Case Reports in Medicine / 2012 / Article / Tab 2

Case Report

Osteochondritis of the Distal Tibial Epiphysis

Table 2

Comparison in clinic, diagnosis, and management of different cases in the literature.

AuthorPublication yearNumber of casesAge (years)/sexEtiologyTreatment of etiologyClinical presentation of AVNRadiologyTreatment and evolution of AVN

Siffert and Arkin [1]1950111/MComminuted trimalleolar ankle fracture (Salter Harris IV)(i) Reduction under general anesthesia
(ii) Cast stabilization for 2 months
(iii) Gradual weight bearing after cast removal
(i) Symptoms started shortly after cast removal
(ii) 13 months after injury:
pain, swelling, restriction of motion
(i) X-ray (13 months):
nonunion of the medial malleolus and epiphysis irregular, compressed, and fragmented
(i) Ankle arthrodesis 14 months after injury owing to persistent pain and nonunion

Robertson [2]196413/MLeft ankle trauma without radiological abnormality(i) 4 months after trauma: pain, medial ankle swelling(i) X-ray (4 months):
flattening and sclerosis of the distal tibial epiphysis
(ii) X-ray (10 months):
new bone formation and early regeneration
(i) Immobilization with a below knee cast for 2 months
(ii) 5.5 years after injury: no clinical abnormality

Hassler et al. [3]19602Case : 7,5/FKnown to have:
(i) Congenital anterior bowing of the tibia
(ii) Absence of proximal one-third of the fibula
(i) Started walking at 3.5 years
(ii) At 7.5 years:
clinical widening of ankle was noted
(i) X-ray (age 7.5 years):
fragmentation of distal tibial epiphysis
(ii) X-ray (2 years after diagnosis):
reformation of bone trabeculae in the epiphysis
(i) Walks with a knee-to-ankle brace
Case :
Known to have:
(i) Mild spastic right hemiplegia
(ii) Valgus deformity of right foot
(iii) Mild recurrence of left metatarsus adductus deformity
Brace for valgus deformity(i) Prominence of left medial malleolus
(ii) Tendency of the left foot to go into varus
(i) X-ray (age 3 years):
No ossification of distal tibial epiphysis
(ii) X-ray (age 5 years):
Epiphysis flattened and fragmented
(iii) X-ray (age 8 years):
(i) Brace for 1 year to control the varus deformity
(ii) The patient walks in a regular shoe at 8 years of age

Klein et al. [4]2008112/M(i) Known to have: flexible pes planovalgus
(ii) Played football and kicked with his right foot
(i) Tenderness and swelling on the medial malleolus 6 weeks after playing football(i) X-ray (6 weeks after sport):
fragmentation of the right medial malleolus
(ii) X-ray (10 weeks after sport):
signs of repair of the epiphysis
(iii) MRI (same time):
soft tissue and bone-marrow oedema at the medial malleolus
(i) Conservative treatment
(ii) 10 weeks (after sport):
no symptoms

Holland et al. [5]19931 (bilateral)13/FSchool sport tournament 10 months before presentation(i) Bilateral ankle pain
(ii) Unable to practice sports
(iii) Mild swelling and a decreased range of motion of both ankles, especially of the left one
(i) X-ray:
bilateral sclerosis, fragmentation, and collapse of the lateral part of the distal tibial epiphyses and the adjacent metaphyses
(i) Restriction of activity with arch supports
(ii) 1 year later her complaints were slightly diminished.
(iii) The radiographs (1 year) showed no significant changes

Kennedy and Weiner [6]1991112/M(i) Salter IV fracture of the right medial malleolus
(ii) Salter II fracture of the distal fibula
(i) Closed reduction in the ER
(ii) ORIF with 3 pins
(iii) Pins removed at 6 weeks
(i) X-ray (6 weeks):
some persistence of the malleolar fracture and the tibial epiphysis unusually sclerotic
(ii) X-ray (20 weeks):
increased epiphyseal density
(iii) X-ray (49 weeks):
reossification of the tibial epiphysis.
(iv) Bone scan (18 months):
showed revascularization of the epiphysis
(i) Short leg cast for 8 weeks
(ii) Touch-down weight bearing 8 weeks after cast removal
(iii) Clinical improvement
(iv) Nonprotected walking at 20 weeks
18 months after injury: clinically asymptomatic

Gascó et al. [7]20102Case :
(i) Known to have congenital sensitive neuropathy
(ii) Swelling of right ankle started 2 years ago
(i) Below knee cast for 1 month (traumatic suspicion) but persistence of swelling after its removal(i) At presentation: ankle swelling and reduced ROM with subtalar stiffness
(ii) Gait normal with no limb length discrepancy
(i) X-ray (at presentation):
increase in density and sclerosis with height reduction of the distal tibial epiphysis
(ii) MRI:
hypointense band located in the ossification nucleus of the distal epiphysis
(iii) X-ray after 1 year:
signs of reossification with widening of the metaphysis and epiphysis
(iv) X-ray (5 years):
destruction of the ankle joint as Charcot arthropathy
(i) At presentation: ankle-foot orthosis to prevent postural bad habit for a period of 3 months
(ii) At 2 years: mild ankle swelling with normal ROM
(iii) At 5 years: reduced ROM. There is also a varus deformity of the hind foot and subtalar joint stiffness and a 1.5-cm limb length discrepancy The patient still use an orthosis for ankle protection
Case :
Known to have myelomeningocele and developmental dysplasia of the right hip operated at 3 years of age: Dega acetabuloplasty and varus derotation
osteotomy of the femur
Right ankle swelling for 2 weeks(i) X-ray at presentation:
reduction in the tibial
epiphyseal height and an increase in bone density
(ii) X-ray (after 5 years of follow-up):
recovery of the height of the epiphysis
(i) Rest for 6 weeks
After 5 years of followup:
ROM similar to other side. Leg length discrepancy was less than 1.5 cm caused by the pathology of the ankle and that of the hip

Our case201116/FRight ankle trauma without radiological abnormalityRight ankle swelling 1 month after trauma
Right limb shorter than the left limb of less than 5 mm
(i) X-rays (during the first 2 years of evolution): compatible with the diagnosis of AVN
(ii) X-ray (after 2 years of evolution): metaphyseal enlargement and irregularity of the epiphysis
(iii) MRI: areas of fragmentation in the epiphysis
(i) No treatment was given.
(ii) Clinical and radiological followup at regular intervals

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