Case of the month – Feb 2017
Randa Dafalla, MD
Research Assistant, Department of Radiology
Duke University Medical Center, Durham, NC, USA
This is a 3-year-old female who presents with concern for left foot pain, on and off over the last year. She satrted to complaint around the same time her mother had a broken foot, so she thought that her child was copying the behavior. Since then the pain will wax and wane, usually exacerbating once per month. She did attend a ballet camp for a week and that seems to have caused the pain to be worse. No specific injury can be identified, although her mother notes that in the start of her symptoms, the patient did jump from a ladder and did have foot pain at that time, but did not notice any swelling or erythema. The patient will consistently point to the dorsum of her foot as relating to the pain. The patient is very hesitant to wear tight-fitting supportive shoes because of the tenderness on the top of her foot. When the patient is having pain, she will walk on the right side of her foot; and she also will walk with a limp when the pain is very severe. The pain does not seem to wake her up; however, sometimes it limits her playing. No associated swelling or erythema of the foot. No other joint symptoms are present. No family history of any joint problems.
Vaccination: Up to date. Allergies: no Known allergy. Medications: fluoride supplements
PMH: The patient did break her left arm and had a cast, but that has healed up very nicely.
Review of System (ROS): Unremarkable
Social History: Non-contributory.
VITAL SIGNS: Weight is 15.9 kg. Temp is 37.
GENERAL: Healthy-appearing, active white female sitting in a chair in no acute distress.
CHEST: Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm without murmur.
LOWER EXTREMITIES: Appear symmetric without any swelling or erythema. Examination of the left foot: Full range of motion with inversion of the foot and at the ankle. No tenderness to palpation over the plantar surface. There is tenderness to palpation on the dorsal surface of the foot and Abigail is able to point to 1 spot that is more tender. Other spots when palpated on the foot, including the toes, tibia and fibula are not tender. Medial and lateral malleolus are not tender to palpation. Good peripheral pulses, 2+, bilaterally.
NEUROLOGICAL: Alert and oriented X3. On examining the patient’s gait, gait is normal at this time. Examination of the patient’s stance: She does seem to be more flatfooted in the affected left foot.
X-rays were obtained of the left and right foot. The left foot (Shown below Fig. 1 and 2). increased density and multiple ossification centers in the tarsal navicular. Also, the tarsal navicular seemed to be somewhat flattened. X-ray of the right foot showed a normal tarsal navicular and extremity (not shown).
Figure 1 Figure 2
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