I received a few comments….with a range of opinions….am still dragging my feet on the report…..
Phil Tirman said:I think an extra-articular pillar coalition. Ask James Linklater. Looks like it on the second sag and drunken waiter sign on oblique radiograph.
James Linklater said:
The ossicles seem too proximal for a typical accessory navicular. Do the juxta insertion all fibres of tib post look normal? I would be tempted to do an ultrasound to look for subtle side to side difference associated with pseudo tendon formation following remote avulsive injury – bit of a long shot but I can think of another explanation
I agree it doesn’t look like a coalition
Ingrid Kjellin said:
I suspect old avulsion of a portion of the spring ligament complex. There is pes planus.
Jenny Bencardino said:
There is an ossicle in that location: the os sustentaculum. My very first peer-reviewed paper as a fellow at HJD is a case report of one of these ossicles, published in Skeletal Radiology.
It is now believed to be in the spectrum of PEC: posteromedial extra-articular coalition.
So….all over the place.
What I do know is that there is severe pes planus.
There is no "drunken waiter" sign….if anything, just posterior to the big fat distorted sustentaculum there might be an accessory facet, but there are no articular changes on the talar side to suggest non osseous coalition (IMO)
I read the article about os sustentaculi….and it is not in the same location and doesn’t look like the 2 rounded ossicles medial to the sustentaculum in this case
With the history of playground trauma 8 years ago (she would have been 6 yo at the time….I think it’s really hard to sort out what is developmental variant vs distorted anatomy and growth from remote trauma.
Since it really doesn’t look like any developmental variant I’ve seen, maybe it’s old post traumatic?
I think those ossicles are either embedded in the SM-CNL or just posterior to it…..I think it’s a huge stretch to think an accessory navicular took such a fantastic voyage…..but it’s not like I know what’s going on here.
Thanks for your help….still open to more suggestions, if there are any.
Hilary
Thye medial XR is awful, and the lateral view is suboptimally positioned, but there is pes planovalgus
There is broadening of the sustentaculum…I’m not sure if there is an accessory facet at the posterior aspect. There are 2 small ossicles medial to the sustentaculum….I presume these are developmental…but I don’t know what to call these
In the 2nd Cor image the sustentaculum looks broad and squared with the adjacent medial ossicles
The arrow shows the location of the ossicles
There happens to be an accessory soleus and ankle effusion
Do you agree that this is developmental and not old post traumatic?
I can’t call a coalition, but I know that an accessory subtalar facet is associated with extra-articular coalition…not sure that is at all relevant.
