A 65-year-old farmer presents to the ED after his ankle was run over by a piece of farm equipment in the field. His x-ray is shown above (Figure 1: Case courtesy of Dr. Oyedepo Victor Olufemi, radiopaedia.org) He also has an associated soft tissue injury overlying the area that is grossly contaminated with mud and manure. (more…)
Figure 1. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9601
Figure 1. Case courtesy of Dr Hani Makky ALSALAM, Radiopaedia.org, rID: 8720
Stress fracture at the distal tibial metaphysis – note the faint sclerotic line at the tibial metaphysis (Figure 2).
Figure 2. Arrows identifying the stress fracture. Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 8720
When coupled with the amenorrhea, consider the female athlete triad.
Plain film ankle views should be obtained. If a stress fracture is acute, sensitivity on plain films can be as low as 10% [6]. MRI can be performed outpatient with a sensitivity approaching 100% [4,5,7,8]. A pregnancy test should be performed as well given the amenorrhea. A standard workup for amenorrhea should be performed as an outpatient. Inquire about eating habits and anxiety/depression.
The three components of the female triad are on a spectrum of severity in the disruption of bone mineral density/osteoporosis, menstrual dysfunction/dysmenorrhea, and low energy with or without an eating disorder [1,9-11]. Patients will have a degree of dysfunction of all three components.
Stress fracture treatment included rest and analgesics. Immobilization is not necessary, but refraining from activity which exacerbates pain is crucial. NSAIDs may be used for pain control [5,7]. Female athlete triad is multifactorial and outpatient follow up should be ensured. Referral to adolescent medicine, sports medicine, or close primary care follow up is important.
Check out ALiEM’s SplintER Series to brush up on other can’t miss diagnoses of ankle pain.
A 30-year-old female presents with left second finger pain with overlying erythema, warmth, and swelling the day after her cat bit her finger. She cannot fully extend the finger, it is tender and she has pain when it is passively extended. Her hand appears as shown above (Figure 1. Case courtesy of Kristina Kyle, MD).
Figure 1. Image prompt: AP view of the pelvis and left hip. Authors’ own images.
A 70-year-old male presents with left hip pain and inability to ambulate after a mechanical trip and fall. Examination demonstrates that the left lower extremity is shortened, abducted and externally rotated. Hip and pelvis x-rays are obtained (Figure 1).
A 29-year-old male presents with right shoulder pain, throbbing, and swelling. He states that a bulge has appeared over his right anterior shoulder recently (Image 1). While he was doing pushups today, he began to have numbness, tingling, and weakness in his right arm. While in the waiting room, his symptoms have completely resolved.
Image 1: Bedside ultrasound of the anterior shoulder at the site of the bulge. AA=axillary artery. AV=axillary vein. Author’s image.
