Stress Fracture Of Fibula Research Articles

Surgical Intervention of a Fibular Stress Fracture in a Male Basketball Player: A Case Report

This is a case of a 21-year-old male, African American Division I basketball player with a fibula stress fracture. The athlete initially reported pain, without distinct injury and was diagnosed with a stress fracture. After a short period of immobilization in a walking boot, this individual opted to undergo surgical intervention consisting of an intramedullary screw inserted in his left fibula. This was in consultation with the orthopedic team physician and orthopedic trauma surgeon. After a brief period of rest and continued immobilization in a walking boot, weight bearing as tolerated, the patient was able to start rehabilitation. He continued rehabilitation and progressive return to activity and was able to return to limited practice approximately 4 weeks. He played 13 min of a game in under 5 weeks (31 days). Stress fractures are not uncommon in basketball players, but a fibula stress fracture is one not often seen, and there is a paucity of data in the literature regarding this injury. A nonoperative approach to treatment of a fibula stress fracture typically yields good results but may lead to longer return than a surgical intervention. Providing athletes options for treatment may result in a quicker recovery. This case demonstrates a novel treatment option resulting in a quicker return to play.

Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design: Case series; Level of evidence, 4. Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Fibula Stress Fractures: A Systematic Review.

Fibula stress fractures are moderately common injuries among athletes and military recruits. Most of the available data for treatment come from case reports with a limited number of large studies. This systematic review aims to evaluate and present the current literature on fibula stress fractures to help set evidence-based goals and establish realistic expectations for return to activity and sport in injured patients. Systematic literature search using 3 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol and the Cochrane Handbook guidelines were followed. The terms "fibula stress fracture" or "fibular stress fracture" were searched. Date range for inclusion was 2010-2022. Pediatric, non-English, lack of full text available, and studies lacking differentiating fibula stress fracture versus other types of fractures in their data were excluded. A total of 3 studies with 10 987 subjects were included. Among 521 stress fractures in all 3 studies, there were 45 (8.6% of all fractures) cases involving the fibula. All fibular stress fractures healed successfully with nonoperative measures and non-weight-bearing precautions, on average, by 7 weeks and patients resumed activity, on average, by 9 weeks. Among the 3 studies, there were no reported cases of nonunion or delayed union. This review found that fibula stress fractures have a relatively moderate incidence among stress fracture injuries with a frequency up to 8.6%. Despite this high number, there is sufficient healing in fibula stress fractures when managed nonoperatively with activity modification in a weight-bearing foot to allow for resumption of baseline activities, on average, by 9 weeks. This review can be used to help set evidence-based goals and establish realistic expectations for return to activity and sport in patients who suffer from fibula stress fractures. Level II.

A modified induced membrane 2-stage technique using a thoracodorsal artery perforator free flap followed by vascularized or non-vascularized free fibular transfer for the treatment of complex bone infection with concomitant severe soft tissue lesion–A case series of 9 cases

Treatment of post-traumatic complex bone infection is very challenging. The two principal bone reconstruction approaches are the single-stage vascularized bone graft technique and the two-stage induced membrane technique (IMT). Here we introduce a modified 2-stage induced membrane technique (MIMT) for complex long bone infection with a major bone defect and a concomitant severe soft tissue lesion. The 2-stage procedure consists of bone debridement, placement of a PMMA spacer and soft tissue reconstruction with a thoracodorsal artery perforator free flap (“Tdap”) at stage 1. At stage 2, the thoracodorsal artery perforator flap is elevated and a fibular strut graft (either vascularized of non-vascularized) is placed for bone reconstruction.We retrospectively analyzed the extents of lower extremity, long bone, post-traumatic bone infection treated via MIMT from 2008 to 2020. There were nine such cases (eight males) of mean age 59.8 (range 31 to 79) years. The osteomyelitis durations ranged from 3 to 360 months (mean 53 months). The cortical bone defect sizes was ranged from 9 to 14 cm (mean10.7 cm). All skin resurfacing employed Tdap. Vascularized fibular grafts were placed in six patients and non-vascularized grafts were placed in three. The fibular graft size ranged from 12.5 to 19 cm (mean 16.2 cm). Non-vascularized iliac bone grafts served as the fibula docking sites.Unfortunately, all patients suffered complications before bone union was achieved. One case of plate stress fracture and one case of screw fracture required plate and screw change. In three cases of cellulitis, one resolved by use of intravenous antibiotics, others required plate and screw removal. Wound disruption required re-suture and distal skin flap partial necrosis was covered by perforator-based island flap. One case of fibular stress fracture needed cast for 4 weeks. A peroneal nerve palsy patient recovered spontaneously. Bone union was achieved after 6 months in five patients and after 8 months in three (mean 6.9 months). All patients were able to walk unaided. The follow-up period ranged from 2 to 14 years (mean 6.2 years).MIMT saves the limbs in cases with difficult post-traumatic bone infection. It is valid treatment option for complex bone infections with severe soft tissue lesions. However, even with this technique potential complication must be considered.

Low-Risk Foot and Ankle Stress Fractures in The Pediatric Population: A Case Series

Background: Stress fractures are a common overuse injury in the pediatric population. Distal fibular and calcaneal stress fractures are considered low-risk stress fractures. Due to their rarity, they have not been studied as thoroughly as other stress fractures. Purpose: To present a descriptive case series of distal fibular and calcaneal stress fractures in the pediatric population and elaborate on demographics, mechanism of injury, management and outcomes. Methods: IRB-approved retrospective study included patients under 18 years at a tertiary children’s hospital who were diagnosed with a distal fibular or calcaneal stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, and outcomes were collected. Descriptive statistical analysis was conducted. Results: 11 patients, 6 distal fibula (4 female, 2 male) and 5 calcaneus (2 female, 3 male) with stress injury on clinical exam and on X-ray or MRI were included. Mean age was 11 years (1-15) and average BMI of 23.5 (16-30.7). The common presenting complaint was pain aggravated by activity that began an average of 3 weeks prior. 7/11 (63.6%) participated in competitive sports: 4/6 with fibular stress fractures were runners (cross country, soccer and sprinting) compared to 0/5 patients with calcaneal involvement. Typical radiographic findings (periosteal reaction, cortical thickening) and a corresponding physical exam was sufficient to diagnose fibular stress fractures in 5/6 patients, with one requiring MRI for definitive diagnosis. 4/5 patients with calcaneal stress fractures required an MRI for a definitive diagnosis, delaying the diagnosis by an average of 3 weeks. 5/6 patients with fibular stress fractures had no other associated pathology, such as additional stress fractures, bone cysts, or osteoid osteomas, whereas 3/5 with calcaneal injuries had at least one of these associated pathologies. Patients with isolated fibular or calcaneal stress fractures (7/11) improved with conservative management, including a controlled ankle motion (CAM) boot, PT, and full activity rest over an average of 6.5 weeks. Out of the remaining 4 patients with associated pathologies, 3/4 improved with conservative management alone after an average of 20 weeks; however, one patient required surgical removal of a bone cyst before complete recovery. Conclusion: A history of pain with significant running, X-ray findings, and physical exam findings were sufficient for diagnosis of fibular stress fractures; however, calcaneal stress fractures were often occult, requiring MRI for definitive diagnosis, and were associated with other pathologies. Conservative management was sufficient for treatment of 91% of patients, regardless of additional fractures or pathology. [Figure: see text][Figure: see text]

Treatment and Outcomes of Atraumatic Subtalar Dislocations in Adult Acquired Flatfoot Deformity

Category:Ankle; HindfootIntroduction/Purpose:Painful adult acquired flatfoot is classified into multiple types, with a one category reserved for those that have rigid deformity. However, there is a subset of patients with rigid progressive collapsed foot deformity (PCFD) in which navicular and calcaneus are subluxed from the talus causing sub-fibular impingement and erosion and fixed abduction of the forefoot. This condition is not well described in the literature. The treatment of these patients can be technically difficult given the attenuation and erosion of soft tissue and articular constraints. In this study we sought to identify reduction technique, shared characteristics, treatments, and outcomes in patients with severe hindfoot valgus deformity with subluxation and subfibular impingement who were treated by subtalar reduction and arthrodesis, and talonavicular arthrodesis at a single institution.Methods:A retrospective chart review was done of all patients who underwent flat foot reconstruction by a single surgeon. Patient were included in the study if on preoperative weight-bearing (WB) CT they met the following radiographic criteria: 3 sequential sagittal cuts of the calcaneus without the talus present, 3 sequential sagittal cuts of the talus without the calcaneus present, and the presence of a calcaneofibular articulation on coronal cuts. Patients with neuromuscular disorders or peripheral neuropathy were excluded. This review evaluated demographic data, comorbidities, complications, and the need for reoperation. Plane radiographs and CT findings were compared to identify subluxation on plane images. Patients were treated with a double, triple, or pantalar arthrodesis based on the treating surgeon’s discretion. A cohort of 23 patients has already been identified, but additional data review is currently underway.Results:The initial patient cohort consisted of twenty-three patients who met the inclusion criteria with an average age of 64.5 (range, 48-79) years. The initial cohort consisted of patients who were treated from 2009-2014. Seven of the twenty-three patients (30.4%) required reoperation for various reasons ranging from late infection to nonunion and symptomatic hardware (Table 1). We found that the average BMI for patients with this disorder was 34kg/m2. Four patients have fibular stress fractures on presentation, these patients had an average BMI of 41.6kg/m2. Specific techniques for reduction included use of distractors at subtalar and TN joints. Radiographic findings on plane films are linked to findings on CT scan. Recurrence of deformity occurred with tilt of the talus requiring bracing in 2 patients. Incomplete correction was common, particularly early in the study period.Conclusion:PCFD is a very problem seen by foot and ankle surgeons. Physicians should be aware of the challenges presented in treating the subset of patients who have atraumatic dislocation of the subtalar joint. Diagnosis can be made on plane radiographs, though WB CT is useful for treatment planning. Treatment of these patients requires careful physical and radiographic examination. Reduction and arthrodesis is the treatment of choice. Patients should also be counseled about the possible need for reoperation given the high rate of reoperation in this population.

Osteochondroma of the Distal Tibia Leading to Deformity and Stress Fracture of the Fibula - A Case Report

Osteochondromas seldom arise from the interosseous border of the distal tibia and may progress to involve the distal fibula. We present the case of a 14-year-old teenager with a stress fracture of the distal fibula, secondary to an osteochondroma arising from the distal tibia. Early excision of this deforming distal tibial osteochondroma was necessary in order to avoid a progressive deformity which would affect the biomechanics of the ankle joint resulting in gait disturbances.

SAT-337 Ga-DOTATATE and Tumor Induced Osteomalacia: Finding the Culprit Lesion

IntroductionTumor-induced osteomalacia (TIO) is a very rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection can be curative; however, these tumors are typically difficult to identify due to size and location.Clinical caseA 43-year-old man was referred to Endocrinology for evaluation of recurrent fractures and hypophosphatemia. First stress fracture was diagnosed at age 41, followed by musculoskeletal pain in several locations. Lower extremity MRI showed chronic left fibular stress fracture, new stress fracture in fifth metatarsal and right tibia. Tc99m-MDP bone scan revealed multiple foci of increased tracer uptake in bilateral ribs, hips, and lower extremities. Laboratory evaluation showed normal calcium (9.3 mg/dL, normal range [NR]: 8.7-10.2), low phosphorus (1.5 mg/dL, NR: 2.5-4.7), low 1,25-dihydroxyvitamin D (13 pg/mL, NR: 19.9-79.3), low 24-hour urine calcium (78mg), high phosphate excretion fraction in urine (27%, normal <5%), high ALP (163 U/L, NR: 38-126), and high FGF23 (238 RU/mL, NR<180). 25 OH vitamin D (36 ng/mL) and iPTH (5.7 pmol/L, NR: 1.6-6.9) were normal. Patient was started on calcitriol and phosphate supplements. Due to concern for TIO, a PET scan with 68Ga-DOTATATE was performed which showed multiple somatostatin avid lesions concerning for metastatic disease. However, after re-review with radiology, it was felt that other areas of uptake were due to fractures and not tumor given remarkably higher SUV in left acetabular lesion (SUV 20 vs 4-5). The left acetabular lesion was biopsied, followed by surgical resection. Pathology was consistent with phosphaturic mesenchymal tumor with uninvolved margins. FGF23 normalized within 24 hours after surgery (127 RU/mL) and calcitriol and phosphate supplements were discontinued on post-operative day 10.Clinical lessonTIO is a rare paraneoplastic syndrome commonly caused by phosphaturic mesenchymal tumors that secrete FGF23. Once the diagnosis of TIO is confirmed, the tumor is localized by anatomical or functional imaging. 68Ga-DOTATATE scan is currently the imaging modality of choice for localization. However, there are other pathologic processes, such as fractures, that could affect the interpretation of PET scans. Osteoblastic activity is increased in fractures, which results in increased uptake in Ga-DOTATATE PET scan since osteoblasts express somatostatin receptor. Our patient was initially thought to have multiple avid lesions concerning for metastatic disease, but culprit lesion was differentiated based on SUVs and confirmed with biopsy. Clinical and biochemical abnormalities resolved after surgery. Early recognition of culprit lesion in TIO is crucial, as successful surgery is curative and would lead to significant improvement in the quality of life of patients.

Isolated fibular stress fractures: Radiographic parameters

BackgroundFibular stress fractures are uncommon injuries with an incompletely understood pathogenesis and predisposing characteristics. This study investigated the demographic and radiographic risk factors for fibular stress fractures. MethodsA retrospective chart review from 2010 to 2018 revealed thirteen patients with isolated fibular stress fractures. Demographics, history of fracture, fracture location, bone quality, and heel alignment were collected. ResultsThe cohort consisted of six men and seven women with a mean age of 41.8 years. The average BMI was 28.5kg/m2. Three patients used tobacco. 69.2% of fractures were in the distal third, 23.1% proximal third, and 7.7% middle third. No patients had evidence of osteopenia. Distal fibula stress fractures were more common in women (66.7%) and associated with hindfoot valgus. ConclusionDistal third fibula stress fractures were most common and associated with hindfoot valgus. This could be due to a greater amount of axial force through fibula in this alignment. Level of evidenceLevel IV, Retrospective Case Series.

Isolated Fibular Stress Fractures: Demographic and Radiographic Factors

Category:Ankle, TraumaIntroduction/Purpose:Fibular stress fractures are rare injuries that are incompletely understood in terms of pathogenesis and predisposing factors. While stress fractures all involve relative stress concentration in a finite area leading to local mechanical failure, the risk factors for this injury have not been assessed. Their relative rarity has made understanding of these risk factors difficult. In a retrospective case series, we sought to define demographic and radiographic risk factors for isolated fibular stress fractures.Methods:We retrospectively reviewed the records of 13 patients with isolated fibular stress fractures at our institution between January 2010 and November 2018. We collected and analyzed baseline demographic data and radiographic parameters including prior history of fracture, location of stress fracture, bone quality, and heel alignment.Results:The cohort consisted of 6 men and 7 women with a mean age of 41.8 years at the time of diagnosis of the fibular stress fracture. The average BMI in the cohort was 28.5 kg/m2. The location of the stress fracture was in the distal third of the fibula in 69.2% (9/13), proximal third in 23.1% (3/13), and middle third in 7.7% (1/13). There was no evidence of osteopenia on radiographic analysis in any patients, by assessment of the senior author and attending radiologist at our institution. Isolated stress fractures in the distal third of the fibula were observed more commonly in women. Distal fibula stress fractures were associated with physiologic hindfoot valgus, while proximal fractures were seen with a varus hindfoot.Conclusion:In this retrospective case series of a rare injury, isolated stress fractures in the distal third of the fibula were the most common fibular stress fracture. Proximal fibular stress fractures were associated with a varus hindfoot. All fractures in this case series healed with immobilization in a walking boot with or without a short period of nonweightbearing.

Leg Pain in a 23 Year Old Football Player

HISTORY: A 23 year old male reported getting kicked in the leg during a collegiate football game. He noted immediate pain in his lateral calf after attempting a tackle. He did not feel or hear a pop. He had a noticeable limp walking off the field. There was no pain in the ankle or foot, but he noted pain with ankle movement. He had pain with weight-bearing but denied any numbness or tingling. The next day, he developed worsening pain that was unbearable with any change of position or movement. The pain was greatest along the mid-lateral leg but extended along the entire leg anterior and laterally. He had limited ability to move his toes and foot which was a new symptom. PHYSICAL EXAMINATION General: Alert and oriented in mild distress at rest. Left leg Edema: Anterior and lateral leg without pitting. Compartments: Diffusely tender but not tense. Tenderness: Diffuse, anterior and lateral compartments more than fibula and posterolateral. Range of motion: DF 0 degrees, PF 30 degrees. Pain was worse with initiation. He tolerated gradual passive stretch of the anterior, more than the lateral. Pain with inversion and eversion . Strength: 1/5 anterior tibialis, EHL, EDL, Peroneals with pain, 2/5 GS/PT with pain. Neurovascular: Intact, 2+ PT/DP pulses, cap refill < 2 sec. DIFFERENTIAL DIAGNOSIS 1. Gastrocnemius Strain 2. Compartment Syndrome 3. Popliteus Strain 4. Fibular Fracture 5. High Ankle Sprain TESTS AND RESULTS XRays 1. Fluoroscopic imaging of the tib-fib and ankle were negative. 2. Tib-fib and Ankle xrays were negative for fracture and stress view demonstrated stable joint. Compartment Testing Diastolic pressure: 74 Left lower leg anterior compartment: 20 Left lower leg lateral compartment: 28 Left lower leg posterior superficial compartment: 27 Left lower leg posterior deep compartment: 26 MRI 1. Nondisplaced fracture of the middle third of the fibula. 2. Acute grade 1 muscular injury of the peroneal muscles of the lateral compartment. FINAL WORKING DIAGNOSIS Midshaft fibular stress fracture TREATMENT AND OUTCOMES 1. Patient was admitted to the hospital for observation for one night. 2. Patient was discharged and allowed to weight bear as tolerated in the tall CAM boot for two weeks. 3. At two weeks, he was weaned out of the boot and allowed to progress into activities. 4. At six weeks, he was participating in football without any limitations.

Effectiveness of one-stage total knee arthroplasty with tibial stem extender for knee arthritis complicated with tibial stress fracture

To evaluate the early effectiveness of one-stage total knee arthroplasty (TKA) with tibial stem extender for knee arthritis complicated with tibial stress fractures. Between January 2014 and November 2016, 12 patients (12 knees) with knee arthritis and tibial stress fractures underwent one-stage TKA with tibial stem extender. There were 5 males and 7 females with an average age of 71.5 years (range, 60-77 years). There were 8 cases with osteoarthritis and 4 cases with rheumatoid arthritis. The radiographic examination showed the 6 cases of intra-articular fractures and 6 of extra-articular fractures (including transverse fractures in 4 cases and short oblique fractures in 2 cases); 2 cases complicated with middle and upper fibular stress fractures; all patients of varus deformities. Preoperative Knee Society Score (KSS) clinical score was 31.5±8.4 and functional score was 33.3±9.0. The preoperative range of motion (ROM) of the knee was (65.6±9.6)°. All indexes healed primarily and no wound infection or skin necrosis occurred. All patients were followed up 36.5 months on average (range, 6-52 months). X-ray films showed that all fractures healed at 3-7 months (mean, 4 months); the position of the prosthesis was good, and no loosening or signs of infection occurred. At last follow-up, the KSS clinical score was 90.5±8.9 and functional score was 92.1±7.8; the ROM of the knee was (115.0±9.8)°. All indicators were significantly improved than those before operation ( t=40.340, P= 0.000; t=32.120, P=0.000; t=8.728, P=0.000). One-stage TKA with tibial stem extender for patients with knee arthritis and tibial stress fractures can restore limb alignment, facilitate fracture healing, and obtain the satisfactory early effectiveness.

Pes Planus and Distal FIbular Stress Fractures

Category: Ankle, Hindfoot Introduction/Purpose: Fibular stress fractures accounts for 4.6% to 21% of all stress fractures. There have been isolated reports of distal third fibular stress fractures within 4-7 cm of the tip of the lateral malleolus in young and athletic patients related to overuse injuries. We examine a case series of middle aged female patients with planovalgus foot deformities and associated hindfoot valgus who presented with distal third fibular stress fractures. We propose that this type of distal fibular stress fracture is a result of increased stress loading of the distal fibula at the superior margin of tibio-fibular interosseous ligaments. Methods: From October 2015 through September 2016, we evaluated six patients (six cases) who presented to Baylor College of Medicine foot and ankle specialty clinic. These patients were found to have distal fibular stress fractures. Detailed initial history was documented. The diagnosis of distal fibular stress fracture was confirmed with both clinical examination and radiographic evidence among all patients. Additionally, all patients were found to have planovalgus deformity with associated hindfoot valgus. Radiographic measurements were taken in all patients, including lateral talo-calcaneal angle, Meary’s angle, calcaneal inclination angle, and AP tibio-talar angle. Distance of distal fibular stress fracture location to tip of lateral malleolus, as well as the distance between medial cuneiform and 5th metatarsal were measured. Single independent observer performed all measurements. Results: Among the six patients in the study, all were female, with average age of 58 years (45-64). Four patients carried the diagnosis of osteopenia and/or osteoporosis from DEXA scan. There is no evidence of association with tobacco use or alcohol use. The mean radiographic distance between location of stress fracture to tip of lateral malleolus is 5.8 cm (4.2cm-7 cm). There was evidence of pes planus from Meary’s angle, which averaged 6.7° (3°-11°) convex downward, and measurement of calcaneal inclination angle averaged 19° (13°-30°). Furthermore, measurement of tibio-talar angle averaged 1.7° valgus alignment consistent with chronic hindfoot valgus deformity. While all patients were treated successfully with immobilization, one patient underwent medial calcaneal osteotomy to correct the hindfoot valgus after recurrent fracture. Conclusion: It is hypothesized that increased stress loading of the fibula due to lateralization of the load axis contributes to this condition. The apex of this stress culminates in the lateral aspect of the fibula above the distal tibio-fibular ligament complex and results in a characteristic valgus fracture of the fibula. The increased stress from deformity results in the fracture rather than increased load from exercise or other repetitive stress. The significance of this proposition is that recognition of this type of fracture should lead the clinician to address the underlying planovalgus deformity in the treatment of this fracture type.

Manual therapy and barefoot run training in the treatment of a fibular stress fracture in a marathon runner: A case report

Manual therapy and barefoot run training in the treatment of a fibular stress fracture in a marathon runner: A case report

Leg Pain in Swimmer

HISTORY: 20 year old NCAA Div. 3 female swimmer who was recently diagnosed with Hashimoto’s thyroiditis and placed on Levothyroxine 50mcg, about one month prior to presentation with no other significant PMH. She was running on the treadmill when she developed pain over the lateral right ankle. This was her only third time training on a treadmill, she typically does not run. She denied any trauma or falling while on the treadmill. She immediately stopped running, thinking the pain would subside, however it did not. She reported to the athletic trainer at her college. Her monthly menses that had not changed in frequency or intensity. PHYSICAL EXAMINATION: Well developed, well nourished, in NAD, slight limp. Thyroid: slight enlarged, no nodules. Skin: not dry Hair: not falling out CV: RRR, no murmurs, rubs. MSK: demonstrated normal strength, intact gross sensation of the foot and ankle, with TTP over the distal fibula, no deformity, minimal swelling of distal fibular. Her fibular rock test was negative. Her ATFL, CFL, and PTFL were all intact. Distal sensation was intact. Single leg heel raise was painful but could perform. DIFFERENTIAL DIAGNOSIS: 1) Lateral Ankle Sprain 2) Distal Tibia or Fibula occult or pathologic fracture 3) Tarsal Tunnel syndrome 4) Gout/ Pseudogout 5) Peroneal Tendon subluxations vs. tear 6) Degenerative Joint Disease 7) Osteochondral Lesion of Talus 8) Distal Fibular Stress Fracture 9) Popliteal Artery Entrapment 10) Exertional Compartment Syndrome TEST AND RESULTS: X-rays demonstrated a non-displaced transverse fracture of the distal fibula just proximal to level of the mortise. CBC: WNL, Chem 7: WNL. Following labs were ordered: PTH, TSH, estrogen, CBC and vitamin D levels. FINAL WORKING DIAGNOSIS: Non-traumatic Distal Fibular fracture in a swimmer TREATMENT AND OUTCOMES: She was placed in Short leg cast and made non-weight-bearing for 6 weeks. She progressed and did well. Lab work that was ordered was never acquired. She ended up transferring to a college in Colorado. Phone follow up was done. She has returned to swimming without issue. She no longer runs.

Free vascularized fibular graft bridged vascular pedicle by vein transplantation for infective long bone defect reconstruction

Objective To explore the surgical method and curative effect of free vascularized fibular graft bridged vascular pedicle by vein transplantation for infective long bone defect with or without soft tissue defect reconstruction. Methods From June 2008 to January 2014, 17 patients with infective long bone defect were treated, 11 male and 6 female, 1.5 to 55 years old and averaged 31.3 years. 8 cases in femur, 5 cases in tibia, 3 cases in humerus and 1 case in radius. Bone defect were 4 to 19 cm in length with an average of 9.4 cm. 8 cases with soft tissue defect, from 5.0 cm×3.0 cm to 17.0 cm×5.5 cm. Required adequate surgical debridement, and vacuum sealing drainage (VSD) was used. Free vascularized fibular (skin) flap was designed and harvested. Artery and veins close to the health site were dissected, and bridged vascular pedicle of free vascularized fibular flap by autologous vein transplantation with end to end anastomosis. The length free vascularized fibular graft was from 5 to 18 cm, with an average of 9.6 cm. The free fibula flap ranged from 6.5 cm×4.0 cm to 18.0 cm×6.0 cm. Results All the 17 cases of fibular flap survived, no vascular crisis happened. Post-operative wound primary healed in 11 cases, delayed 1 to 2 weeks to heal in 6 cases. Callus was seen in the 6 to 8 weeks later. 15 cases were followed from 9 months to 6 years (averaged 30 months) while 2 cases were lost to follow-up. Bone defect primary healed in 13 cases, and the fibula graft unhealed in 2 cases, but healed again after a second operation. Fibula stress fracture occurred in one case at 7 months after grafting procedures and bone union was achieved 4 months after reapplying an external fixator. Infected bone defect healing time ranged from 4.2 to 9.8 months, averaged 5.9 months. According to the Enneking score, 11 cases were excellent, good in 3 cases, one in fair. Excellent and Good rate was 93.3%. Conclusion Free vascularized fibular (skin) graft with vein bridged vascular pedicle can not only effectively repair infected bone and soft tissue defect, but also improve local blood supply and control infection, shorten the course of treatment, which is an effective treatment of infective long bone defects with or without soft tissue defects. Key words: Fractures, bone; Infection; Wounds and injuries; Fibula; Surgical Flaps; Blood vessels; Transplantation, Autologous

One-Stage Long-Stem Total Knee Arthroplasty for Arthritic Knees with Stress Fractures

PURPOSE. To evaluate the outcome of one-stage long-stem total knee arthroplasty (TKA) for patients with arthritic knees and tibiofemoral stress fractures. METHODS. Records of 11 men and 18 women aged 47 to 78 (mean, 66) years who underwent fixed-bearing posterior-stabilised TKA for osteoarthritis or rheumatoid arthritis of the knee with tibial (n=31) and femoral (n=3) stress fractures were reviewed. All the tibial fractures involved the proximal half. There were 7 associated fibular stress fractures. Of the 31 knees with tibial stress fractures, 26 and 5 manifested varus and valgus deformity, respectively. RESULTS. The mean follow-up period was 51 (range, 24-96) months. The mean tibiofemoral angle improved from 23.2 to 1.9 degrees varus. The mean Knee Society knee score improved from 38.5 (range, 15- 63) to 89.6 (range, 80-95) [p<0.05]. The mean Knee Society functional score improved from 25.5 (range, 0-40) to 86.5 (range, 60-100) [p<0.05]. All fractures were united at the last follow-up. No complications were encountered. CONCLUSION. One-stage long-stem TKA restores limb alignment and facilitates fracture healing, with excellent outcome.

Fibular Stress Fracture in a High School Athlete

The patient was a 15-year-old adolescent male who was referred to a physical therapist for a chief complaint of bilateral posterolateral lower-leg pain, which was worse in the right lower extremity than in the left. Due to findings that were concerning for a stress fracture, the patient was referred to a pediatric sports medicine physician. Subsequent radiographs revealed findings that were concerning for a stress fracture along the medial aspect of the midshaft of the right fibula.

Leg Pain in an Adolescent Female - Basketball

HISTORY: A 13-year old female basketball player presented with a 3-month history of progressive left lateral leg pain. She had sprained her left ankle 1 year earlier, though this had resolved with 1 month of relative rest. Her more recent leg pain began insidiously as she began the subsequent basketball season. She described throbbing pain, localized diffusely over the lateral lower leg. Pain was worse with walking, but was present even when not weightbearing. Concurrent symptoms included intermittent swelling and purplish mottling of the leg, as well as occasional toe numbness. She was initially treated with a 3-week trial of relative rest and a walking boot, but her leg pain continued to worsen. PHYSICAL EXAMINATION: Initial examination revealed an obese, otherwise healthy appearing adolescent female with normal gait. The left ankle was slightly edematous, and mild purplish mottling of the left leg was noted. She was diffusely tender to palpation over the left lateral calf and fibula. Left ankle ROM was normal. Strength was normal, but her pain was exacerbated with activation of the left ankle evertors and plantarflexors. In a subsequent examination, the slump test and left straight leg raise both reproduced her left lateral leg pain. Neurologic testing was otherwise unremarkable. DIFFERENTIAL DIAGNOSIS: Fibular stress fracture Calf muscle strain Deep vein thrombosis Complex regional pain syndrome Lumbosacral radiculopathy TESTING: Left tibia/fibula radiographs: No fracture. Lower leg MRI: No fracture or stress reaction. Increased T2 signal throughout left extensor digitorum, gastrocnemius, and soleus, suggestive of muscle strain. Similar, less severe findings in right leg. Left leg ultrasound: No venous thrombosis. Lumbar spine MRI: Left paracentral disc protrusion at L4-L5, impinging the traversing L5 nerve root. Congenitally narrow spinal canal. FINAL DIAGNOSIS: Left L5 radiculopathy TREATMENT AND OUTCOMES: 1. Physical therapy - dynamic lumbar stabilization program. 2. Gabapentin titrated to 300 mg three times daily. NSAIDs used as needed. 3. At 6 months, resumed strength training and low-impact endurance exercise. 4. Leg pain improved, but intermittent flare-ups continued. Refused epidural steroid injection. 5. At 1 year, still unable to return to competitive basketball.

Fibula Stress Fractures: A Treatment Review

Fibula stress fractures should be managed with rest from any precipitating activity, physical therapy, and treatment of any contributing factor, whether metabolic, nutritional, postural, or other. Most fractures should uneventfully heal within 6-12 weeks by implementing this strategy. However, certain locations of this injury deserve specific attention as unique static and dynamic factors may be related with fracture pathomechanism in these areas. Proximal fibular area injuries may be related with either direct repetitive pressure applied over the affected area, or muscular forces that increase stress transfer in this area under exceptional exercise conditions. The distal fractures area may be related with specific pathologic functioning of the syndesmotic joint. Although operative intervention for direct fibula stress fracture fixation has never been described in the published studies, for syndesmotic dysfunction, surgical intervention may be necessary to recreate load transfer through this joint to the distal fibula area. Several modalities for healing enhancement of fibula stress fractures have also been described in the literature, and should be thought-of. These modalities include low-intensity ultrasound, pneumatic bracing, and electromagnetic field therapy. However, evidence-based published data to support the usefulness of these modalities in the healing process of this injury is lacking.