A 19-Year-Old with Acute Ankle Pain While Playing Hockey

Differential Diagnosis

• Acute compartment syndrome
• Peripheral vascular injury
• Soft tissue injury
• Tibia fracture

Diagnosis

The patient has an acute posterior malleolar fracture of the tibia, also known as a Volkmann’s or Earle’s fracture. It is uncommon and usually occurs from abduction and external rotation. They are more common in younger adults.

Learnings/What to Look for

• Clinical presentation is usually pain and difficulty ambulating and weightbearing following trauma
• Radiographic findings include a vertical fracture along the posterior distal tibia, usually extending up to the articular surface
• A variable degree of articular surface involvement and separation of the fracture fragment is present
• Accompanying joint effusion/hemarthrosis may be visible with bulging joint capsule
• These fractures may be accompanied by medial or lateral malleoli fractures
• An optimally positioned good quality lateral view is needed for visualization of the fracture. Poor quality lateral views obtained in oblique projections may miss nondisplaced or minimally displaced fracture
• CT evaluation of the fracture is usually indicated for assessment of fracture, extent of involvement of the articular surface, and the surgical planning

Pearls for Urgent Care Management and Considerations for Transfer

• Small and nondisplaced fractures may be managed conservatively with immobilization, although surgical treatment with internal fixation is preferred for faster recovery and better outcome
• Surgical management includes open reduction, internal fixation, and restoration of the articular surface
• An improperly treated fracture may result in a chronically painful ankle, limited range of motion, and premature osteoarthritis

 

Acknowledgement: Images and case provided by Teleradiology Specialists, www.teleradiologyspecialists.com