Ankle Injury - Soccer

Abstract

HISTORY: A 12-year-old previously healthy 6th grade soccer player developed pain in his right ankle after a soccer game which became progressively worse to the point of non-weight bearing over the next 24 hours. He was completely asymptomatic until an hour after the game. He did not recall a specific injury, but x-rays at his pediatrician’s office revealed a small possible avulsion fracture from the lateral talus. He was placed in a stirrup brace with crutches, but continued to have significant pain along the lateral malleolus and was still unable to bear weight on his right ankle 1 week later. PHYSICAL EXAMINATION: Office examination revealed edema of lateral and anterolateral ankle with minimal ecchymosis and significant tenderness to palpation over lateral malleolus and distal fibula without tenderness over suspected avulsion fracture of the lateral talus. The ATFL, CFL, AITLF ligaments were tender to palpation. Range of motion and strength were limited due to pain and swelling. Anterior drawer demonstrated minimal laxity, talar tilt was minimally positive in neutral position and mildly positive in plantar flexion. Cotton test (syndesmosis) was moderately positive for pain without laxity. Squeeze and Thompson (Achilles) tests were normal. DIFFERENTIAL DIAGNOSIS: 1. Salter-Harris 1 fracture with possible syndesmotic sprain 2. Osteochondral injury of the talus 3. Mild left lateral ankle sprain TEST AND RESULTS: Left ankle MRI: -Marrow edema and complex subperiosteal fluid throughout distal fibula without fracture -Linear signal within posterior aspect of talar dome with minimal associated marrow edema -Intermediate T2 signal within PTF, CFL ligaments Ankle radiographs: -No fracture, dislocation, or other osseous abnormality with intact joint spaces FINAL WORKING DIAGNOSIS: Left ankle osteomyelitis TREATMENT AND OUTCOMES: 1. Washout of the right ankle performed by orthopedics 2. Initiate treatment with IV Nafcillin and Clindamycin 3. Once patient clinically improved, PICC line was inserted for outpatient antibiotic care with Cefazolin for a total of 14 days of treatment then switched to PO Cephalexin. 4.Treatment successful, return to soccer without any restrictions.