What is the best course of action for a 44-year-old female (F) with a history (hx) of a fall and ongoing pain and swelling in her left foot, with radiographs showing a multiloculated lucent focus along the lateral aspect of the distal tibial metadiaphysis?

From the Guidelines

The best course of action for this 44-year-old female with foot pain, swelling, and a multiloculated lucent focus on radiographs is to obtain dedicated ankle, tibia, and fibula radiographs to further evaluate the indeterminate lucent bone lesion. Given the patient's history of a fall and ongoing pain, it is crucial to thoroughly assess the lesion to determine if it represents a stress fracture, which could be at high risk for fracture completion, especially if the patient has underlying conditions such as osteoporosis or is on bisphosphonate therapy 1. The radiographic finding of a multiloculated lucent focus along the lateral aspect of the distal tibial metadiaphysis is concerning and requires further characterization to guide appropriate management. Key considerations include:

• The location of the lesion, which could suggest a high-risk stress fracture if located in areas prone to nonunion or delayed union, such as the anterior tibial diaphysis or the medial malleolus 1.
• The patient's risk factors for fracture completion, including osteoporosis or bisphosphonate therapy, which would necessitate prompt identification and management of the lesion to prevent progression to a more serious fracture 1.
• The potential for the lesion to represent a benign or malignant bone tumor, although the radiographic description suggests an involuting nonossifying fibroma, which is typically benign but still requires confirmation through further imaging or biopsy if necessary. Further evaluation with dedicated radiographs, and potentially advanced imaging such as MRI or CT if the radiographs are inconclusive, is essential to determine the nature of the lesion and guide appropriate treatment, which may include non-weight-bearing regimens, pain management with medications like acetaminophen or ibuprofen, and possibly referral to an orthopedic specialist for further management 1.

From the Research

Patient Presentation and History

• The patient is a 44-year-old female with a history of a fall and ongoing pain and swelling in her left foot.
• Radiographs show a multiloculated lucent focus along the lateral aspect of the distal tibial metadiaphysis, which is indeterminate but may reflect an involuting nonossifying fibroma.

Diagnostic Considerations

• The presence of a lucent bone lesion in the distal tibia suggests the need for further evaluation to determine the nature of the lesion 2.
• Magnetic resonance imaging (MRI) can be helpful in evaluating bone tumors and tumor-like lesions, particularly when radiographs are indeterminate or show signs of aggressiveness 3.

Treatment Options

• The use of a rush nail for fibular fractures and minimally invasive percutaneous plate osteosynthesis (MIPPO) for tibial fractures may be a viable treatment option for distal tibial fractures, as it can reduce the risk of soft tissue complications and infection 4.
• A fibular notch approach may be considered for the treatment of ankle fractures involving the distal tibial plafond, as it provides excellent direct visualization of the fragments and articular surface without significantly increasing iatrogenic injuries 5.

Next Steps

• Consider dedicated ankle, tibia, and fibula radiographs to further evaluate the lucent bone lesion.
• MRI may be indicated to narrow the differential diagnosis or make a specific diagnosis if the lesion is indeterminate or shows signs of aggressiveness 3.
• Referral to an orthopedic specialist may be necessary for further evaluation and management of the patient's condition.