Nonunion of a medial malleolus stress fracture

Abstract

This is a case report of a nonunion of a medial malleolus stress fracture in the left ankle of a collegiate football player. Foot and ankle stress fractures account for only 30% of all stress fractures according to one study&dquo;; of these, only 9% are of the medial malleolus. Although Shelbourne et al.' have only recently defined stress fractures of the medial malleolus, a nonunion of a medial malleolus stress fracture has not been reported. To our knowledge, this case report represents the first documentation of a nonunion of a medial malleolus stress fracture, a rare yet disabling sports medicine injury. CASE REPORTA 21-year-old college football player came to our sports medicine center in 1987 complaining of a painful mass in his left ankle. The patient originally noticed ankle pain 2 years earlier while playing football, but denied any traumatic episode. He had reported to the sports medicine center at another university in August 1985, complaining of medial ankle pain and swelling that increased with activity, especially dorsiflexion. He was treated with ice, ibuprofen, and range of motion exercises. One week later, aspiration of the ankle was attempted unsuccessfully and betamethasone was injected. Despite decreased swelling 2 days later, medial pain persisted. Radiographs were obtained in September 1985 but were diagnosed as negative (Fig. 1). The painful area was again injected with betamethasone and lidocaine. Although he had swelling and pain, the patient continued to play football.Two weeks after the radiographs were taken he returned to the other clinic complaining of a twisting injury to his ankle. Their examination revealed swelling and medial malleolus pain. He was treated with a third injection of betamethasone and a 5-day course of phenylbutazone. The patient was told he had &dquo;irritated an old injury&dquo; and no further studies were ordered. Despite chronic pain, the patient continued playing football, including an appearance in a major college bowl game. Throughout the school year he continued activities, but usually by day's end he had difficulty playing recreational sports. The patient transferred for the following school year and was, therefore, prohibited from playing football for 1 year. He remained active with weight training and recreational sports, but he had pain throughout the year. He did not seek further medical attention.The following football season, August 1987, he came to our clinic complaining of a painful mass over his left ankle. He stated that the pain was present every day and increased in intensity as the day progressed. Our examination revealed a large mass of bone proximal to the medial malleolus. He experienced pain on both palpation of the medial malleolus and motion of the ankle from a dorsiflexion to a neutral position. Radiographs of the left ankle revealed a nonunion of the medial malleolus running in a vertical direction from the tibial plafond. There was exuberant new bone formation on the medial tibia and the fracture line had a sclerotic border, but there...

Medial Malleolar Stress Fracture in Athletes: Diagnosis and Operative Treatment

“…Especially the potential severe complications should be taken into consideration when determining the optimal treatment (9, 13,14). Even though the treatment method in most cases with early diagnosis could be conservative, operative treatment is necessary in certain fractures.…”

“…These same factors can also have effect on the healing process of medial malleolar stress fracture resulting in delayed healing and non-union of the fracture; and even dislocation (13,14).…”

Double Threaded Screw Fixation for Bilateral Stress Fracture of the Medial Malleolus

“…Orava reported two cases with delayed union managed by drilling with a 2.2 mm drill bit [10], while Reider reported a patient with nonunion who underwent internal fixation with bone graft after debridement of fibrous tissues [13]. For patients presenting with short clinical history as the case reported here, screw fixation without bone graft has generally been adopted as a procedure option.…”

Medial-sided Stress Fractures: Medial Malleolus and Navicular Stress Fractures

“…Some nonunions of medial malleolar stress fractures also underwent percutaneous drilling across the fracture site with good success. 28 Shabat et al 24 aggregated the data from 4 case studies and 23 patients 25,28,29,37 in 2002. Although they did not provide any statistical analysis, they did show some differences in those treated with surgery and those treated conservatively.…”