Medial Malleolar Insufficiency Fracture of the Ankle in an Elderly Patient with Osteoporosis
A 65-year-old female patient presented with left ankle pain of 2 months' duration. There was no history of trauma or bisphosphonate use for osteoporosis and the pain was activity-related and relieved partially by rest or elevation. In the past medical history, no special diseases such as diabetes, hypertension, and cerebrovascular diseases were present and she was a non-smoker and a non-drinker. The physical examination showed mild localized tenderness in the medial aspect of the ankle and no swelling. The range of motion of the ankle was full, and stability was intact. She was 157 cm in height, had a body weight of 58 kg, and her body mass index was 23.5 kg/m2. The bone mineral density (BMD) was measured utilizing peripheral quantitative computed tomography (P-QCT; Somatom sensation 16, Simens, Erlangen, Germany). On assessment of the results, severe osteoporosis was considered because the BMD and T-score of the lumbar vertebrae (L1-4) were 40.4 mg/cm3 and -4.31 (). At the time of visiting, a plain radiograph of the left ankle showed a fracture that was not clearly depicted but showed as a faint vertical sclerotic line in the medial malleolus of the ankle joint (). She was treated with restriction of activity and non steroidal anti-inflammatory drugs (NSAIDs). After 3 weeks of treatment, she still had pain in the left ankle. Magnetic resonance imaging (MRI) was performed. The MRI of the left ankle revealed an irregular vertical low signal line with surrounding marrow edema at the junction of the medial malleolus and the tibial plafond which did not extend to the medial malleolar cortex of the tibia (). We diagnosed a medial malleolar insufficiency fracture of the ankle.\nAn operation was performed because of progressive pain and difficulty of ambulation during the follow-up, leading to early recovery and normal activities. The patient was placed in the supine position under spinal anesthesia. The fracture was internally fixated with a percutaneous cannulated screw under c-arm guidance () and at the same time an arthroscopic procedure was performed. The arthroscopic examination revealed no displacement of the medial fracture line within the joint but synovitis was observed. Arthroscopic debridement was performed. After surgery, she was kept in a non-weight bearing cast for 5 weeks. At the fifth week, she was allowed to perform ankle range of motion exercises and partial weight-bearing walking. As of the 4-month follow-up, there was bony union and she had recovered to full activity with the treatment including osteoporosis medications (). The patient was informed of this report.