Every Treatment Plan Has Its Consequences

Abstract

HISTORY: A 24 yo male tri-athlete presents 5 days after an injury while playing ping-pong. The athlete jumped to celebrate a point and landed on the lateral portion of his left foot inverting and twisting it at which point he heard and felt a "pop." Thirty minutes later he still had excruciating pain at the base of his 5th metatarsal and presented to the immediate care center where he was diagnosed with a fracture, and was placed in a posterior splint, given crutches, and told to follow up. At clinic, he had been non-weight-bearing for 4 days and kept his left leg immobilized in a posterior splint. In the past two days he noticed dorsolateral foot numbness following several bouts of intermittent left calf cramping lasting several minutes which was not relieved by massage. Today he notes left foot and ankle joint swelling, stiffness, and weakness. He denied using tobacco, drugs or alternative medicines. PHYSICAL EXAMINATION: General: Muscular, healthy appearing, well tempered male in no acute distress. Left foot: Tender, 5th metatarsal, yellow-brown discoloration, unable to weight-bear due to pain. Left ankle: Erythema, 1+ swelling, slight discoloration, full ROM. Left Calf: Tender to palpation medially, increased calf pain with dorsiflexion. Negative Thompson test. Left knee: normal. Right Foot/Ankle/Calf/Knee: normal findings. Neurological: Numbness/tingling in his left foot post calf cramps, but otherwise no abnormalities. Skin: No petechiae, swelling, erythema, and discoloration only in locations noted earlier DIFFERENTIAL DIAGNOSIS: 5th metatarsal Jones-Type fracture 5th metatarsal stress fracture, lateral ankle sprain Calf pain due to inactivity/immobilization with posterior splint, Deep venous thrombosis, as complication of immobilization Calf strain due to injury TEST AND RESULTS: X-RAY: Foot films consistent with Jones-type fracture. No evidence of stress fracture. Doppler Ultrasound Left lower extremity (LLE): an acute venous thrombus in the LLE Peroneal Vein. FINAL WORKING DIAGNOSIS: 1. Fifth Metatarsal Jones Type Fracture on Left Foot- metaphyseal area 2. Acute DVT LLE in the Peroneal Vein TREATMENT AND OUTCOMES: Placed in a hard shoe with crutches Aspirin 325mg 2x/day Scheduled for a f/u US with Vascular Radiology in 5days.