Young man with persistent calf pain

Knowledge to Practice: Diagnostic Challenge CASE HISTORY A 26-year-old healthy, athletic male presented to an acute care setting with three months of worsening right calf pain. [Figure Omitted; See PDF] QUESTION What is the next appropriate step for this patient? a) Begin broad-spectrum antibiotics and consult surgery b) Measure compartment pressures c)Obtain urgent orthopedics consultation and advanced imaging with CT or MRI d) Begin low-molecular weight heparin e) Consult vascular surgery ANSWER The correct answer is c) obtain urgent orthopedics consultation and advanced imaging with CT or MRI. Patients are often initially diagnosed with sports injuries potentially delaying diagnosis and contributing to the high metastatic rate (95%).3Interestingly, while over 70% of patients present with clinically localized disease, over 80% of patients who have only local resection will experience recurrence, indicating that microscopic metastasis at time of presentation is the rule rather than the exception. Radiographs may show lytic4or periosteal lesions; ultrasound has previously been noted to help identification of soft-tissue masses in Ewing sarcoma.5One study by Traki et al., reported a case in which initial radiographs were non-diagnostic and ultrasound identified irregularities of the cortical bone suggesting possible malignant origin and triggering further work-up.1Treatment of Ewing sarcoma includes chemotherapy, possible radiation, and surgical debulking or amputation.2There are no major differences in survival or response to treatment in skeletal vs. extraskeletal Ewing sarcoma. An abscess should appear on ultrasound as a roughly spherical collection of anechoic or hypoechoic fluid, possibly swirling with compression.7"Cobblestoning" of the tissue would suggest cellulitis.7Treatment of an...