The clinical presentation is suspicious for a stress fracture of the tibia following free-fibula bone grafting. If plain radiographs are negative, more sensitive imaging such as a MRI or bone scan should be performed.
Tibial stress fractures are a known complication following free-fibula bone grafting. Radiographs may be normal (as is the case in figure A), or might show the "dreaded black line" and/or new periosteal bone formation. If a stress fracture is confirmed with imaging, appropriate management would then consist of protective weight bearing until symptoms subside.
Pacifico et al detail a case report of tibial stress fractures after vascularised free-fibula graft to the mandible. They report non-traumatic stress fracture to the tibia following a vascularised free-fibula graft is an uncommon but important complication.
Ivey et al detail a case report of a tibial stress fracture after vascularised free-fibula graft for repair of non-union of the humerus.
Emery et al report a case-series of 5 patients who sustained tibial stress fractures after a graft had been obtained from the ipsilateral fibula for use in anterior reconstruction of the spine. They theorize that the increased load the tibia bears as a result of the missing fibular graft may result in stress fractures.
Illustration A shows new periosteal bone formation on the lateral cortex of the tibia consistent with a stress fracture.
Incorrect Answer Choices:
1: While compartment syndrome is on the differential diagnosis, his signs and symptoms are not most consistent with that diagnosis.
2: While CT scan may show evidence of a stress fracture, MRI/bone scans have been shown to be superior methods for detection.
4: As infectious laboratories are normal, an ultrasound to rule out a deep abscess would likely be negative.
5: Bone biopsy is not appropriate without evidence of a lesion or concern for osteomyelitis.
Pacifico MD, Floyd D, Wood SH. Tibial stress fracture as a complication of free-fibula vascularized graft for mandibular reconstruction. Br J Plast Surg. 2003 Dec;56(8):832-4.
PMID:14615264 (Link to Abstract)
Ivey M, Hicks CA, Hook JD. Stress fracture of the tibia after harvest of a vascularized fibular graft for repair of nonunion of the humerus. Orthopedics. 1995 Jan;18(1):57-60.
PMID:7899169 (Link to Abstract)
Emery SE, Heller JG, Petersilge CA, Bolesta MJ, Whitesides TE Jr. Tibial stress fracture after a graft has been obtained from the fibula. A report of five cases. J Bone Joint Surg Am. 1996 Aug;78(8):1248-51.
PMID:8753718 (Link to Abstract)