05/16/2013    

Difficult Post-Trauma Case

Six weeks ago my patient’s right foot sustained a
triangular-shaped blunt trauma to the dorsum
centered about the midshaft of the second met
shaft. A matching triangular, mildly ecchymotic,
area of swelling appeared soon after the trauma
and remains; this triangular area and the
immediate surround is hypalgesic. Initial x-rays
were negative for fracture.

The triangular area of swelling continues to be
as painful as the initial injury; this pain is
mitigated by use of Xanax and Lidoderm patches
that reduce the pain sufficiently to allow the
patient to sleep. I did not prescribe opiates for
fear that this was an RSD/CRPS.

An initial ultrasonogram shows an area
suspiciously like a ganglion cyst but more
superficial than the classic presentation.
An MRI showed “slightly loculated subcutaneous
fluid collections underlying the skin marker
[placed at the midpoint of the triangular area of
swelling] over the first metatarsal web space,
collections up to 5 mm in thickness extending
over the dorsum of the first and second
metatarsals and medial aspect of first metatarsal
up to 2.2 cm in greater transverse dimension and
4.4 cm in greatest dimension. No definitive soft
tissue gas. The fluid collections are not
associated with dorsal tendon sheaths or vascular
flow voids.”

The radiologist goes on to say that the fluid
collections “are consistent with possible
resolving hematomas, loculated edema, or abscess.”

On two occasions, I removed about three ml of
thin, bloody material that was sterile to
culture. The fluid builds up again after each
evacuation as the pain does concomitantly.
Steroid injected into the area post evacuation
has not reduced the pain nor the swelling.

I have entertained the idea of some type of
compartment syndrome, but the pressure of the
bloody fluid is not great, and the area of
swelling is not turgid though not flaccid either.
Rest and elevation have helped but the swelling
remains; the area of the trauma remains
hypalgesic.

Any help or ideas for treatment would be
appreciated.

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