TRAUMATIC CELLULITIS AND ESCHAR FOLLOWING A LATERAL SPRAIN IN A 20-YEAR- OLD COLLEGIATE BASKETBALL PLAYER Parisi, DM*, Derosier, M+, Manners, JA*: + Princeton University, Princeton, NJ * Salisbury University, Salisbury, MD

The objective of this case study is to educate athletic trainers about a unique clinical outcome resulting from a routine ankle sprain. The athlete in this case study suffered a right lateral ankle sprain in August of 2003 while playing pick-up basketball. He reported immediate numbness and tingling over his entire foot, as well as a sharp pain over the lateral aspect of his right ankle. The athlete described this pain as feeling like his foot was “on fire”. Approximately eight hours after the , the athlete reported to the local Emergency Department due to a continued increase in pain and swelling. Radiographs taken in the ER were ordered to rule out any lower extremity fracture and were determined to be negative. The athlete was given a prescription of Vicadin for pain, as well as an ace wrap and crutches with instructions for self treatment. At the time of the initial Emergency Room visit, gross swelling over the entire ankle and mild discoloration were evident. By the next afternoon, two small began to form over the athlete’s lateral ankle. Over the course of the next 24 hours, the blisters, which were determined to be fracture blisters, grew together and continued to increase to the size of a golf ball. The athlete remained non- weight bearing for two additional days with minimal improvements in pain and swelling. Five days after the initial injury, the athlete attempted to self-drain his fracture . By the following evening, the athlete began to report extreme pain in his foot and lower leg that was accompanied by redness in his skin over his entire foot. Approximately one week post injury, the athlete saw his primary care physician who immediately referred him to the Emergency Room due to cellulitis which had developed and spread throughout his entire lower leg. At the time of the Emergency Department evaluation, the athlete was running a low-grade fever and was subsequently diagnosed with a cellulitis infection in his lower leg. The athlete continued to complain of lack of sensation from the first and second digits to the ankle mortise. Treatment at the Emergency Room included intravenous antibiotic medication (Ancef) (at a rate of one gram every eight hours), as well as constant monitoring of the cellulitis to prevent further growth of the infection. Also, antibiotic dressings for the area of the , where an eschar had formed, were applied and changed every few hours. An eschar is a scab or slough that forms over an area that has been burned or damaged by a corrosive substance, such as an infection. The athlete complained of extreme pain in the foot and lower leg whenever the extremity was not elevated above the heart. The athlete was hospitalized for five days and then released to at home care for an additional nine days. Following release from the hospital, the athlete was placed on a two-week course of oral antibiotics and was prescribed Silvadene, a cream, to treat the eschar on his ankle. The athlete’s primary care physician warned that if the eschar were to fall off without proper healing, a skin graft would be necessary over that area of the ankle. Approximately 3 weeks after the initial injury, the athlete reported to the Princeton University athletic training room to begin the fall semester. During this evaluation, the athlete still lacked sensation from the great toe and 2nd digit to the ankle, however he was independently ambulating without pain. The eschar appeared to be healing well, however, the athlete’s skin around the ankle continued to be red and almost “leather-like” from the cellulitis infection. Initial rehabilitation included joint mobilizations at the talocrural joint, toe curls, milking massage and active range of motion activities focusing on dorsiflexion and plantarflexion. Although joint mobilization of the subtalar joint to increase inversion and eversion was indicated for this athlete, the eschar on the lateral ankle did not allow the clinician to obtain the proper hand position to perform such mobilizations. AROM measurements at this time revealed a decrease of 20 degrees of plantarflexion, 11 degrees of dorsiflexion, 7 degrees of calcaneal eversion and 14 degrees of inversion as compared to the uninvolved side. As of the date of this abstract, the athlete has continued to increase his range of motion however there has been little change in sensation or discoloration of the foot. This case is important to athletic trainers because it emphasizes the importance of proper treatment of ankle sprains to avoid complications. It also shows the importance of educating athletes about blister care and how to treat acute to avoid infection or other additional injury.

Key Words: Eschar, Fracture Blister, Cellulitis This abstract will be updated to demonstrate improvement prior to presentation at EATA.