A Unique Case Of A Limping Child

HISTORY: This is an 8 y/o M who presents w/ his guardian for L foot abnormalities and altered gait. His guardian reports a growth on his left 4th toe ever since birth. Patient denies any associated pain but the growth has caused his 2nd and 3rd toes to overlap. They are also concerned about a growth on the back of his heel. Patient is still able to run, but limps during activity. Prior records indicate a crush injury to his left foot in 2016. Denies any acute injuries, fevers, night sweats, weight loss, & fatigue. PHYSICAL EXAM:L foot/ankle/toe-Inspection: Non-erythematous, nonpainful swelling over 4th phalanx; 4th toe is elevated compared to other toes; medial deviation of 2nd and 3rd toes with overlap; enlarged non-erythematous, firm, superficial growth over his heel; abnormal gait. Palpation: No TTP. ROM: Reduced flexion and extension of 4th phalanx. Strength: Intact. Special test: neg ant drawer; neg post drawer; neg talar tilt; neg external rotation. DIFFERENTIAL DIAGNOSIS: 1. Primary neoplasm of bone, 2. Multiple fracture malunions, 3. Secondary malignant neoplasm of bone, 4. Aneurysmal bone cysts, 5. Child abuse TESTS AND RESULTS: XR L Ankle & Foot: Patchy sclerosis throughout the 4th metatarsal bone, proximal, mid and distal phalanx. This digit demonstrates prominence of the soft tissues. Exostosis at the plantar aspect of the base of the 3rd and 4th metatarsal bone. A large bony protrusion at the dorsal aspect of the talus and calcaneus. FINAL WORKING DIAGNOSIS: Hemimelic epiphyseal dysplasia (Trevor Disease). TREATMENT AND OUTCOMES: Trevor disease is a congenital bone development disorder that affects 1 in 1,000,000. Treatment is controversial, but asymptomatic patients are followed clinically since malignant potential is non-existent. Our patient was referred to ortho surgery for possible surgical interventions. After a lengthy discussion with the patient and his family, they decided to pursue surgery that included a posterior ankle cartiliginous exositosis resection, 4th toe EDL lengthening, and amputation of the 4th toe at the proximal interphalangeal joint with associated epiphysiodeses to slow down growth in the future. After surgery, patient was non-weightbearing for 8 weeks, followed by PT for 3 months. Once pain free, he can gradually resume sporting activities.