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Saturday, January 26, 2013

Ankle Injuries: Fractured Steida's Process

The 2 photos below are of a patient who presents with an ankle sprain. Initial treatment for swelling and pain went well, but after 6 weeks the patient was not back to normal activities. The sprain was the usual type where the foot and ankle are inverted, but there was a fall afterwards which can produce more force. The patient did not remember what the ankle did in the fall landing forward and to her side. Initially the entire ankle was sore--laterally, anterior, posterior, and medially. It was the patient's first sprain, so she had nothing to compare this injury to. She was placed in a removable boot and on crutches. It took 3 full weeks to get safely off the crutches to full weight bearing with no increase in pain, and another 3 weeks in the removable boot progressing to full day to day activities without any flareups. An EvenUp was used with the boot on the other side to balance the hips. Physical therapy was done twice weekly from the onset to reduce swelling, and get the range of motion and some strength back. By six weeks, there was still some limited inversion which is common, but she was very sore when I plantarflexed the ankle (pointed her foot) in the back of the ankle which is uncommon in a typical sprain. The initial xrays taken at an ER were reported as negative, but I never saw them. Here are the 2 side views of the ankle at 6 weeks showing a fractured Steida's Process of the talus in the back of the ankle. 

This is a side view (lateral view) of the ankle showing the front and back of the ankle well. The marker is placed above the injured part of the talus which is it's back and lateral most prominence. When the ankle joint points too far (plantarflexes or bends downward), this prominence called Steida's Process can get damaged. Since many patients have this bone normally in a separate piece never completely fusing to the parent bone(called an  Os Trigonum), many times, including this time, the xray was read as normal with the presence of an Os Trigonum.

Here a blowup image of the area shows the jagged edges between the 2 pieces typical of a fracture not a extra bone like the os trigonum. If the piece of bone is an normal accessory ossicle, the borders between the bones are normally curved and smooth. Due to the possible surgical implications of having to remove this bone if the symptoms continue, either a bone scan or MRI is needed to confirm the diagnosis. Pain on plantar flexion of the ankle in this area, coupled with this xray, should be enough to go on at this point. To protect the bone, the removable boot will be left on for the full 3 months, and forced range of motion around the extra bone will not be done in physical therapy. The physical therapist is now notified that we may be dealing with a healing fracture, so the "no pain, no gain" rule commonly imploded will not be adhered to if the pain is coming from this area.

This is one of the most common problems in young ballerinas. If they are unlucky enough to develop this bone in the back of their ankles (starts forming around 8-9 and fully formed 14 or so years old), this could give chronic pain in the back of the ankle as pointe work is being accelerated.

The goal with this patient will be to calm down all the inflammation, rest the ankle for a total of 3 months removable weight bearing cast, then 2-6 week attempt at weaning out of the cast with an ASO ankle brace maintaining a pain free environment, build up the walking up to 60 minutes then a walk/run program. She is to avoid pointing the ankle, such as sitting back on the foot while kneeling. The sensitivity in the back of the ankle could take 2-5 years, but many patients can avoid surgery and return to full activities over a 6 month period. I have considered, but not used, a bone stimulator for this problem, but it is not contra-indicated. As with any fracture, diet counseling on Vit D, calcium, and also bone density history should be done so that the patient has the best chance of healing. 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.