Progressive Lower Extremity Pain Following Traumatic Fall in Young Adult

Case at a Glance

A 27-year-old female presents with worsening right lower extremity pain, instability, and functional limitation 1 month following a traumatic fall, with suspected ligament injury and concern for potential thrombotic complications.

Patient's Story

The patient sustained a right lower leg injury in June following a fall. Initially, she sought medical attention at a local hospital where X-rays ruled out fractures, and clinical assessment suggested ligament damage involving the knee and ankle. Over the subsequent weeks, her condition has progressively deteriorated. She now experiences severe pain at rest and with movement, describing it as 'unbearable' and causing her to cry. Her occupation requires prolonged standing, which has become impossible. She reports frequent joint instability with audible popping and cracking sounds when the knee and ankle sublux or dislocate.

Initial Assessment

Emergency department evaluation revealed no acute fractures on plain radiographs. Clinical examination suggested ligamentous injury pattern affecting both knee and ankle joints. Patient was discharged with conservative management recommendations including immobilization, elevation, and over-the-counter analgesics.

The Diagnostic Journey

The patient's symptoms have progressively worsened despite conservative treatment measures. Current symptoms include persistent pain in multiple positions, significant swelling, joint instability with frequent subluxations, and severe functional impairment. She has been unable to find properly fitting orthotic devices, and standard pain management with acetaminophen has proven inadequate. The patient cannot tolerate NSAIDs due to contraindications.

Final Diagnosis

Suspected complex ligamentous injury involving right knee and ankle with progressive instability. Differential diagnosis includes multiple ligament tears, possible meniscal injury, and potential chronic instability pattern. Risk factors for venous thromboembolism given immobilization and orthotic device use.

Treatment Plan

Immediate recommendations include MRI imaging to assess extent of ligamentous injury, orthopedic surgery consultation for definitive management, and consideration of thromboprophylaxis given prolonged immobilization. Pain management optimization with appropriate analgesics, and evaluation for properly fitted orthotic devices. Physical therapy consultation once acute phase resolves.

Outcome and Follow-up

Patient seeking affordable care options due to insurance limitations. Orthopedic consultation planned with self-pay arrangements. Emphasis placed on thromboembolism prevention through appropriate anticoagulation and early mobilization exercises. Patient counseled on importance of definitive imaging and specialist evaluation to prevent long-term complications and ensure proper healing, particularly given history of previous ankle fracture with malunion.