A 60-year-old woman is admitted electively to the neurosurgery service for a multilevel posterior cervical decompression and fusion. The procedure is completed uneventfully and without complication. The patient is admitted to the neurosurgical floor.

In the middle of the night, you receive a call from the nurse stating that the patient is complaining of moderate pain and swelling in her left ankle and foot, which occurred after she got up to use the bathroom. The patient denies injuring herself. She complains of pain with weight-bearing. Since the pain is tolerable and pain medication has already been given, it is decided to assess the complaint later in the morning. 

On evaluation, the left foot and ankle are mildly swollen, with tenderness on the lateral aspect. There is minimal tenderness on the foot. Distal pulses and color are good. The calf is nontender. The patient’s medical history is significant only for mild hypertension.  Radiographs of the left ankle are obtained. What is your impression?

ANSWER

The radiograph demonstrates mild soft-tissue swelling and an oblique, mildly displaced fracture of the distal fibula. In addition, there is a small bone density adjacent to the medial malleolus, which could represent either an unfused accessory ossification center or a sequela of prior trauma.

On closer questioning, the patient acknowledged that a few months prior, she had stepped in a hole and been treated for a “broken bone.” She had been in a cast for an undisclosed period of time; at a follow-up appointment, the cast had been removed and the bone had been declared “healed.”

A new orthopedic consultation was obtained prior to the patient’s discharge from the hospital, which resulted in placement of a short leg cast.