ANKLE INJURY - TELEMARK SKIING 421

Abstract

HISTORY - A forty four year old male was telemark skiing and sustained a hard forward fall with marked dorsiflexion of his left ankle. He had immediate onset of left ankle pain but was able to ski to the base of the mountain. The patient was evaluated by his primary care physician at that time, and radiographs revealed no evidence of bony injury. Conservative treatment with ice, elevation, and limitation of weight bearing was instituted. Four days after the injury, the patient noted marked swelling of the left ankle and distal leg, associated with a significant increase in pain. On the fifth day post-injury, because of worsening of these symptoms, he was referred to an orthopedic surgeon. PHYSICAL EXAMINATION - There was moderate swelling of the left ankle and distal leg with no ecchymosis. There was marked tenderness to palpation of the distal left leg and ankle. There was anterior leg pain with passive flexion of the toes. There was also pain with active dorsiflexion of the ankle and toes. There was decreased sensation to light touch over the anterior and lateral aspects of the distal leg and dorsum of the foot, as well as weakness of extensor hallucis longus, extensor digitorum, tibialis anterior, and the peronel. DIFFERENTIAL DIAGNOSIS: Syndesmosis disruption Compartment syndrome Proximal fibula fracture with common peroneal neuropathy Anide or talus fracture Vascular injury TESTS AND RESULTS: Compartment pressure measurements: Pressures less than 30 mmHg in the left foot and mid leg. Pressures greater than 100 mmHg in the anterior and lateral compartments of the distal left leg. FINAL/WORKING DIAGNOSIS: Anterior and lateral compartment syndromes of the distal leg, secondary to crush injury. TREATMENT: Anterior and lateral compartment fasciotomies, with return to surgery twice for debridement of the most distal aspects of extensor digitorum, extensor hallucis longus, peroneus longus and peroneus brevis. Non weight bearing for three weeks, then partial weight bearing for three weeks. Follow up CT scan was negative for syndesmosis disruption. Range of motion exercises initiated after one week. Gradual increase in strengthening of affected muscles. Return to skiing three months post injury.