Vertical Medial Malleolar Fracture in a Collegiate Soccer Player With Tibia Varus

Abstract

HISTORY: 18 yo male collegiate soccer player with history of nondisplaced, isolated, vertical medial malleolar fracture treated conservatively with short leg nonweightbearing cast for 3 weeks followed by walking boot for 3 more weeks. 6 week radiographs showed interval healing and no change in alignment, and he returned to full activity after achieving full range of motion with physical therapy. He was asymptomatic until 7 months after initial injury when during a soccer game he felt a pop and developed medial ankle pain after landing flat on his previously injured ankle. He presented to our clinic for evaluation. PHYSICAL EXAMINATION: Mild swelling without ecchymosis over medial ankle. Small joint effusion palpable. Medial pain with attemped weight bearing. Tender to palpation 3cm above medial malleolus. No fibular or syndesmotic tenderness. Mildly tender over deltoid and posterior tibial tendon. Nontender over lateral ligaments. Negative lower extremity squeeze test. Normal Thompson's test. No pain with calcaneal squeeze or palpation over navicular, cuboid, or fifth metatarsal base. Normal neurovascular exam distally in his foot. Tibia varus alignment. DIFFERENTIAL DIAGNOSIS: Medial malleolar fracture Deltoid ligament sprain Avulsion fracture medial malleolus Posterior tibial tendon strain or subluxation Syndesmotic sprain Talar dome fracture. TEST AND RESULTS: Radiographs of ankle showed no displacement but increased lucency through callous formation from previous fracture. No widening of ankle mortise. No talar dome lesions. No other fractures. FINAL WORKING DIAGNOSIS: Nondisplaced fracture through previous fibrous union of vertical medial malleolar fracture. TREATMENT AND OUTCOMES: Patient underwent operative plate fixation with bone grafting of medial malleolar fracture. Current literature supports conservative management for isolated, nondisplaced, medial malleolar fractures (Richter, Orthopade 1999;28(6), Thordarson, Physician and Sportsmedicine 1996;24(9)). This case is very similar to that of a well known professional basketball player who underwent 4 surgeries and missed most of two seasons for a similar fracture. In these cases, it is hypothesized that the tibia varus alignment contributed to the vertical orientation of the fracture, incomplete healing, and subsequent reinjury. Anatomic alignment should be considered in management decisions for vertical medial malleolar fractures. Patients with tibia varus alignment may have a higher rate of complications and may need longer immobilization or initial operative fixation for these types of fractures.