Pediatric Distal Tibia Physeal Injury Presenting with Acute In-toeing: A Case Report and Literature Review.

Ankle fractures are among the most common fractures sustained in the pediatric population. Given the frequency of physeal involvement of the distal fragment, complications including growth arrest, overgrowth, and rotational deformities are not uncommon. This case report describes a 12-year-old adolescent boy who presented after an acute right ankle injury sustained while playing. He noted right ankle pain, swelling, and in-toeing of his foot. Radiographs of the ankle demonstrated a distal tibia Salter-Harris type II fracture that appeared nondisplaced. However, a CT scan of the ankle demonstrated a 60° difference in the rotational profile between the injured and noninjured tibias. The patient's acute rotational deformity was corrected with closed reduction and percutaneous pinning. Pediatric distal tibia physis fractures presenting with in-toeing are rare and difficult to diagnose accurately with radiographs alone. Accordingly, a detailed history, physical examination, comparison radiographs, and CT scans are imperative in making the correct diagnosis and determining the appropriate treatment.

Descriptive analysis of Acute Ischemic stroke in COVID-19 patients through the course of the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) has been associated with Acute Ischemic Stroke (AIS). Here, we characterize our institutional experience with management of COVID-19 and AIS. Baseline demographics, clinical, imaging, and outcomes data were determined in patients with COVID-19 and AIS presenting within March 2020 to October 2020, and November 2020 to August 2021, based on institutional COVID-19 hospitalization volume. Of 2512 COVID-19 patients, 35 (1.39%, mean age 63.3 years, 54% women) had AIS. AIS recognition was frequently delayed after COVID-19 symptoms (median 19.5 days). Four patients (11%) were on therapeutic anticoagulation at AIS recognition. AIS mechanism was undetermined or due to multiple etiologies in most cases (n = 20, 57%). Three patients underwent IV TPA, and three underwent mechanical thrombectomy, of which two suffered re-occlusion. Three patients had incomplete mRNA vaccination course. Fourteen (40%) died, with 26 (74%) having poor outcomes. Critical COVID-19 severity was associated with worsened mortality (p = 0.02). More patients (12/16; 75%) had either worsened or similar 3-month functional outcomes, than those with improvement, indicating the devastating impact of co-existing AIS and COVID-19. Comparative analysis showed that patients in the later cohort had earlier AIS presentation, fewer stroke risk factors, more comprehensive workup, more defined stroke mechanisms, less instance of critical COVID-19 severity, more utilization of IV TPA, and a trend towards worse outcomes for the sub-group of mild-to-moderate COVID-19 severity. AIS incidence, NIHSS, and overall outcomes were similar. Further studies should investigate outcomes beyond 3 months and their predictive factors, impact of completed vaccination course, and access to neurologic care.