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Fibular Stress Fracture

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Other Names

  • Fibular Shaft Stress Fracture
  • Stress Fracture of the Fibula

Background

  • This page refers to stress fractures of the Fibula, an overuse injury
  • Acute Fibular Fractures are discussed separately

History

Epidemiology

  • Incidence in athletes and military recruits is reported to range from 3.5% ‐ 29.6%, depending on the population[1]
  • Kahanov et al: proportion of fibular stress fractures among runners to be 7% ‐ 12% of all stress fractures[2]
    • However, the proportion may be as high as 33% and 20% of stress fractures in female and male distance runners, respectively[3]

Pathophysiology

  • See: Stress Fractures (Main)
  • General
    • The vast majority occur in the distal 1/3 of the fibula
    • May be overlooked initially
    • Proximal 1/3rd is much less common
  • Proposed mechanism
  • Proximal third potential etiology
    • Direct contact, for example a circus performer hanging upside down[4]
    • Repetitive jumping while both knees were fully bent in a squatting position[5]

Pathoanatomy

  • Fibula
    • Only caries 6-7% of bodyweight with ankle in neutral[6]

Associated Pathology


Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • History of overuse
    • Pain with activity only can progress to pain at rest
  • Physical Exam: Physical Exam Leg
    • Point tenderness along fibula
  • Special Tests
    • Hop Test: hop on affected limb ~10 times to reproduce localized pain
    • Tuning Fork Test: place tuning fork on bony area of concern

Evaluation

Radiographs

  • Standard Radiographs Tibia Fibula
    • Initial imaging modality of choice
  • Early Findings
    • Lag behind clinical exam for weeks
    • May demonstrate subtle radiolucency, poor definition of the cortex
  • Late findings
    • Thickening and sclerosis of the endosteum
    • Periosteal new bone formation

MRI

  • Gold standard for stress fractures of the tibia
  • Benefits
    • More sensitivity than XR
    • Helps to differentiate stress fracture from shin splints

Ultrasound

  • Role in evaluating stress fractures is not well defined

Classification

  • Not applicable

Management

Prognosis

  • Proximal fibula stress fractures
    • More common in military recruits[9]
    • May have a longer recovery period
  • Distal fibula stress fractures
    • Typically resolve with appropriate nonoperative management

Nonoperative

Operative

  • Indications
    • Failure of conservative measures
  • Technique
    • Unknown

Rehab and Return to Play


Complications

  • Delayed Union
  • Delayed return to sport
  • Physical deconditioning

See Also


References

  1. Behrens SB Deren ME Matson A Fadale PD Monchik KO. Stress fractures of the pelvis and legs in athletes: A review. Sports Health. 2013;5(2):165‐174.
  2. Kahanov L Eberman LE Games KE Wasik M. Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners. Open Access J Sports Med. 2015;6:87‐95.
  3. Snyder RA Koester MC Dunn WR. Epidemiology of stress fractures. Clin Sports Med. 2006;25(1):37‐52, viii.
  4. Al-Kashmiri, Ammar, and J. Scott Delaney. "Case report: fatigue fracture of the proximal fibula with secondary common peroneal nerve injury." Clinical Orthopaedics and Related Research® 463 (2007): 225-228.
  5. Symeonides, P. P. "High stress fractures of the fibula." The Journal of bone and joint surgery. British volume 62.2 (1980): 192-193.
  6. Goh, J. C., et al. "Biomechanical study on the load-bearing characteristics of the fibula and the effects of fibular resection." Clinical orthopaedics and related research 279 (1992): 223-228.
  7. Lehman, Thomas P., Michael J. Belanger, and Mark S. Pascale. "Bilateral proximal third fibular stress fractures in an adolescent female track athlete." (2002): 329-332.
  8. Lacroix, H., and J. N. Keeman. "An unusual stress fracture of the fibula in a long-distance runner." Archives of orthopaedic and trauma surgery 111.5 (1992): 289-290.
  9. Hong SH, Chu IT. Stress fracture of the proximal fibula in military recruits. Clin Orthop Surg. 2009 Sep;1(3):161-4. doi: 10.4055/cios.2009.1.3.161. Epub 2009 Aug 17. PMID: 19885052; PMCID: PMC2766750.
  10. Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005 Apr 18;2005(2):CD000450. doi:
Created by:
John Kiel on 7 July 2019 07:18:20
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Last edited:
6 April 2021 18:14:42
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