Missed metatarsalcuneiform joint avulsion fracture; case report

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I saw a lady last week who I felt was a good illustration of benefit for having US as extension of fingers during physical exam for improving diagnosis in MSK foot injury.

51 yo female, reported being in good general health, no prior history of foot surgery or trauma, left foot episodic dorsal lateral midfoot pain.

Her presentation was of sudden onset pain in Jan 2011. No recollection of a traumatic event, her pain; VAS 4: (visual analogue pain scale range 0-10; moderate pain which interferes with tasks) to VAS 8: (very severe pain which interferes with basic needs) seemed associated with weight-bearing, worsened with increased activity, improved with rest, burning stabbing in nature and accompanied by heat and redness dorsal to point of maximum tenderness. Pain on rising from bed in morning but denied rest pain. Typically her routine cardio-vascular exercise regimen involved walking dogs 1 hour daily two days per week. She mentioned provisional diagnosis of tendonitis by primary care physician. radiographic exam report; no significant findings.

I observed; no signs of swelling, erythema, heat or skin lesions, tenderness to palpation at and discomfort with passive range of motion of left foot 5th metatarsal cuboid joint. Diagnostic ultrasound exam) was suggestive for avulsion fracture at medial joint margins and review of radiograph suggested subtle signs were missed without benefit of prior US. See attached .pdfs

Initial impression was of non healing avulsion fracture of dorsal metatarsalcuboid ligament at proximal 5th epiphysis.

Plan: temporary immobilization with short leg walker patient was pain free with ambulation whilst using the brace. Repeat radiographic exam (lateral oblique standing only) after approximately 3-4w. Assuming the site appears healed at this point we will taper return to normal foot-wear and activity.

Any others with experience of managing similar case, particularly failure from immobilization?

Cheers

Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com