21/07/2022 at 5:00 pm #39439
I had this case the other day I was hoping someone could shed more light on. 17yr old skinny tall boy, kneed in shin at basketball 6/7 ago. No bruising and minimal swelling. Still very painful to weight bear (using crutches), but focally pressing with probe wasn’t too bad.
Haematoma involving tibalis anterior and posterior at level of mid lower leg (superior to AOC) with rupture interosseous membrane.
21/07/2022 at 7:02 pm #39446
I think you have nailed it really,
I agree there is a haematoma straddling the interosseous membrane.
In the short axis I am convinced there is a tear of the interosseous membrane with a haematoma either side of it.
In the long axis it is more difficult to appreciate the defect, however the haematoma is obvious.
I think the only thing that makes sense here is that the trauma has perforated the interosseous membrane and then it has bled causing the haematoma.
It is a lovely case and it is a diagnosis that I very rarely make.
Your case is the second one I have seen this year where I have been convinced of an interosseous membrane defect.
You can tear the interosseous membrane as an extension of a high ankle sprain AITFS injury and in your case it seems it is just a direct impact injury.
Whenever you tear the interosseous membrane it is really painful and the patient is unlikely to be able to weight bare.
The reason there is no bruising is that the blood is trapped adjacent to the interosseous membrane by the overlying muscles (tib ant and tib post) so has no access to the subcutaneous space. Hence there will be some clinical swelling and tightness of the anterior compartment but no swelling.
It reinforces the idea that it is indeed worth looking at the interosseous membrane in patients with high ankle sprain symptoms or direct calf trauma.
I love your work,
This is worthy of being case of the week,
Let me know if you would like me to record it as case of the week.
28/07/2022 at 2:01 pm #39622
I spoke to his physio today, physio consulted with a surgeon who was happy with conservative treatment from the physio.
Patient is back running on treadmill 4/52 post injury. Improving every week. Will be interesting to see the follow up scan.
I had another case today patient broke tib and fib water skiing 3/12 ago. Metal rod inserted into tibia. Still persistent pain and limping. Surgeon dismissed her concerns. No previous ultrasound or MRI. GP referred for x-ray and ultrasound to FI. 2 focal pain areas. 1. distal fibula near site of # 2. distal tibia location of screws
Ruptured int membrane mid lower leg to ankle. More of a classic injury for membrane rupture. Another one you can use for your case of the week.
Any tips for what to look out for at the screw location. Surrounding oedema noted.
22/07/2022 at 9:14 am #39463
Thanks for the reply Steve!
I was thinking the fact the he has tall skinny legs that didn’t offer as much protection to the membrane as most people.
His physio works next door to me, I’ll follow up with him to see what the outcome was.
28/07/2022 at 2:15 pm #39629
The follow up will be interesting.
Nice to have a physio next door to review cases with.
Your next case is another great example,
You are a walking case of the week machine!
When I look at a screw site that is causing pain I consider the location of the screw (does it protrude out too far at either end etc), the structures adjacent to the screw (is it rubbing on a tendon , nerve etc) and then look for evidence of regional inflammatory change or infection with Doppler and soft tissue b-mode assessment.
Not rocket science really,
05/08/2022 at 8:38 pm #39847
Patient returned today for follow up ultrasound, 4 weeks since the previous scan.
His pain is improving with no limping, but still feeling pain with his increasing running last couple of weeks.
Previous lesion has resolved, there still appears to be a defect of the membrane.
06/08/2022 at 7:35 pm #39871
It is a great case to follow up,
I agree the defect in the interosseous membrane has a persisting defect and the surrounding muscle now looks much better as the surrounding haematoma / interstitial b blood / oedema has resolved.
I still think the muscle immediately adjacent to the tibia has an abnormal appearance, but it is much improved from the last scan.
I doubt the defect in the interosseous membrane will ever completely recover, I suspect a layer of fibrosis will develop across the defect.
Great follow up!
This case has made me much more focussed on assessing the interosseous membrane, something I don’t think I have considered enough in the past.
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