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F/U 6 yr old foot pain

X-rays





What do you believe is the diagnosis, how would you treat?

6 year old with foot pain

This case was sent to me.

Patient is a six year old male with a three week history of right foot pain. Mother and patient relate no history of trauma. Patient came home from school three weeks ago with pain and swelling over the medial aspect of the right foot. Symptoms have persisted for past three weeks. Mother states patient has been ambulating with a limp.

PHYSICAL EXAM : There is tenderness to palpation and minimal swelling over the medial aspect of the right navicular. The lateral border of the foot is straight without significant metatarsus adductus. The hindfoot is supple and there is a normal arch. Examination of the left foot is unremarkable.

What is your differential diagnosis and how would you begin to work up this patient?

Call for Interesting Cases

I'd like to invite anyone with an interesting case they would like to share to contact me or feel free to post here. I'd like to open up the discussion beyond my own personal interests. Thoughts or suggestions on how this online forum is going are also welcome.

So obviously this guy needs ORIF. I believe surgery was somewhere in the neighborhood of 10 hours. Fun. The intra-op film shows provisional fixation with clamps and k-wire. I guess you just have to be there.

So I placed distal femoral traction. This can be done without c-arm. Your insertion site is about two finger breadths above the patella or four above the adductor tubercle. You should insert from medial to lateral. I found it helpful to put several blankets beneath the leg to elevate it and get better access when reaching across the opposite extremity. I used 2% lidocaine 10 cc medial and 10 cc laterally to anesthetize the skin. A 0.62 k-wire is then inserted using a drill from medial to lateral. You can feel the femoral cortex. Try to go for the anterior third. I try to get the patella pointing straight toward the ceiling and at the same time palpate the epicondyles. This gives me an approximate axis for inserting the wire (it should be essentially parallel to the ground with the leg in this position). You use a Kirschner bow with the k-wire. Really not too difficult.




Anybody got any tips?

Always get films to confirm placement.

Here are CT 3D reconstructions.

Outlet


Inlet


AP




What views would be more helpful in assessing this injury?

How would you describe this fracture?

What temporizing measure can be done to partially reduce and splint this fracture?