Fibula Stress Fracture

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Fibula Stress Fracture

Authors, Editors, Case Information Author: Drew Duerson, MD Affiliation: Nationwide Children's Hospital Senior Editor: Wesley Troyer, DO Clinical Vignette: 13-year-old female basketball athlete that presents with insidious onset lower leg pain. Exam with focal tenderness to the distal fibula. Radiographs of the tibia and fibula were unremarkable. Type of Probe Used: 6-15 MHz linear array transducer SAX Fibula with doppler labeled Short axis image of the distal fibula with power doppler revealing hyperemia of the periosteum and nearby soft tissues. #2 - Video View Video Short axis view of the lower leg sliding proximal to distal revealing normal fibularis brevis and longus muscle and tendons with hypoechoic periosteal elevation of the fibula at the end of the video SAX Fibula labeled Short axis image of the distal fibula with hypoechoic periosteal elevation. Pain with sonopalpation at this site. Normal appearing fibularis brevis and longus. SAX Fibula Short axis image of the distal fibula and adjacent fibularis brevis and longus. LAX Fibula labeled Long axis image of the distal fibula with a focal area of cortical irregularity and thickening with adjacent hypoechoic periosteal elevation. Pain with sonopalpation at this site. LAX Fibula Long axis image of the distal fibula Interpretation Image Interpretation: The distal fibula has a focal area of cortical irregularity with hypoechoic periosteal elevation and nearby hyperemia on power doppler consistent with an early bone stress injury. Teaching Pearl: Bone stress injuries are common overuse injuries seen in sports medicine clinics. Radiographs remain the mainstay first step in evaluation of these injuries however they are often normal appearing. Most often MRI or bone scintigraphy have been the imaging modality of choice to further evaluate these patients but it is now known that US can be used point-of-care to look for characteristic findings of early bone stress injury. The earliest findings are often hypoechoic periosteal elevation and hyperemia. Later cortical irregularity and thickening with callous formation and hyperechoic surrounding soft tissue secondary to edema can be present. Pain with sonopalpation often becomes a very important aspect to the evaluation as well (1). While case studies specific to fibula stress fractures diagnosed by sonography are limited it has been shown as a tool that can be used to differentiate lower leg pain secondary from muscle injury compared to bone stress (2). References: 1) Hoffman DF, Adams E, Bianchi S. Ultrasonography of fractures in sports medicine. Br J Sports Med. 2015 Feb;49(3):152-60. doi: 10.1136/bjsports-2014-094217. Epub 2014 Dec 24. PMID: 25540189. 2) Hoglund LT, Silbernagel KG, Taweel NR. DISTAL FIBULAR STRESS FRACTURE IN A FEMALE RECREATIONAL RUNNER: A CASE REPORT WITH MUSCULOSKELETAL ULTRASOUND IMAGING FINDINGS. Int J Sports Phys Ther. 2015 Dec;10(7):1050-8. PMID: 26672683; PMCID: PMC4675190.
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Authors, Editors, Case Information

SAX Fibula with doppler labeled

#2 - Video

SAX Fibula labeled

SAX Fibula

LAX Fibula labeled

LAX Fibula

Interpretation

UPCOMING EVENTS

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