Neuro-epiphyseal injury around the ankle: a case report

An epiphyseal injury without obvious trauma is a diagnostic dilemma; in neurologically impaired children, the lack of sensation and repetitive trauma can lead to neuropathic injuries of the physeal plate, with bizarre X-ray changes; the problem is compounded by lack of awareness in the average orthopaedist, leading to treatment delays and unnecessary procedures like biopsy, or even surgery for osteomyelitis or malignancy, with increased morbidity and disability. We report a 12-year male child with myelomeningocele and neurological deficit; he presented with painless swelling and redness of left leg and sensory-motor deficit below the knee joints. X-rays showed distal tibial epiphysis plate widening and irregularity. A diagnosis of neuropathic epiphyseal plate injury was considered; the clinico-radiological picture only resolved after rigid immobilization in below knee POP casts and abstinence of weight bearing. Lesser changes were noted in the opposite side also. The injured physis displaced somewhat posteromedially over 8 months, but ultimately fused; contra-lateral changes subsided with partial physeal fusion. The objective of reporting this unusual case is to increase the awareness levels, and to report the bizarre radiological changes. Management involves non-weight bearing immobilization; diagnostic delays lead to more reactive changes with higher incidence of subsequent physeal closure.