Lateral ankle/fibula swelling

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I have seen an unusual case in my joint physio/pod clinic this morning and wondered if anyone has any ideas/thoughts.

A 14 year old girl presented with swelling just proximal to the lateral malleolus on the right leg. The has been present for approximately 9-12 months. She recalls no injury/trauma to the area. The swelling is not well defined ie. is not obviously a bursa etc but looks more like there has been a sprain (although there hasn't). It is warmer over the swelling. She has VERY slim calcs on both feet, with met adductus, but all biomechanical findings are bilateral. All ROMs are normal. It was not painful to palpate but she experiences pain on prolonged activity and particularly of note was night pain, and reports not sleeping most of last night due to pain. She was unable to describe the type of pain. She is in 'ballet' style shoes, but my gut instinct is that this is something more complex than a tendon strain? Any ideas? I have arranged for the GP to see urgently today to arrange an x-ray.

Many thanks for your help in advance.

Ella

 

Ella:

X-rays and possibly other diagnostic studies are essential to rule out fibular stress fracture and/or bone tumor.

 

I agree with Kevin;
At that age with warmth, swelling, pain at the level of an epiphysis or metaphysis, you first need to rule out tumor then go from there.
I think the referral is wise.
Steve

 

Dear Kevin and Steve

Thank you for your advice - you have confirmed what I was thinking really. I will make sure her Dr doesn't ignore it. I hope for her sake that it is something benign.

I will post again when there is more to report.

Thanks again, Ella

 

Attached is the x-ray of the girl mentioned above. I have never seen this kind of thing, but I think that is a tumour? It certainly doesn't look good anyway, but I'm by no means an expert. I am in close contact with the GP and we are making an urgent onward referral - but can anyone give me an idea on diagnosis?

Thanks, Ella

 

Hi Ella:
Thanks for posting the x-rays.
Of course pathology gets the last word, but I think there is room for optimism. It appears non expansive with somewhat well defined borders.
My first impression is UBC.
D.D.: Benign Chondroblastoma, Chondromyoid fibroma, Atypical Osteoid osteoma.

Hopefully nothing more.
Please let us know.
Steve

 

Hi,
Very interesting post and replies. Thanks people.
Probably should be obvious, but can you please clarify what the acronym UBC stands for?
Thanks
Colm

 

Colm,

I think UBC stands for Unicameral Bone Cyst - I'm sure Steve will confirm or put me straight!

Ella

 

Hi Colm:
Ella is correct; UBC=Unicameral Bone Cyst.
It is what it sounds like, a cyst within bone containing fluid.
The reason I put it first is because it is fairly common and the patient is the right age and the lesion is in the right place - children to adolescence, found in "growing" bone in metaphyseal areas adjacent to the epiphysis.
My only concern is clinical finding of "warmth" and the symptom pain.
Steve

 

Yes, the warmth and night pain were my concerns also. The Orthopaedic Consultant is seeing her tomorrow and she is booked in for an MRI. The GP is questioning Osteomyelitis as a diagnosis - it doesn't look much like that to me though.

Ella

 

Steve:

I like your call of unicameral bone cyst on this young lady's fibular bone tumor. Probable cause for pain and warmth is microfracturing of cortex around the thin lateral wall of the cyst during weightbearing activities. Will be interesting to see what the MRI results show.

 

Thanks Steve & Emma!

I will be following this thread with interest.
What a brilliant forum.
Colm

 

Emma? :bang:

Correction: Ella

Duh

 

Hi Kevin:
Did you notice the small calcification at the medial border of the Fibula (on the AP) with what appears like an adjacent depression in the cortex? About 2 or 3 cm proximal.
Also soft tissue irregularities lateral and just proximal to the lesion itself (also on the AP)
What do you think?
Steve

 

Steve:

Looks like a little bit of periosteal lifting on the medial fibular cortex but I'm not impressed with any destruction of osseos tissues subperiosteally. I don't know what to make of the soft tissue irregularities lateral to the distal fibula. Can't wait to see what the MRI shows. I pray that there is no bad news for this young lady.

 

We've had the radiologists report back now, and it suggests "Brodie's Abscess" as a possible diagnosis, which I believe is a form of osetomyelitis. Any thought? Still waiting for the MRI. Will post further info as it becomes available.

Ella

 

Hi Ella:
Brodie's is possible, though it's not classic Brodie's. Was that the Radiologists only suggestion?
Steve

 

Yes, but he also referred for urgent MRI and advised a specialist opinion. He described the lesion in more detail. I'm afraid I don't have access to the report again until Monday (4th) so will transcribe the entire thing then.

Ella

 

Steve - as promised, this is a copy of the full radiologists report:

"There is abnormality in the left distal fibula
involving the meta-diaphysis. The bone is expanded and there
is a smooth periosteal reaction. There is cortical thickening
and at the lateral aspect of the metaphysis is a radio-lucent
lesion measuring approximately 1.5cms. There is associated
soft tissue swelling. The lesion does not transgress the epiphyseal
plate. The appearances suggest a relatively slow growing lesion,
but it has aggressive characteristics. It could represent subacute/chronic
osteomyelitis (Brodie's abscess), but I suspect ultimately a
surgical biopsy is going to be required. I will arrange for
an urgent MRI scan and in the interim I would suggest a referral
to a bone tumour surgeon".

MRI happens today, so will report back when I have more info from that.

Thanks, Ella

 

Hi Ella:
Thanks for the update.
Let us know what the MRI shows.
Steve

 

Dear All

I have the MRI report back now -

"There is a tarck running through the complete width of the lower fibula. This is filled with soft tissue. The margins are relatively well defined very there is very extenisve surrounding soft tissue oedema and marrow oedema extending proximally within the fibula. There is periosteal thickening at the abnormality that extends over a total of 11cm in the cranial caudal plane. There is relative protection by the epipheseal plate but some oedema is seen inthe epiphisis and certainly the soft tissue abonrmality extends eactly to the level of the plate anteriorly. The abnormal tissue extends into the region of the interosseous membrane but does not appear to communicate with the ankle joint. I think by far the most likely explanation is chronic osteomyelitis possibly involving the epiphiseal plate which could have growth implicaitons but there is no definite destruction of the plate. Urgent Orthopaedic referral is needed."

This is a bit of a relief - it doesn't look like the worst thing it could have been! Ortho are now dealing with the case, no doubt she'll return to us for physio and orthotics when it's been treated?

Thanks for all your advise and suggestions. Does anyone know what the orthos will do now? I assume IV antibiotics and a biopsy?

Ella

 

Oops - just noticed the typo - "tarck" should read "track"! Sorry

 

Hi Ella:
That is fairly good news. The radiologist was correct with his Brodie's abcess Dx.
The second cortical defect proximally on your xray must be a sinus track egress which accounts for the soft tissue swelling as well.

Normally in these cases (assuming it's localized to the Fibula and she has no other issues)........
like any abcess - I&D, IV antibiotics.

Thanks for sharing this case with us, let us know how it turns out.

Steve

 

Ella:

Typically, a surgery will be done, like Steve said, to perform an incision and drainage (I&D). During the surgery, a bone biopsy will probably be taken to determine the organism causing the infection, and then perform a culture and sensitivity (C&S) of that organism to various antibiotics to determine the best antibiotic(s) to use to treat the infection. A drain may be used initially to exit from the skin and then the incision closed secondarily once the surgeon is certain the infection is being treated successfully with the antibiotics.

Thank you for providing this wonderful teaching case to all of those following along. You have done a superb job of keeping us abreast of this young lady's progress.

 

Kevin & Steve

Thank you for you kind words - I'm hope others can learn from this, and you both, as I have done!

Many thanks again - I will post again if I have any more information once she has had surgery.

Ella