Anterior Tibial Stress Fractures Research Articles

Chronic anterior tibial stress fractures in athletes: No crack but intense remodeling.

Delayed healing of anterior tibial stress fractures in athletes is related to high tensional forces acting across a putative fracture gap. These forces lead to crack propagation and create strains that exceed tissue differentiation thresholds for new bone to form in the gap. The "dreaded black line" is a radiographic hallmark sign of stress fractures considered to represent a transverse fracture gap. However, whether a fracture gap truly exists at the microscopic level remains unclear. The aim of this study was to describe the area of the "dreaded black line" microscopically and to identify signs of delayed healing. Between 2011 and 2016, we included seven athletes with chronic anterior mid-shaft tibial stress fractures. The fracture site was excised as a cylindrical biopsy. The biopsy was evaluated with micro-CT and histology. The formation of new bone in the defect was evaluated radiographically. The "dreaded black line" seen on pre-operative radiographs in all patients could not be seen on the microscopic level. Instead, the area of the putative crack showed widened resorption cavities, lined with active osteoblasts, and surrounded by immature bone. This area of intense remodeling seemed to create a false impression of a fracture line on radiographs. Complete cortical continuity was restored at the biopsy site at median 8months (range 6-13months). Tibial stress fractures in athletes normally show no fracture defect, but a region of increased remodeling. The healing process is already ongoing but seems mechanically insufficient.

A complete posterior tibial stress fracture that occurred during a middle-distance running race: a case report

Posterior tibial stress fractures are more frequent than anterior tibial stress fractures, and they are considered to have a good prognosis for returning to sports; cases leading to a complete fracture are rare. A 17-year-old male involved in high school athletics middle-distance running had a 3-week history of pain with training. He was running up to 300 km/week on streets and cross-country in an even distribution. He had posterior tibial stress fractures, but despite the lower leg pain, he continued running. One year later, he was brought to the emergency department after having sustained an injury to the right lower leg while running in a middle-distance race; bilateral tibial stress fractures, with one side complete and the opposite side incomplete, had developed simultaneously. This relatively rare case of bilateral posterior stress fractures, with one side a complete fracture and the opposite side an incomplete fracture, that was treated surgically via exchange intramedullary nailing is reported. The patient could begin light jogging from 3 months after surgery and was without symptoms at 5 months after surgery. He could resume middle-distance racing after 1 year. Posterior tibial cortical fractures are more common and respond better to conservative treatment than anterior tibial stress fractures, and they are a common fracture type in runners. We believe that close, careful follow-up is necessary if patients continue excessive training.

Tension band plating of an anterior tibial stress fracture nonunion in an elite athlete, initially treated with intramedullary nailing: a case report

BackgroundLeg pain in athletes is a common condition and is often related to tibial stress fracture. When non-operative treatment fails, the optimal surgical treatment is controversial. The aim of this study was to report a case of tension band plating of an anterior tibial stress fracture nonunion, treated previously with intramedullary nailing. To the best of our knowledge, this is the first reported case in which tension band plating was placed without removing the preexisting intramedullary nail.Case presentationThe tibial shaft is a common location of stress fracture in athletes. Anterior tibial stress fractures are difficult to manage. When conservative treatment fails, intramedullary nailing is the mainstay of treatment. However, nonunion is a serious complication. In our case, a non-united anterior tibial stress fracture, treated with intramedullary nailing, was addressed with the application of a compression prebended plate over the nail in a 23-year-old French man of African origin who is an elite football player. At 3-months postoperatively he was pain free and started light exercises. At 6-months postoperatively, complete radiologic union of the fracture was evident. He was symptom free; he resumed at that time a full training program and he returned to play football at preinjury high competition level.ConclusionsCompression plating is a valuable method of treating non-united anterior tibial stress fractures. We believe that anterior tension band plating is superior to intramedullary nailing in managing anterior tibial stress fractures, not only after failure of intramedullary nailing, but also as a first-line surgical treatment. This technique offers advantages, such as no violation of the extensor mechanism and risk of anterior knee pain, and directly addresses the underlying problem of distraction forces acting on the anterior tibial cortex and compromising fracture healing. Especially in high-level athletes, who cannot tolerate prolonged inactivity, early surgical intervention of anterior tibial stress fractures with tension band plating is a reliable option that can accelerate recovery.

Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review

Background: Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. Purpose: This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. Study Design: Systematic review; Level of evidence, 4. Methods: In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. Results: A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. Conclusion: The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Anterior Tibial Stress Fractures: Intramedullary Nail vs Anterior Tension Band Plating

Lower extremity stress fractures are common overuse injuries in endurance athletes. Most fractures are low risk and respond well to nonsurgical management involving rest, activity modification, and slow resumption of activities after symptom resolution. However, some high-risk fractures or nonunions warrant surgical intervention to prevent fracture completion and continued symptoms. Anterior stress fractures of the tibial shaft are tension-sided high-risk stress fractures with significant risks of delayed union, nonunion, and fracture propagation. The gold standard surgical treatment has traditionally been antegrade tibial intramedullary nailing. However, the risk of anterior knee pain following intramedullary nail placement has prompted clinicians to seek alternative methods of fixation. Anterior tibial plating with biological augmentation is biomechanically sound in that the plate is placed on the tension side, able to resist tensile stress, and biologically sound in that bone graft may be used to enhance fracture healing. The purpose of this article is to describe the presentation, evaluation, and management of patients with anterior tibial shaft stress fracture. The surgical techniques for intramedullary nail and anterior plating are discussed and illustrated in detail.

Recurrent Fracture After Anterior Tension Band Plating With Bilateral Tibial Stress Fracture in a Basketball Player: A Case Report.

The tibial shaft is the most common location of stress fractures in athletes. Tibial stress fractures are divided into 2 groups, anterior and posterior, based on location. Posterior tibial cortex fractures are more common and respond well to conservative treatment. Fractures in the anterior cortex are less common, accounting for only 4.6% of stress fractures,14 and they often heal poorly because of relatively poor vascularity and constant tension exerted by posterior muscle forces. In the absence of operative treatment, a persistently painful stress fracture may result in delayed union, nonunion, or even complete fracture. Different surgical treatment procedures have been described, but there is no consensus on the best approach for anterior tibial stress fractures. Intramedullary nailing is an established technique for treating delayed or nonunion tibial stress fractures.10 Recently, several authors have reported that anterior tension band plating offers a number of advantages over intramedullary nailing for anterior tibial stress fractures in athletes.3,7,13,20 We report on the surgical treatment, via exchange intramedullary nailing, of a new stress fracture that developed after anterior tension band plating treatment of an existing stress fracture.

Tension Band Plating for Chronic Anterior Tibial Stress Fractures in High-Performance Athletes

Background: Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. Hypothesis: Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. Study Design: Case series; Level of evidence, 4. Methods: Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. Results: Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. Conclusion: Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.

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Introduction:Stress fractures are overuse injuries most commonly seen in athletes, military recruits, and individuals with endocrine abnormalities. It has been demonstrated that chronic cases of anterior tibial stress fractures refractory to conservative management respond well to intramedullary nailing. To our knowledge, only one report has been published concerning patients with bilateral tibial stress fractures treated with bilateral intramedullary nailing. All patients in the series were high-level athletes. We present the case of a non-athletic patient with chronic bilateral tibial stress fractures and associated deformity successfully treated with bilateral intramedullary nails.Case Report:A 23-year-old Caucasian female full-time student presented with chronic bilateral shin pain for approximately five years. She had failed an extensive regimen of conservative management. She was diagnosed with chronic bilateral tibial stress fractures based on history, physical examination, and radiologic findings. She subsequently underwent sequential intramedullary nailing of her tibiae. Both tibiae were in valgus alignment; however, this did not preclude nail placement. The nails deformed upon insertion into the sclerotic canals to conform to the deformation. Post operatively the tibiae united and patient was relieved of her symptoms.Conclusion:Bilateral intramedullary nailing of chronic bilateral tibial stress fractures should be considered as a treatment option for all patients, not just high-level athletes, who fail a trial of conservative management. Additionally, mild to moderate tibial malalignment does not necessarily preclude tibial nailing as the smaller nails placed in sclerotic canals will likely deform on insertion and conform to the canal.

Tension Band Plating of a Nonunion Anterior Tibial Stress Fracture in an Athlete

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion.

Anterior tibial stress fractures treated with anterior tension band plating in high-performance athletes

The non-surgical treatment of anterior tibial cortex stress fractures requires long periods of abstention from sports activities and often results in non-union. Many different surgical techniques have already been previously described to treat these fractures, but there is no consensus on the best treatment. We describe the outcome of treatment using anterior tibial tension band plating in three high-performance athletes (4 legs) with anterior tibial cortex stress fractures. Tibial osteosynthesis with a 3.5-mm locking compression plate in the anterolateral aspect of the tibia was performed in all patients diagnosed with anterior tibial stress fracture after September 2010 at Santa Casa Hospital. All of the fractures were consolidated within a period of 3 months after surgery, allowing for an early return to pre-injury levels of competitive sports activity. There were no infection, non-union, malunion or anterior knee pain complications. Anterior tibial tension band plating leads to prompt fracture consolidation and is a good alternative for the treatment of anterior tibial cortex stress fractures. Bone grafts were shown to be unnecessary.

Left Leg Pain- Basketball

HISTORY: 21 yo male collegiate basketball player presents to the team physician with complaints of anterior left leg pain for 1 month. One week into his pain he states he noticed an area of swelling on his shin. He experiences pain only when jumping and landing in basketball. He is pain free with jogging, weightlifting and daily activities. He denies tingling or numbness in foot. PHYSICAL EXAMINATION: Muscular African-American male. Tenderness and palpable area of induration over the anteromedial cortex of his left tibia. Mild pain with fulcrum test. Negative tuning fork test. Neurovascularly intact distally. DIFFERENTIAL DIAGNOSIS: 1.Stress fracture 2.Medial tibial stress syndrome 3.Chronic exertional compartment syndrome 4.Neoplasia: osteosarcoma TESTS AND RESULTS: X-ray: Periosteal elevation over anterior cortex of left tibia with a faint linear lucency extending perpendicularly MRI: Incomplete transverse stress fracture of the anterior mid-tibial diaphysis Vitamin D 25-OH total: 10 mg/ml (30-100 nl) Calcium, intact PTH: normal FINAL WORKING DIAGNOSES: 1) Anterior cortex tibial stress fracture, 2) Vitamin D Deficiency TREATMENT: 1.Player treated conservatively; non-weight-bearing to tall pneumatic brace to gradual return to play over four months. Started Vitamin D replacement-50,000 units twice weekly × 2 months, then maintenance dose. 2.One month after full return player admits a gradual return of pain. Re-imaging shows persistent radiolucent line. Vitamin D level is still deficient, player admits poor compliance. Player shut down for 2 weeks, bone stimulator, then gradual return to play. 3.Six months from initial presentation, pain and fracture line persist. Sent to surgeon, lateral compression plate surgically placed. FOLLOW UP: Patient was aggressively rehabbed and back in practice 8 weeks out from surgery when he jumped off his left leg, heard a crack, and fell. Player incurred comminuted tibia-fibula fractures at level of plate. Player underwent a second surgery with intramedullary nail placement in left tibia. Vitamin D levels remained slightly deficient, again due to poor compliance. At this time, the player is taking Vitamin D under direct observation in the training room. He is finishing rehabilitation and has returned to sport.

Anterior Tibial Cortex Stress Fracture in a High Demand Professional Soccer Player

Anterior tibia cortex consists a less common location stress fractures. Treatment and return-to-play decision making can have the greatest impact on an athlete’s career. We report a case of a 33 years old high demand professional soccer player who suffered an anterior tibia cortex stress fracture. After a short period of conservative treatment we proceeded in an intramedullary nailing, drilling on the fracture site and insertion of autologous growth factors were performed in order to assisst the healing process. He returned to full activities (every day training and official games) 9 weeks after the operation. The last radiograph 6 months post operatively showed healing of the fracture. We believe that intramedullary fixation of anterior cortex tibial stress fractures when combined with drilling and the use of growth factors helps return sooner than expected to full pre-injury levels of performance. doi:10.4021/jmc249e

Anterior Tibial Cortex Stress Fracture in a High Demand Professional Soccer Player

Anterior tibia cortex consists a less common location stress fractures. Treatment and return-to-play decision making can have the greatest impact on an athlete’s career. We report a case of a 33 years old high demand professional soccer player who suffered an anterior tibia cortex stress fracture. After a short period of conservative treatment we proceeded in an intramedullary nailing, drilling on the fracture site and insertion of autologous growth factors were performed in order to assisst the healing process. He returned to full activities (every day training and official games) 9 weeks after the operation. The last radiograph 6 months post operatively showed healing of the fracture. We believe that intramedullary fixation of anterior cortex tibial stress fractures when combined with drilling and the use of growth factors helps return sooner than expected to full pre-injury levels of performance. J Med Cases. 2011;2(5):210-215 doi: https://doi.org/10.4021/jmc249e

Anterior Tension Band Plating for Anterior Tibial Stress Fractures in High-performance Female Athletes

Stress fracture of the anterior tibial cortex is an extremely challenging fracture to treat, especially in the high-performance female athlete who requires rapid return to competition. Previous reports have not addressed treating these fractures in the world-class athlete with anterior plating. We hypothesize that anterior plating is a biomechanically sound approach to treatment of these fractures, and will lead to an earlier return to full activity than either nonoperative treatment or intramedullary nailing. We present a retrospective series of 4 case reports of 4 world-class female athletes with stress fractures of the anterior tibial cortex treated by anterior plating between 2001 and 2004. Average follow-up was 15 months (range 12 to 48 mo). Anterior tension band plating resulted in fracture healing in all 4 cases and return to full activity at a mean of 10 weeks. All patients returned to preinjury competitive levels. There were no complications of infection, nonunion, or malunion. Anterior tension-band plating of an anterior tibial stress fracture leads to rapid fracture healing and return to competition for high-performance female athletes. This approach should be considered in those athletes who wish to avoid the more prolonged convalescence associated with nonoperative treatment, or the problems, especially of the knee, associated with intramedullary nailing.

Chronic Anterior Midtibial Stress Fractures in Athletes Treated with Reamed Intramedullary Nailing

Background A chronic anterior midtibial stress fracture is a serious, difficult-to-treat injury that can adversely affect an athlete's career. Hypothesis The use of a reamed intramedullary nail for a chronic anterior tibial stress fracture is a safe and effective treatment for an athlete. Study Design Case series; Level of evidence, 4. Methods Seven collegiate-level athletes with 11 chronic anterior midtibial stress fractures were treated with reamed intramedullary nailing between 1997 and 2000. These patients were followed for a mean duration of 17 months. Results The mean age of the patients at the time of stress fracture diagnosis was 17 years. Seven of the fractures occurred in male athletes, whereas 4 occurred in female athletes. All patients had failed nonoperative treatment, including rest, activity modification, use of an orthosis, and low-intensity ultrasound stimulation, for a minimum of 4 months. Patients had experienced symptoms for a mean duration of 12 months. Clinical and radiological union occurred at a mean of 2.7 and 3 months, respectively. The mean duration for return to sports after surgery was 4 months. At last follow-up, all patients had full range of motion at the knee and ankle joints and were satisfied with the results. One patient developed bursitis at the tibial nail insertion site that was resolved with a steroid injection. Another patient sustained a traumatic fracture of the distal tibia 1 year after intramedullary nailing of the tibial stress fracture. This fracture healed with nonoperative treatment. No other complications were observed. Conclusion Intramedullary nailing of the tibia for chronic stress fracture has a high union rate, allows for a low complication rate, and allows for an early return to competitive sports. This procedure is an excellent alternative treatment for those fractures that have failed nonsurgical treatment.

Chronic Knee Pain And Anemia - Basketball

2031 HISTORY: A 13 year old, female middle school basketball player admitted with a five day history of diarrhea and fatigue. Reports about ten dark stools per day. Also reported emesis progressing to hematemesis about two days ago. Since onset of symptoms, patient lost approximately 12 pounds. She was admitted after concerns about marked pallor and lethargy consistent with impending shock. Hemoglobin was 6.9g/dL. Patient reported chronic bilateral knee and hip pain whilst playing basketball. The pain is described as aching just below knees. Had been evaluated by rheumatologist and was being treated with ibuprofen 400 – 800mg every four hours for an unspecified diagnosis. PHYSICAL EXAMINATION: Vitals: Weight 41.4kg, Height 66 in, Pulse 120, RR 24, Blood Pressure 127/75. Tanner Stage II. General: Lethargic, pale adolescent. No evidence of clubbing or signs of heart failure were noted. Examination of hip revealed good range of motion with no evidence of weakness or pain, both knees revealed tenderness, swelling and prominence of the tibial tuberosity. DIFFERENTIAL DIAGNOSIS: Weight loss, hematochezia, pallor and joint pain Gastrointestinal hemorrhage or bleeding secondary to gastritis Systemic Lupus Erythematosis NSAID gastritis Juvenile Rheumatoid arthritis Bilateral Knee Pain Apophyseal Avulsion fracture Idiopathic Adolescent Anterior Knee Pain Syndrome Proximal tibial stress fracture Osgood Schlatter's disease TEST AND RESULTS: Hemoglobin 6.9g/dL. Hemoccult positive. Ova, parasites, bacteria negative in stool, C. difficile negative, H. pylori negative. Meckel scan negative. Abdominal Xray consistent with mild ileus. Endoscopy and colonoscopy revealed chronic gastritis and colitis. Normal hip xrays, films of knees showed some evidence of fragmentation and microavulsions of tibial tuberosity. FINAL WORKING DIAGNOSIS: Acute Gastrointestinal bleed with impending shock due to treatment of bilateral Osgood Schlatter's disease with NSAIDs. TREATMENT AND OUTCOMES: Immediate resuscitation with blood products and fluid. Ensure hemodynamic stability. She required three units of packed red blood cells and subsequently did well and was able to venture into further diagnostic and treatment options. Nonsteroidal anti-inflammatory medication egflibuprofen in monitored doses of 10 to 15mg/kg evert six to eight hours. Ensuring proper use and caution about use on empty stomach. Consider use of Misoprostol. Use of knee pads to protect area. Hamstring and quadriceps flexibility exercises. Referral to Physical therapist. Activity modification. Rest. Return to sports once anemia and fatigue resolve and tolerable pain with activity.

Chronic Knee Pain And Anemia - Basketball

2031 HISTORY: A 13 year old, female middle school basketball player admitted with a five day history of diarrhea and fatigue. Reports about ten dark stools per day. Also reported emesis progressing to hematemesis about two days ago. Since onset of symptoms, patient lost approximately 12 pounds. She was admitted after concerns about marked pallor and lethargy consistent with impending shock. Hemoglobin was 6.9g/dL. Patient reported chronic bilateral knee and hip pain whilst playing basketball. The pain is described as aching just below knees. Had been evaluated by rheumatologist and was being treated with ibuprofen 400 – 800mg every four hours for an unspecified diagnosis. PHYSICAL EXAMINATION: Vitals: Weight 41.4kg, Height 66 in, Pulse 120, RR 24, Blood Pressure 127/75. Tanner Stage II. General: Lethargic, pale adolescent. No evidence of clubbing or signs of heart failure were noted. Examination of hip revealed good range of motion with no evidence of weakness or pain, both knees revealed tenderness, swelling and prominence of the tibial tuberosity. DIFFERENTIAL DIAGNOSIS: Weight loss, hematochezia, pallor and joint pain Gastrointestinal hemorrhage or bleeding secondary to gastritis Systemic Lupus Erythematosis NSAID gastritis Juvenile Rheumatoid arthritis Bilateral Knee Pain Apophyseal Avulsion fracture Idiopathic Adolescent Anterior Knee Pain Syndrome Proximal tibial stress fracture Osgood Schlatter's disease TEST AND RESULTS: Hemoglobin 6.9g/dL. Hemoccult positive. Ova, parasites, bacteria negative in stool, C. difficile negative, H. pylori negative. Meckel scan negative. Abdominal Xray consistent with mild ileus. Endoscopy and colonoscopy revealed chronic gastritis and colitis. Normal hip xrays, films of knees showed some evidence of fragmentation and microavulsions of tibial tuberosity. FINAL WORKING DIAGNOSIS: Acute Gastrointestinal bleed with impending shock due to treatment of bilateral Osgood Schlatter's disease with NSAIDs. TREATMENT AND OUTCOMES: Immediate resuscitation with blood products and fluid. Ensure hemodynamic stability. She required three units of packed red blood cells and subsequently did well and was able to venture into further diagnostic and treatment options. Nonsteroidal anti-inflammatory medication egflibuprofen in monitored doses of 10 to 15mg/kg evert six to eight hours. Ensuring proper use and caution about use on empty stomach. Consider use of Misoprostol. Use of knee pads to protect area. Hamstring and quadriceps flexibility exercises. Referral to Physical therapist. Activity modification. Rest. Return to sports once anemia and fatigue resolve and tolerable pain with activity.

Complications of Intramedullary Rodding for Chronic Tibial Stress Fractures inFemale Athletes: Three Case Reports

The purpose of this case study is to present complications in three cases of female intercollegiate athletes with intramedullary rodding for chronic tibial stress fracture. Three female college athletes underwent tibial rodding insertion after diagnosed with chronic tibial stress fracture. Postoperatively, the stress fracture healed; however, unusual stress reaction occurred at the distal end of the anterior tibia a few months postsurgery, resulting in a high reoperative rate. The athletes’ cases were unique in two distinct ways: (a) literature presents one case of a successful intramedullary rodding for anterior tibial stress fracture; (b) the athletes later developed a painful stress reaction at the distal tibia near the tip of the rod, requiring additional surgery. Treatment and rehabilitation of the intramedullary rodding ultimately led to satisfactory clinical and radiographic healing. Study of the material of rod, its degree of stiffness, geometry, and rehabilitation regimen on treatment outcomes remains deficient.

ANTERIOR TIBIAL STRESS FRACTURE-TRACK

HISTORY: A 15-year-old male state champion track hurdler presented to the Sports Medicine clinic with the complaint of left shin pain. He has had pain along his left shin for approximately five months during the recent track season. He noticed a significant worsening two days ago while running the 400-meter hurdles. He states that while making the final turn he went from feeling good to one step later having severe pain in his left shin. He denies any recent trauma to the left leg, other joint pains, numbness, tingling, fever, chills, or weight loss. PHYSICAL EXAMINATION: General: Well-developed, well appearing male. Musculoskeletal: Normal gait with obvious severe genu valgum and bilateral pes planus. He has tenderness to palpation along the anterior portion of the left tibia approximately 17cm proximal to the medial malleolus. There is full range of motion at the hip, knee, and ankle. His muscle strength in the lower extremities is 5+/5. He is neurovascularly intact with no obvious focal deficits. ANTERIOR TIBIAL STRESS FRACTURE-TRACK: J.M. Buchanan, S.M. Simons, FACSM, Sports Medicine Institute, South Bend, IN, USA DIFFERENTIAL DIAGNOSIS: Anterior tibial stress fracture Medial tibial stress syndrome Exercise induced compartment syndrome Neoplasm TESTS AND RESULTS: Bilateral anterior-posterior and lateral tibia and fibula radiographs: Left anterior tibia stress fracture with a dreaded black line. MRI of the tibia and fibula: Bone marrow and cortical edema noted in left tibia on T2 weighted images. Repeat anterior-posterior and lateral radiographs of the left tibia and fibula: healing anterior tibia stress fracture FINAL/WORKING DIAGNOSIS: Anterior stress fracture of the left tibia TREATMENT AND OUTCOMES: Placement of electronic bone stimulator. Restriction from all running and stressful activities while substituting non-weightbearing exercises until radiographs reveal healing. Provide patient with customized shoe orthotics for upcoming track season. Patient was followed every 6 weeks with plain radiographs which revealed gradual resolution of the tibial stress fracture. Patient has returned to full participation in track/hurdles with conservative management alone eliminating the need for operative intramedullary rod placement.

STRESS FRACTURES OF THE ANTERIOR TIBIAL DIAPHYSIS

Stress fracture of the anterior tibial diaphysis is rare and occurs mostly in leaping athletes. Thirty-six of these fractures in 35 patients have been reported in the literature. These are combined with 15 similar fractures in our experience to provide combined data on 51 anterior tibial stress fractures. Comparison of the various treatments utilized disclosed that there is a high risk of complete fracture if affected patients are allowed full activity, and that treatment by rest alone allowed only 40% to return to full activity even after symptomatic improvement. The treatment recommended for these patients is excision of the fissure, transverse drilling at the fissure site, and cancellous bone grafting of the defect. In those patients who suffer a complete fracture, open reduction and internal fixation is superior to closed treatment.