J Bone Metab.  2013 Nov;20(2):119-122. 10.11005/jbm.2013.20.2.119.

Medial Malleolar Insufficiency Fracture of the Ankle in an Elderly Patient with Osteoporosis

• Kim GD
• Chae SU
• Cha MS

• KMID: 2286305
• DOI: http://doi.org/10.11005/jbm.2013.20.2.119

Abstract

Insufficiency fracture is a type of stress fracture, which is the result of normal stresses on abnormal bone. Postmenopausal osteoporosis is the most common cause of insufficiency fractures. An early diagnosis is best made with a bone scan or magnetic resonance imaging, as radiographs may initially appear normal. Insufficiency fractures of the lower leg and ankle are less common. Furthermore, reports of medial malleolar insufficiency fracture without any history of trauma in elderly patients are extremely rare. Thus, we report a case with a medial malleolar insufficiency fracture of the ankle in an elderly patient with osteoporosis. This case shows that we should be aware of the possibility of encountering an uncommon medial malleolar insufficiency fracture as a cause of pain in the ankle region of an elderly patient with osteoporosis.

Keyword

Ankle; Insufficiency fracture; Medial malleolus; Osteoporosis postmenopausal

MeSH Terms

Ankle*
Early Diagnosis
Female
Fractures, Stress*
History
Humans
Leg
Magnetic Resonance Imaging
Osteoporosis*
Osteoporosis, Postmenopausal
Wounds and Injuries

Figure

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  Fig. 1 Bone mineral density of the lumbar spine by peripheral quantitative computed tomography (P-QCT).

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  Fig. 2 (A) Initial radiograph of the left ankle shows a fracture was a faint vertical sclerotic line in the medial malleolus of the ankle joint. (B) Coronal T2-weighted and (C) proton density weighted magnetic resonance image shows an irregular low signal line and surrounding bone 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.

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  Fig. 3 (A) Postoperative radiograph of the left ankle shows good fixation with a cannulated screw. (B) Radiograph at 4 months after the operation shows bony union.

Reference

1. Pentecost RL, Murray RA, Brindley HH. Fatigue, insufficiency, and pathologic fractures. JAMA. 1964; 187:1001–1004.

2. Kaye RA. Insufficiency stress fractures of the foot and ankle in postmenopausal women. Foot Ankle Int. 1998; 19:221–224.

3. Daffner RH, Pavlov H. Stress fractures: current concepts. AJR Am J Roentgenol. 1992; 159:245–252.

4. Maheshwari AV, Kounine MM, Soaita M, et al. Osteoporotic insufficiency fractures of the pelvis simulating a malignancy in an elderly man. Am J Orthop (Belle Mead NJ). 2009; 38:E45–E48.

5. Tsuchie H, Miyakoshi N, Hongo M, et al. Insufficiency fractures of bilateral distal tibias associated with chronic liver disease. J Orthop Sci. 2010; 15:678–681.

6. Gurdezi S, Trehan RK, Rickman M. Bilateral undisplaced insufficiency neck of femur fractures associated with short-term steroid use: a case report. J Med Case Rep. 2008; 2:79.

7. Bischoff MJ, Reininga IH, van Raaij TM. Atraumatic bilateral insufficiency fractures of the talar neck in a rheumatoid patient. J Foot Ankle Surg. 2013; 52:231–234.

8. Breer S, Krause M, Marshall RP, et al. Stress fractures in elderly patients. Int Orthop. 2012; 36:2581–2587.

9. Lempainen L, Liimatainen E, Heikkilä J, et al. Medial malleolar stress fracture in athletes: diagnosis and operative treatment. Scand J Surg. 2012; 101:261–264.

10. Krestan CR, Nemec U, Nemec S. Imaging of insufficiency fractures. Semin Musculoskelet Radiol. 2011; 15:198–207.

11. Cabarrus MC, Ambekar A, Lu Y, et al. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol. 2008; 191:995–1001.

12. Ito K, Hori K, Terashima Y, et al. Insufficiency fracture of the body of the calcaneus in elderly patients with osteoporosis: a report of two cases. Clin Orthop Relat Res. 2004; 422:190–194.