Ryan Fitzgerald, DPM PRESENT RI Associate Editor Hess Orthopedics & Sports Medicine Harrisonburg, Virginia

HPI: The patient is a 44-year-old female who presents for a second opinion wearing a cam-walker, complaining of pain in her right ankle. She relates to having suffered from a previous ankle fracture with required operative fixation approximately six months ago.  She states that her previous surgeon had told her that things had "not been healing well" and so he had revised her fixation and removed some of the hardware.  She presents today complaining of persistent pain about her right ankle that is worse with weight bearing and resolves somewhat –although not completely—when she is off of the foot.  She relates that she is currently taking percocet daily for her pain, and is concerned that she may be developing a dependency problem.

PMH: HTN

Sx HX:The patient relates to previous ORIF Right ankle with subsequent revision, c-section

FMH: Noncontributory

Medications: MVI, Atenolol

Social History: ½ PPD tobacco usage, social alcohol consumption and denies drug usage

Physical Exam: The patient demonstrates palpable pedal pulses that are graded as +2/4 at the dorsalis pedis and posterior tibial arteries. CFT is less than 3 seconds in the digits. There are no varicosities or telangectasias. She does demonstrate some mild swelling about the right ankle. However, there is no ecchymosis or other skin lesions noted. Evaluation of muscle strength on the right demonstrates +5/5 in dorsiflexion, plantarflexion, inversion and eversion, with pain noted with ankle dorsiflexion as well as ankle instability with rotatory motion.   There is pain noted to direct palpation along the medial and lateral malleoli.

Imaging Studies: Plan film radiographs demonstrate evidence of previous operative fixation along the distal fibula with apparent nonunion along at the fibular fracture site as well as fixation noted in the medial malleolus with evidence of radiolucency noted at the fixation site (Fig. 1a, b).

Considering the clinical exam presented, and the physical and imaging findings, how would you proceed in the management of this patient?  Follow this link or click on the image below, to participate in the on going eTalk thread on this topic. The Conclusion of this case will be posted in an upcoming Residency Insight.

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