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Possible tarsal coalition??

Discussion in 'Foot Surgery' started by sspod2001, Mar 26, 2013.

  1. sspod2001

    sspod2001 Active Member


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    Hi Guys,

    I have a case which presented last week that I'd like to share, particularly the x-rays which I didn't recognise and was wondering if anyone had any thoughts.

    the case as follows;

    PP:24 yr old male presented with painful R/foot/ankle
    HxPP: Pain has been present since pt was 15 yrs old, no hx of trauma, and no previous investigations/treatment carried out. Pt feels relief when compressing the joint only for pain to return almost immediately.
    Med Hx and Meds: unremarkable, occasional Tylenol to help with pain.
    ASSESSMENT:
    NEURO: WNL
    VASC: WNL
    DERM: WNL
    MSK: R/STJ ROM RESTRICTED (UNABLE TO GET ANY STJ EVERSION, AND R/CALC IN STANCE IS IN VALGUS POSITION)

    I suspected a tarsal coalition and referred Pt for X-Ray (see attached images) x-rays I think show a small Talar Beak on lateral view however i'm not sure as to which image (more to the point what angle) im looking at with the 1st image (it says lateral???) but there is an unusual presentation I think.

    Anyway not been sent the report just the images (apparently the report just notes a small spur somewhere) my question is am I looking at a Tarsal coalition possibly Calcaneonavicular or is this nothing at all.

    I would appreciate any thoughts
    regards
    Steve
     
    Last edited by a moderator: Mar 27, 2013
  2. Lee

    Lee Active Member

    Hi Steve.
    It looks like a talocalcaneal coalition. Two points though:

    1) edit your post to preserve patient anonymity so you don't get into any bother
    2) please post a full lateral view so everyone can see the ankle joint, STJ and calcaneus

    Do you have any further imaging? Do you have an oblique view of the foot? From the part of the lateral posted at the moment, it doesn't look like a calcaneonavicular coalition. What treatment have you tried so far? Ankle splints, orthoses, injections, etc... ?
    Thanks,
    Lee
     
  3. Looks like a middle facet talo-calcaneal coalition to me. As Lee said, a full lateral view of the foot would be helpful, not just a partial lateral view. In addition, a CT scan is the best test to properly diagnose this condition, not plain film radiographs.
     
  4. sspod2001

    sspod2001 Active Member

    Thanks Lee: I tried with the images but not been successful in blocking out the pt's info, not to worry though as he was in clinic today and gave me permission to use the images as is.
    Only saw him last week and whilst awaiting images tried a firm low dye strapping which he said helped alleviate his ankle pain a little, next stage ive today casted for pair of orthotics which if not successful then I would have to refer for Sx.

    Thanks Kevin: I'll try and upload a different lateral view. After more digging around I found that it looks most like a middle facet talo-calcaneal coalition, regarding the CT imaging I was told by the GP that I would have an easier time getting blood from a stone. Image referral here in Ontario is a little slow to say the least.

    regards
    Steve
     
  5. sspod2001

    sspod2001 Active Member

    As requested this is the best lateral image available sorry.

    also can you tell me what view the first image is, certainly not lateral as written on the image?

    Regards
    Steve
     
  6. Steve:

    You should still block out the patient's name here, regardless of what the patient says now. Send me the originals and I'll do it for you and send them back to you. It is bad form, and possibly not legal in many countries, to have identifying information of a patient on an open internet forum.

    kevinakirby@comcast.net
     
  7. drsarbes

    drsarbes Well-Known Member

    Hi
    No doubt what this is.
    At 15 it may already be too late to resect this.
    Usually what happens with these is an attempt at resection does not really increase the ROM but does, frequently, decrease symptoms.
    As the patient ages he may require a triple.

    Good luck

    Steve
     
  8. sspod2001

    sspod2001 Active Member

    Hi DrSArbes,

    Patient is now 24.

    Anyone have any ideas how to remove the current images with the patients details, I now have images without pt details (school boy error)

    thanks
     
  9. drsarbes

    drsarbes Well-Known Member

    perhaps the administrator can delete them for you.

    without getting into too much detail....these are, at age 24, treated by either decreasing whatever painful motion is available (various braces) or a triple arthrodesis. .
    Not much in between that I am aware of.

    Steve
     
  10. sspod2001

    sspod2001 Active Member

    More appropriate images for this forum

    regards
    Steve

    ps sorry about the poor quality best we've got
     

    Attached Files:

  11. sadders

    sadders Member

    "C" sign and "Anteater" sign.
     
  12. JLarholt

    JLarholt Welcome New Poster

    Hi,

    Your patient definitely has a coalition of the middle facet of the STJ. The joint also looks arthritic.

    I think your steps so far are the way forward (insoles), but often they fail especially if there is already OA at the joint as some motion will still be occurring and the amount of vertical load through the STJ is great.

    Kevin's suggestion of a CT scan would be the next investigation as it can determine the size of the coalition as well as its composition.

    If conservative care fails surgery would be the next step and the surgery would be depenednt on
    1) Size of caoaltion
    2) Extent of 2ndery OA

    If the coalition is not too large, in relation to the facet, and the OA is minimal then resection plus splitting of the FHL to interpose the superior portion between the middle facet can be carried out. However the only papers on this are in relation to kiddies and are case studies, at best.

    If the OA is extensive or the coalition large, whihc means there will be a greater amount of destruction of the facet then a coalition resection plus STJ repostional fusion would be the way forward.

    Regards

    Jonathan
     
  13. mr2pod

    mr2pod Active Member

    In answer to "what view is that" in what is labelled "lateral". I believe that is a Harris-Beath View, which is often used to show possible coalitions. CT is still the way to go as mentioned to give better clarity on dimension and composition.
     
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