Author: Charles Ware, III, MD
Co Author #1: Thomas L. Pommering, DO, FAAFP

Patient Presentation:
A 10 y/o female street hockey player presented to the sports medicine clinic with pain on the lateral aspect of her right ankle.

History:
The initial injury took place four months earlier during indoor street hockey practice where she was struck with a plastic hockey stick on the right ankle. During the initial injury there was no bleeding, break in the skin or penetrating trauma. The significant swelling and bruising which resulted, led her to follow up with her PCP who at that point recommended RICE. Two months later while jumping off a couch she noted similar pain in the right ankle. She was seen at an urgent care where it was recommended she see an orthopedic surgeon. At that time she had moderate swelling and plain radiographs of the ankle yielded lucency in the distal fibula. She was diagnosed with a lateral ankle sprain and a Salter I fracture of the right lateral malleolus and placed in a stirrup splint.

She continued to do well over the next two months when she was again struck in the same ankle eliciting a similar pain and presentation. She then presented to the sports medicine clinic with a significant limp. She denied fevers, rashes, weight loss, diarrhea, abdominal pain, conjunctivitis, dysphagia, oral ulcerations, history of osteomyelitis, previous ankle injury, or any additional joint arthralgia. Her family history was positive for rheumatoid arthritis in her mother. Social history is positive for daytime childcare, exposure to both dogs and cats, but negative for exposure to farm animals and travel history.

Following her MRI and awaiting her biopsy she developed a new onset 1 x 1.5 cm skin rash on the outer heel that was associated with redness, scaling and purulent drainage. She was then admitted to the hospital for three days and a consultation was placed to infectious disease for definitive diagnosis and treatment. A nuclear medicine bones scan was performed as well as interventional radiology performed a sterile CT guided fibular biopsy yielding unusual multiple pathogens.

Physical Exam:
She appears healthy, in no apparent distress, though walks with a minimal limp. All vital signs are normal. Inspection of her right ankle reveals lateral soft tissue swelling, 2+ joint effusion, and mild erythema but no ecchymosis. Palpation displays TTP over the lateral malleolus. She has full ROM with minimal pain upon inversion and eversion. Neurovascular exam reveals normal pulses and intact sensation throughout. Special tests including anterior drawer, talar tilt and external rotation tests were negative. A full multi-system physical exam was also completed that was normal.

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