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CT scan right ankle
11%
371/3303
Early multidisciplinary evaluation of the patient
79%
2622/3303
Non-weight bearing and prolonged casting
5%
153/3303
Tarsal coalition excision and adipose tissue interposition
2%
58/3303
Referral to a foot and ankle surgeon for another opinion
76/3303
Select Answer to see Preferred Response
This is an example of Munchausen syndrome by proxy (or caregiver-fabricated illness in a child). The next best step would be an early multidisciplinary evaluation involving medical, psychosocial, child protective services, and legal professionals. Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child’s illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. It is most commonly perpetrated by the biologic mother who has knowledge of medicine. Medical professionals should have an index of suspicion when there are discrepancies between the history, physical examination, and health of a child. Flaherty et al. reviewed caregiver-fabricated illness in a child. They state that caregivers who seek another medical opinion when told that the child does not have illness, or who resist reassurance that the child is healthy, should raise concern about the possibility of fabricated illness. Squires et al. reviewed Munchausen Syndrome by Proxy. The most common orthopaedic manifestation is usually hip pain. However, these patients are unlikely to present with a limp. The medical records are also generally extensive and usually involve multiple medical sites. Figures A and B show normal radiographs of the foot and ankle. Illustration A shows the indicators of fabricated illness in a child. Incorrect Answers: Answer 1: The physical examination and radiographs are normal. CT scan will expose the child to unnecessary radiation. In addition, tarsal coalition would be difficult to diagnose by CT in a patient this age. Answer 3: Non-weight bearing and prolonged casting would be an appropriate first line treatment for tarsal coalition. However, the age of disease onset is usually in older children (calcaneonavicular = 8-12 years old; talocalcaneal = 12-15 years old), and only MRI would be able to visualize a fibrous or cartilaginous coalition. Answer 4: Tarsal coalition excision and adipose tissue interposition is considered as treatment for resistant cases of tarsal coalition when nonoperative management has failed to relieve symptoms. Answer 5: A referral to foot and ankle surgeon for another opinion would fail to recognize the maltreatment of this child.
2.3
(15)
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