Fatigue Fracture of the Fibula

Fatigue, or stress, fractures have been described as occurring in many situations and at widely differing ages from 15 months to 64 years. Most have occurred in young adults, particularly soldiers in training and athletes. Although fatigue fractures usually occur in weight-bearing bones, in particular the metatarsals and tibia, they also occur in the fibula, and have even been described in the first rib and in the ulna. The distinction between fatigue fractures and all other varieties of fracture arising in the absence of direct trauma has been clearly made by Blair Hartley (1943). Jackson Burrows (1948) in a comprehensive article, reviewed the literature of fatigue fracture of the fibula. In it he discussed the relationship between intensity and duration of stress. He described how stress of adequate intensity acting once produces a traumatic fracture, whereas a recurrent stress of much smaller intensity produces a fatigue fracture, and suggested that types intermediate between these extremes also occurred. Fatigue fractures have been reported in several situations in children. Roberts and Vogt (1939) described a series of tibial fractures, the youngest child being 4 years old. Blair Hartley's (1942) series also included several children with tibial fractures. ' March ' fractures also occur in children. Three cases were reported recently by Macpherson (1951), and during the year in which I collected these fibular fractures I saw six metatarsal fractures in five patients of ages ranging from 5 to 101 years. Siemens (1942) described a case of bilateral fatigue fracture of the middle third of each fibula in a boy of 15 months. Ingersoll (1943) described three cases in boys of 9 years, ascribing the lesion to the stress of learning ice skating. Fractures in one of his cases were bilateral. Siemens quotes Brandt as having done a biopsy on a girl of 10 years with a periosteal bony thickening above the lateral malleolus. In the absence of a history of injury he considered the case to be in the nature of a stress fracture. The following eight cases were also in children, and show a number of points which may throw a little light on this interesting condition.