Working Diagnosis:
Delayed union of distal fibular fracture

Treatment:
Given the x-ray and CT findings, the athlete was referred for evaluation by the orthopedic foot/ankle surgeon for consideration of surgical stabilization versus ongoing conservative treatment. Although his x-ray showed persistent fracture with minimal callus, his pain continued to improve, and he was able to tolerate up to an hour of training and playing without pain.

Outcome:
The athlete completed an ankle rehabilitation program with the training room staff. He was relatively pain free on palpation 2 months into his program (10 months from injury) and was cleared to play baseball in an Aircast. He was encouraged to follow up with his surgeon and team physicians for ongoing consultation given his persistent fracture but ultimately, he declined medical recommendations and left the baseball team.

Author's Comments:
This is an unusual mechanism of injury as the player did not have blunt trauma to the leg. Fractures to the shaft of the fibula are generally treated nonoperatively and may weight bear as tolerated. Most patients have union within 6-8 weeks. However, due to lack of medical compliance, this patient had prolonged non-union. Plating and bone grafting may be considered in these cases. Isolated distal fibular fractures with less than 2mm of displacement and no medial ligament injuries have excellent results. Mortise involvement and talus displacement may warrant reduction and surgical fixation. Asymptomatic non-unions treated conservatively may spontaneously heal years after initial injury.

Editor's Comments:
As described above, an isolated fibular fracture without other bony or ligamentous injury are fairly rare. This case illustrates the risk of non-compliance which can be a relatively common pitfall with treating highly motivated athletes. Working closely with the athlete and and athletic support staff to ensure proper follow up and compliance with immobilization when needed is important for good results. Repeat plain films at follow up can help guide aggressiveness of treatment recommendations. Common complications of this injury include superficial peroneal nerve injury as well as vascular compromise and should be promptly evaluated at the time of injury. Although a malunion can continue to heal for a great deal of time as noted above, a large portion of high level athletes may chose surgical fixation to possibly allow faster return to play.

References:
1. Canton G, Sborgia A, Maritan G, Fatton R, Roman F, Tomic M, et al. Fibular Fracture Management. World J Orthop. 2021;12(5):254-269.
2. Walters BB, Constant D, Anand P. Fibula Fractures. [Updated 2023 Feb 26]. In: Stat Pearls (Internet). Treasure Island (FL): Stat Pearls Publishing; 2023 Jan-

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