I:(l ntu'lons; puplb cllual. round. and reactive 10 light and accomodilnon: c.\lfoocular musclcs m
!J<.:t; \hu.11 inl,1d. PeJal pulsc5: dorsalis pedis, posterior tibial Vascular: capi llary fill
J 5 51-I!! no opcn no fracture lateral aspect of fOOl and ankle extremely
and tcnllng of slin of mid foot le\"cl. Ncurologlc: cpicntic sensation intact;
!lulJ pare,the'I;1, Jht:llly guarding and weakness upon plantorflexion and dorsiflex
Ion. il13blllty 10 or (; \.:11 : fOOt In position of sc\crc invcrsion. planUlrflcxion. anJ adduction. wltll
Jor"lI l.ucrJI prominence at rOld foot Ic\'cl; mild to palpation over medial mallcolus; sevcre
pam ,l long unr'RI 1l1ld toot :mt! .'Ith metatarsal.
J.tlfJ<JrfllIJry Findillgt: RlKliogrnphs: < 25% talonavicular apposition, Willi medial Jisplaccment
of IIUlltlplc fractures - latcrnl navicular, medial talar dome, post talar process,
Jnd melJtJr.,11
Qlln/iun: Whm your diagnosis ?
96
Jnd JUlie) tir;1 le-
I",n.'\! ",ubt,IIJr dl,I(x:llron, 111 1811 By dchmllon
Injury Inluhcs J dhlQCalion of
tho! and tJlona ... ".'ular JOints. II.llhout as-
-.(Xiall-d of the: cakaneo.: ubord or
Iit-roralar .ro"n.;. and .... ,Ihoult,rlar ned. fr.ICtufC. In
1 .... 53. Broca funher lhe-.e InJunes 11110
nedrJ!. tall"ral. and ..... hKh n::fcrs to 1M
. ;U'<."<; tlon th:llthe fOotlall"\ In relation 10 the t ..
.Ifter lho;> injury Thrs purely an.ltorni.:: d:&5llka-
uon ..... hlCh II.tdely 1I!>Cd to.llY. hJ5 progllO!>tic
''''uc becallll< of The rum:tional OtliComes
,I<'d II.lth lhe
Also rdcrred to a.\ fOOl or :lCquircd
dubfoot, medial dl,IOC:Jltons are ttl.! com-
mon of ,uhlal.!r Jnull d,.,I.I"atrolh, representing
'iO"f of "'poned ln<;\. The is
th,,' uf high energy Wllh jon;clul Irl\er:slon of a
fool The injury IS l'ommonly as..o-
.... ,Ih 11\0101' vchide .l\;ddlnts \\ell as falb
[rom J hel ghl
Ttl.! three artl,!!lar faeeh otlhc JOint arc
,I.!hlliled h)' Ihe inherent hOIl)' ';lmClUre as \\cll a!>
Ih!. .. ,uPI'O"', The u.:n'>C lalt}-
l.llcan.:al IntefOl,!>I..'Uus hgJment \tren}/Ihened by
lhe ,upcrrlria] deitold medial!)' Itle ,'all::a",:o-
hbular liganlCntl..r.[,r..r.lJy. for IIIJUry to OClur.
,dl thre(' 01 [he.-c: ligaments InU)1 teM. spanng the
--'rnng" JigJrllCm
Clrmrally. the appt'aranee IS a mc:dlalJ}
di\pl,w.ed heel .... lIh ..e\ere in\er<.lon, plamarl!cJ\-
I(>n. Jnd a<.Iduulon or Itle enlUl.' fOO( lb .... ell "" ap-
p.1rt:nt )ht)f1cnrng 01 mcdi..r.1 bonier. Forry p.:r-
of m\ohe an open inJury: lOO<;e thaI do
001 u,ua1l) pn: ..... m \\ llh tenlmg O\Cf the dorsolal-
ol.'pet.:1 uf tho.' mid fOot Radiugraphi.:all). the
el.:men! to 3,'.:ural': diagno"ls the relation_
of the lalar held 10 lhe which
\houtd ('11 all ... iews. In Ihls inJury,
medIal and pl.,nl:tr of thc
""ell medial dl'placement of the
""lIhoot dIsruption of the ealan<'OCuboid JOint. Ill\'
al'iO 1>CCn. Additionally. there of len are associaled
1'ra.:lure" of Ill.! lateral na ... "ul:tr. dorsomedial la-
lar he:ld. prn.tenor talar tubercll". and ,alar dome .
... prompt reduction III aloKiing skin
rlC'Cmsis and crJt"ulJtol) L"()mpromlSl.: Reduct ion is
clbll)' a..:hie\cd ,n the mapnty of patients by plan-
tMlle\lOn and 1Ii\'(r;")f\ of the foot. followed by
el'crslGn and OOrslil':\lOn. Applying drn::<.1 pressure
to lhe prommcntlalar head foclJilates the reduction.
\\ hrch is of len " .. :en. heard. and fel t. To assist re-
duction, thc llll."(' ,hould he ne.\cd 10 n:la.\ rhe pull
01 the comple,. Impcdi-
Illents to closed reduction melud ... : bUlloohollng of
Ihe laJar head thn)llgh Ih( eXlen>Ot rclrnaculum. in-
terposition of the deep peron.:al neurovliSCularbull-
die, and impaction of the Iliteroll nalicular into the
nl<.-dial lal!lf head In these parrenrs IS-I()q, of
open n:ducllun "w:lrmnred, Jlo"t reducllon
imporUnt: the lack of deformity allo ..... s
much belter cvaluati(ffi for fractures. es-
po!\:laJly [aIM dome that
....ol"5l.:n the olcrall
Olcr"ll outcomes "'a!) Irllerscly .... l1h Inc force
of mJuf) Results arc- .... oo.e when mtmanlcular
are espccmll) tno-c lIl'oh IIlg
the "ubtalar JOim. mdudc
arthritiS, instabilm. a'ascular
necrosIs. and mf<'l:ltOfl -
In the l'!"e5.('nt patrcnt, the .... as re-
dlK"<'tl all<i maintained In cast Immobdr.c.1tion.
Clinical Pearls
Medi,ll Joint tSTJ) are hlgh-efli!rg) IlIJuries 1lI10lvinl! force-
fullnl c ..... lvn of:1 fout
2, F .. 'rry percent of these injuries arc open .
.1 \.kdlJl 'iT} di,location IS often ... d an :Inkle d"I(l(mluII .
..\ KC) dlllgno'lic are talml3lkulM apposllltln all imad I,C;I!r.:alle..r.1
)<Hnl
'i. A"(l(i.llcd indude Imeral nll\ dnr-.\lmedraluriu,. la!:Ir dOllIe. lind
taJar pr(lCes,
6 PO\t rcdUltlun uftcn t;llar .. lome fmlillre,
7. Jntra -3rtle""lr fl.1\ HIre, .... "r!>Cn the twernll I'rogn",,)
REFERENCES
1k1l.1-..rN l". ::'JIkl<'" It ,>1'be 1"'-" j .. lhr IOOI .. no! "nU . 'Ih ed '" l,{"",,. Moot I"" . 1999
U",-" O. \<I ...... ." A \u"'-ol .. ,""n! .. " .. , Fo-.-.. "'nU. Inl fIJi 12\ ...... \- .... '11 ",1,
\, "th r ll<_I<:0,.,...." In "'rrdkn.". r""""",- ('/ FnoI Sun:,,')'. R .. I""""",, W,lh...",anJ 1Q9!
"
PATIENT 46
A 2S-year-old runner with persistent ankle pain
A lS-)car-old man presenl5 "" Ith pain in his righl ankle. HI;: fim experienced II \\ hilt be \\115 run-
nmg ..... 1111 his On. IRltlally he thought lnal he may ha\c spr11;ned hls :mlle. bUllbe pam suI! has IlOI re-
soiled after 3 months.
Physicol E.rominariOI1: Skin: righl ankle moder-udy edematOUs. with IOS5 of appeamnce of ten-
dons compared 10 lerl foot and anklr: lal1::r.li aspecl of righl ankle warmer "'hen compared to medial
aspect. Musculoskeletal: pam elicited al distal aspect of fibula; ROM 31 ankle jolnl restricted due 10
pain and guarding; dorsiflexion, plantarficxlOn. and c\crsion all hmued In comparison to
JOints
IA fx}r{Jl ory Fifldings: WBC. ESR: normal. Uric acid. crc:allmne clearance: normal. Radio-
grnphs: In fibula MRI: c'{pansi!e mass in metaphysis of right fibula. measur-
ing 2 l< 2 x I em. T I.weightcd show soft tissue in\olvcment with destruction of an adJaccnt conical
margm ofbonc: Tl-wclghted show incrcas.!d in distal fibula; mass "'ell drcumscnbed;
remaining osseous struclUres unaffected, with no change in Tc 99 bone scan: increased
uptake on all three phases.
Cours,: Surgical pathology Wb performed and the resulb vuscular channel hemorrllage
anll hemOSiderin llcposition. Mu1tmuciealed glllnt cells were nOlellm the
QUlstion: What IS your diagn()l;ls of thiS osseous IeSlon'I
..
DiscussilHl: In tho! pn:s.:-nt..lllon 01 ..llk:UT}smaJ
bone C}st [ABC). the differenllal diagw>sis
Iw;ludc osteosarcoma. gl..lllll'ctllUmnr.
lastoma. and osteobla.,toma. Tho: of
thiS P'llient IS eOfbl5tcm "Ith honc
.:)st fOf sc\cnll rc:asons, FirM and II ne0-
plastic lesion such a;. ABC )hould be CQffildcred In
II patient ,,110 prc:sems with pain and for
less than J months In tho! ahscncc of trauma. Sec
ond. "hlle bone may be in
Jny bone, tllty I}PIC31\yoccur in lilt
long bones. ""h ..In incidence of <I!lPro,imatcl)
7()<l,. nUN, Since 85'" of ancul'},mal bone cyst;,
uccur m pallcnts under 20 }car.. of :le . ..In ABC
must be con' ldcn..'d in a younger pallent.
1llorough of the r.Kliogra]mlc
(If :meuf) ,mal bone cyst. IS cnlClallfl narm" ing lhe
lllagnosis. Roologntphlcally.uneul'},mal [)one!:),t;,
rnay mimiC malignant bone le"ions due 10 their os-
leol)lic. de!.trut:llve nalure und p.:n()!,teal c\p,m
,ion. However, ABCs can be diff\!rcnllaK'tl from
more uggres,ivc: h:'lon, by the L'Cn:mrK;
blowout in the of long hone, In wt'lich
lhe COl1U remams imac!. Earh of tTh..-c rudio-
grJphic remures ,,'a:. present ullhis tilms,
IlrKI all "ere: funher conflrmdl hy r.IRI
While the clinical of thl" leSion
c(namly allo\l,-S for mclUSlon of cdl tllmor
m IhI; differenllal dllignosis. the p;ltholuglcal and
mlCfO'>(ll!lIC 3n! more with 3n
ABC. Microscopically. ABCsc.,hihll blood-filled
l'..llemuus by fibrous scptile and
I\w;: prc'oCl1Cl' of muilinuclealed giant cells, as JII
thiS Intraopcratllcly. thIS lesion pre-
'oCnh .. 'tl a thm-",IIJ.:d 'pace "lth copious
amounts oft>lood In addition 10 itsehnical:and ra-
diogl1lphic pn',<nlallon, tIM: intraoperatl\e ap-
pearance of an AHC along wllh the palhologlcal
confimllhc
Despite bemg benign, bone cysts
can be for mliligmmttumors both r.ldio-
log..:ully and pathologl.:all) due 10 thei r I11pld
gro"th mte ,Ind extensive o"It'OIYSis. ABCs :are
anomalies. which ore Induced by
mmO!' ur mJjOr Imuma Jnd rna) become associ-
ak'd "Ith p.lthuloglcal frJctlln! In
20, of patient"
TIle IrcaTnlCnt for Ihese of com-
plele Cv;\cUJtion of the t:Jvil} with hone grafting.
Thi, perfolTT1Cd upon conhrmal1lJn of the le-
,ion's benign ml1ure by frlllen lrthe
JI,int is "mdicmed 111 mWi-
lion 10 the bone gmh
In the prc,elll palien!. e\;KU..lllOn and bone
grnfting wa, romplct<'d. lle I'D.<. im-
moblhled for 6 "ccb m a bela" knce re-
ph}sICJI thcr..lpy for 2 and
normal IJI..III I' uhm 2 monlhs
Clinical Pearls
I. When reserl1ng the mass. care be taken due 10 the Ihm nature ,)f the: tonu;:al

2 Insp<'tuon of nearby )OInb IS IInponanl
3. Due to their nalure. booe H1a) be mistakcn fOf rna-
hgnantlu\l1OfS. Clinical and radil'8r.tphic presentalions :111.1 111 the <l138no'I". WhKh is
confirmed by p;lthological cl'u]uallOfl.
REFERENCES
I Clou,II JR ('HG A .. t><- ')'01> Re'",,' nr I, , .. ;, J Boot J,,,nl 181) '0(1 t th. IQf,(j
2 D>hhn OC. Md ..... wJ R ......... \1" ...... 1 bone ,,,lIN non """"""-"'1 Rad,('o\ K !41, 191H
.. n t:.\S, ""un n, 'r, M' '''''''''l''''''' 1'0"", <''0' E I""",," "r tlf .'u .... u .. gc ,n;!tl
.">d Cion 0111"-1' Rd Rc- ItS' I 11>,
4 K, M,dilicl"" R" D '\'1("",,,,,,1 bo..,., '1'1> R.,,,, ... "f III '"'''' .... "_1 Rud,,,1 ! 1 1"\1. 1"1I!!
Ma""'lT}' K lIu,d Til Rc."d.l)' R. fl''''''''' WB. (j"uuh, II In" .. """" h,,,,,,,,, ',Iltl( . ,I.an.,", (1111><'I"',li" HI .11' !Z!I, Zl.101
b O. r; I)ial!n"",' \It BOIl<' "r;.! In,nl D,,,,,,,,,,, C\l I'. II I'IU. J'P
181L 1,...1
..
PATIENT 47
.\ 50-)"ear-old woman with recurring root pain
,\ ,",oman IS pain In her left fOOl. She does not recaJltrauma to the area,
t>ut r:uher 'Imply .... oke up one morning VI ith the pam. After imltnl onset II conllnued for 6 .... uk!. but
then gradually di .... It has 00,"" suddenly reappeared and IS more severe, .... hlch prompted to-
Jay'l> .. Ll>1t to me emergcnty dcpanm.:m (Of C'ialuation. 'The JXlucnt relates that the pam seems to be
mo<'! '<VCri.' ",tllk ,hoe j, ambulatory She also menuons thaI she IS unable to find any shoes that are
mmlunJbl<. l1l ... .. 1 is significant for the removal of three basal cell masses from her
f:'ICc JpproxtmJldy (, months earlier. and a mastectomy plus chcmOfhcrapy and radlallon therapy about
! )car- ;>go
PhYliicul Exumil/U/iQf/ : General: healthy appearance. Musculoskclcml : pam In medial of
left ftlo.>4 no erythema. or calor. Gait: (00( el(lrc'meiy on IImbullilion and m ab-
wllh obVIOUS break m mi(jtarsal regioll; alltlllgic gait; weight shift 10 Illteral Side off 00(
Ilam.
LlIborflUlr)' "-;IIdillgS: Ral.hographs; lytic area m first melatarsal base. occupying en-
1m.' Illcdullul) rt'j.!11l1l TI.99 obI ious uptake at of first metatarsal in delayed phase: remain-
.Jt'f (If ".:an non,:oll1ributofY for adJoccll1 uptake. Pathology (from ill1raoperative biopsy); hyperchro-
m.!lic. 'pmJle-,hap.:d ,cjXltaled by hyaline intercellular
Qllu/;mu: Whm j, thc (jiagnow;; of this lesloll" Whllt surgical opIlon shoul(j be
100
(!cJr .. ell \)C-
L Uf nk1f(, "lieU ,II men th.ln m 110111('11 the
1nl.llltJ 5th Uel.'J<,-,. Olc...: Me rel.Hlldy
"Olllrnon 111 the eillphy .... :l\ IlId re-
luhul..r I>ollle' 'I.l\:h a .. the lenlUf and
hlll11CRI<', btu the), .. ,III u, .. lI r in other Re-
pnncU 1(> t>,., ,I"", d e.lf .. ell
.. l,lma.\ are- prten dlffllUil to dll!!'no<;.e In borte be-
lnU\l;' til<.') .Ire In Ihe- ..oft tis,ue.
ClInKal re"IUI\'\ m..lllue loo.:.aliletl p."Iin 01 long
uurali('n. Ilillikd 1I1t'IIUIl ;Iltel l<-d :md
!reI< tUIt:, In lY, ,.f
R;II.hu!!r.ll,h" . .Ilh. Ih ....... IUnK)!' .Ire ITIll'lly 0:;-
1<'QI}IIC and nll-l lI 'lie. ;1' III Ihl \ For
Ihl" rea ... ,n. Ihn nUl'It>.: ,Jirt er< ntl l ted frum orl1.:r
rumor, '1I11lbr r.ltJillgr.lplll,, pre ..... ntalll)l1'
'Ill. h II' lh"nJ,,,hl.hh,m , all.:un ,m;.1 hone
")I .. 1,:1.1111 ,dl IUll lllr. hhnh"rcnm;l.
leo,arcuma .. ln. 1 rl",m,,.-ytum.1 Addllional radlo-
111,11 in,lud ... .:nJo_te,,1 .;o1l
II_Mle mJ,,,',, "'111 Ih,'1 arc
1\1" C In lIatufe
Imr.I"r"" ' JIIVe el tlll,II"'II '0il . gr.lIl1llar
wnh .-]",1( ur JluuJ. ,1, ,,"ell as
IUllklT 1,,11, wllh .. on-
lirmation oflho: cells
in ,heelS wllh abundant clear and cen-
lrally l0I731ed h}pcrc-hromit nuclei, Immune assay
,tains are an integral part of 11M: diagnosis. Rur-
rente IS high .... n.:n curellage is per-
formctl :md lherdore r.alhtal resection is both in-
dKatcd and Metastases to the bram.
lungs. and olher may occur .
The clinical and rocitologic presenlatJOO or clear
cell chondrmarcoma qUilt simJl.lrto th3t of cbon-
droblaslOllla Due 10 the rTlOIlignam nature of clear
l'cll. 1 .... 0 emUICS be differentiated. Clear
.:el1 dl()ooro:;.trComa can be baseU on
Il\Oo.'Currcncc In un older patient population. and the
pre-cncc 01 tumor cells Upoll examinallon. As with
mosr bonc bions. biops) and patholog-
Ica! are cnllnll to an accurarc diagnosis.
In rhe pallent. Ihe lesion oc-
cupied Ihe eli llre medullary regIon or Ihe
IIIdlcating Ihm il had a hi]!h prubabil .
it) 10 ]Xllcillially malignanl,
W;H adl'ullcin}! .\.0 slllwly Ihm it re-
mained within Ihe cortical rnargms of the
Therelort. radical reSo:C'lIon re-
qUlrcd.
Clinical Pearls
I II ,""rU\;IIII'"I' IIC,c"ar .... , IIItr:ulp<! rall\e blOfl'i e, 10 \ahdale- lotal reloeC'uon are
!e'luil\'J ,II Ilk' ."IIrUI.1I Ion Mlc
lI!l<hng' Jld III n,lnu .... mg the diffnenllaJ III a dear cell
dl<lIlJrIlI'OIr'"ITl.lI'>,",eJ ,)n Iunw{\pt. ... , fi c
l B"ne relll;llll' 'hi.' nJO'1 a.:l uralC means or clear ceJj dlOOOro-
-..:lfU'IlM
REFERENCES
H,,",,,,,,, 'I , "" \);ohl", IX n..., II.-hondrosarroma 0' bono ot,.,.""",..,." In \m J Sur, P3dIoI
,,1,1. l""S.'
(;,,1. ,e, II" \, 'r' ." lit . \\ ,>kI1 r "'or >.;ry ,'<;ondl ....... oma of"'- \ un",,,,, 1t".j<Ol 2-10. 1999
I Iwm., R. ro,,.J k ." ...... ell , ... 1t>oJI.q) I'i-I 43.
lI .. n .. (I. ".-l' ......... II, ...... . ,,, "I 11."., JOlnl DI>ORln-l.. 100 cd PhIl..,."lrh,a. \'<1'1 S.uIMkB Cump;uoy. pp
II I'"
\ "'''' k \, or lUll \ Th",i')' Jf' ('It 11<[,>", ",. "" .. I.' .. " .,r,hr P.'holooa
... J'"
II. p"" .,
,.,
PATIENT 48
A IO-year-old boy a limp
A JO-year-oJd boy presents with a 4-monlh hislOl)' of limping. He no of trauma.
Physical Examination: Gail : obvious foot drop. Musculoskeletal ; limitation of dorSIflex-
ion: strong pov.er of plamllrfl exion. Vascular. dorsalis and posterior tibial arteries palpable. with
no trophic !;hanges; no knee flexIOn or hip comrolCtures: transmaleolar a:ds and hip rmalion in cx-
ternal and internal mmion, Neurologic: good sensation plamarly: dorsal in t ..... o-point dis-
crimination: deep tendon reflexes inlact, Palpation: mass at proximal !tbula: "omender. IlO redness.
LAboratory Findings: Radiographs: normal. MR1: I-em mass along fibular notch of fibula.
EMG and nerve conduction veloci ties: decrease in velocities of peroneal nerve.
Qutstion: Whalls your differential diagnosis?
102
DiogntJ$is: Ganglion wuh common peroneal nerve compression
Discussioll : In the preSl:!nt patient. surgical re-
moval and biopsy were A ganglion
was the moSt likely diagnosis. but neurilemmoma
and nt:urofibroma had to be ruled out. Ganglions
are common. and if they are loc:lted near aloint un-
der the tight bands co\ermg ncnes,
entrapment can occur. This can be seen in the pos-
terior and anterior tar;al tunnel. If prm:imally lo-
cated, of the main nervc can lead to
atrophy of the muscles innervated. In this patient.
the ganglion was located in the lateral and anterior
muscullllure. The result was an overpo .... ering by
me posterior group.
Due to ganglion locations, recurrence is still
high after aspi ration and injccILons with steroids,
The motion at the joint level or tendon creates an
irritation and produces a return of the hyaluronic
add.
Clinical Pearls
I. When a tlanghon is located around a ocrve, the ganglion needs to be followed
completely 10 ils origin. The stalk's origin is within ajoint or tendon sheath. It muSt be
remo'cd completely or it will return.
2. Simple aspiration should be attempted fir.;t: howe'cr. It is unsuccessful,
and the ganglion returns due to the localnalure of the corlUnual irrilation at the ,rle.
REFERENCES
!. Grrcn DP, UOIchki" R, Pt'drrwn we i..u). Grttn'. Opt .. ll>e U,nd Surlel)', 4th 0:<1 . York. ClIurch,\l Li"ng,cone,
.m.
MC'Glamry I:D. el Comprt'htn,,,. T.'IOOcl. of F"", Surxcry. 2nd ed. Balli"""". W,lham. '" Wllk,ns, t992, pp
un-It'\.!
]. Start RE, ufcbe- 1m""'" po"""" ..... 've by gangl,on cy! . J 80"'" .Io,nl Su'g "7A!41:n}--178. 1965
.. S'OIl11W1S Mrdical Oto:lOonary, !61h 0:<1. IhJllrTKlre. Wilham> '" Wilkuu. 1995.
103
PATIENT 49
A hoy " ilh
A J-)eur-boy is n:ti::m:d for eVll lunlion or bowing of his leg\. The mother ,Inu pc>JI3Iri-
cian 'laiC th:!! the condillon goncn "'Of!>C !llllCe the child ,1:II'Il:d \\ hen he was
9 months old. The ,hlld quite hcal!hy. and there .If<: no other famdy mcmh.;", " [Ih OO\\ lng.
Pllysical Exami"utia,,: General: Significant bo\\'lng on frontal plane; Il'<InsmJlcolllr :I\is 10' ex-
ternal bilateral!). ",j lh equal rolmion of clItcmal and imernal mOllOIl ,II knee joint. (jail no toe-
in: no difficulty running Of walking. Musculoskeletal: In knee dor.lflc'KlI'I of fOOl al ankle 10':
in e.\tensiorl. 15. Nomal 2: I ratio of in\crsion 10 cvcr..ton of \Ublalar JOlUl. nlll.>!.'!c runCIJ{)n normal;
knee Joint "llll no !a.lliIY or e.\cessi\'c mOllon.
Laooralol") Findings: (af angle
:Ind thickening af medial can ices or ul:>iae bilaTerally I see hgllfe)
What .:andi llon present? What are wme af the caos<:, ot bo .... lng1
'04
DiscI/Him.: Jnfan!iJe 15 pro.-
lht! ,mu the di"ai femur
produce :In abnurmally high comprl!ssil e force act-
IIIgacrrn..-.lhe medial (lIthe )OInt. This
.:au.es rel,lnl:l1iun U1 g:ml\lh in tha\ area. or In-
.:re:l.<;('J fo .... th 1((lIn the pro\il11ai aspect of lhe
fibula illld Ihl! \;ul!rnl aspect of Ihe pm of
the or both. If a child begms at an
carly age. when the are in marked
laruS. Ihen "'eIght-bearing fOR'':s will
be grc3ter on the rn.::Jial :l.'pcl:t of lhe phy,is.
Continued cllnrpr6'lun rc>nlb in limrted
groll th of both the phy", .Ind the The
medial oflhe epiphysi, become, narrowed.
and lollg:ilUdinal growth from the medial of
the h inhrbrted. rnternal !lb-
iar lo""un al,o 0 .. .... 1"',. \\ hen lhlldren are 110t
Ircmed. -.eV"n: J,lrn! dr...-:",... devel-
ops dUrI!!!,! e .. rly adullh,,,--..)
Other lalr-.e, ul libi .. mdudl" phy>lolllglC
gl"nu IMum. which reduces ali the child grows.
Hypopho_' phatemic rickets-a sex-linked. domi-
nant. inherited panem-is the mOSI common Iype
of rickets crealing a genu \larum. The diagnosis is
mad.: after till! child stans walking. Metaphyseal
splasia IS an rnherited disorder of bone
gTOII th thm causes bowing of the 101',er ex-
lremitlcs. In the most common type of metaphy-
seal chondrod),'plasia. height lind limb alignment
are within nonnallimits at binh. but genu varom
persists. and relarded growth becomes obvious in
til<: years. Focal fibrocmilaginous dys-
plasia rs an uncommon disorder that causes a uni-
lateral and progressive tibia varum.
In the present patient with infantile tibia \lam.
an ol1hosis was prescribed. It was an abovethe-
knee brace wilh a free ankle. ,ingle medial up-
right. and no hinge joint at the knee. Every 6
\\.-eeKs. the medral uprighl bent to gain funher
valgus atigrllllCnt at the
Clinical Pearl
tor T:l(liogmph'; to differentiate tibia \lara from physiologic
1!o.)1I;n:! ludude
Genu l.lrtJmlhat 1'; rdJlrvely '4!\lere for the chrld's age
Genu th.H 1l011111provl-d or has golten worse ol'er the J-.1 months
intemall ibwlWr,iun
\ ramrl) hi_tory for genu varum
,l"ymmetl) 01 limb alignment.
REFERENCES
Bk'Itl"r WP Tini.,' . !' ,},' ..... :b,''''',,,,,, ,1<,.""",", I &', ... )o,nr 5urg
Ie 1'''<J,.u",' ... < J,,,,,Jc,, hl "I1l<\I')n.,1 (",,,,,,,.. Lc..'UI. Ullh<" Annual \Iterong o(lllc "'c;adom} of 01
IIk"' .... JK- SU'l-"''''''' II< 0 C . Fe!> 11. IWl
WB 1"I.m"r. ".w.o. Coo"", Lc,,u.-.,. Tho "'"",,,can Of Onh<opaoW'" Survon . J lion<!
)"Inr SurS -, 0\, I '1 "",1
J G",ellC" V. B K"hI.r \G l!'I"'POO,rhole",,,, "d." SHit ,m.,J'"g""",d and , .. aled Southtm Mod J 78,
1179-IIM. t%'
\ T,nia ,," 0\ .,,,,,al .. Clin (lrd",!, 20ft,. I\lS'!
105
PATIENT 50
A 12-year -old boy u ith painful. aching ankles
A 11-year+{)ld boy presents complaintng of painful. achmg anlJes bilmewlly The pall! is inteT-
mittent and of 4.week duration. It is aggravated occasion:llly by ambuJalion. bUI noted most markedly
following periods of rest.
Physical Examination: General: multiple bony prominences at ,houlden.. wrists. fin-
gers. knees. ankles. and hips. OrthopediC: nuld lordo,is of lumbar 45 ij1(cd forearm pronation
bilaterally: 20" #lel(ion contracture of hips. wi th 70 e.tlcmallind 20" internal rotation of femonll seg-
ment bilatcrnl1y; I-em limb length dis.:rcpum;:y. wilh nght left: no pelvic tilt in SI:lnce; Allis
sign positive: bilateral gaJolrocnemius.,oleus equmus (left greater than right): mild libia! varum on left
side; foot type with components of rerufoot and forefoot varus bilaterulty. rearfoot
restricted frontal plane ROM bilaterally: hyperextended left hallux. of 5th toe btlaterally:
crepitus in both first metatarsophalangeal Palpation: no pain o"cr bony protuberanc<.'s of medial
malleolus nor at laleral ankle ligamenls. Gait: toe-walkmg with no heel contact: was necessary
for balance due to fl exion contrnClures at and knees as ..... ell sagmal plane spinal altgnment.
lAboratory f'indings: Radiographs (fccI and unkles): multlpk bIlateral defonmties
of shortened, stubby metatarsals and proximal ptmlanges: cystic areas In proximal WIdened
areas in bones of forefool: grossly irregular of lower legs. "'llh widening of
t;iloubial region - thiS area slamed on frontal plane btlah.:rally and bony O\wgro'" Ills evident.
Question: WhO! is clinical diagnosis'
106
Diagnosis: Ostco.:hOnuromatnsls.
Discussion: Ostcochorn\rmnatosis or ostco ..
cartilaginous are muluple pmtubcmnce
from the surfaces ofboncs prcforrnt....J in cartilage.
Males arc more frequently than females in
a ratio of J: 1. It is an autosomal dommant finding .
.... !th exostoses on tlk! rnetaphy:.eal regioru; of lOllS
IUbular bones In a S) mmctricaJ fashIon in chrldren
and adolescents. Malignant degeocrJtion of mulh
pie exostoses leaJing to is re ..
ported in less than IO'1l of caSl!s.
The charncteristic appcar .. llIce of O!ik."'OChondroma ..
tosis is the trumpet sign: a dlffll.>e. thrck-
enrngoftht: metaphysrs. The thickelll.'d area IS usually
by many sessile ClllJSlos<;:S. [n the: Iu .... cr ex ..
tremity. bodr ends of the bones typic-.llly arc
in the upper('xtn:mity .JuS! one end of the tubular bnnc
is il1\ol\oo. intcr"el.ungly. other than thecaJCMeus. <Ill
of the tarsal bones an: sparedof
are affected al. My location of the shaft.
IS a benign condi tion of
tumor .. like areas of long
bones. In the lo .... er e'tremity. the condition mani-
fests itself as palpable bony masses near major
JOints. and thesc masses may restnct motion and
compress )tructures. Ddomllty of
the and phalanges is prominent in the
foot. Ankle \algus and limb lengtiJ discrepancy are
addi tional notewonhy features. Surgical excision
lIlay be II<:cesSl!ated in cases of chronic pain or se-
vere restnction of motion.
Secondary arise due to shortening
and deformities. Rarel y does the promi ..
[}fnce c:ruse direCl pain unless there is sofl-tissLIC
s .... eliing al the cartIlaginous end of the
This fluid-lilloo burYe surrounds the exostosis. In
Ihe lo ..... er extremity. half of all the lesions are in the
ankle. lhey are dcfonned .... nh deviation or promi-
nences.
The resllil of the defonnilies is compensation
to lhe aneular deviarrun. Treatment ad ..
dress the either by surgical orcon-
realIgnment. If the is painful.
Ihen the exostosis IS removed. MUltiple radi-
ographic views may be needed to detect the pres-
ence of Ihe III a chIld becausc the
pronllnence may still be cartilaginous. An MRI
lIlay be indicated.
In the present pllllent. a biomedmnical exam
WItS performed. and onhotics were constructed to
prevent frontal plane angular deviation.
Clinical Pearls
I. Always tnkc muluple x-ray projections. as the exostosis may be sessile and there-
f{lre dlfficuil to detect on a <tandard view.
1. MRls lire helpful in the young foot or Wllh a prominence that is nO( 'iecn r.l{iJo-
graphically. "The outgroMh may be cartil:tginous.
REFERENCES
I Jail" M. R n.. fOOl .. nd ,n muillple Mrcdltary ClIo,to><!> Ankle.l: 1980.
2 f . "1. Hen'\l,tary muluph: Uo>lOKl J 900e JOInt 6tAa'1816. 1\179
107
PATIENT 51
A 5-)car-old hoy wilh IWrs ish'nllcft fool plain
}\ 5-)car-old bo} presentS l'oIlh a complaint or" Idr rOOI pain tlial be..:" pre-.enl ror 1 mllnlhs.
The morhndoc) nm know or any tmurna (0 fool. Thi s wa, hi' UN "'l lh :m) 'yp.:
of pail!.
Physica/ Examination: /'alpallCm: pain un a'pt:ll uf 1<:11 fOOl Skill: lef! f,)Q1 Iluldl)
ruborous. wilh inl'rease in temper-Jlllr.: ,I, 10 nghe. JOIn! ful!
and pain-free ROM: mIUlar'>J.! Jtltlll Ilomwl R().\l. bill pninlul, p:1I11 h>': Jliz;:J to 11;1\ k uJ Jr area II hen
hrsl del aled.
l.aburatory Findi"gs: General: normal For age Ih,ho.\!raplw Innea. ..... d radio-op;'CIIY; [rag-
menled and narrow ranoal navicular bone; no jlJlhulogy In remainJer ,lru.:turcS
thar were Jewlnped.
Qlltltions; Thi, ..:hlld h:b '" hi,h p<! 01 \\ h.ll art: (ho: appWpfI,L(C IreJlmo:nlS
for O,I<:OlhonJrosis'!
108
. lIlS .. ers: treatments include rest. ice. and elevation: short
k ,In.! ,)nhutlr,>.
Discussion: o, t ...... -.:ho.)lI<!r''''I' i, more
po:vaknt In wy, thall girh (4 II. r-,Iost of the time
the disonkr will rewi-e witlJt)ut treatment H.)w-
report' rhal rnullobl li 7arlOil
the ;IJiO" , Ihe .:ondllion 10 abate fi\e
times f;l)ler. This IS u'"olily a <cit-limi ting Ji<;eruer.
and lhe bone" III
IIi, lheoriud Ih,ll Jllrtrlg the rapid gTOII III plw,.c
of the le"d supply of Ihe taro;al n:lVi,ul:lr
nucleus. nl lhi, "':'-.cl.:ould pro<.hlle i,
cllernia. i"<.hemin alOIl!! Wllh rhe of
pron3110n Jnu grtnity ;mu
coll:lpse nf lhe ,""l ll C nude li S. re,uiting In reactive
h)pereml,j and pam. Kohler, gel lemll y
prcwm 111 adok .... ,nt buy, IInil"terally lends 10
'pontaneOthly re-..,hc l"'er lime.
tlklUghl to oc.:ur >econdal) 10 l'omprl'
siorl. slmil.lr hJ the- way F'relberg, infractinn 01 the
-.ecunJ mt.'l:1.I;u,,,1 h .. aJ (1o.;,1Ir)
ill,,:a'-C !,!.'nerJll y prescnts I};un and
a!<)ng the mcJial rnidfoOf 1.11 an JClilt.'
kenage male fh!.' raile-III ma) he anti un-
,!blt:' 11.1 pertorm auivi t} for any
penod of lime tG Ji'>Comfort I::\al\la-
tion that pl ln 111"'1.'11,...0, IJpt'i! "eight hear-
mg. Jnd Ihe dlild may \upinJle the foot to
po:'nsate lor the P'\III olllhc medial of tht.' toot .
Radiograph, ,hOIl an irregular ly
ular oone "lIh ....:kW';I'.
frngment:l!Inn Ill' lile U"ltl,at llln ,'cntt.'f. btlilt.'
JemUrtstntlC, an incrca.o.ed of patchy ar-
[I al"o may appt:ar uniformly dense. Magnetic
fcwnance Imaging reveals II homogenous de-
creasc in ,ignal intcnsity Qn TI -lleightcd images.
The inllialtrt.'atmem bf:gins with rest, icc. and
c!c\Olion of thc affected fool. Limilntion of the
nggr;J \ ating aClivily is onen sufficient 11.1 calm Ihe
inItial Seleral siudies rt.'Com
mclld short leg casl immobilization fGr approxi-
mOld)" 2 months. Hlc fOOl s hould be held in a
plantjrflt"",cd and Ill\ertcd positioll. Childrcn
for 2 months havc cGrnplete resolution of
pain nnd return to normal nell\ it) within 2.5
months. Wocn Ihe child h lakcn {lUI 1.11 the cast il
that an aceommol.!alhe device
he u.cd fur appro,i!l1o!ldy 2 The medial
,iJe be loOft to limit pressure nil Ihe navic
ular. Permam:nl orthutics can he di'pcn.-cu when
lhe child is
In the va,1 major ity of p.11lcnls, Kohlcr"s dts-
.... a:.c <'\entually ithout long-tenn iSCque
Huwc\t"r. II dhlorku :tml '>t:ierotic
bollC develop in loOme thb can lead
10 an ,mhritic talon3vicular joi nt . If this is lhe
a rniularsHI Joil1l llIay be required
in adulthood.
The p!'I:.<cnt p.1tient gi\<:n a modifi<.-d Cam
"nlker ..... hi<h consisted of n molded orthosis made
ufplllsti7-Oate. AI the endorJ hc W3S provided
with a moltlnl a..l)lic OrtiKbb \0 pre\t"nt prun..1!ion.
Cli nical Pearls
MIJI.u'il l Joim p:lln 11\ a ,-hlld "hose bolles ha\c nOl l'OrnpJete!y lIIay be
all 1II(\lc.,1\0n 01 ,tTl.''' fradure. I"hol.lgh rarc. the posslbllily should be considereu-
e'pt!I.'IJliy when lhert' IS no C\ Ider"-'t"' uf related trauma. Evaluate for the osleo.:hondroscs.
2. BII,Heml hlms are most helpful in the uiagnosisof KQhler' s. as it is usually a uni-
IJtefal ddornlit}
J Pam" relieveu by Ilmllmg 1ht' motion Grtlle II;11icul3r rone
REFERENCES
rS"-<'n R\' f1Ic n .rm:.t .,nJ II", .. mul ,.kolno.1 oIjl\'['h)''' .-.I lar .... 1 " ... " "I .. elin o.thup In
1"37
W Th.: ,,,.m, .fI,'" ,mJ ,.""t.","'>on "I ,N- I"".I IW,,,:uiardlklllr,. rd .. h(m r" K"/,k"d,,,,",,, J!Ione /0.01
III B -,,5 777
II, th .. m.G"" (".,,,.11 HR' .. "'''T TI", 1dJ'>a1 fi>"",I .. , Ch" Onhot> 158
109
PATIENT 52
A 6-ycar-old girl with discomrort in her hands and feet
A 6-year-old girl is expcriem;ing dlscomfon in hl."f hands and fecI. The pain IS not related to any
activity. as has pamful feel and ankles both after play and dUring rest. Her TIKllhcr has limed dail y
temperature elevations and w<."lg1111055. The child's appetite has decreased. as .... I.'ll.
Physical E;[aminatians: Musculoskeletal: range of motion of nonna!. Palpation: ten-
demess of ankles and feet.
Wall-hfu] waiting ",as Indicated. and the plltient ",as!>ent home. Pain conllnued for:'l few months.
proximally 10 mclude all orher jomts. On subsc'lucnl examinmion, the child's right
ankle \las red. hOI, and swonen. Sevcl1Illab teMS \lell:' undertaken.
Laboratory findings: Blood studies (from kcmoglobin 10.5 g: while blood count
17 .500fIJ.I: 6S pulym{lrphonur:1ear leukocytes. 29 lymphocytes. (I eo"inophib. ESR 34 mmfhr: fiJI.
alion lest m:g3ti,e: ASTO titer < 166 Too!.! umts: febrile agglutinin, normal: 5- 7 while bloot.l cells on
urinalysis. aspirate: turbi!.! !lui!.! y, I1h a weak mUCin clot . Radiographs (hoth no changes In
bone nor joints.
Quesfion: An appropriate treatment for this thlld would Ix- a daily regimen of what drugs"
110
Diagnusis: Juvenile rheuillatoid arthritis
DiscussiQn: About 70-80% of alJ aduhs with
rheumatoid (RA) positJ\c for rheurna-
toid f3ctor. In RA. the ralc is 50%. 11':1
child presents .... ith rheumatoid factor. it is likely
that juvenile RA will continue Into adul1hood. Ju-
veni le RA symptoms dh.appe-ar in lJlorc than half
of all affccll'd chi ldren.
Typically. the child looks ill and has high fevers
and \aguc JOint pain. Rashes. hepatosplenomegaly.
lymphadenopathy. and leukocytosis usually develop.
Abo common is small statun.: ..... ith resultant retarda-
tiun of growth. PoI)arthritb dc\'elop!' .... nhin the
fiN fe .... months and often is confused .... ilh So!plic
joints.
Laboratory blood tests help rule out uthcr con-
ditions and classify the type of ju\cnile RA. ANA
is found in the blood lJlore often than rheumatoid
factor. and both are found in only a portion
ofjuvcnile RA patients. The rheumatoid factor
differentime the three types of j uvenile RA.
Not all C'hildren .... llh active joi nt inflammation
ha\e an elevated cl) thll)(:ytc scdinll:lltation rate.
Treatment indude:
NQnSTeroidal anti-inflammatory drugs (NSA [Os).
These drugs often are the first type of medica-
tion u.ed to treat ju\entle RA. Most doctors do
not treat children with asprrin bei:ause of thc
poSSibility that it will cause bleeding problems.
stomoch upo;et. Iher problems. or Reye' s syn-
drome. But for some children. aspirin in the
corrcct dQse (measured by blood test) can CQn-
1m! juvenile RA symptQmS cffectively y,ith
few serious srde effects.
llilti-rheumatic drugs
(DMAROs). If NSAJDs do not relieve symp-
toms, DMARDs slow the progression of juvenile
RA. 1lley often are taken with an NSAlD be-
caU!>e they take w\!eksQr months to relieve symp-
toms. A \ariety of DMARDs an: available. in-
cluding hydroxychloroquine. oral and injectable
gold. sulfasalazine. and d-penicillamine.
Methotrexate. Researchers have learned that this
t} pe of DMARD is and effective for some
children with RA who.'iC symptoms are not re-
lieved by other medicatiQns. Potentially dan
gerQus side rarely occur because only
small doses Qf melhotrexote are needed to re-
!ieve anhnlls symptoms. The most serious
l:omplicutiQn liver damuge. but it can be
3voidt:d WIth rcgul3r blood screening tests.
CQnicQsteroids. These rm:dicatiQns may be
added tQ the tre3tment plan to cQntrQI severe
They can be given either intra-
venously orowll y.
Clinical Pearls
! . In rnJull rhcum3loid 3I1hritis. the disease is diagnosed by the presence or absence
uf rheumatQid factQr (RF). RF is infrequently seen (less than 10%) in children.
2. When in dQubt as to whether the diagnosi s is septic joint or rheumatoid arthritis.
ajoint is indic3lcd. BactcriQlogic identr fication will establish the diagnosis of
septrc arthritis.
J. The main treatment Qf juvenrle RA is tQ restore joInt motion as soon as possible.
4. Therapeullc levels Qf con be achie\cd with 0 starting does of60-80 mg
J'l!r kilQgram per doy.
REFERENCES
t S"",,,,,,rd WJW: IlI\d Ft&<w", . B)a<k,,;dt Sc,entific. !91 t
2. T""hdijion MO Onhopa<dic_ PhllJd<tpt>IO. W B Saufkk",. t972.
III
PATIENT 53
:\ 59. yt"ar -old man with a hallu'\
A 59-year-old mall Wilh 3 chief rompl3lm (If pain III hi, nlOhl hi;! [(\e It" the p ... ,[ '\elcral
months. The pam hns be.::omc .... ONe in recent \\t:('ks. lbc roe j, ,off. ,I' " ... 11. and is mO,1
painful early In the morning wh<'n he first The pallcm nu lr"UlllU to hl< bl,!! to!!
The only ttl d:nc over-the-cOUnter ibuprofen, which II,L, \Onlcwh'l helpful I, Ir pain relief.
medical hblory Indudes non-insulin-JcpcnJ ... nt (habele' \,)r 'i Jnd h>penen-
sian. Meui.::l!lons InduJe GlucUlrul.'<L 5 mg une,' a d3y ,mti 2() Illg '''1,'<' .I .L,} \11 .... rgic,in-
clude sulfa r;bl surgical hIstory is unremarkable. The patienl nO! ,mol..c. lI><!S al-
cohol MlCially.
Physical Exa",inut;Q/I : General: well nourished: no oemc Ji,trc" Luv.er <"\Iremlt) bibtcral
IOVoer and fttl: normal cillor. turgor, and IcmpcrJlllfe. hd,'lcr.llly.
Skin: mild cf)'thema and nllnimal edema at IIn.t \Iep jomt Ill" right toOl. n" open Mu..cu-
loskeletal : rmld tendl'me" ut fin.t Mep; considerable kndl'me" lln ROr.1 (If ti"t \K P. on
e'treflll! dorsille,ion; limited ROM On aPl'rO).imJtdy 5 PrOllllllcnl arc.] UI bun ...
hie on doral of first rn ... T:ltarsa! head. Neurologic Jnd (,"Ilng: mlrrnnl btlmt:rall).
Laboratory f'il/di"gs: Rodiogrnph, Imeml-Iargc dOl"'oal :LnJ nlthrill\. ,h,mgc, II uhi."
firM Mep jOint: ontcmpostcflllf l..ee figure) head i1311elleJ. I,"h 10" ut jOlm _p",'c: ,""cuphytic
dmnges nOIt'u :llung of JoiO!. ;11"'1 ray ... leValeJ
What h the mosllikel) cnllse uflhe pallen!", pain .lllhe IlN i\1CP joinl '
11 2
-nlO! patient h:"I) h .. llu\
nn mlliogr'lph. 'ignitKam J"rm '1"1(', n:m'o" ing
.. nd S<lme ,ulxhondr"l .... krO'I' .Ire e\'lJem Jt the
\ICr on the Jors.1l-plant.lr rhe
IUkral projectll,n hr,t mCI.lIM,;al elcyatu>
:UIJ ,mne dor-al ,purnng. lun"i,!!;nt I'ilh j.1l11
nllng nl the J<}int. I'd!.
IlaHux limllU, I' on.: I,f Ihe lIlu.,tl"l'mm('n
t'ncoltntaed In J fX'Ilimrit pTJdilO! It gO!ncr-
ally .1f!"etb trlllhJle-,l)1:e,1 p.ni<::r1b. mId I' more
prcvJlem in men than 1'0111<'11, Some ,'ommon ell-
vl0gits indudc.1 !.)IIg tIN nWtnt,lr-al.
prilllll' cJev.ltu,. trnumn to the )01111. and.1 h)po:r-
mobile hrst r,,) F:Kh ut IhcM: JI-
tt'ret.! medlani,', 01 the juint. l"C,ulUng In the ha>e
01 tilt' protimal ph<tlan, J.umnmf ;lgainq the head
"llhO! liN CUll li llllllU" J.lmmmg "I the
luim ov",r Innc lead, 10 ,h:lru!e, within tht' J"inl ,I,
I'ell u., peri;mH.ul.1r1y
'rhe>e: .m: J!ell<:rall) vl,ible on rolho-
groph ;lnd.1re pl'(')1:[\"""c in IMIUIe. "'1Ih v."fM'mrlg
JOIn! ,l nd ,)mpt,ml' JUlnl ew,iolls
!I.IITO" III$- I" I11Inl. ,LOu c .. pal.lI"-
til'ubr o,toophjl" f"rlTwtLOn. most al"n!!
dl<! dor<;al a,pel! ot the tlN nJoetat:u",11 TIrc on>-Ci of
!ht. prr-<m r:.flcm, ,'{liocide, wnh the
amount 0\ JOint whld h.l, occurn-.J to
point. A" J,)ml d, .. p:ukm
10 dccreU5C weight bearing ut the first
\K"P ./vinL 'omplainl.'i include
bser mctatursJlgia. especially 13terally. hypcrikx-
ion nfthe hallu)l. IP joinl causing box pressure.
and joint (XlIII nt the tirst tllCtulatS:ll-cuneifonnjoint.
COII...erv:tli.'e 1(('3tmem includes altering the
blumcrhanical ubnorm:tlity contributmg 10 the
limited joInt motion. For a first met.1t:lr.;al eleva-
IuS, whkh gcnerJity caused by 11 pes plano lIal-
gll\ dcfllrmity. inWal therapy mvolves an orthOlic
m<oCrt wilh:t lir't-ray cutout to allow plantarllex-
lun of the For more hallux
hmllUs. ol1hot lc ",ith a Monon' s e)l.tension to
limit hrsl joint motion can be helpfUL
When fall 10 rnpond 10 ,'onservati\e
tn:atmcm. some Iype of surgical imer.enlion may
reqUlrt.'d. Proc<,uures 10 correct limi-
lIl,-,rigidus can be cla.sified into Joint-,paring pro-
wdures and jointdesll1lctiYe procedures. 10int-
'pllflng procedures mdude simple cheilectomy to
dean up periarticular o'leophyies (sce figure be-
low). :u, a> mctalaNal and haUucal us-
leolUmie, If Ihe le\cI of JOint adaplilliun i$ 100
grem. Ihcn JomHlestnlctiH' can be
done to pain-free ronge of mOllon at the
til'l>t Mep [)e,tmcti\'C procedures include lilt'
bunlOn.:ctomy. Joint rep!:lccmem cniler
wnh total or hcmi- implanl. and arthrodesis.
'"
Clinical Pearls
I. The laU'raJ radiographic pmjection is critical!) imporm.nL [t Wl1\ fe'ea! a first ray
'" hi ... h caused the h)permobi1ity that allowed Ihe JlImmmg orlhc great The
d""atus can be conceled if surgical illter.enl ion becumes necessary.
2. A dorsitluion , -my helps determine If an isolated dorsal condyle is present
and wIll need 10 be remo\cd. Jamming will continue. and if 10 of mOll on is attained on
dorsitle,ion. then consider n cheikctomy.
REFERENCES
HI FUn<tH>flal hallux Iom'tu>. J Am !'oJ \led.tisOC 76'().I&-652. 19S6
2. ROOI M Abnorm31 and Nom",1 Fu""""" <>, tho: FOOl Los 8 ",m".:1",",", 1'177.
114
PATIENT 54
A 52-year.old womlln with burning pain in her forefoot
A 52-year-old woman of an IIlIcnnittcnl slabbing/burning pain in her right forefOO( . TIle
pain has worSl;n\!d over Ihl! 6 months. and il is nggru\3tcd by her high.heeled shoes.
She any preceding trHuma 10 the area. Attempted treatment with icc and ibuprofen has been un
successful. PaSt medical history is significant fur and gastroesophageal refluJt disease
(GERO), bUllhc pUlient denies any previous bOKk or fOOl Injuries. She is taki ng Topro\ XL and Prilosec.
There arc no known drug She is cmplo)'ed as a and is slightly overweight.
Physieal Examination: General: no acute distress. well developed, well nourished. afebrile, vi-
lal signs stable. Neurologic: nomlal: sensation intact. Pedal pulses: palpable. Skin: mild right forefoot
edema: no open lesions. posuive Tinct's pain on compression of 3rd interspace.
Gmt. mild nt:l\ible pt'"s planus foot type .... ilh adducto ,arus dcfonmty to the -'th and 51h digits billlter-
ally. Manual mus.:le testing: grossly inlact lo ..... er muscles.
Qutstit}n: What is your diagnosis?
115
DiaglllJ!iI: " [m1un',lleuromJ
lJiS('1I5si on: Th..: cundi l lOIl 11-<: now IU as
Morton' neuroma was iI" lUall) tir-:l de<;.:;nbed h)
an English <"hiropodi"l by of Dur!:lI;hl"r
in 11145, T,G, )\ [Ol1on of Philadelphia
cn.'dil in 1876 following h" of a be-
nign eniargelllt'ni 01 Ihe 3rd ,tlmmon dig,wl
brJnch off 11M! medial pllllll,lr ncr".:; loc:llcd be-
ty,cen the Jrd :lmJ -lih mel,lIar',11 head", Today, y,.:
bellcve Ihal Ii'll" repr('scnts a mechaOlcal entmp-
ment neuropath), It j, most foun,' in
lhe 3rt! inler_pace of nbc"e \I omen who \le;IT
point ... d ,h00:"
Pallenb t)pi<::ally wlIh compL!lIlb oj
eomfort from \\'alking on a \I ti nkle in lhelr
Of a lump III lheir shoe. de..crip-
lioo is II "p;i!o\),m:t1 burning ..... WJlh 1111
10 femon' "hoc, Onl)
r.m:ly lhere II 'l!nllOJ) delle'U, <Iud IbuaJl} Ihen:'
a degree of hypere'lhe,ia, pali.:nh"" ill
have palO landoflell hear a did.) .... 1k:11 Ill.? In'olled
web "pac,- is compre,,'>Cd h.;I",'elllhc Ihumh :Inll In-
de, finger "hill" Ihe fordQ(1{ i, ""l1lCC1CJ Thl' h<t!.
become knU\\1I 3S a i\ [ulder's Atkli-
lIon:.Il}, fiD'e radi:lllllg lh"l,dl)
Of pro\imaU) (Vallei, ', I
Tfie differential
:'l1hr;II\, I'relOcrs',
infarction, blll'Oi l is. tarsal tunneL penpfieml Ill"U-
anti Hef'e mot While radio-
graphs an: u'eful 10 rule OUi Olhcr C(\nUillon"
:lntl MRh loan iJcnllfv ,ome neufoma', ultra-
,(llmd the mils! ,<ceurale di(lgno,ue A nor-
mal Inter(\lgllJI Ilcne be :lppw'Hn:llci) 1
'16
mm in Uial11dt'L ""d LI L.i'-u,rlly he,tllllt" \)mpIO-
maliC "hcn 2r .. ,Lter Ih.Ln <; 111111,
,\ J\lorlull', nCllI\UIIJ ".,du,llIy n,lt ,l nCIIWlIla.
and II " nOI a nC"I'I,I,m II I' " lumomlb nodule
f,ee tigure) ("rllled 1;>, pl."I,1 "t' N'Ih
,uuj S.:h .... ann ce)l, I he de::<,ucr,Lll1 e PfL)('C', Ihal
i\ l'har.Jl.'leri7ed tw cIIJ<)lIcurJ! ,lfld
,'pllI,'ural. ,LflJ fl-
hmsi" Jud h}p<'nmph,'
Con,crvalive ,',Irc lIl.:itl.ie, '\I.ler ,hnc., arch
,upports, rncl:unn.dl p"J, ("t1)CI low
J}.: ,1t'app"lg, :Iud ,' .. "I"I11-II\o,I.I ... d PrTh,'Il"',, The
gun1 of blollledl<lllical adjll'lmenr I) 10 \ilml
pront,Iury Olher mdho,h m\'lutle
IIlJ<xlion) with ,lerouJ urdihlk .I', dil'"ht11 I'de-
ulll"-'n,,Il'l.' pro-
"dc, r,'lid lit :11._10', \\1
\\'h,'n l"lm",'n,IlI"C lI""lnWnl LuI-.
l'I'lnu J 7h,9("1 'lI .. ,',-" f,.I,', mo'l.:mn-
111,\[1 nppn,);ll'h i, J"r',11 1,,"o!itIiJill;r1 IIll'l'I"". as
by r.,kke<'h'r In C,reful d",ec-
11"11 ,mJ l11ellulh'tI, hCII1'''I,L'I' arc Im-
i, ,I .k,m U"",,'dl\\n <.'1 Ih,' ncnt' 10
p."lop.:rJIIVe hl.'I1l.l1011l'''' .II,d re,'ulTCnt
"lUmp nellrulll'"
In Ih,' pre"'nt p.,u<!m, JlI<'an, tailed
10 reli ... ,\.' Ih.: ,hi: underv.cnt
.I, dur,;iI ,'uryrimc<lr 1111.'''1011
wa, 1II:lde o,'er ttl<' IhuJ mlt.'r'p".:e, np,,,ing Ihe
neuroma, .... Iudl \<.',1' Ih<;'11 dl' .... deJ IreI.' JIlJ re-
\II{)\c(], PO\lOperJII\C .L",'''lIltlll,H () lIlolllh, re-
'<;,aled a hCillcJ m"I'lIlIl ,Ill.' [1,1 reL.:UITtn!,'e of
pam
Clinical Pearls
L Morton's neuroma is an entrapmt:nt neuropathy. The Iypical patient is an Over-
weight female in high-heeled shoes
2. Patients complain of Ii paroxysmal burning sensation.
3. Mulder's sign is an important diagnostic aid.
4. Ultrasonagraphy IS the most convenient, mosl accuralC. and least expc:nsivc diag-
nostic ttst.
5. Histopathology is consistent with perineural fibrosis.
6. Neuromas are always located distal to the rnelDlarsal heads.
REFERENCES
Miller S Monon', ncu""",,' A syr.dromc. In EO. elOOks AS. u.".ncy M5 le,hl . C",nprt:hr..,,,. T."book of
fool Surv'Y. 2nd cd. Williams and W,lkin., 1992.
2. Wu K MOI'IOI'I" in'<I'diZ".o.l ncUR)mI.; A clinICal ... ,;. .... of III etIOlogy. U '"",nl. WId ""uh. J 1'"", A"l.Ie Surg
112-119,1996.
117
PATIENT 55
A lIl an \\ it h a ... flalll' ncd font ancr a minor fall
A 4O-)o:;u--old mdrl toJ the elllerge",:y dep,lflmenllEOl after foiling off a stool and m
juring his Id\ foot. lnallnnc ",dl'ma and a superficial abrasion on the
dorsomellial of lhe Idl (,\(!I. Till' pnticm c\hibitcd paill on palpation of Ihe medial metatarsal
area; the: pain ... cu,:crnatcJ by <lmbul:lliun. l'eT1inc!1l medical history was sig-
nificant unly for a lung I)f in,ulin.kpcmklll I11clliIU<;. 1\lclilcalm:l.nagcmcm of his di-
included 60 01 HUfllulin in,uli n in the morning aud 40 \LIlliS illlh.:: c\'cning.1be patient re-
hued thai he \las Olllcrgil- [0 Kcrlc'l ami \lCO!ll),-111 \ 1131 "crc 'Iablc. and the ncurQva.<iCular status
was intact to both f('ct,
At that time. x-r>lys "'efe negmil e fur I r:kture ,)Ild di,k"'::llion, nnd the patient .... diagnosed as
haVing a of h" 1.'1\ foot I"re:nmcnt ,'.In,i-tcd vt the .. and dispens-
ing a 4-mt'h ACE bandage. [n'tru .. "!'r<.' tor R[CE th .. 'rJp). ",cight-ocarlng as to[erated. and follow-
up with hisloca] mcdkJl doct,'f
One .... eek Imrr. the patient returned to tt,... [D cornplaming of pain and swelling. Upon
physical examinatiun he 'tated Ih;!! h<.' h,ld fCIl1Jufn[ the ,:lIlIe tOOt rarlier fhnt d:ly :ll1d felt "bones
mtl\e" In fuol The [eft iuot "'il\ for amI do]"';aHy. with pain on pa[-
putlon of the medi:l[ pl.lnt:lf [ongIHhJin.li M .. h rhe Jhra,i<'II W(l' he;Iling. and there v.ere no of in-
fection. ,tatm rern'Hned Illt,u:1 to hoth f .. Another -.ct of foot was obtained
and comp:lred to the "hl .. h relea[cJ n" .hange. a diagno,is of
the left fOOl was nl:'lde. Th.: I',lll.:nt 1U rCnl:lin non-v.eight-bcaring on tl!.! left foot and
was glvcn an to 'Iuh the onhopelhn The onhoptdist casted the
limb for 6 rlon-wt'ight-tx-aring.
Ten months the fClumell with a dcronn.lIlon of his Icft foot involving a prominent
bump and build-up 01 on the pl'"llar The p:lticllt ",eight-bearing in an anklc-
foot onhosis. bUI complained ,,( p:llll hv the enll 01 the day and an inability \0 ambulate comfonably.
PhY5ical t:.ramiIlUfillll: SkilL ,wdling. t'rythcm:t Tl' mpcrature: inrfeaM!d from midfOOI to [:If-
soroctatarsal area. ImaLl: ho"'ever. dimInished response. Ped:ll pulses:
strong and bilateral!) ,) mnlctrical. GaH fordOnt abdu .. ted upon rearfool. with depression of medial
longitudinal arch. large. medial. hony plUmbera",;e.
taboraliJry Radingr.! ph, (newI: marked cteMruction al Li<franc's aniculation frag-
me"t:ltion. including di'llHcgralion Jnd OSh!oJ},'*: rncdi:ll cuneiform di,loc:ned from media! column
(llI'C hgul\'s/. Technetium OJ9 and lllJlum I II ,[uJles: both posltile. 'iO infection could not be ruled out.
Culture and sensitivity: Gram \tain: negati\t: P:uhology: benign bone ",ith fibrous marrow,
increased osteobla,llc actIVit), few mononucte:lr inflornmat0l) and surmundiug den>c fibrous tis-
sue: no evidence of o\1<"'1)[!I}cliu,
11 8
11 9
Diagnosis; Charcot joint
Discussjun; Joint IS the loc<l-
lion of Charcot in <l patient that is not
excessively pron<lted and has a stable midt:m.al
Joint. Patients that are pathologically pronated in
<lance tend to suffer breakdown within and around
Chopart's joint The breakdown can start '" nh an
cpisode of macrotrauma or repetitive mkrotrJuma
across the joints. A prim<lry ur secorltlnry l"Ontrac-
ture of the tendo-achilles. '" hich limits the dOl"1ii-
flexion of thc fOOl on Ihe ankle. is seen.
Since dorsiflexion cannOI occur at tfl.! ankl e. the
midtarsal joint Slaru. to dorsJ!!ex. This IS the mi
crotrauma that oc.:urs .." ithin the diabt:w;: patiem.
and the entire foot starts to pronate and collapse.
The clinical appear-mee of Ihe Charcot foot 111-
lohes and abduction al Lisfranc's or
Chopart 's The dorsiflexion component
onginates from the ,tress of push off durtng am-
bulation. and is exaggerated in the smhent who
extremely pronated m A dbunet patho-
physiologic characteristic in Charcot is
tion of the plantar hgamems and atroph} of the
plantar mus(ulature. This means that the
Windlass action of Hi cks not functioning prop-
erly. and til.:: plantar tension banding effe(t which
produces stability within the tarsal joints is not
pre.ent. The of this important
gft1und reacti\e 10
dOr.lillex the forefoot during propulsion.
One notable poInt U1 rcgarUto Lt sfranc's break-
down IS the olxiucllon of the fon-foot on the
fOOl. This author beliews that the pull of tile per-
oneus longus amJ peroneus brevis is mainly
responsible for til.:: abductIOn. Once the breakdo.."n
begins. the hr;t ray a uon.iflext'tl po5ition.
and the action of the peronem. longusehanges from
plantarflexion and evt:f"ion to abduclton.
Although the peroneus longus b responsible
for some oftht: abduct ton in the Charcot foo\. it is
the pull of the that provides the
force. nle brevis insens
distal to the breakdown and is unopposed In its ab-
duelion pull. The tibiJlis :mterior al,o has its in-
'\Crtion di';(al to the Lisfrane breakdown. bUI has
lin!.: abduclOry force at this level to oppose the
The po'lerior has some
that di,tal to the breakdown. but
largcly tt tnserts into the na\icular and acts as a
of the ,nidlars:tl Jotn!. Therefore. the
continuous unopposed pull oflhe peroneus longus
,Iud peroneu, mUS4.le, is the main defom-
ing force respon'lble for the abducllon (If the fore-
foot on the rearfOOI. to the patient'" ith Ii Charcot
at Jomt.
The pathogenesis of the neurop;l1hie Joint has
bt:t>n dcb3ted it I!r;t described. It is be-
to be Ii combination of ...evaal factors: (I)
the of neurologic proleCtl'c (2)
secondary to nuto-
nomic neuropathy. and ()) 'Ire,s applied to the
",ealened bone wmlUnding JOln!S. productOg
trnclUres an.! Iniliattng the Charcut process.
In the prc-.ent pallen!. eOl1scn ;UI\C control by
imrnohili7ntion to allo..,, the ;lc!ive to reduce
fOr:l .,hon pcrio(L long-term im-
!1lnhlitl-:ltion wa, un.!ertaken via 0 medial column
fu,ion. 3nd the, smllent was given an orthosis post-
operathcly
Clinical Pearls
I . The Im!ial concem- rcg3rdless of tre;ltrncnt- must be to nrle Ollt
2. It is imperative to allow the acutc-ph::r..-e Chare(lt joint to calm down. !O prc,,:nt
further dllmage 10 the lI1volveu jomts.
J. Realignment of soft :'nu further brcAdo.." n
4. Realignment of the forefoot-torearloot decrease, Ihe of a
return ofCharcotlhangcs.
REFERENCES
B.n'" AS. McGl:unry IoD D,.m.lIc "nd D,.d>ell<. CbarM F"", R<con" !(ld,(>n Re' (I""ruL""" Su,<,,, 01 lhor fou, and UII.
lIpd.'le 89 Allanl.1. GA. Pod,alry tnSlllu"".
P T.IOII.lv'c'utd' .1\11 II,KlfOOI a,rhmr.!b) on """rop;Ilh" d,,,t-,,t," I,V Ct.n On ... '!' 21t;. t 98'1
120
PATIENT 56
A 14-Yl'll r-old hoy with Ilcrsislcnt pain in his knee
A 14-)car-old boy wllh pain In right knt:t:. He Ix!cn e1(pcriencing the pain for 3
months. and it not improved With rest or dcv:ttion. ! Ie plays basl etbilll every afternoon. and when
the game is completed Ih.:: pain excro.:i:.umg. Be doe, 111)1 lnJllnng Ihts knee and denies
any histor} of high fevers thiS )car.
Ph)'sica/ EJ:Ulllilllllioll: PHlpatiun: pmxlmal a,peet of right leg lnd quite tender. Mus-
culosl.detal; jOlllt nonnal ROM compared to sIde: no pain on mOllon: aeuve extension
of Tighlteg diftkuh. with in hamstring'; full clltcnsion could nOt be maintained when leg ac-
tively McMurray and L:lchl1lan i<:<;\S and patella tracking negative.
l..llboratory f'indi//gs: ,oft tissue )wdling ant.: rior to the tibial tuberosity, with
fragment ation of tibial \ub...'rck (Me ftgun:). MRI: inert:;l'l:d signal in bursa.
QllesliQ//.. What dis.:as.: is affelling this apophy)is7
121
Di$C'U$sioll : A mrnmon condition of
Schlancr's 1.11><.':1:'<: i, JII 01 the hblnl
tuberosity. It bellcled to be the \Jf mi-
croavulslonscaused by relX'atcd trae!lOI1 on the an
terior portion of the de\eloping
of the tibml tubcro,l1y. Inflanun:.tioll .. nd
the: cau...e pilln. ,v.elling. and
Osgood-Schlatter's IS r.:fcmd to as o.'teocholl
dmsis. but a\ascular ncero,is '>C('m, sinn'
the blood supply in the prescnt patient is I'xco:lleill.
It is an syndrome thJt o,:curs bt't\\L"t:n 9
and 15 )CUTS of age lhe
adolc!i(:cnt apophYSI\ of the proximal tibia I p.lrtic-
ularly in young athlete',) and is more commonly
seen in boys than girls 13: I) The'Te a frequent
lOry of re]kllihe runnmg .1111.1 Jumping that ini tiates
Ihe proce", P.lln ;lIld ,v.elhn!! over the tibial tuber-
de i\ diagn<hti.: ot the dl...ea"c, The characteri stic
phYMe:!1 timJmg I, a may be
erythema wrroundlng the "".olkn libial luberele.
X-ray, enn be c0nhnllJlory. but seldom diag-
nmtic. All children of thiS age group usually have
fragmcnl<.lllon on 'It-my of lhe IIbial tuberosi ty.
The fragments OCl,t,ionally do not uni te. causing
a '<"p:mue to remain Into Jdulthood. These
may be requiri ng removal ,
In tile palien!. trealment consisted of
rc,t ,md Ji from ,trenuolls activity. A cylin-
der ,,",b fmm Ihe ankle to the thigh in

Clinical Pearls
1. Conscn!uiw treatmenl for ... puph)'ltl.'> pannmlulH. Ix'.:ml\c 90'1 of re-
wllh the only
2. Never JII1IlI any Iype of in Ihi< di,onler: contraindic:llcd .
. AI\\ mainlam the 01 the I<"mlon. but d.) nOt 0' cr 'Ires, Ihe ten-
don. The child sholiid refrain fmm all flgorou, ,,,:tivlly,
REFERENCES
t<r.w ... BL. d aI h"I"'" <If ,1<,.-" .... J ""hatrOnh,,,, lIJh.'I. I'IQO,
2 UM. d .1. (}o,,go<lol, ,1< ....... In .I<lolc"","nl .\n, J Spun, J..I<J I.>! 41:2.J.6.
D!ldrn lA . l al' O<iw.l,s.,hlJ"""-' Ji ....... Jo .. iopm<nl Cion Orth"p 11(' 110:0. 1976
122
PATIENT 57
A 27-l11onth-olcl girl "ho is unabl e 10 walk
A 27-month-old girl is cvalU:lled (or an m'lbilil), [0 \\,all(. The l:hlld JUSt WTivcd from an eastern
European country after being adopted by an American couplc:. Very liul\! prcn:U:1I history is available.
Olher than that the child was premature. The eXacll!,I.'Slaliol1;l1 age 11> unknown.
Physical ExaminoliOlI.' Genel'lll: lo .... o:r 10% fl)r height and weight. Gail: nOI w(tlki"g.
loskeletal : delayed motor fum:lions: legs severely hee li!!lIfC). dcla)'ed men!;j] fune-
lions.
lAboratory Findings: Radiogmphs: mchltlc changes of femoral epiph)scaJ line; epiphysis
widened: severe angular bowing of tibia evident on and 1>aggi tal planes. Alkaline phosphotnsc::
mildly increased.
Qutstion: Whal vitamin deficiency is present m this
l23
J)jagnosis; Vitamin 0 is Udicie"!.
Discussion: Children with dietary rickets
rickets) are nommlly
secn bet\\een 6 months and 3 years of age. [nci
dence of dietary rickets increases wi th prematu+
rit). Rickcb In\o!\es insufticient intake of vita
min 0 and inadequate eJlpmure to sunlight. It is a
very ran- finding In the United States. Children
who are on anticonvul sive medications have to be
oosel"\ed for simple dietary rickets.
The clinical features of dietary rickets ure mus
cular .... and lethargy. The present palient
has a prombcr.J.nt abdomen. Walking and standing
are usually dela)ed because support is
insufficient; the child will experience stress frac
tures III and about the mcmphyseal-epiphyseal
junctions. l1\e smooth metaphyseal-epiphyseal
junction is distorted and bulbous because of the
failure of the orderly endochondral bone se-
quence. Additionally. the ankles. knees. and
wrists are thickened.
The treatment of vitamin D-deficienl rickets is
simple vi tamin D. which can be obtained in forti-
fied milk. The recommended dosage is 2000 to
5000 international uni ts for 6-12 weeks. If this
fails. the problem is not vi tamin-sensitive rickets.
bul renal tubular insufficiency or renal refractory
rickets.
In the present patient with dietary rickets. sim
pIe treatment with fortified vitamin 0 milk reo
versed the process.
Clinical Pearls
I. Bo .... ing of the legs is lhe characteristic finding in rickets.
2. 1llc: diagnosis is predominately made by metabolic al)d clil)ical changes.
3. Radiographic findings vary in rickets and an: not reliable for diagnosis.
[n .tli foons of ncket s. therapy mllst be started first before consideration of brac
mg ur surgery 10 correCI the structural problems.
REFERENCE
AE Pedi,trk Imaginll DiDgllOilric Radioloay IIf tnflllts and 2nd ed. 1Iostoo. (Jr
8m"n. 19Q1 . PI' 11>3-410
'24
PATIENT 58
A 12-year-old boy with a painrul and swollen ankle
A boy wilh a of pain and sl\clling of his right ankle. The pain first be-
gan '" hen he rt!lumed [0 M;hwt after hh \'aculion in New Englund. He has no oflrauma.
other dlun a "normal" ache he feels in his ankle after he runs. His mother noticed that the ankle would
occa-.iona1!) I1e red and and it did nOl respond to nonsteroidal anti-inflammatory drugs
I icc. or dc\ ,Illon. The child has no hIstory of fevers, ChIlls, or rashes.
PhYJ' i cal f. :comi ll(lII'(JI/: General : ankle moderately swollen: no local swelling in groin or
popliteal areas: no other joint ,>wclling or pain. Gail: antalgic. Musculoskeletal: ROM of an!';le limited
in dorsiflexlolliplanturflc,ion a" "ell as inverSIOn/eversion. He had
LaboralQry Findings: R3dlogmphs (righl ;\nkle): increased sofltissue s .... elling, consistent with
joint effUSion, no wny Aspiration: tluid ELISA tilre for Lyme disease:
I :640. blot: poSIIII'c.
Questions: What is the What is the relevance of the serologic t<:Sling'!
125
VilC'USlioll: 1I mUlh"),km infcell\,n
.-ausrJ by Ihe 'p!ro.;hele, Borre/HI
and b} It\c deer lick, The IUle,
Infeelion hlage 3) of L)'lllC is
quile m It i>
mono<U1iculOir amlusuully Ihe larger
The jOlm Iypically ,md !lO1
consislem wilh Ihe amounl of pain,
ELISA b the rnO)1 nmlnlon!} .'l1lplo}cd m
Ihe diugnosi, of I.) l11e di...:use, The
the JnltboJics IlgG lind IgM) of the
and Icry 'ien.,i l i,,, m the laler 'tJge of .mhrilic
Involvement. II is nOi "<!Iblliv;:, in the eari) '1ag.e",
wLih an IIlCn!OIse In fol,c po_"tivcs; for this reoson
a ... m biOI uloed 10 lontirm,
In the pMlcnt. mlm-anu:ular '<Icroids
nnd 'H're giH'n 10 Ihe ani<:ular in-
tbmmulOry response. The P:III.:nt W>!S on
du'\:)(yc1inc 100 mg AID tor JO dJY,. Jnd an EKG
obt:unctl 10 rule out c:lrdiac .. bnormahties.
Clinical Pearls
,truclion,
2. The dlfteTCIIII;d ,lIagllo,,, ,hllUIJ IIlduJe ,,-,pll .. .l{lhntl", JIII'em!.: rheum,Hun!
IlI1hnl", OIOJ reactive Jnhmh (eg., toxic- 'Ylloviu" Reiler'" ,yndrome).
J. Se,crilY of Joml l'ffusion and pain can wax :md ",lIle for St'vcral months. When rbert:
hl"o!) (If jQit'l\ p,lIn ,,"J no rrJUI11;t, rule OUI Lyme with <.crologic tc .. rmg.
REFERENCES
1',..,.,]: t ("u" Op," IU.tUn",I,,1 '11\ t'l'l3
2 I.M. RI, JV Onn..pao:Jl. on"",lr,LlIitJn, "r Lymt ,I,,,,,,,.., Onhop Re v lQ'I-.iI_I, t'l'>.l
j K"h,h R Rf><um [)"("h,, Am 1'lI1r:1'l<l--4!Il, 1""1
L.. .... \" I""'ml". \)nI01l I <III J tilt t \ \5, t'J'l,
126
PATIENT 59
A 17-year -old hoy uil h a red. toe
A 17-year-old boy prcsenh wIth and s\\elling of the lateral nnil border of his hallux. These
symptoms aTOllC about J month ago. He has a history of multiple mfccl ions Oflhls hallux border, and
his primary care ph}sician has prescribed muillple cour'\Cs of ant ibiotic: [hempy. The patienl"s hallux
would impro\c during the course of lrcatmem. but would flare up again aftcr II few weeks.
Physical E;romilrolion: TempcrnlUre 97_9' F: pulse 62: rc_'pir::uions 15: blood pressure 98169.
Skin: cr)thcm:uous. edemdlous later:!1 border II. tth sloughing at periphery of other-
lI.'ise normal. HEENT: nomm1. clear. Cardiac: nonnaL Abdomen: nonleoder Lower extremity:
palpable DP arId IT pulses: diffuse \CIlUerneS!i, proud flesh, erythema, edema, and purulent drainage
on hallull media! nULl border (!;Cc figure).
lAboratory Findin/:s: WBe SOOOlfLJ. 16.7. H.: t 36.9: platelets J{)O.OOO/ILI. UrinalySiS: nor-
mal.
Question: What is the diagnoslS';t
127
Diagnosis: Ingrown toenail with bactcrilll infCClion
J);scussiQlI : Paronychia IS uelined IlS influm-
Illation of nail boruers. The inflammation is
causeu by a portion of the nail implantil1g Itself
iuto the soft tissues of the nail border a;, the nail
grows. The offending portion may arise from im-
proper trimming of the nails or from tr.l.uma.
spicule of nail caUM;S a foreign body reaction and
an mflammatory response. anu the llrea can be-
come seconuanly infected by bacteria.
The bacteria thai invade the area usually infect
the tissuc r . .1Iher than the nlli! plate.
The most common orgllnisms from In-
fected tissues are Staphylococcus.
Streptococcus. cIJli. Pseudomonas.
and Proteus. P.>eudomonas is capable of infecting
the nail plate and causing a blue-green discol-
oration called a pyocyanill.
When evaluati ng a patient wllh an apparent
paronychia II is important 10 rule out OIher enti-
ties. should be taken to aid in diagnosis.
Osk'Qm)'clitis can occur from II puocturc .... ouod.
chronic paronychia. or UlcerJlion. ;md can present
as a simple paronychia that wa:o;es and wanes with
anllbiotie therapy. Subungal ewstosis can also
mimic a recurrent paronychia secondary to pres-
sure abnOnnlllities: it be treilted appropri-
ately with surgical c:o;eblon or increas...'l.!-dcpth
,hues. BOlh benign and malignant are
often mistaken for parony,hias. Sume common
tumors that can be misdiagnosed arc osteochon-
droma. melanoma. cell carcinoma. ver-
ruca. acquired digitallibrokeratoma. periunglll ft-
hroma. myxoid cyst. and pyogenic granuloma.
Clinical e:O;llminmion and history arc im-
portant III making the proper diagnosis. Labora-
tory are usually not indicnted bcclllise
lemlc is rare. Culture and sensitivities
,hould be taken if drainage is present: ho""e\er.
most pawnychias dear before cul ture results are
rewmcd. [ftumor is suspected. a biopsy soould be
perfonned.
The guld standard for treatment uf a paronychia
is 10 remo\e the offending border of nail. Until this
portion of the nail is remo\oo. the problem will oot
resohe. Antibiotics should be iniliUloo if the pa-
tient has systemic in\ol\"emem or extenshe cel-
lulitis. or is immunocompmmised. If hypertrophic
b prescnt. exr.:bioll or nill-:tlc Can be
used to remove gr .. lIIulation tls"ue Some
lhut a V l"ut into thedistaJ tipofthe nail can be USl'U
10 in the comers. but lhis author
has not seen ..... ith treatment .
Clinical Pearls
I. Paronychia can develop from Improper oail dipping. trauma from
pronallon. or improper shoe gear.
2. Other etiologies must be ruled out by :o;-r .. y or biOpsy.
3. The gold standard of treatment IS to remove the offending mul spicule.
4. Antibiutics are nO{ necessary in cases of cell ulit is. immune <;ys-
tent nonresponse to previous thcmpy. or sysfemic in,ohelllc-nt.
REFERENCES
l. Borhn SJ A I"bonlll)<)' rt".", of 61.000 fOOl lumorS and 10SIOOI . J Am Pod As>OC" 74 3-11 _]47. 198-4
Gunnnt RE: uflhe: na,ls: How 10 =ugnll< and 1I"'-'31lhtm. ""'Igrad M("d 1-1. 357 :162. t98.1
128
PATIENT 60
A -'I -year -old woman with a darkened and painrul toe
A .j I-year-old "oman presents .... nh paUl in the dhlai aspect of her right second [01,: for severnl
da)'s. She is <'ccondarily conccmcd about darkening and discolor..!I;O" of the digit at the m.>dial aspect
ofrhe nail fold. The patient denies any tmuma!O the area. Symptoms are nOI aggravated by
walking. weight bearing, or any par1icular shoe gel1f. However. she docs relate thaI her current com-
plaint 10 correspond to the change in the we;tther ami is particularl y symptomatic with cold
wcathcr. She has reccivoo no tremment for this condi tion. Previously_ a purtill] second-digit amputa-
tion was pcrfonncd on Ihe plllicnt's left fool. lind multiple digital amputations were performed on her
bilalcml tmods.
Physical Examination: HEENT: nonnal. Chest: dear. Cardiac: regular. Abdomen: nomender.
{..awI'r rHr .. miry- Pulses: dorsnlis pedis and posterior tibial 2/4 bilatcrally. Vascular: immediate cap-
Illary rdill [0 digits. T gradient : nonnal proximal to distal cooling of leg to digits. Skin: no
ecchymosis or .:dema of right Sd."Ond digit or foot; mild darkening! discolorntion of distal aspect of
right second digit. hut no healed left 2nd digi t incision site. Neurologic: epicri tic sen:.ation
inlact. mOlar function of extremi ty/foot ;OI.:lCt, no onhopcdic defonnily. Up-
Jlt'r eflrfmiry- Partial :lmputatiQn of digits z. 4. and 5 of right hand. and of thumb and 2-5 of
left hand at proximal and di stal iotcrphalangeal joints.
Laboratory Findillgs: CBC with diffcntial: noma!. Chemistry profile:: nonnal. Radiographs:
Righl joot-panial second-digll amputation; no bony regrowth at remaining ponlon of proximal pha-
lanx; mild diffu:.c usteo(X'nia: no vascularealcifications. Lt1tjoo/- Mild diffuse: oste:op.!nia. no osseous
JXlthology of 2nd digit or foot; no vascular calcitication: 10illl space of 2nd interphalangeal joints con-
gruous and without con[rJctuTC \lr dcfonni ty.
QllI'stion: What is caus<: uflhe patient's symptoms in her right second digit and the multiple dig-
lIa1 amputations?
129
I>ingnosis: di".;a...:
Discussion; di".;a,,: an idio
patllic. symmetrical. and bilatcrul eontrm:-tion or
spasm of the -"mall arteries or of the dig
us of the hand and til<- foot. The etiology 10
be an extreme to C'old temperatures, An
unack can also occur as a re>uh of an emotional
respon.!rC' or e.cnt. ahhough this is rare, The pri
mary lreatment for the a!tack or condition
wanning of the cl trcmity,
lbediagnosisof is mal.!c from the pa.
tient's history-particul;u-Iy the response to tern
perature changes- anI.! ph) "cal euminallon.lbe
chnician keep in minI.! a few key points .... hen
conSidering Ra)l1<md's as a di".;ase entity. orcauS<!
of local gangrene or infection to a digit.11te disea>e
IS more pre. alent in females; it prllllHrily affects
those aged 14-40: and It lII.ol;e, both Ilk:
hands and the feet. bamllle both the! upper and
lowerememities. and look forcolorchunges in the
digits. lbe color changes can go from white to blue
to red. depenJing 011 tlk: of tile attack, and are
typically accomp;lnicd by paill,
If gangrene or infection III as a resul t of the
di'iCase. it must be Ifl:ated accordingly. A local
mfection may be treatcd with debride-
mem and amibiotics. A partial or complete digital
;Imputatioll may be necessary 10 properly treat
gangrene or osteom)eli ll s,
The pres.::nt pallent had Immediately wanne<!
her ell.lTemity when she felt the onset of symp
toms. and as a result her 3ttack .... as reversible. The
pam III her digit wa;. slow!y resolvillg, and
the color ch;lIlge was likely related to previ
ous atl3cks. Gangrene did not \Ct in: therefore,
mtef\"cntion andlor ampumtiOIl was not
The pallent was remmded of the need
to avoid cold water and cold temperJlUres to pre
vent anOlher anack or forther ampUlation.
Clinical Pearls
I. Digital in n patient With Ruynnlld's may be nonnal or dimmished
depending on the tcmpcrJture of the room when the noninvasi.c vas.::ular test is per
fonned
2. Gangrene of a digit rna) occur in the of nonnal arterial pulses.
3. am'cls Ihe digit, of the hand more commonly than Ille feel, and the ill-
\'olvement is usually bilateral and
4. Raynaud's primarily occurs because of a local sensi ti vity of the digital to
cold. Rarely, it tan occur as 3 result of emotional arousal.
5. Pallor I .... hlte). cyallosis (blue), and reactive hyperemia (red) are the typical colors
secn in the digits upon all aCUle Raynaud's attack and ,uhsequcnt resolution or reo
wanmng of the extremity.
REFERENCE
Creagr. MA, D,.U \ I V.><ul ... d"'<"a'>CS "r thr tn (. ",Ibaehr. K, Hfdun".IJ E. W,I",," I. al (.d'i l1>m"",' ,
Pn""'plo> of 1 .. ,em.1 \1 .. '11"" .... 1.\lh W. N ... , Y",k MeG ..... 10(". , 1Q9.t. PI' 11,$-114'
130
PATIENT 61
An 86-yt:ar-old man .... ilh chroni c rool pain
Anli6-}c:lr-<.)ld man prc,,ntcd ",llh.1 6-mOllth of right f01l1 pain Pain was present only
.... illl .... eight t-cJTmg. hllll III dio;comin\lc .... nll..ing. he had walked 2.5 miles daily.
His past remarkable only for If<::lICd WIth ;1 dlltrelic. He lIad undergone
of the left fooL bUI uellied trauma \0 til.: nght foot.
' >lIy.rical rxulII; llill!rm: Tcrnpcr:"lurc 97$ . pul.,.: SO. respiration, IS. blooJ pressure 160.90. Skin:
normal. L}rnph 110nnal. HEENT: alhcrt),.:icTU!I. 1\'lll1al vJ'CUlahll<:. nu bruit
dear. H,'an: normal. Abdomen: nonnal. Neurologic: d,,':crc:ls..."d ,cll':lliull!O lighllouch. pinprkk and
1hennal ..en,allun bduw the knee,. rnarl:<.-uly joint po'ilion ... n,c in th .... toes. nomlal in the
/tngeN. ahsent anlle j .... rh. l\.' lu!>Culo.kelelaJ: "'armth and over dOrloum 01 right miJtOot with
colJnp....:d plJnmr JRh and nonnal mOllon
LUMmltJryfi" dillgs: \\oBC 1I.0001}LL; Het 415'1:; Na - 140 mmoll L; K'
J 5 mmoil l.; CI 98 mmoll L CO, J2 mmol/l; BUN 28 mgldL: glucuM: 139 mgidl; crt'nlinine [.J
rng.dL; 9." mgldL. S> novial tluid }cl1ow. cloudy; WBe ! I cell:,./IJ.L '" ilh 3Yt neu-
lrophlb. 7
1
; 60ft ma.;rophag .... s; glucose 90 mgldL: i.1ratc and CPI 'O l'r) <Ials STS:
Foot mdiograph: h .... ;lled at of 2nd metatarsal, '" Ilh .. of old
lnu changes l11"ul"l11 Ihe tarsal bones. T cchnelium MDP bone !>Can
I,hll'" n incre:lscd acTi\ iTy on flov.. inuncdlme and dda)'c:d images uf right foot.
131
Diagnosis: Diabetic neurOilnhropathy \Charcot jOint).
Discussion: Charcot described the association
of c('nain anhropathies wIth neurologic dls-
ca!ies- primarily tabes dorsalis - and the term
"Charcot join!'" now applied to most articular
abnormalities related to neurologic deficits. The
terms neuroanhropathy and neutrophlc and neu-
ropathic joint disease are synonymous with Char-
<;01 joint. Neuropathy leads to loss of protecthc
:.ensations of pain and proprioception which. in
tum. lead to le<;urrcntjoint injury. ma!alignment.
and progressive degeneration of the articulation.
Lesions of the central or peripheral ne1"\-'OUS sys-
tems can lead to neuroorthropathy. Eltamples Ln-
dude s)philis \tabes dorsalis). syringomyelia.
memngomyelocele. traulnatic spine lesions. Charcot-
Marie-Tooth disease. diabetes mellitus. alcohol-
ism. Pl'miclUtlS anemia, and mtra-anu;ular ud-
mmistration of steroids. The distribution of the
anicular involvement varies among the neurologiC
disortkrs and may be: a clue to diagnOSiS. Tabes
dorsalis. complicated by neuraarthropathy in 5 to
10% Cil.'ieS. m(bt commonly involves the knee. hip.
anlde. or spine. Syringomyctia affccts the shoul-
lIer. elOOw. wrist. or spine. Alcoholism affects the
foot and Toes.
Diabetes mellitus is now a more frequent cause
of neurolli1hropathy than is syphilis. Neuroarthro-
pillhy has been nOled rn 1l.15% of hospitahzed di-
abetic patients, but the troe incidence may be
greater. Typically. diabetic neuroarthropathy oc-
curs in the pallent with long-standing diabetes
mellitus. Occasionally. as in the present case. neu
roanhropathy may be the initial clinical mamfes
tatton of diabetes melliTUS. The joints in the fore-
fOOl and midfoot are most commonly affected.
although the ankle. knee. spine. and joints of the
'"
upper extremities ..rls.o be affected. Osseous
fragmentJtion. <;c lero<.b arK! ordisloca-
tion Oct:ur in the orUlJ'.Omct:ltarsaljoinlS.
The radiographiC linumg.-. in the fOOl may re.-.ctnble
an acute Lisfr.!IIcs fr..rclUll,"-dblocation !II which
fracture Of the base of the Inctat;m;als Gnd- 5th/ and
cuboid is associated "'ith lateral di.,locntion of the
2nd through 5th metat:lr>al bont's. Scintigraphy
"'lIh boneseeking lln.'a, of in-
ncaso..-d accumulation of tho: ra<.lionudide.
Bony eburnation. fmcTure. and
joint disorgani7.atlon are more profound in lleU-
roarthrop3thy than In any other anhropathy. E.1rly
cases may Calcium p)ro-
phosphate dihydmtc crystal deposition (CPPD)
di.-.ca"e can ncuroanhropathy. or may co-
elllst .... Ith ncuroanhrupilth) . Similar dc,tructl\"e
changes may occur in the shouluer with calcium
hydrmyapatite cl)stal dcpo,ition. Osteomyelitis.
particullirly in the di:1betic foot. rna) mimic or be
superimposed on a ncuroarthropmhy. An Illindlum_
labeled .... hitc blood cell ,can rna} help differenTi-
!Lte infeded from rapldl} progressive

Treatment includes di'-Ccm1ng the underlying
cause of neuropathy. Diabetic neufO.1rthropathy
of the foot may respond to total-comact cust
or brace. Some case, !mpro,c .... lIh
those that faLl may require amputation.
In the present case. a diasnosis of dLabelic foot
neuruarthropathy was bast'(l on the presence of dis-
tal sensory neuropathy. hyperglycemia. artd char
attensTic r..rdiogr..rphic and scintigmphic changes.
The patient had only a partial response to J. molded
orthotic Insen and mcdical management of the di
abetes mellitus.
Clinical Pearls
I. Neuroanhropalhy. or Charcotjoinl. may occur in a,socimion with a \'llficty of cen-
tral or peripheml ncnOLlS diseases.
2. Tabes dorsalis. once the most frequent caus..: of ncuroarthropathy. general!) af-
fects the kllt:c. hip. :mk1e or spine.
J. Diabetes mellitus.s now the most frcqllcm ulll.krlymg cause of ncurl';,nhrupalhy.
usually affecting the Joints of the forefoot and ,mdfoot.
4. Neuroanhropathy is occasionall y the initial clinicalll1unifc,t:uion of diaOCIC, md-
lilliS.
S. Consider the diagnosis III the pallen! .... il h neuropathy 311d radiogmph,
showi ng osseous fragmentation. ,.;Icrosis. sublux;uj'LII. or dislocati on with Joim disor-
ganization.
REFERENCES
R.,;n .. k D Noumanh"-'l'"lhy. In. R.,n",k D. N"".)am& G Ictl,j. N B,",. JOIn, f'1"1a.klph .... WB
S.undt.,; 1988. pp J I SoI-J 187
2. ['''1'"1. M. Girard P "'Ih unhrod<,;'. in Inl"-J<I.bk d.,,,",uc " t Ihe ",,-,..00
J Bone: JI)ln' Sur, (Am) 199),
3 LM, Mlli4cn OR. Bhddol H Cboir<<Ii unhropalhy a, "" unu,,,,,) in;II.1 '" d,,,I>c'," _Iht", Sr I
Rbeunu'QII99J;
4 M)'crson MS. H.II<k,""", MR. SubyT. Sn.on KW 1-bn"gr"",nlofm..JfOOl d'al>clk. otumanh"'I'_lh, Int 1'N4.
233--241
5 W Tbt oturOl"'lhK" jO)lRl. Clin E, p Rheum3101 19'1-1. ;)7,
6 s",hau",k., DS. D,ff<",nIl8Iion 1>1 ,nf'"led from nI""nfo<lcd rop,dly l""t'."'>C 1"'10:1 \1.:.1
)99.'i;
133
PATIENT 62
.\ 1O-)tllroohJ 00) with a p;linful,s\\ullen fool
A iO-)'ear-olJ boy l'ome\ ttl 'he lIepa)'1mcnt of pnm and of 10-
day duraTion In hi, right foot .""buut ' .... 0 ago he a puncture wound \0 this foot while
weanng T .... o dap Imer he nlltctlpllin amI s\\.dlinj; ;md .... as treated \>'llh cephalexin by his
pcdl:llrki .. m. However. hi, pcr'l'ted. and hI! no .... unable to walk on the fool. The paliem
deni\', fncr, chills. (If mal"j,.: I'a" ,neulcJI hi-tOT) "unrctnarkabk_ no known allergies.
Physicul EX(lmj l/(JliQfI : l"c!I1llCraturc \7'. pul'': <)I): re'plralion\ 12; blood 110/60. Gen-
ernL no IIEENT no regular rh}thrn. no muonuT. Chest: dear.
AtxlomclI: <.Oft, nomender. IXhitivc how.:! pl,lI11ar !>urface of right foot erythema-
!I'U'. tender. ' .... o1len.
Lllbor(l/ory EXUlIlillfllivll." Illl '()', \\ Be 1 tU"ll)(l' 1l1 .... ilh ()II)'} 5 bands. 5<[ lym-
phocyte.;;: platckts :.'OO.Of(ll lll. [SR 70 mm.'hr. R,,,Jio1,!raph 01 toot: negmive. Technell um bone scan:

13-1
Dmgno!;i s;
Dist ussi un; P5<'U'/(JIII(JII<lS "tile
most ,ommon cau'le of mk"<xllondrltis inlolving
tile ,artilagc. small . lnd uf Ihe fum
PseudomomlS osteochondntis was !iT'lt dC'lCribcd
after pun' ture wounds of the fOOl in l'hlldrcn
wearing and PsewfomVlhiS ha" bc .. n
isolated from the 'oli:) of the ,neaker,. Patient-
usually present a \>,ocek after the inJury . .nd ther
up)' with TOutine amibiou,s lI'eu for .. cllulit" "f-
ten has failed. There may be early ImproWlnem
in pain and swellmg :.fter tbe PUIIUUn: wound.
followed by \\'or_enmg ,ympwm< ,ch'ral ,Jay,
later. The mcY..! common pn:s.:ntallon ,. a
swollen. tender foot. Examination of th .. plamar
surface rna)' cellulitis and
drainage. Patients u,ually .. afebrile. and "y".
temic I)pi"'lll) an: Jb,cnl Ibdlo-
graphs may be negative carl) on in the ,Ji>e.1><:.
bUt hone scans ,hould be positive. The diagnosis
" b} growing P. aertlginf)sa from an
of the affected area. Infection can in-
\ohe the pro.\imal phalanges/metatarsals. tarsal
b.,mc,. and
Tremment of surgical debridement
a ntipS(' udomonal antibiotics, such as piperi-
edltn or .:eftaziulrne. combined wi th gentamicin.
111e lenglh of therapy is controversial. Some pa-
tients n:spond to J. ,hon eourse (1-2 lI<ecks); how-
ev.:r. n:lap"'-', can oc.:;ur.
In the p:ui.'nl. the radiograph of the fOOf
"as neganve for osteomyeli tis. but a bone s<:an
was A.,pnatlon of the foot revealed 0
,mull mnounr of purulent materi al which grew P.
" .. rugmol<l. He was trcJted with a 3-week ,ourse
of pipcliullm ,Uld gcntamici n plus surgical de-
hndemcnl. .... lIh II goooJ response.
Clinical Pearls
L Sneakers are the ,,)urce nt/'\'ew/ol/10ntU 1I1'1uI[ilw5U in o'lt'ochondntis following
pun,ture
2. Systemic 'llch as ft'\cr and usually arc absent.
3. Technetium scun i., positivc in PSI'llllommws but
REFERENCES
I""ob. RF. Ado-Im,n L. ('\1. ci JI \"'n.-18e"1<'''' r>f <.>" ....,.. hon,J"h<comph<"IIi,ng .... oondsoftht
fOOl Pedialnco 191!2. 1!-.I_5
2. Me. Gokl>mllh IF. GllhXJn PI! "r,uk . .. , J' a -.()IJrte.1f on cloildro:n ",,,h osteomychus rol-
Iow'"B puIlCIUn: ... ooTld . I I'cd,.u 106.601 ti09
3 I""ob. RF. McCarthy RE. Ehen 1M "'1<"00.11000"", punclll .... wounds oflhe rOOI In cloildn:n: A
to year cv.ju""oo. J lnfeu D" 160 M7 661
135
PATIENT 63
.\ lIlan "ilh painful. wlI .. m. !>preading cellulitis ufthl.' leg
A lTlao to th<' ... rgen.:y JcparllHl' n! complaining M ,I p,uuflll right kg. TII,o
c:lflicr he wu, blll.:n by an in""x:I u" his lower leg. The ne,1 do')' he nOled and .... clling
around the bile. tmd the,,: ,ymplom, rapid!, ,pn-.u.lup hi .. leg. Hb hi'lor} j, ullremarl
ub!':. and he ha, nu 1..00 .... 0
Exomillutilm: Temperature pul,e 12('1; !"l."pimtion, LL blonJ 1.10180.
Gem:r:!l. IIlOJCT<ltc Ji'[f<-'''. fIEI::NT: no I'h.uyn!!lli" Nc,-l. supple. CanJ"u:. nu IlIurrnur. Abdumen .oft.
nonlcm.!cr. nomml bowe! '>Quod, right leg. "".oUen and lcnd ... r I '-C\' figure).
lAJborarory Findings: ilet J6" c: \\ Be 21 .0001 .... 1 with gr.'nok .... y\t"s 10or: Iympho-
.. 10'1 : platelet) 150'(XXlI f,l.1
'J<i
Diagnosis: Group A \\replocoecal celluliti s
Discussion: TItc group A streptococcus is II
common cause of infections of the skin and soft
tissues. especially impetigo. erysipelas. lymph:In'
gitis, and cellulitis. Streptococcal cellulitis is a
rapidly spreading In" ammat lon of {hi,! $kin lind
subculllneous tissues, USUlllly occurring after
trauma (sometimes mild or inapparent) or surgery.
11K: patient delelops fe\er. chills. malalM!. IOClll
pain. erythema. and s .... elling. and Ihere is a
lidal desquamation of the skin overlying the area
of cellulitis. Blood cultures may Ix' positive for S.
plogents.
Streptococcal cellulitis may be complicll1ed by
streptococcal shock syndrome (TSS). Pa-
tients with streptococcal TSS most often hllve in
vasive soft tissue infections. mpidly developing
hypotension. mUltiorgan failure. and sunburn-like
macular rash. Most patienls with streptococcal
TSS are previously healthy individuals. Some
cases have occurred IIll'hildren due to secondary
infection of varicella lesions with group A strep-
tococcus.
Recurrent group A streptOl'occul cellulitiS has
occurred III pallents with impaired Iymphmil'
drainage. Women who have undergone" radical
mastectomy are ut mk for reCUrITni arm cdluhth.
Recurrent leg cdluliti' d(,ldopc.J in pJliem,
after l'nrQn!l1) h}pas, surgery III the leg frulTI
.... hich the saphenou, I'ein I"as remoled.
in the of tinea p.:dis. StreptOCOCCi pre-
gain entrance il1to tile extrenllty thnHlgh
the between Ihe ThcrJp), in-
volves treatment of the ,treptococcol Inf('>:lIon a"
.... el! as topical :uuifullgul fur th ... tinea pcdb. Par-
enterJI drug lIbuscr; also hov ... Iln increaS<.:d of
",reptocoeeal often a'Ioci'lto:<! with bac-
lerenlla. en.Jocarullis. or thrombophlcbitb.
Peni ... illin I, the drug of choice for , Ireptococ-
cill ho .... pro'iding
broader coverage are a good choice for t:mpiric
therapy. In the pcnki!lin-n!kfgic palicnl. van-
COm}c1n or dmd:llll)l'in arc
The prcS<!nt patient \\Jlo 'lhpe..1Cd to hOle
mcplococcal cellulitis 01 the leg on the of
the bite hlslory. rapid 'pr<,ad (,I <'l)tlk'Ill11. and
fever. DemOnqral lun of S./II"gfll<'J on blood cul-
ture l'onfirmed the lie wa, Ire;:Ucd with
ccfalOhn. I g Intr:tvcnnu,':- every,'j hUllf', ..... ith
prompt of hi, rapid im-
provement of cellI lilli, ol ... r the 7 d3}\.
Clinical Pearls
I Patients with impmred lymllh:.t ic dr:tinage may hale recurrent
2. Recurrent leg cellulitis mny occur in pallents alier h.1
surgl!ry If the saphenous vei n was removed.
3. Parenter:tl drug abusers have an increased risk of strepaxoc.:aJ uften
socialed wit h bacteremia. endocarditis. or sepac
REFERENCES
Sinen. OL TlJIlIC.'t Mil. W,,,-,h,p J. el.l: group ,\ ... llniecl"'n$ ,,"h. "" .. ,h""l U.e ""
drume and ""ariel fe'erlo>!n N Engl J Me<! 1989. 321 1-1
Z, Slov.n. OL In ....... group A >lttptoco<c.o:J ,nfecloonS, Clm Inf"'l 0,,; 1'J'l1. l.l 2- I _I
3. lIoge Clio'. Sch"orIl 8. TalkinglOfl OF, <'I 01 'The ch""gmg epldem,ology " I 'n'-,ISI". \ ",rOd."",
!he of ,lrtploclXc.1 10\1< .hncl Ill. ,)mpl""" A ,e"""[I<','II'-. popul.", .. _IUJ) J-\\t ... I .... J.
269:3&4-.\89
137
PATIENT 64
A 50.){ar -nld di ahdic mall with a fool ulcer
A 50-yc:1r-old m.1n \\ nh a 01 di.li),.:w, ..:omplains 01 a nonhcaling ulcer on the plan-
1M left Ihlt. I k 0(01<:<1 the ulcer about 1 "ech pnono his vbi!. after discu\cring a pu-
I'lllenl disdJarge slaininS [n ,ldl.h1l(In. he ha' wille ,",,-,lIing and rcdll\'ss of the dor-
of his f(lVI. A low-gr.lllc tncrha, been pn: .... nl for any pain. and C:II'II'IOI recall
any "pecitlc ImurnJ 10 lhe ,lrca. ,\It,'r nOlin!! tile ulcer. h,' hmJ a podnunst .... hQ prescribed a
".,alve:' hOllhe p:llicnl .. 1i.1 nnll.ccp hi' loll"",ul' Jppt)lnUncnl. HI, piN mcdk'al hi!>lory is significOint
for diaoclcs mellilu,> of 15-)car dur-Hlon. with kIlO" n cornpliciltion, of p<"riphcrnl neuropathy, ret inopa-
thy. and chll'nic renal in,uftilit'llcy. He raking glyhuride and c1IplOprii for hypertension. He
any drug allergies.
PhYI'icaf EXUllli nariOlI : ."\7 pul .... 8 ... Il",piraliuns 14; blood 160195.
II E;ENT: rclin;1I -C"rTlng duc to prior phulocuaglllJlion. CMdiac: nomlal. Abdomcn: un-
rcmarkable. El lrcmilil:s: hJirlc., bcl()w knel", rnuluplc in variOIiS stages of resolulion,
dUT"ialis pedis Jnd lIblJI pul-..:) dimlll"hed bil<lterJII).:!+ nght edema .... ilh overlying
.... pllnc heu-uur ulcer 2' in di:uncrcr on plantar sur-
face of left fOUl o\er Circa of \oCcond rnc1a(ar;;11 tll.:ad ..... Ith dCI it:llt/cd tissue and purulent diS(:harge.
LIlboralOry \Vile 15.JOO' 1-'-1 "1\11 88% ncutropllll,. 2q. 94 lymphocytes. 1 %
monocytcs BUN 2 .. rng/lll. crcatlllll1C :'U lIlgldl ESR 9!l mm/hr Cuhure of foot ulcer: Srapll)"lunx'-
ells ,lIIrt'IU, S <'pid, (vli. and f:.lltl.'rtKO{TII$. Radiograph of Icft foot: sec rigure.
'"
Diagnosis: Di3bcllc !"'Ol UkH Wllh l'hrnlill'
Discussion: Diabelic fool infe\.llon,.
limit<.--d 10 lhe or .of! arc
caused by the same ;b in
These pathogens include S. a"r<'IH. E.
C(Jfi;md omeremcric gr:un-nt'gative b.'ll:ilh. lind en-
terococci. In the di3bdiC palknt with dC<.'p. pcne-
tr.I.ling infe-=Iions. a 01
such 3.!0 f>t'pIUCYXClIS.
leria. and Bacteroides !>pp. abo bc cOI1'';IIJcred.
Diabetics presenting "'ith dttp. p.:nClr.l1ing ul-
cers or chronic. dr.llning sums Ir3Ch uf the toot al-
most always h:wc an un,krlying (;hrunic 0,-
leomyelirh, E\ cn c:m:full) taien cuitun:" of til.>
ulcer or $inus tr:lC1 n:prei>C1lI ,urf:lce culunil<llion
and shoold nOl. be equated with the
pathologic process or the p;llhogenlc or-
ganism. Only bone bi opsy cuhures Me
and can be n:lied upon to <;cICCI or .lnlibi
oc:ic thempy.1lIerefore. bonl' biOpsy al",ays
be performed. Prolongcd empiric lh" rapy ,houlJ
be avoided. Extem.i>e s urgical dehridement. In
addi tion 10 appropriate antimkrobial therapy. Ill-
variably is required for cure 01 chronic \)'-
toomyelitis. Inadequate debridelllcl11. In the
of preserving in or
won;ening infection despnc arltlblotlcs.
Initial empiric Iher:lp) ,hould COI1!>hl
of a brood-spe;:trum agCI11 that activity again\t
the organisms mentioned Monuthempy
with a third-generation (e.g,. cefo-
ce!oper.aonel or a penicillin-
II1h illitO!" combination (e.g .. ampiciHinl
,ulh .... lam, p'I'Cracillinltazobilct3m. ticarciJ1inl
.:Iavulanate) pro\ Idcs 3ppropriale covcrage. In the
pallen!. clllld.amycin in combi-
n.,lion WIth an aminogtycoside, quillOlone. or aztre.
Ol1aln recommcnded. Generally. monothempy
'" Ilh an ulder qUlnolone should not be reli<.'d upon
bccnuse of potcl11ial developmem of reSiStance,
in \taph)lococci. TrovafloJCacin, a
4uinolone, is an e.\ceptlon 10 this
ruk. Although a "mall percenmge of diabetic fOOl
11fe cau.;cd by Pseudomonas
cmplrlc cOlcrage for this organism is not
warr.lI1teu. P (Jf'ruliinusa should be suspected.
ho",cver. III cases fullowing puncture wounds
Ihrough a ,ne3kcr. and double Pseudomonas cov-
crage be pending culture in this
'lIU<lliol1.
Thc prcenl p3l1ent"s fOO( uker -of prolonged
Jur.ltion - In combination With a markedly ele-
:lIed ESR i, for an underlying os-
le('!ll}elltls. nle dcslructi I'e bony changes on radio-
gmph conhnn the diagnosis. If tile radiograph had
t-..-cn a beme scan would
h3V<: been mJic.-:ucd llIe patienl ullderwem a ray
Jrnputatiun of [he <.ceond phalanx and distal meta-
t:lT,>:!1 bune. Whik an inpatient. he was given a
of IV amplcillinlsulbactam, ..... hich subse-
i.ju.:nlly ch:lngt'\l to an oml combi nation of
chndamycin and 0t10Xaclll fOl" an additional 3
wCt:h oUlp;.ti.:m.
Clinical Pearls
I. In a diabetic ",ilh II nonhealing f0\11 uker. 3n elevated ESR is suspicious for un-
derlying osteomyelitis.
2. SuperfiCial r.lrely arc helpful III thc pathogenic organism III
OSloom}eiitis complicming:. diabctk foot ukef A hone cullure !>hould be per-
fonned 10 direct antnnicmblal themp)'.
3. "urgicat debmlcment (//"U\\' I" requircd for cure in of chronic os-
teomyelitis.
4. Empiric 3nti'PSl'lufommros Iher-lpy i, only for ",ho huve expe
rienced puncture wounds through II
REFERENCES
Capuro GM. Clva""g/l PR t JS. [)"t>ru,' j("" onf .... '."', N t' ngl I 1'1'14. J.l1.8'!4-MO
Cunn.. RA. Int' D 1'", ... , I'I'J-I. IH hI
3 (:,bben>GW Ha,""ha" (j\10 .. """'- h<>l .01<,;<,,'0'- In!<,' I),,('[m ",,"h \m 1'l95." III
139
PATIENT 65
\ mUll ",ilh rc\'cr.cr)lhcma. lind purult'nt draimrge
from till" riAht Ie!;
A man compbin, lit tClcr, lip 10 llU c." or,cning Cf} !l1<,; ma, and puruknt dr,unage
from Ihe IUII.:r nwdial lIf hi, right kg. cununcnccJ iuu,!y. Ilis leg "as
inJurt'(/ at rllc <arne ,itt: III an ,llItumobik )e.II' agu. lk Jenic, 111,\01) of di.!b.'t<''i IlldliltJ,
nnd h 11(11 mking 1O<!(lkalltJlI,
ExamillQliQn: T"Illp.:rature 1:-; . ]Iul-.c Ii/>: 16: blood prc".,r.: 142 82. (jell -
cr .. 1. 'H:II -devdl'ped, ".:l1ntJuri,hcd m:ln. nll'dial asp' .... ! of nglu 10\,\<:1 ic!! "",Ikn. cry-
thematou". \\:1[111. Icnr.kr. "jIll !,umknl fronl:\ ,ulilil ')IJo\:uiug. Clte_, ""mlJl. Canliac:
.. rbbk, IIEENT noml:11.
UliJnrulory FllldlllgI: \\ Be 14.!SIII)' I-L1 \\ ilh by"' r nn,rphunud.:"r celb. 16<"( Iymphocyle"
I 'f ESR 76 rnrnl hr. Gram <;I:,in ul w\lund dramage: C 111 idf'll-
uhemi"/l BI('<.1d (uhllre,: negali\e ComptJIed lornopal'hy of righl leg: 'oCC ligur.:
'40
Disn/ uirJII; ;"
or dq)l:ndlng \\11 Ih..- llillital
lauon and the rr,Jlologtl and hl'tolol:lic fmdings, 11
al>o ,;<1n be Jctlned ." ,,:1.:om,lary [01
a foclI, of illfcttloll. VI wilh
penpht:ral i ..
(.'an IJ<' dCS<:lIbed Ii.' medu!!ary.
pcrt":ial.locahuJ. ur IlJfrU"::. dCJX!nding un
tt:m 01 hon) ,-\':Ulc
ICUllly.:hli, -.cen in chIIJr.:n. bUl lS unctJlllmon Hl
It uwnll} in\'"hes the .mJ mrdy
Ih.: long bo'llt', 01 Ihe [o",.:r When the
Il"H'r ill\olwJ. <l!\::as
in :lnd Ih.: In
Immumxompn:mll"::u and inlr" ..
dn,!! ahu,c".lre .. 1 for atlillmng acute
"!til hadaemi .. ,
'rread 01 lul ..... Uon. "'hi'h .. 'om thc' cOrtl-
call"onl' k;ld 10 soft u",uc ab ..... e" Chronic
hcmlltoye/loulo tn<)re
than J,,Uh: . :mJ a prlilracte.! d,nica[ ,;nuN.'
I<'current reao.:tlv:uil\n, ,,1';1 4I1i<''''';cnl lOCUS
.lnJ ttJ.: rOm1all{)n "I "Illb 0,-
in "dllh, i':l (lr J con
ttguou, ,,1 10 lwuma;
Ilo"lCominl LIltc .. tinll.1 .. '<.[UIl<'J dUlilig ,urgical prj).
cffillre,: mser1ton of .. pn"lhe,I"; or >pr':JJ from
.til owllying mf,,<.!ed ",,,Uri.! By lime i[ 11Ie
'enl>. it u,u,III, i, .hroni .. In "n
lion 1.,f ... hmllil p:ltlenb pre,cnr with
kl<.r. in<.ren'tJ '''''tllmg. ,111<1 purulent
.!r:unagc tmln .. 11 ukeraronn lIr 'lilli' tm ... l.
or may not bill
th..- "..dlrnlnt:IUOII r.IlC is cle-
,md Ih" 11IKling ':"11 tx: u .... 'tl to m'-'nllor ther
ap). 1llc puruknr dminage ,hould be culture.!, anJ
blood ... ululre, ,houlJ he urnu" on all
p.:o.toollf mleOlll)elill<;, differ
entlal 01 JUJliguan!
.tnd I'ocnigll tIlIlWf'. p:t'l tnUOUM. nnd rone infan:b
from hcll"l!1I"i>ulul()P;lIhk-s Radk'gr"ph, ,hnuhl he
ohrairl<.--.J in ,111 I'a"<' n" ,u"Pl'.;led u!
If the Initinllillnges arc nomlal they ,hould b.,.. n'-
lle"!ed Ithlll 2 weds. bcC:lU"" the mdiogrophlc
of generolly aT\' dclayt\l.
T)I'I';;ll III ::.cUle induJe
'ofl ,\lei ling_ or ele\':\.
lion. :md lytic l'hanges In "'hmmc O'k'Olll}ehtis.
lyplc"ll finJmgs are aud fr-
:kllon_ Indtum-Iabeled o;o:alls are U>l:IU! fordclll"ll'::n.
iog Ihe of in acute lb-
tC<.)lllyeiiu,_ Il owcvcr. magnetic imaging
iMRl) " Ihe 1\1'0'\1 -cn,ihve leM fOf chronic (h-
Thc rathogen IllCl>.t frt.'qucntly i'\Ol;tIl-d
in SliIplll'ItICOCCtfI
,lIIr<lll', Oth..-r organi,m. :\SM)Ciak'xl ith tho:: di>oOr-
,Ier Include !>. Streptococcus P.w,c.mes.
Fmcm" " ,'CIL< '1"-"1: iI'" gr.tmncgallvI; hacilli. :md

For chroni .. u,twlll}ell1l.'. anllbiOllC treatment
can be ha-.cd un the of hone. >uf! 11%11(.'. or
blwd .. ,h(1l1ld be obtained be-
lOre nlllibloti .. th('rap} IS or afler the pa-
tient h .. , been <If! antlhlOt ic) f(lr 24-l8 hOUfS. III
Iht' trt'lInrlClll o f (hrome o_kurnydi",. both an
debrili.'rnenl :if.: necessary
for ",ure, \t tlehriuern"l1t. al! l1ecro!k bone and
,,,ft ,I\(,uIJ he remll\".!. and Jntibiotic' ther-
apy ,IIOUll\ he on Ihe of the or-
gJIlI'1ll i-.oI.,led from bone cultures or deep hont"
billl''')'. The r;ll ient ,hould recei\c an-
ubluli..: 10 cllmpkle a .f-v..:d. cours.: after
Ihc I .. uebridcmcnt Sup.:rliclal
o<lcomyehus ('iiI be tre:l\('u l :!----' "'eek
COliN: 01 anllhu)!k, after sU!,<"iicial dcbndcmctlt
and Il"p
The pre""1I1 patienl v.:lS admuu.-J 10 the hospi-
tal and "tnrted ull .Intlbiutlt"s for In aeun: e xacer-
bation of cellulitis filer chronic-all) bone
anu !l.I Rl .. ed chromc oslcum)e-
lili, of Ihe tibia. T",o II cd, 1:lIcr. he unJer-
"cnt vt the in",lIed bone ...
l\I grc\\ \', OIW,"" The I';ui;:nl a6-
\I "c!;. l',lUf>,e ,)1 antib,,)ti ... ,
'41
Clinical Pearl s
ACUle hemmogcncotl\ affecting the long bones is rare in adults.
2. In u.::UIC raJro!!raphic b.: d..:1a)cd JIlJ may aclua\ly
\\o ursening although Ihc fXllicmls clinically
3. The most common of IS p:lln in llie arcOl of i"fcCllon.
4 Acute OSlcomycli li\ rna) Ix" by Jnl,binlic\ (110m:. Chronic re-
quires surgIcal debridement of infcllcd bone lor (ure. and anllbl Ol ics are ancillary_
REFERENCES
Wo.Id""d I' A. Mtdoff G. S"'arll MN "'" "f d,n" ,h<,-.tp<Il'..: c"",,<l<."''''In'. >tid Ilnu,ual
N Engl J Mcd 1970. !(l6, JIIo-11:
2 Wnld'ogd FA, V"",,) H The p." ,", .. .oJ., rio J \1<,[ IfJll .170
J. Modo, fT. Cllhoun I Loog t.. .... doJ .. n' J-{",p P,-""'k."C . .!<J:71-Sb
142
PATIENT 66
A 33.yt' nr.old woman with a cold foot
A 3J-year-old woman had a I-da) hi,lOry 01 a cold nJ;hl rOO! .K.'compnmcd by pallor and pares-
thesias. She denied si milar I:hangc, in Ihl" left foul or although had a of
epiMlO.llc. triphasic color of the toes induced by cold and compJic:Ued by
digi tal ulcn 8tions and She .1lso hJd a long nl\lory of dy'phagia and gasuucsophageal re-
"broken blood lc ... s,cls" ('n the face. Jnd \1 thl" on'Ci orlhc prc ...... nt IIlne" ,lie was
takmg nifedlpine. cnulapdl. ;tnd omcpral.Ole.
Pllysical examination: Temper.nure 99Y-, hl'an nile 128; rJie 18: blood pres,ure
100/60. Skin: tdangieclasms o,er f:j(:e and hamh: with hcakd Ihgilnl pitted scars.
HEENT: circumoral furrowing ""ith dccrea.;eJ <.)fal apenurc. normal. Cardiac; normal. Ncu-
rologic: normal MU5Culos]..ekfa1. E,tR'mltl<:s: wid. pnle right loot With no palpable
the pedis or posterior \Ihlalh MtCl)'
Laboratary Findings: WBC: ..... lIh 73(1' nC\IIruphlls. 17<::l- lymphocytes. 10% mono-
t:)'tes. H,'t n8%: plaldcls 362.UOO/ ]J.L: ESR -' 1\11\1 'hr Serum norm,d. normal.
radiograph: nOfma!. Echocardiogram: lIumla!. amibody and lupus amicoagu-
IJnt: n..-gative. PT and PTf' nurmal. Crynglobutilh: ne,!;arilc AN A [:320 centromere pal-
tern. AneriogrJm: 'iCC below
Qlln /iQn: What i\ Ihe diagnOSIs and trc:Un1<'m I
nillC:llmis: I'RI-S r ') ruJ""II" I'I!h IJrgc dbeaM!.
,,-icru>.b (sSe . ...cicm-
.I,nn.li I' 1-1.,,,,l1ed tw tho! l"ten! of In-
'UIH'IlJelH allJ lh,' <lr uf
ul (;{!!1Il1-'l.:li\"(' !b'[IC di,ca;so:s.
lUpl" t'rythent,H'hU' 1",I:rm)lJ,iti,. and derm;llo-
IIIv,),'h'_ hI tht, e"islS
," tltflu...; cu!alK")II' SSC. limited sSe, or
,III P"lleltb "'ttl! Itmned cuta-
IJeUU' SS, lI'IIJll) h,,\c tJUI ,"m 011 tho.: fingers
lo,cl.,-.rtlol.lClylyj ;lIld LICe Hnd M)metnnes on lhe
h",W JIKl tort',mn ,\lany patIents with limtted
nl1:moou, SSt: h..!\"<' phenomenon 0l.S
pT<'-<:nting ,vl11ptum .utJ Ut!\.::Iop calculo:.is.
e,,'phaseal J) ,m\'tllity. ,md lclang-
u\'a the ""Ur-..! uf Thts con-
,tel1.,ti,'n (It ,i!!u, DluJ is kno",n by the
,lu"nY,1l ( RLS'I. I\ppm\im,lIc1y S01> uf CREST
,yndrome p.ltlc'nts ,uHkentromcre
I \(".\j.
Obl<lcr;uiH' I11IUOI.NU1Jr dl)Ca".; and ".ISO-
phel11lnlen;1 ;ire halhllJ.rb ufSSc. but large
i, infreljul'"utly.
It ",,"uld ,Ipp.:.tr.lumnn. th.,t nwau\;!">\.'ular dis-
mare ;tIlH"!ng SSc than Itl
cllnll"l\l popuJ.lIlun_. L,r!!e les..:! di-..:u...; may
,,, in the prc'>Cnt I'lth .,,->Ule pallor
.Ultl pJ11i du<" In Jnnial (',,:<'IU'lIl11. or ..... lnlermit-
cbudll';nion, :mglll;l ,unl tr.:1II"<"1l1 ,.;;chemic
h)p.:rt ... or hy-
IX'n.h'lk,to:n,lcITlI:t lIlJY playa role III some
\ltriph'''ph,)lIl'id ,Intl!'>"dk,. or tl! ... fllllico-
ul!ulJm. Ill"Y to large and medlum-
,,;, .. d 1'01" ,liM In ">Ome SSe patients. In
uth.:r c.l'<"'. 'Ull! ," rhe present patient. Ileither
, ....
alhcro:.clerosis nor antibodies
arc detectable. T.:sts for the lupus anticoagulant
and antlphospholtpid antibodies ",ere negallvc,
and there was no arteriographic cvidcoce of 31h-
erosdcrosis, The aneriogram revealed normal
vascular anatomy to the le\el of Ihe right calf, al
'" hich point the anterior Ilbial artery was found to
be occl uded: the perilOlleal and posterior tibial ar-
teries "'cr.: o<:cluded al the Ic\el of the ankle.
""lthout ancriographic evid.:nce of atherosclerosis
or vasculi tis (SI.""e figure).
MedIcal management ofischcmk episodes isof-
ten difficult aoo incffe:elive. Digitallsdtemli!. may
rc:spond to vasodilator therapy including calcium-
challncl blockers, topical nitroglycerin, and chem-
Ical sympathectomy. Low-dose may inhibit
platelet aggrc:gauon. alld pcnl()xif) Ilinc may in-
creru.c rt'il blood cell flow, Surgic-a! debridement or
amputation is MlmellrneS required.
Thrombolytic agents ha\e been shown 10 im-
pro\C symploms and ,ktn blood flow in SSc pa-
lients ",ilh digital but there is linle rc-
poned experience with thrombolylic therapy for
largc ICSS4!1 occl usive disease in SSe pallents. In
the present case. a microcmhctcr was advanced
tnto the poMerior ubial artery to the level of the
ocdusion and a bolus of urokinase was ghen, fol-
lowed by continuous infusion of urokinase and
heparin. Within 24 hours. the foot was warm and
tile pulses were palpable:. Repeat angiography
a patent pnstcrior tibial al1ery and
phl.lltar arcades reconstituling the distal dorsahs
pedis anery. The patient was plru;ed on long-term
cournadillther.lpy.
Clinical Pearls
I. Sj ,\.'1\'10\1, (SSe. ,,'I .. rndcrmaj .. las,ifi.:,J b) the extent of ,hln inl'olw-
menl ;1> IImlt.:'u l'UlJIlCOl1\ \Or .. 5$,' ur In owrlap v..jlh ka-
tun,', of lupu, ur 1'"lyltknnatornjO'llis.
111<: limneu vanam 01 5S" h abo kllown as the CREST ')ndromc.
, \l'pW\inhltdy of r.!lil"oL" \\ ilh limited SSe h3H" the .. pccifi<: ..111 -
li .. clltrurncrc unllbod).
4, I Jrg ... \JC,lu.,ivc d,sca,\' ma) "".:cur in SSe patients. p.lrticu!arly I'.ilh
the CREST \ arian!
5. hIC[Ut'i ,onlrihutlng 1(\ .. iH III 55 .. include
h) IlIhcr<)""kros[" ami antiphu'phulipid anliboJies,
6. b. .. -hemi" from laT!:,\' \cs-,eJ occiu,j\c ..... CUll tie improvl-d by thrombol)tic
rh ... rJJl)
REFERENCES
LS L ,.,,<1 """,;.I,h"""I>o, ',m "(',n,, ... k,,"" ;,h "h,'pho"rI",tiPKt I Rheum.',,1
17
"". j"", E.\_ 1(1 Gu,,, R I -r .. ,t,. IJ, !lAo< RD, [>';rl<m' C. I")"",, MIl.' \ <l<",b!e blind placebo ,On_
""Ibl 1",,10)1 "",onlbll",,,II,,,",,, l'b,m""Ken ... ,,,,,10' in Ir.. .... m 01 ,.",hemi" In ')'""''' .... !em" . J Rhe""",-
1,,1 t I', 7 II> ',0
\ P II. Ikn,""h I t ... ,""d ,xci"",'. d,,,, ... ,,, ... ' ....... 'a.cd .... "h CREST ')00'''''''' loJ "'krotltnna Ann
Rhturn Dj, Pi'll. 12.l.t----l1l'1
\'<,,1. OJ (ull,d"" T-\. Ikkn JJF ,"".",cd P'", .. h:"". "I ""'1'10"'''''' ",_Il"",'."-,,I .. , JI ..... ", on ""ernie .. k,,,,;, 'nn
Rh<um \1" IlJO" __
,,,
PATIENT6?
A 50.}ear-old \\ ith at'ute calf p:lin
A 50-year-old man felt II. 'liuJen. '-<!n_<!liun In [he calf uurmg hr.! of II. len-
Ilis m8tch. The pam was I>.Ofl>e '" hen the fOOl wa, then sudden!) 1Illrslfkllcd. There was
immediate s .... cllmg of the call. and Ilc not conlinue pl'lying tennis. One day !:Jler the 10ll.er leg
and fOOl appeared brUJ,cd. and ,w.::lling per'l,red for week" and he :.ought medical anention.
Physical Examination: \ ita I nnrrt1.11 C.cncral cXJminmion: nurmal E.\(remilil's; full range
of mOlion of knees and ankle,; 2 elll 1L lll111cll)' "I' lJi! circumference. right greater Ihan leFt: tender to
p:!JpUlIon at lI1uscuJoicndlll{)u\junctllln ofnghl medial g:a,(w(;n.::miu,
l..ilooraJory f ' indings: CBC.l'ooglllnllon le,IS. .::hcmtstnc, r.'IRI or legs: see figure.
'-16
Diagnosis: Ruplure 01 Ih..: plalll.Jri, mu_c It". 1.11 kg."
DisClusion: Sirains or I..:a" of Ihe pialllam
mus.;lc or of Ihl' rnt"dlal of Ihe !!,h!nxnellllll'
mu!ocle, referreJ 10 "tcnni, ,.re
,e..:n in lennis o!ckr Ih,m -W Similar
inJunes in m"Jdle-3gcd engaged In ('Iher
endeavors. a,' ,liinf or \t.lIr-,I<.'pplng
eAcrt'I'<!S hnvc been Ih ... intii
vidual a painlultearing s.:n
_alion in lhecalf muscle with im!\lcdi<lIC
and swelling. followed by pmgres\-
ing down the leg into the lankle and foot. P,tipatlon
m"y revcal !\lltltm31 s\\.clling in a fir;t -JegTt"C
qrain. ranging 10 a defect m the med;;11 heall of tile
gastr(ICnemius at the musculotcndi11<lus Juncturt'
in:l ,tram. ConH'ntion<l1 r'1Jiugraphy alld
bone s(:anlling hale lillie value in .hagnu,,, 01
SU!I ti ssue .njury. .U1d J\!RI ,,-an
nlng may demUnslfah! IIuld eulle':II'"1, ,nul
ell: lears. Asshnwn III the Figure .. 111 /T.IRI",",m n
veals an hematuma tlli.'
,ulcu, mu".:!.: And lhe hea..! 01 lht:' ga,lrCII:-
nemiu . The plnnwris mu,,-1c. whl.:h "h",nl III
7 to 10% of the fnlill 7 tn I,
.:m long, \\Ith Ihe my()l.:ndmVlh unUl"-
ring nt the ie,'el of the origlll uf the IIlU"-'!c'
in the pT'll_'irnal por110n of tIl<' lower k.L'
Olh.:r uf "cute .... p;lIn to be .... nn.;id_
a.:d indm1c db'celinn or ruplul"l' of " poplitcal
nlpture of the tenuon;
The i, mort' likely tu oc.
lllr in il inuividu;ll. oflhe
tunn.:r .... onJltion' I)plcall) on-Uf during
.... Rupture or di-'<!ttlon of a popl ileal cY_I i\
u,u .. tlly aJlle(\:ltcU by knee swelling. Rupture 01
till: Aehllk, o.:eurs I to 2
pru"JU.d t<) Ihe J,'I"I <lttaehmem oflhe lendon on
the LaILan.:u,. ,\ "pop" b
lell. with ;1Il in<lhllity 10 un tiptoes. A po,;_
11\'': fhomp_l,n leM (failure of plant.lr II.:",ioll
wilh compre"iun of Ihe gastrocnemius
on the 'IJell' present w Ilh ruplure oflhe
Ikhille, tl'nJon hul nol II ilh Mr:'ln or t.:arof Ihe
<>1 th.:
1\< l'"n: or pl.lntans ur ga'i lrocnemius mus-
de ,trJIIl e('Il",I, of ice. atlil il)'. gen-
tIL' 'trekhmg hecllif15. and J
,"': pwgr.l1l1 Inunobilization and
nun may bt- in more
,e'ell' hl al!!)11. c(lmplctc hen1ing of the
mll,d<,.
tn Ihe pr6cnt ..-a-.c. occurred
f"lh,wlng :I pen,,,! uf :Ie!ivit)'.
Clinical Pearls
"Tennts leg" refel'> 10 ,n;lIn, ur tl'JrS of the plantan, mu_dc (lr of medial head
of Ihe u,u<lll> 'Il,urring ill [eIllU., playc" I'ler rhe age ut -W. but .,lso oc-
('urrmg in olher alhle!ie .lll\\ ilie'.
2. Consider the (\i"gno,i, in the .,thlele ,'Ompl,linll1g of painful tearing sen
sat ion in the ralf muscle_ with IInrnediate ,II clhng by en'h) rno,is progress-
rng down kg.
3. The differential diagno_i, mplurc 01 a flOplnea! C)'1. rupture of the
Achille, lendon. or d<:ep I':ln thrombmi, _
4 MR imaging 111<1) re\c,,1 an bt-lween Ihc wleu,
and the medial heau uf lhe "n PJninl I<',IT (If the me-
dial hCJo..I of the ga.,rrocnelluus mu,lIl' ... 1", m.IY ut>_.:ned.
REFERENCES
(i,I""" r '>'n<:tIl1 .\ ",n"" rbH'" llh" 'w .. .,.iT 11"'1" 1'.-: .. , 1""1 :1. , ,",- '
2 Men! L",,,,, (;! M .. g .... u, .. ",n ....... Im"'"r '" "'pI'''''''1 II,.. "",.[,.,1 I-o. ... I .. T III< ",''' ........ mlu' "", .. .:I. ,I c."" re-
p<IfI ) 1I0nt J(ll"1 '''mil '1'11.7.1 I I ".2
J Ut.. .. t II Ch>plu 1 un, k .,,.J In I'k"',.",, \1[0.. fl.LII ' 0.).'. InjUry B.I"m.>re.
W,ltia"", &. 'W,lk,n,. l'I'H, f'1' <1"
lIelm' C \. Fml R(. (i""m (,I ,'t.NJ'" ,"""Ie ml"'Y ", .. \t,.,II,m" In,.,:"",, !til
,,,
PATIENT 68
.\ S-' )ear-old man \'li th painrullhigh muscl es
\ '"'in \\ ilh .1 5-}C<lf histury of diabetes mellitus lmd coronary disease dcvel-
up<;:J bd ... tcml thigh pain T .... o .... (Xir::s later tile left anterior thigh became indurated and mon: painful.
11..' had no bm the of the pain limited .... a' ",ng_ His only was glyburide.
";Xfl/nination: Vital signs: nonnal. E.!ltrcmuies: mdUf31ion of the kft latcralthlgh with
C.\'1U"ilc of both quadri<.:cp" must:les.
Lllhurl/fory wac .... ,ith 6O'i/- nemrophils, 13'l, lyrnph<x:) ItS. 7'} monocytes:
Hd 411'.; . pIJ!clc! ,\(l).OOOi j.l.L BUN, creatimne. and Ij\cr function nonnal.
l ' rlU,liv", tOO mgdL prolem. 5011 mgl,JL CPK. 109IU1mL (,,\4-180). Westergren ESR: 92
Inln. hr f1loP'Y oj 1.:11 l<lter,11 qu;rlhkeps f,,'mom (see figure),
,t d. :
; . ,--
J , .... ,., '.
JOY "
:-\'
, , <t' ' ",
I'"
UiOK//Osis; Dlllbcuc musdc m!:1rcli"n.
DisCllSsio//: SUOOcUIC. pnlllful. ant.! \wullcn !nUS-
cle nUl from onl) a fl'\\' pa!liolollic pr-esS<!s.
Intr.J.muloCular hemvrrhage fmm vr II
lalion def .. '"I.! l"an cau<;c picture. out is e,l"]Y e."(-
duded by history and laboralory Il"sli ng. Tropical
pyomyosuis frum slaph) 1000fll'C.tI inf<.-c-
lion IS seen (lilly in the IroPICS and is the rcsul! of
.pread from a localil.ed infection. Infhunma-
tory musck (pol) - or dcnnatom)"lhitb) is
chumclcnzed by rotol"r than pain. and is
associated \\.llh proximal mure than muscula-
Nre. One unusual fonnor mtlmnmatory mu-.c!edis-
ease is "Iucahz<!d m)o'lt is in \\hkh ju.t OIlC mus-
cle or muscle group b invo!vt'<l. The pathologic
features are those of Idiopathic intlammatory
cle di.>C:ll.C: inUammatory l"1!11 intiltr"te with degen-
erJllon and regeneration of muS<.le tibers. Diabetic
muscle infarl' tion is the other entity to be
in this setting,
Diabetic mus.ck infarClion generall) occur> 111
p;itiems with 10ngStallUing. poorly conlrolled dia-
beles The clinical picture I. that of II
pamfuL swollen. and tender thigh. either unilatcml
(If hllJteral. Most p.1tients are insulin-dependent.
and Ihe liN 1h"icnts \0 be dcscribt.-d had evi<Jcncc
of endorgan invol\<:mcnt. particularly renal db-
ea.>C with prolt:inuria or uremia. Mon: recCnl
I\:pons lIlc1udc tyP'! II diabc!ks. but most have
crosc1crosis :md poor glycemiC control, The patoo..
logk findlllgson biopsy are muscle alld in-
tlammatlon (<;cc figure).
Treatmcnl of musc!.: infarclion In-
cludes analgesics ,md gl)Cemic Control. with re
habilitation when pain lmlllunosupprcs.
>Ion is nOI beneficIal. and l:orticQ1>teroids may
on!)' \\.orsen the situation.
The patient had been on steroids
Inttially. as he was belie"cd to have hnd localized
TIlCrc \\.(lS no impro";mcnt o\er a 6-
penod. and control of hIS glucose bccam.
4ulte difticult. wru. .topP'!d. pain con
twl was (nsfituted. nnd gentle ph)sical (hernpy
wus begun. Hc impro\cd gradually lncr a .t-
month period.
Cl inical Pearls
Dlabelll' Illu!>dc mf"Tltlun occur. m the S<:Ulng of poorly t'(lIHrollcu dlabetc . 1I10't
often m \\. ith e\ idence of end-organ damage.
2. PlIIICll\S \\. ith dl3betic rnu<;clc mfarc!ion complai n of 5C\Crc unilateral or bilateral
thIgh pain. S\\ellmg, mdurutlon. and el)'lhema of the quadriceps lllu,c1e are l'haracter-
Istic.
J. Treatment of dwbcoL"" mfan:tion In\(.hes analgesics. rontrol of blood glu-
and gentle exercIse. CorticoMermds are not helpful and ,hould be 'Hoided.
REFERENCES
8>rton KL. UF ,"La",""" nllh< ,.,1", lJler"',, Inu,d" '" ad"bc,,,.!"'l,,,,,, . e.Sc ",po<!.md of,ho
hl,r.l1ure J Di.b<-lc,COlnphn"OIl> 199J.7
Rocca PV. Ail",,'")" JA. /'Ia,hoID). I),abcl,,- mu>cul., ,nhm:""" !)o,mJrl Arth"I" RheUm
J Bod,.,., RA. DS. G. 0"""1,,, mo",'" ,nlaocU"" I-Iu .... '" Nof'"e ('}9.L.t7 9-l9-o)W
EK. Cany MR. KOIl Ai. CI"I mo .. de ,nf",".;"., .,.,. ... 1"'f'lpe<"li"c OIl p.nh(lgc,.,.<t, an..!
"eun",,",""ut D1><J<d
149
PATIENT 69
A wanUln with heel pain
A 3J-y ... :tr-old wuman Wllh.l ]-}car hl)lory uf right heel pain 'eel'!. 5h<' lknied [mUIlI.'!!l In
jury, bm ",orked in a [emit: mill on her feet for up 10 \4 hours d;lIly. She had no Olhn IllU,-
l'uloskc)clJl (':umpiulnt). Shc Jellied hu\ mg :.I r.\)h. C}C m!i:lmmation. ur dpuri.l. Th.: p,ltl;'nl neme-Ill-
bcrcd having a 3,""ed dlarrheJI befOre! onset of the heel pmll and Millnu\c, IllIJ>C '(Oul) I ..... ke
1<(.-.:\(1),. Her father had an innammatory arthriw; of the right clOOw.
Phy,\-icu/ f.' .wmill/Jti .m: Vital \lgns; n{Jrma\. Skin: numml Il EENT: norm;!1.
normal. Abdomen: numla!. Neurologic: nonna!. IhickcllCJ. tcmkr right. \,lIlllc, ten-
dOli wi th atrophy of Ihe calf. pain on dorsiflc,ion and of the right fo,>Ot, ,111,1 p,linfu)
S.:h6ber flormal.
I ,aoorafllry rBC: norm,tl. Uri.: aenl RF: negalive AN -\ nega!!v..- \\
ESR: 6 mm/hr. HLA B-27: pmt li\<: HI V: Sa..:rOlliac roJiograph,: nomlaL \tlkl ...
planlllf 'pur and opacificolion of lhe fUI Iriang!.; 01 inlbmm;lllon.
t-. 1RI beluw\: incrca!><!d wl1hm Ihe right lend,," 1 .. 1
em in trans\(.'rsc diamelcr.
Qlustion: \I, hat IS Ih.: .:au.,.. and tn:ntmCnl of thiS heel pllUl!
150
Diagllosis: Incumpll'!c
Discussioll : Rl:ltcr 's s)'ndrome classit:a!!y
refers to pedpheml anhrills. ure[hn[is
and follul'olng a u}SClllenc illness
or venereal ui!.ease. Rencr' s a rellC-
live arthritis that oceurs in a genelic;,!!y suscepti-
ble host (HW\ -B27 following infection
of the gut by Salmon ... !!a. ShigdlJ, Ycrsmia. or
Campylobacter. or of the g.:nliounnary lract by
Chlam)uia. An Incomplete form of Reilt:r' S
drome occurs as an asymmdric oligoarthnlls of
the IOl'oer wllhou[ urdhnti s or con-
junclivitis.
One should the of Reiter' s
syndrome: in an) p;!lient with an ttsymrnctrtc
oligoarthritis In"olving 10l'ocr e.ltrc:mity joints.
pecially if there heel pai rl . Unlike rhcummoid
ttrthritis. Reitl:r\ ')'lIIlrumc b mUldric and has
a pn.'liiteclion for IOl'oer euremi ly jollltS. Patients
wilh Rei ter's syndromt" are RF negative. and the
ESR is often normal.
patients 1'0 ilh long-standmg Reitcr'S
syndrome develop allial dlst""asc and. like pmicnts
with ankylosing have limited lumbar
tte.\ion arid abnormal SchOber test. The Schober
tesl entai ls a measurement of IU cm over [h.: lum-
bar area wilh Ihe patielll erect. ,\ n increase uf le<s
Ihan 5 cm when th.: pallent IS ask.:d to touch the
floor Implies Inahtlity to re,'cf"C the lurnhar lor-
dosis and is often .>ecn In paheflls I'o'i th
ti,e
ArlfJ{hcr feature of <;crofl<!g:lIh'c
arthropathy. inrtuding Reller ssyndrome. it:-. [en-
dcllCy \0 cause \IIf1ammation at terldinous mscr-
tions into bone: thb is called f"nthesupalhy. This
81\'eS rise 10 the 'i.ausage digit"' in the or fecI.
ns well :ll.lo Achilks tcndi nllis and plllllt.lr
in tnc fOQ(. Similar rna)' be seen in the
other HLA-B27 related ttnkylrn;.lng
spondylitis. psorialic anhritis. and mflarnmatory
bow!.""1 disease.
Achilles tellll imt is du .... to
gives nsc to chroniC hind foot and p.."1in
\tulalgta). Other causes of acute or chromc Achllics
tcndintlis incl ude Ir.luma. ath!cltc overu>.:. RA.
gOUt. psclldogoul. llaOlhomas in hyperlipoProlcmc_
mlas. and the oLhcr i-ILA-B27 asSOCIUled condi-
tions. The presence of h..--el pam often
I'oilh a poor and may lead to wm
disability.
Pl ain radiographs. uhrru.ound. and MRI may be
todcmol\S[r.Jt.: Achlltes tendinitis. In normal
individuab the thickness of the Achilles tendon
be[ l'o een 4 and 8 mm at the level of the calcaneus.
With inllaOlmulion. the tendon is thickelll."'d. An
retrocalcaneal bllrsilis may obliler.lte
the normal mdloluccncy that al lea$1 2
mm helow the prn;.terrn.uperior surface of the cal -
cafl<!us.
Treatmcnt of A(.hliles tendini tis includes
NSAIDs. ht:er support. splinting (unkk-fool or-
tnrn;.is). and gentle str!.""tching. The Achilles tendon
is to ntptur .... and must not be injected
1'0 ith but relro.;:alcaneal bursitis and
plantar fascii ti s may respond 10 Injectcd cortico-
Resistant cases may impro\'C wilh sul-
fasalnzine. melhotrela[e. or 31.3thioprlne. Reiter's
di.;ease may be the pre.>enling manifeMation <If
human immunod.:ficiency virus IHI V) infection.
In It is usually lIIcomplete I'ouh enthc-
Hnd fusclltls of the fl'Ct !:>elng domlnal1l
features. therapy is con-
traillllic3tl:d 111 P(II!CIIIS. LOC31
radiotherapy to the heel Olay YIeld prompt nnd
persistcnt impro"emenlll1 cases refractory to con-
<iCr'oath"c treatment.
10 the presenl case. a dingnosis of incomplete
Reiter's syndrome I'oas made in this }oung woman
woo was HLA- B27 positive \>'Ith Alhilles tendi ni-
tIS following a diarrheal Illness. IIcocolonoscopy
was negative for IIIflammatory bowel di.loCa,e.
Achtllcs lelldlllilts faded to 10 NSAIDs.
alld nJethotre.,ate. Soft liS'
we resolved with local radil,thcrap). but
pam and disability
151
Clinical Pearls
I Talalgia. or Il.'cl pam. may be lhe 11m s),mptom of sponuy-
In,inl! IiI is. mn.lmma-
lury bowd disciL'>c.
1. Rei lcr"s urcrhritb. lind conjuncm ilb) may pres-
ent with arthrili s alom: (i ncomplete ReitcT' ndromcl. in whi ch pmn is uw-
ally a promlllclll feature.
3. Im;umplclc Reiler 's !ldromc. and fasditis of Ih.:- fcc!.
may be a manifcs\Oltion of human immunooclicicnc) virus IHIV) infection .
.. J. Heel pain \0 IS nftc" chronic alld may bt- ul'abhng.
5. RadI ographic features of Reltcr ', ,)ndrome involVing the hce! mclude thKkening
orthe Ach illes tendon. oblilcr:lIion of the relro .. :lkanc:11 1"1:<:,'".
eros lOllS of Ihe plall1ar :lIlU ui the cnkullcus.
6. Rcfractory of may to u l,f locill radio-
therapy.
REFERENCES
Smllh DI. . lI.nnell MO Rellcr' , di-.e ... ,n Anh,,, .. Rheum IQ!;Il;1.1"5-1.u,
0.", Ie. S<rnd.rn Y. Folie, Gil Talalg., 'cr .... ", ,,[ I() .. ,.", I Rho;ulIU10I I I b
j D. F.rngold \11.. Curd I. G. {ior.S"'" n. Colic-an<al In ",,,,"1...- J,,,,,,o.-,,

Fu\ R. Cairo ,\ . Ge.hr, RC. (l,t>-,on D. n-.. 't) uf 'lm[ll<>n",oo Jj"'b"lly In Read, 'I nJlflm< ,\n oi 1\1
''''l1l>rtu'''. pa''''"'' o\nn In,.," Mod 1'17'1.'11 1'/1
W, .... ho:".,R AIt)Su .... ,hrm.u"'"<Ii,d''''''-'''' III
b GnU V. Smllh M. \r..m M. Lm\ciQlln G. LIXJl poJ.1 m.<",I.-w",,,,, "r HI ,\ II,' ... 101,.01 ..-,hll'l"',h} II,
I Rheum,.01
152
PATIENT 70
A "O-) {'llr-old dfllbelic man "ith a persistent ulcer
A -UJ-ycar-old man wilh chronic mellitus is n:fcrred for an c'alumino of a chronic ulccr-
:nion on his left fool. The ulcer been prCSCIlI for R months. with a gradual inc reus<: In length ..... I(Jlh.
and depth. The increa>..: In size has continued d.:spite weekly dcbridcments. P:m medical history in-
cludes a righllcg bell)1\-lhc-'I;ncc amputation, due to an "uncontroll ed infection,"'
Physical Examirwtio1l : Va,cular lid! lower "lremiIY): mlaC! tree. Palpation: po::dis and
posterior tibial pulses e,idenl. Sku!. 6 em x 5 em x 7 em plantar u!ccr:l\ion located beneath cuboid
bone: ,upcrfidal, flU clinical of mfection.
Laboralflry Fill/lings: Tc-99 bone .>Can: neg311ve for osteomyelitis. Radiographs: Significant
amount of Joint sublu'ulli on and especially In mid-foot region Blood work (including e BC
\\.Ith diiferentilll).
QUfStions; What the cau.>C of an ulcerallon of this Slle III this location'! What IS the .. ,-
planallon for the healing -c'pcdally In the presence of mtact
"3
Diagllmi s; Char.:"t Jiah<;u.: uMeoanhropathy
DiS(UHiQn ; A chronic, nonhcOlling uker in
this locatioo is common, In the
preSt:nce of a mid-font, The of
the contralmeral limb ,lCccntuaTes The weighT
bearing and The H:nkal on the
remaining font, As a result, especially III The pres
clICe of lo<:nloOry tleuropathy, the lack I)f tho.: "pro-
feedback mechanism" may be de\a5laltng,
The 3t,:cepted tremment for :kUle neuropathic
anhropathy of Ihe fool and/or ankle in pallcnts
wiTh has been prolonged Immobilizmion
III a or C:l.'it untt! con<;()lidarion and
healing arc eVIdent lind clinical
of the foot and :lI1kle ha-. been reStored
ThiS nlt:thoo is cfft:i:tive in patients, espe-
dally when treatment b inqilllted early, before a
Ilxcd deforrnt ty has de\cloped. Howc\cr.
prompt immobili1.3UOn and protected weight
bearmg. >evere deformities llt:velop in some pa-
tients. Aho, after some neuropathic
of tlk: pcritalar or anl..Je Join!. whether aCUle or
chronic. the 100 un-table TO be
m a..Ie'!uate alignment by cllhcr a brace or a plas-
tcr cast. In addition, wme patiellts lila)' notloCck
trelliment unltl after fi)(ed deformities
ha\e Deformed ncuropnthic c\trenll-
tics, if tll the of .... eight bearing,
are susceptible to UICerJIlOn mf.-ctlon as well
to the of e\'emual amputallon.
Operati\e treatment is ....
10 aloid these o;equelac. Enthusiasm for opeT:ltive
treatment has genemlly becn tempered by thc an-
ticipated high frequellcy of p-.:udoarthroses and
other complications. Numerous physicians have

\
---
154
reponed lhe result s of ('per:ltIVe treatmt'IH ,'I neu-
ropathic Ilnhropathy. but most HI the>!.':
hill';: concerned II smgle p.lflellt ur .I
small scrics. u ..... tulmformatloll h.!,
bet:n provided.
Shibata et a!. reponed the rc,ulh 01 tlolotalar
and tibilXaklllleai in who
had Icprolic ncuropathic arthropathy With .In 1Il -
tramedulllll)' nil il used for It\Jt lon. wtb
19 palients. The In-
cluJed seven pseudoanhro\es .lI1d four IIlfelllllll,.
UIlJ two patient, hau,In Jmpiltatll,n,
Stuart lind Mom:)' reponed lhe re,"lts "f anhro-
of the anlle and pent,dar JOint, in I -' patient-.
\I 1m had 11l5uiin-dependent di:llx'tes mdlttu,. ntlle
of ..... hom had f'Jdiogr.!phic evidence of llCurop;nhtl-
JJ1hmpathy. TCMllts .... cn: ""ti,la..lJJT\ III only
ti\'e of the 13 patu:llIs. and there cumplica-
lions in seven of the ninc patient, ..... ho h,ld
p.1thie changcs. The complic3ltons illcluJed t\\'O
nonunions alld lhree Jeep utl<:':lIolls. ,HId trn..'re
.... ere also t\lO belo\l thc ampuUtlOn), I!ow-
C\'t;'r. a I'anety vf opo.'rall\e Ic .. :hl1;4I1C_' W,I' <'111 -
ployed for the arthnxle .... ' m 1h<:lr .... ne'. and
tcmlllfhation used in nlnc Ql tlk- I J
In s ummary. most patl<'llIs whu h:l\t' Ilcuro
pathic arthropathy cun be mmtJgeti
wuh immobtlization til a plaster ca,t or by In or-
thosis, Opcrame lrt'allnelll tel'hnicJlly demanJ-
mg and a'isociUled with a high ratc of compllca
tions, Howe\'cr. when there i, --.even: in't,loility O!'
a fixed deforrnity. open 3nJ aucmpted
anhrodcsis with rigid Ilxallon (SCt;' may be
Ihe best \I D) to salvage the
Clinical Pearls
Pursue an) and all dingnoslil' 10 rule OUI in a palient with Char-
CO[ diabetic OMoo;u1hropattly.
2. Determine Ihe poim of weight-bearing and initiale u plan to
"off-load" the pressure.
3. Devise a plat! \0 trigger wound healing_
4. First at!t:mpt [0 off-load and use an :Ipcnure-Iyp;: casi. allowing weight
bearing but Without pressure on Ihe deformity underlying the wound.
REFERENCES
Shihm T. T""'" K, Ihbhllu,"" C 'llIe af arlhro<k,,, uf ,,., for kPHlIic IICuroanhroplllhy J Bo;me Joml Surg 12-
" 199()
2. ,>,nh'odt"'ollr.c.U'.>t>r" ....... rup.lhICWlllcJO'nl ChnOnhopH3 209-211.1'190
155
INDEX
A
Ab",-=css. It 83
Adlille:. ttnut,"
rupture, 7-8
Acquirt.'d dubfOo.)1. 97
Addiction. 11 -- 1
Alhright's 73
Ancul)small1one 98- 99
Anteater sign.
Antioblotic-imprcgnatcd beads. J3
Arch pain. 25--27. 60-61. 9.+-95
Arterial ocdusi\c
Athletes. 17- Jt), 56-57. 74-75. 96- 97.

At1hroplasty
5-1-55
Avascular necrosi", 57, 6H
B
Ba]I-:.lI1d-sockctjoim.
'Ba:.lctball foot," 97
Blount's disease. 10+-105
BUlle: fk-cks. 20-2 t
Bone J5- 36, 48--49. 81
Hom'/iil 125- 126
Bowed legs, 10+-105. 123--- 124
Brachymetatarsia.73
Bump. 28-29
"Sunling" pain, 115- 117
C
Calcium pyrophosphate dihydrate cryst:IIs.
132
Ccfawlin. 12. 14,33
136-1.17
Churcot-Maric-Tooth 6U--61. 6')--71
surgery. ljUCSI1011S 10 before. 70
Colenwn block 70
CharcOljoim. 118-120. lJI - H .'
Chondmbla!>tomu. Y9
Chopart joint. 110
6
Clear l'cll 100-10 I
Clora7imine. 66
Coalition
lalcanconavicular. 39-4 t. 46-47
pscudIXoali!ion.
4+-45. 86-87
talonavicular. 44-)5
Colchicine. 2. R3
Coleman block test. 70
Compartment !>yndrome. 5-6
Congenital convex pes valgus. 93
CREST syndrome.
Crush injury. 5-6
Cutaneous T.cclllymphoma. 30-31
Cyanosis. 1 1- 12
o
9- 10. 13- 14.32-34.
37-38.62--64.65-66.88-89. 112-114.
13S-139.15.'\- 155
Diabetic neuropathy, 131-[33.153-155
Dimple sign. 29
Dls..:ascmodifying antirheum'ltic drugs.
III
Dbloc<ltion. submlar jomt. 96-97
Dorsiflexion injury. 56--57. 67-68
Down's syndrome. 73
Doxycycline. J3
Drop foot. 6
Dv. yer calcaneal oSleOlOmy. 61
E
Ecthyma. 10
Electrical 23
Enchondroma. 15- 16
Emhcliopathy, 151
Entntpmcnt ncuropalhy. 115- 117
Epidermal inclusion cyst. 14,W-91
Erythema indumtum. 10
fscherichia ('oli. 118
F
Falling, 50-51
6
Female athlete's Ifiad. 81
FllIt fool. 51-53, 92-93. IIK-120
157
1-0(\.'lgn Dildy, 13 Iq.54- 55
Fracturc
avuhion, 2 I
delayed unioll. 23.U
nonunion. 21-23
35- 36. RO- 81
t:llar. 56-57. 67- 68. 85
Tillaux, 58- 59
infraction. -12---43
Frostbite. [1 - 11
degree, of inJury. 12
three treatment 12
G
Ganglion. 76 -77. 83.102 10J
Gas gangrene. 1-1
Gastrocnemius .... qUIllUo;, I
Genu rc .... urvalum. 51
Giant cdltunlor. 99
Gout) arthnti" 1- 2.83
Granuloma annulare. 10
"GrowlIlg pains:' -18----'9
"
Haglund', ddofnllty, 7- 8
Hallu, [12- 114

cia,sifiCalion. of Illlar fnlllures. 57. 68
<,ign. 57. 68
Heel pain
Chrclllic, 150- 152
. .1---4. J5-36
7-8
I krpcio II
Hb!iocytoma.28-29
Ilyal ;ne-typc l' artilage. 16
H} pcrglyccmia, IU
Ilypcrpronatinn. 18
Hypo:nlncemia.2
Hy,!cna. 4R--lQ
InJorn..:th'lun. I 2
Infalllil .... tlbia \ara. 10-I-1(J5
Ingrov.n t(lenail. 117-128
Intoeing. ;;2- 5J
.J
J 13
J,llnt'''paring II J
IS!!
INDEX
Jones procedure. 61
Ju\..:nilc fr<tcturc ofTillau"(. 58-59
K
Kohler', disease, IOS-IOQ
'"Knobby knee:' 122
L
Ligaments
partial tear!>, 20- 2 [
Limb length di\crcpanr:y, 18
Limp. 102- 103
Llporn:l.
of the calcaneus 3-4
I
amputation. 89
Joint, 1]0
L) me Jil>(:ase. 125- 126
"
KI
"I\-!ct c\)ul..ic<' 116
Metachromat ic 50-51
illkluCIUS, 52- .53
Methotre,,;!!c.82-!U
Melronidal.ole. 1-1
Microtruuma. repcti ti\e digital. 78-79
Monosodium urate 2
Monon's neuroma. 115- 117
sign. 116
1\1}cosis fungoides, .lU-JJ
MY'OId 76-77
N
lipoidlca diabcticorum. 9- 10
Nt':uroma.22-13
o
Open reduction with rigid internal fi:ution,
85
J 21-122
I .1 4-1 35
O'teochondroma!osis. 106-107
108- 101,1
Osteoid -18---49
14.32-3-1 . .17- .'8. 54-55
chronil' .133- 139
cplphy,eal. \)-1-9.5
mctatar;al head. 62- 6-1
1-11
(COlli,)
SIII/,/n""" n, {!H 1/111"11\, 140-142
{)9
'N
(h tligOllU1ll ,,}'nJrnm<!. 7-1-75
r
P,tnllirul!!j" oudul:lr. 10
P"nt;.tlar tmino. 40
127- L'X
ro:,!uinn. IS. 19
31
I'.:roneal 45
Pipt'rdllm. JJ
61
PI:lnt;trlk,lon inwNon injury. 96-97
Plantarb. alld 146-
1.7
I'o"krior tibt:llll'ndoll ::!5- :!7
26
Ifl",Hnlcnl. ::6
Pu,ltr;Jummie tlhro,,,. 10
Pr ... .. 66
p",uuv..,,,lilion.47
i'scudolllonm <I .. 14.135
Punltur.: WOllllth. 13- 14. 134--1 J5
PlIV,..\.31
P)Olkrnl<l 6S- tl6
R
rewarming. 11
R'I'h. J0-31
dheasl". 129-130
R<!lt ... r'" 150- 152
Rhl"uml\1\lld 81--83
ju\tnil .... 110 111
mclh,'lrl",atl". R2-S3
rh.:um:lIoiJ ])oJull"'. 10. to
Jidary. 123 124
Hlgi<ll,1HI' I R
Rocker-bottom loot. Q2- 93
RIIIHler', P,ljl1. 17-19.80--81. 91P)9
S
'\ ,m:oi,1. 10
Jigil:' I:; [
\\I',",te;11 hl,lIl11:.nl. 63
Scp\i,. /4
SCPIlt: If

IN[JEJ(
Silicon. 55
SoIl 82-83, 90-91
Sprain. ankle 56-57
Spur. 7-8
SIUIJhdfJ<-'OfTUS mrrrlls. 10, 14. 38. 63. 95.
!41
S/(IIJItY/Ot'C.I(C!lS t'piderll1idi$. 14
Stasis 10
"Slor[.. leg" 71
Stress fractures
right fibula. 17- [8
right 35-36
'I"o:ond KG-SI
Subungual hemalUma. 78-79
Swelling, 1 2. 13- /4
Syno\ ial cysts. 76-77
Synovitis. acute. 21
143-145
T
Tal"r bcaking. 40. 47
leg:' 146-[47
Tethering. 29
TicarCllIrn,33
1-2. 11-/2. 15-16,42-43,72-73.
78- 79.112- 114.127-128.129-
130
Trnurna
ankle. 20- 21. 84--85
fool. 5--6
repetitive. 90--91
Trumpet sign. 107
Turner's syndrome. 73
U
Ulcers. 9- 10. 32- 24. 37- 38. 62- M. 88-89.
lJ8-139.153-155
V
Val1mllt}dn. 10. 14.38
Vaso,pastic phl'nf>mena. 11-4
Vertil:lll mlus. 92-'J]
01. 'J3
IV
"\V:lrcr,hcJ" ",rea, R
X
Xanthuma. 10.83
}.eroradiQgraphy.14
159
THE PEARLS SERIES"
The ca!;C prest"nt:lIions In The Pear ls Series'" provide IIlfOnnUUUII 1101 readily in slUndurU
textbooks. The problem-oriented approut:h. ideal for Independent quoy and board Teview, cncourJges the
reader 10 consider a differential diagnmlS and fonnulate a treatment plan. Here a panlUJ 1I.lIng:
CRITICAL CARE PEARLS, 2nd edition
A. Salm, MD. and JoIUI E. I leITner, MD. Medical Univen;ilY of South Carolina. O!:JrIe.;too. South Canllina
19981500 1-56053-224-6
DERMATOLOGY PEARLS-special hardcover, full-color edition
.: Ieanor .:. Sahn. MD. Medical University of South Carolina. South Carulina
19991252 pages/illustrated/ISBN 1-56053-315-3
HAND PEARLS
i\hllthe\\' J. Concannon,MO. FACS. Uni\cp,ity 01 Mi,wuri. Columbia. Mi\'oun. !lnu Jack Huro\. Phi).
i\ ISI''T. CIIT. r.ledical Ccmer- Hcahh Kall$as CiIY . .
20021272 p3ge<Jillu<;trntedlISBN
INFECTious DISEASE PEARLS
Burke A. Cunha,1\ ID. SUNY:It Stony Brook. Stony Brook. New Yurk
1999/21-l pagl.'s/illuqrntedllSBN J -56053-20)-)
INTERNAL MEDICINE PEARLS, 2nd edition
Julm E. HeITner,.\1D and. Stcwll A. Sahn,1\ ID, r. \ooical Uni\clliily of South ClllOlin.:l.. O\ark:;[un, South Cllmlina
::!OOIl27S 1-56053---10-l--l
NEUROLOGY PEARLS
Andrew J. Wm.:lawik. I\ ID, :unl Thomas P. Sulula . \11), I' hl)
Unhcl'>lty of Wi<'con,in-.\Iadi,(m M,uJi,un. Wi,cun,in
20001228 pageslilluSlr.lIedllSBN 1-56053-261..(1
PEDIATRIC PULMONARY PEARLS
l.aura S. l nselman, 1\10, Alfred I. forChtidren. Wilmington. Delaware
20011225 pages/illustratedllSBN I-S6IlS3-3S0-1
RHEUMATOLOGY PEARLS
Richard 1\1. Sih"Cr. r.1I). Hnd Ed\\in A. Smilh. ,\1 0 .
Uni"cr"it)' of South Carolina. Charic';[on. South Carolina
199711 80 1-56053-201-7
Other Books of Interest ...
Fool and lower Extremity Anatomy to Color and Study
Physical Medicine and Rehabil itati on Secrets. 2nd ed.
Foot and Ankle Secrets
ISBN 1-56053-445-1