Non-union distal fibula avulsion fracture in a 16 year old male: A clinical case report

Abstract

Introduction: Distal fibula avulsion fractures are commonly associated with ankle sprains. Reasons for non-union of distal fibula fracture in a healthy young person may be a cause for concern. This report covers the case of a 16 year old male who presented with a non-union distal fibula avulsion fracture at 12 weeks post injury. Presentation: A 16 year old male presented for physiother- apy with a 12 week ongoing ache over the right lateral malleolus on weight bearing and turning, fast walking and running. History revealed a distal fibula avulsion fracture and ankle sprain sustained during a football game 12 weeks previously and diagnosed on X-ray. After a 6 week cast immobilization, follow-up hospital X-rays at 3, 6 and 12 weeks post injury revealed no indication of fracture union or callous formation. Previous musculoskeletal conditions history included left ankle sprain, bilateral medial tibial stress syndrome and ongoing shoulder pain while exercising, all within the last 6–12 months. No other health issues were reported apart from an 18 month history of scalp rash and adolescent acne for 3 years. A dermatologist 18 months previously had prescribed a daily oral isotretinoin agent (Oratane® ) and advised against any contact sports or excessive sun exposure. Reasons for these pre- cautions were not clearly provided, however contact sports were ceased for 8 months while on Oratane® . Oratane® was stopped for a 6 month period and the patient returned to contact sports. The scalp rash returned so Oratane® was recommenced but this time the patient also continued to participate in contact sports. Management: Referral to a doctor for medication review was recommended. At follow-up the patient reported subsequent cessation of oral intake of Oratane® and within 4 weeks a callous formation was reported on X-ray with significant symptom reduction. Discussion: Non-union distal fibula fractures in young adolescent otherwise healthy males are a cause of concern. Symptoms of on-going lateral malleolus pain and non-union fibula fracture after 12 weeks should alert the health practitioner to investigate other causes. Oratane® commonly prescribed for severe acne symptoms in adolescents has many side-effects including myalgia, arthralgia and possible osteopenia. The actions are not clearly understood and precautions in taking such medications should always be clearly explained to young people undertaking contact sports. This case raises the issue of risks involved in taking such medications with the need for increased awareness of the side effects.