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

Abstract

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.

Keywords: Intramedullary nailing; Overuse injuries; Posterior tibial stress fracture; Runner-type stress fracture; Running; Stress fractures.

Fig. 1

Initial radiographs show suspected tibial stress fracture or shin splints. There is no clear abnormality in the radiographs of the tibia in the antero-posterior and lateral views. A Right side; B left side

Fig. 2

Initial coronal MRI scans diagnosed with a stress fracture show a strikingly wide low-signal intensity on the T1-weighted scan (A), and a high-signal intensity on the T2-weighted scan (B) and STIR fat-suppressed scan (C) in the localized bone marrow. The abnormal finding is more detectable on the STIR fat-suppressed MRI scan

Fig. 3

Radiographs of both legs 6 months after the initial visit to our hospital. Obtained 6 months after the first examination, callus formation is seen at the lateral and posterior side of the tibia in the antero-posterior and lateral views. The arrows indicate callus formation at the lateral and posterior sides of the tibia

Fig. 4

Radiographs at the emergency department with deformity of the right lower leg. Full-length tibial radiographs were requested in keeping with the clinical picture, and they confirm complete tibial and fibular fractures of the right side. A Right-side tibial radiography and 3D computed tomography; B Left-side tibial posterior stress fracture. Arrows indicate callus formation sites

Fig. 5

MRI of the left lower leg after right complete fractures. On MRI, STIR shows an abnormal high signal

Fig. 6

Bone scintigraphs show abnormal local uptake in the antero-posterior (A) and postero-anterior (B) and lateral views of the right side (C) and left side (D) of the patient with stress fractures. Arrows indicate longitudinal linear uptake in the bone scintigraph views of the patient with stress fractures

Fig. 7

Radiographs show fixation of both tibial fractures, complete and incomplete, with intramedullary nailing. Closed reduction and internal fixation of the radial shaft fracture were performed using intramedullary nailing for both the right complete tibial fracture (A) and the left tibial stress fracture (B)

Fig. 8

Postoperative antero-posterior and lateral radiographs show newly healed tibial stress fractures. Postoperative radiographs show antero-posterior and lateral low views. The patient was asymptomatic and clinical healing of the fracture is apparent 10 months after the nailing, and a fracture line is hardly visible on the radiographs. A Right side; B left side