distal tibial stress fracture

The tibia is one of two bones that make up the lower leg, the other being the fibula. . Displaced fracture of the tibial shaft; Figure 3: With an intact fibula it will tend to push the tibia into varus during healing. Tibial stress syndrome (also known as shin splints) is an overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain. Chronic anterior tibial stress fractures in athletes: No crack but intense remodeling. What do they do for a fractured tibia? An unusual case of simultaneous bilateral stress fractures of the distal tibia and fibula in a 45 year old white woman is described. The pain is typically posteromedial soreness and the diagnosis is usually made clinically without the need for further imaging assessment. TIBIAL STRESS FRACTURE Reza Maulana Abstrak. Stress fractures distal to the tuberosity of the fifth metatarsal are termed Jones fractures but must be distinguished from an acute Jones fracture. Careers. It can visualize lower grade stress injuries (stress reactions) before an X-ray shows changes. Annotated images, identifying the spring ligament recess (purple arrow), the medioplantar oblique band of the spring ligament complex (green arrow), and the inferoplantar longitudinal band of the spring ligament complex (orange arrow). But, for full recover you will need from six to twelve months. Rev Bras Ortop. 8600 Rockville Pike Would you like email updates of new search results? Before Distal Tibial Fractures This is a fracture in the metaphysis, the part of tibia before it reaches its widest point. Eventually, the bone weakens and becomes susceptible to tiny cracks, or stress fractures. Also read: show answer. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Examination of a tibial stress fracture will often reveal a more localized pain than shin splints, although this finding is not always true. After a while, pain persists with activities of daily living, such as walking. Dr. David Geier is an orthopedic surgeon and sports medicine specialist in Charleston, South Carolina and Charlotte, North Carolina. When muscles are overtired (fatigued), they are no longer able to absorb the shock of repeated impacts. Injury. Click here to go to Dr. David Geiers Amazon Influencer store! J Am Acad Orthop Surg. Stress fractures can be grouped into "low risk" and "high risk" categories: A low risk stress fracture will typically heal on its own just fine, and may not even require any time spent in a boot or on crutches. government site. 5,6,40 Tibia fractures often result from trauma, and approximately 50% of tibia fractures occur in young dogs and cats. Fibular fractures in adults are typically due to trauma. He has been featured in major media publications and shows over 2,500 times throughout his career. eCollection 2013 Nov-Dec. O'Neill BJ, Ryan K, Burke NG, Moroney PJ. Tibiofibular synostosis in professional basketball players. How 2-macroglobulin appears to stop cartilage breakdown and improve arthritis, 334. If the symptoms are fairly recent, x-rays might not show a stress fracture, so further testing, such as bone scans or MRIs, are often used. doi: 10.1136/bcr-2014-205353. Accessibility So the name implies that when you get a fracture, you can walk with it, and it will heal. Schatzker VI bicondylar tibial plateau fracture with distal extension. Injuries to the distal tibial and fibular physes are generally reported to account for 25% to 38% of all physeal fractures, 78, 156 second in frequency only to distal radial physeal fractures 141; however, Peterson and associates 143 reported that phalangeal physeal fractures were most common, followed by physeal injuries of the radius and ankle. The spring ligament recessis an important anatomical feature to identify when reporting MRI of the foot and ankle, so to prevent misinterpreting this normal structure for a spring ligament tear. The fibula supports the tibia and helps stabilize the ankle and lower leg muscles. Tibial Stress Fractures and Athletes. Unspecified fracture of lower end of right tibia, initial encounter for closed fracture Unsp fracture of lower end of right tibia, init for clos fx; Closed fracture of distal end of right tibia; Right tibia (lower leg bone) fracture ICD-10-CM Diagnosis Code M89.164 [convert to ICD-9-CM] Complete physeal arrest, right distal tibia Medial Tibial Stress Syndrome (MTSS) is a common overuse injury of the lower extremity. 2007 Jan;28(1):25-33. doi: 10.1097/MNM.0b013e328012e3de. Check for errors and try again. THE SITE MAY OFFER HEALTH, FITNESS, NUTRITIONAL AND OTHER SUCH INFORMATION, BUT SUCH INFORMATION IS DESIGNED FOR EDUCATIONAL AND INFORMATIONAL PURPOSES ONLY. Any guidance or information on billing stress fractures would be . But a fracture walking boot isn't really always that helpful and not always necessary for a tibial stress . Advert Symptoms Tibial stress fracture symptoms are very similar to shin splints (medial tibial stress syndrome) and include: Pain on the inside of the shin, usually on the lower third. Disclaimer, National Library of Medicine Rand JA, Coventry MB. It typically takes a major force to cause this type of broken leg. Subcutaneous edema around the ankle joint. Unable to process the form. This injury commonly occurs in the weight bearing bones of the feet, upper and lower legs, and hip area. Ten percent to 20% of all tibia fractures are open fractures, with the distal tibia of mature animals . official website and that any information you provide is encrypted Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture. A stress fracture of the tibia is an overuse injury that typically develops gradually over time due to activities placing large amounts of stress through the tibia beyond what it can withstand. Unable to load your collection due to an error, Unable to load your delegates due to an error. Stress fractures represent a spectrum of injuries ranging from periostitis, caused by inflammation of the periosteum, to a complete stress fracture that includes a full cortical break. Physicians often refer to the x-ray findings as the dreaded black line, which is a break in the cortex of the bone but no fracture all the way through the bone or any displacement of the fracture. Motor vehicle collisions, for example, are a common cause of tibial shaft fractures. It is likely, that this stress fracture was the result of strain on tibia and fibula through this composite lifting operation. Symptoms: Pain while running, but over time, runners also will experience pain while walking and doing other activities. FOIA Individuals suffering from a tibial stress fracture typically feel an aching or burning (localized) pain somewhere along the bone. Stress fractures about the tibia, foot, and ankle. If the upper part of the bone is affected, it's known as a proximal or tibial plateau fracture and if the lower part breaks, it's called a distal or pilon fracture. How can you know if your injury should get better in a few days or if it's more serious? The https:// ensures that you are connecting to the Stress fractures result from cumulative strain on the bone, without enough time for proper recovery. The object was in front and lifted while he partly stood on one leg, which was rotated during the lifting. This checklist can help you plan your next step to recover quickly and safely. Federal government websites often end in .gov or .mil. Case Discussion Distal tibial stress fractures at the metaphysis are uncommon as most frequently they are in the diaphysis. Varner KE, Younas SA, Linter DM, Marymont JV. The site is secure. Q: Can you identify the structures the arrows are pointing at in the first set of images? This kind of injuries can easily be missed because they usually do not follow an acute injury in a fit young athlete, and plain radiographs usually appear normal. Acute stress reactions can progress into chronic posttraumatic stress disorder but also often resolve. Symptoms of a fracture in your tibia can range from bruising to intense pain in your lower leg, based on the extent of your injury. In the office, the physician will perform a history and physical examination. Tibial Stress Fracture After Ankle Arthrodesis: Case Series with Different Treatment Modalities. Felix NA, Stuart MJ, Hanssen AD. Am J . Q: Why is knowledge of the spring ligament recess important? The spring ligament recess is noted, best demonstrated on the axial PDFS sequence. Cross country running. You can use Radiopaedia cases in a variety of ways to help you learn and teach. A serious sports injury or accident, may cause one of bones within your legs to fracture, such as the fibula and tibia (below the knee), and the femur (above the knee). Bilateral stress fracture of distal fibula and tibia--case report. Distal Tibia Fracture 75 Tibia fractures distal to the nutrient artery may deprive the distal fragment of its medullary blood supply, and, in such cases, the distal end of the tibia must rely on its periosteal and metaphyseal blood supply for healing. Tibia sebanyak 59.5% dibanding pada remaja mempunyai ujung atas yang melebar dan (16-19 tahun . If you need more information about your particular injury and options to treat it and recover quickly and safely, talk to me one-on-one! Lidor C, Ferris LR, Hall R, Alexander IJ, Nunley JA. Radiographs or bone scans may be obtained to rule out stress fractures. Medial Tibial Stress Syndrome, also known as 'shin splints", is an early stage in the continuum that culminates in a stress fracture. Distal tibial metaphyseal fractures usually heal well after setting them without surgery and applying a cast. Growth plate (epiphyseal) fracture Distal plated in fibula and tibia may fracture with inversion/ eversion. In a Finnish study of 151 tibial stress fractures in athletes over a 7-year pe riod, 7 cases of anterior midtibial fractures were found, comprising 4.6% of the series (13). X-rays will often show a tibial stress fracture if symptoms have been present long enough. From: Green's Skeletal Trauma in Children (Fifth Edition), 2015 Related terms: Thioacetazone Usually tightness of the calf muscles and numbness and tingling are absent. . Stress fractures most often occur when there is abnormal stress on normal bone, in particular excess exercise or a sudden change in training or weight-bearing activity. Diagnosis is made clinically with tenderness along the posteromedial distal tibia made worse with plantarflexion. References They often develop from overuse, such as from high-impact sports like distance running or basketball. They occur in characteristic locations such as the distal tibia and posterosuperior calcaneum, with imperfectly linear fracture lines surrounded by bone marrow edema. This is potentially a worrisome diagnosis, as continued stress on a tibial stress fracture could lead to a complete fracture and require surgical treatment. I was wondering if CPT code 28470 would be appropriate to bill for a stress fracture as I cannot find any information online or in the coding books that support or deny this as an option for stress fractures. Background: For a distal tibial spiral fracture combined with a non-displaced posterior malleolar fragment (PMF), we proposed a hypothesis that the treating surgeon could assess the size of. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Although much less common, the proximal medial tibial condyle has been cited as an area subject to stress fracture. That's an anterior tibial stress fracture that's in the middle of the leg. Radiographs on presentation demonstrate a periprosthetic tibial shaft fracture distal to a cementless TKA. Background: No osteochondral injury of the talar dome or distal tibial plafond. They're caused by repetitive force, often from overuse such as repeatedly jumping up and down or running long distances. Two weeks after surgery, he developed pain proximal and lateral to the knee. Besides his physical injuries, he experienced acute stress disorder, which is common after traumatic events. The fracture may be closed with minimal displacement, or it may be a complicated open fracture where the fracture segment comes out of the skin. ( 20 tahun) paling tinggi dengan talus dan ujung distal fibula. A Distal Fibula Fracture is another name for a broken leg. Stress fracturesmost often occur when there is abnormal stress on normal bone, in particular excess exercise or a sudden change in training or weight-bearing activity. Tibia and . Before MeSH Please note that as an Amazon Associate I earn from qualifying purchases. It is caused by overuse or repetitive stress. Healing of tibia stress fracture will take about two months. distal thirds of the bone are a sign of tibial stress fracture. Callus formation is seen at 4 weeks follow up. Symptoms often occur after running long distances. A tibial shaft fracture occurs along the length of the bone, below the knee and above the ankle. Tibial stress fractures, especially in the setting of delayed healing, involves placement of a nail down the center of the bone with or without additional bone grafting to try to stimulate healing of the bone. Results: A 59-year-old male welder presented with a stress fracture of the left distal tibia and fibula in connection with heavy lifting. At a minimum, absolute refrain from the offending activities and sports is mandatory. government site. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. They result from excessive, repetitive loads on the normal bone which can cause an imbalance between bone resorption and formation, because during periods of intense exercise, bone formation lags behind bone resorption. The time to return to sports is lengthy, but if the fracture heals uneventfully, return to full participation with no limitations is often seen. Segmental Stress Fracture of Tibia in Recreational Running: A Case Report. Stress fractures can also develop from normal use of a bone that's weakened by a condition such as osteoporosis. Although stress fractures are well recognised . O'Neill B, Ryan K, Burke N, Moroney P. Bilateral Distal Tibial Stress Fractures in a Healthy Field-Hockey Goalkeeper. Symptoms are very similar to 'shin splints' with gradual onset pain on the inside of the shin. A tibial stress fracture is a hairline fracture of the tibia bone in the lower leg caused by overuse or repetitive stress. Findings in keeping with stress fractures. Bilateral stress fracture of distal fibula and tibia--case report. The most important principle in treating any stress fracture is to employ rest and weight-bearing restriction for as long as needed to allow the symptoms to resolve (1,2). Stress fracture in osteoarthritis more commonly occurs in upper third tibia. sharing sensitive information, make sure youre on a federal The biomechanical stress in association with special lifting tasks was estimated. The patient has a stress fracture. Usually physicians will not let the patient return to sports or exercise such as running until the fracture has completely healed. Examination of a tibial stress fracture will often reveal a more localized pain than shin splints, although this finding is not always true. Unable to process the form. 10.5435/JAAOS-20-03-167. The biomechanical stress in association with special lifting tasks was estimated. Often he or she starts having pain that comes on with a run, and over the next few days or weeks, the pain comes on sooner and takes longer to go away after stopping the run. Currently, the method most surgeons use for treating tibia fractures is intramedullary nailing. J Bone Joint Surg Am. A stress fracture can also happen when the tibia is weakened due to low bone density (osteoporosis) or poor nutrition. It is very important to listen recommendations of your doctor, because he/she best knows what is best for you. A: Yes. Bethesda, MD 20894, Web Policies Stres fraktur merupakan cedera yang sering terjadi pada kegiatan yang banyak melibatkan aktifitas fisik seperti pada atlet dan militer. Most stress fractures of the tibia are transverse or oblique and involve the mid or proximal shaft. Two simple ways women can decrease their risk of hip fracture. stress fracture (10-14). X-rays will often show a tibial stress fracture if symptoms have been present long enough. The .gov means its official. Q: Is the spring ligament complex intact? Ongoing ankle and hindfoot pain, non-responsive to physiotherapy. Magnetic resonance&bdy: The work described in this paper was pre-sented at the American Ray Society meet-ing, Washington, D.C., on 1 May 1995 Skeletal Radiol (1996) 25:319-324 Marked marrow and periosteal edema of the distal tibia with an almost complete stress fracture through the metaphysis. . A literature search on occupational stress fractures was performed. The intramedullary nail is screwed to the bone at both ends. YOU SHOULD NOT RELY ON THIS INFORMATION AS A SUBSTITUTE FOR, NOR DOES IT REPLACE, PROFESSIONAL MEDICAL ADVICE, DIAGNOSIS, OR TREATMENT. Marked marrow and periosteal edema of the distal tibia with an almost complete stress fracture through the metaphysis. Introduction Pain generally in the inner and lower 2/3rds of tibia. Recovery from a tibial stress fracture is lengthy whether or not surgery is performed. If the amount of force is too great for the Tibia to handle, a person may develop a tibial stress fracture. ADVERTISEMENT: Supporters see fewer/no ads. As he returned to play, the pain worsened with jumping and lateral movement and improved with rest. A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures. 2012; 20(3):167-176. It is the main weight-bearing bone of the two. A: To prevent misinterpretation of a spring ligament complex tear. 1990 Mar;21(2):122-3. doi: 10.1016/0020-1383(90)90073-4. Due to a large number of questions I have received over the years asking about products for health, injuries, performance, and other areas of sports, exercise, work and life, I have created an Amazon Influencer page. This site needs JavaScript to work properly. Reply Guest over a year ago 1980;62:226-233. If nonsurgical treatment is elected, many physicians recommend complete nonweightbearing and use of a cast or walking boot. It's one of the most commonly fractured bones in the body. Medial tibial stress syndrome, also known as shin splints, is the most common form of early stress . Tibial Stress Fracture - Treatment. The area of focal tenderness should be able to be covered by a single finger (or a pencil), if a stress fracture is suspected. J Bone Joint Surg Am. Findings in keeping with stress fractures. That process can often take three to four months. The tibia, or shinbone, is the most commonly fractured long bone in the body. BMJ Case Rep. 2012 May 30;2012:bcr0120125563. Q: Describe your findings Ortop Traumatol Rehabil. An MRI is considered the best way to diagnose stress fractures. An official website of the United States government. Ortop Traumatol Rehabil. The tibia is much thicker than the fibula. 2019 Oct;29(10):1521-1528. doi: 10.1111/sms.13466. Does the thought of seeing a doctor scare you? From: Green's Skeletal Trauma in Children (Fifth Edition), 2015 Download as PDF About this page official website and that any information you provide is encrypted Management of an Acutely Infected Distal Tibial Stress Fracture A 56-year-old female patient has undergone 2 procedures to treat a stress fracture of the distal tibia and fibula. Bookshelf I really hope that you will be fully recovered up to six months. Radiography Radiographs have a sensitivity of 15-35% for detecting stress fractures on initial examinations, increasing to 30-70% at follow up due to more overt bone reaction. A 59-year-old male welder presented with a stress fracture of the left distal tibia and fibula in connection with heavy lifting. Schilcher J, Bernhardsson M, Aspenberg P. Scand J Med Sci Sports. Two cases are presented in which the fracture line was seen on computed tomography scans as coursing longitudinally down the shaft of the distal tibia, which, to my knowledge, is an orientation and location not previously described in the literature. Subcutaneous edema around the ankle joint. sharing sensitive information, make sure youre on a federal An official website of the United States government. This type of test is also better able to distinguish between stress fractures . Would you like email updates of new search results? They are relatively common overuse injuries in athletes, caused by repetitive submaximal loading on a bone over time. They occur in characteristic locations such as the distal tibia and posterosuperior calcaneum, with imperfectly linear fracture lines surrounded by bone marrow edema. 1993 Jul-Aug;21(4):619-22. doi: 10.1177/036354659302100423. Distal metadiaphyseal tibial fractures are commonly seen lower limb fractures. Through the stories of a dozen athletes whose injuries and recovery advanced the field (including Joan Benoit, Michael Jordan, Brandi Chastain, and Tommy John), Dr. Geier explains how sports medicine makes sports safer for the pros, amateurs, student-athletes, and weekend warriors alike. Bookshelf Federal government websites often end in .gov or .mil. A: Purple arrow - spring ligament recess, green arrow - medioplantar oblique band of the spring ligament complex, and the orange arrow - inferoplantar longitudinal band of the spring ligament complex. Skip to main content. . The fracture occurs when the bone experiences more pressure than it can handle. There was no considerable previous exposure to heavy lifting. If the fracture is not healing, we often consider surgical treatment. show answer. A: Moderate bone marrow oedema is evident in the distal tibia and posterior calcaneum, which are associated with predominantly linear areas of low T2 weighted signal with high T2 signal periosteal reaction surrounding the posterior tibia. During this procedure, a specially designed metal rod is inserted into the canal of the tibia. At that point, activities are gradually introduced. Stress fractures are tiny cracks in a bone. Usually tightness of the calf muscles and numbness and tingling are absent. 8600 Rockville Pike The best kind of tibial stress fracture, if there is such a thing as best, is one that's in the middle of your shin. MeSH Common areas include: 2nd and 5th metatarsals Tibia Fibula Navicular Neck of femur Diagnosing stress fractures A big part of diagnosing stress factors, is in the subjective history, or the story the patient tells you. The object was in front and lifted while he partly stood on one leg, which was rotated during the lifting. Acute plastic bowing fractures of both the tibia and the fibula in a child. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-98389. 1997 Apr;79(4):558-64. Osteoarthritis knee with varus deformity leading to stress fracture is rare but has been reported in literature. Please enable it to take advantage of the complete set of features! Stress fractures of the tibia are most common in these sports: Short distance running/sprinting. Stress fractures are common injuries in athletes. Stress fractures are small cracks in the bone caused by repetitive stresses or overuse, such as the repetitive impact on the bones of the lower leg and foot during running and jumping activities. A tibial plateau fracture is a break at the top of the tibia bone in the shin, which is often due to high energy trauma. Of course, the most common treatment for a tibial stress fracture is to put you on crutches, in a cast, or more commonly, a fracture walking boot. Stress fractures of the tibia are commonly seen in young athletes or military recruits due to repetitive micro trauma. Methods: The rod passes across the fracture to keep it in position. Diagnosis. In addition, there is a moderate ankle joint effusion, a type 2 os naviculare and the spring ligament recess is noted. The site is secure. Show . Five months after the second procedure, she notices increasing varus deformity of the right distal leg, as well as swelling, pain, and fluid collection. Typically athletes complain of pain that increases over a period of time, usually in response to increased stress. Clipboard, Search History, and several other advanced features are temporarily unavailable. Recommended Products and Resources 5,6,40 A majority of tibia fractures are diaphyseal fractures. He helps athletes and active people feel and perform their best, regardless of age, injuries and medical history. You can use Radiopaedia cases in a variety of ways to help you learn and teach. THE CONTENT DOES NOT AND IS NOT INTENDED TO CONVEY MEDICAL ADVICE AND DOES NOT CONSTITUTE THE PRACTICE OF MEDICINE. Tibial stress fractures located on the posteromedial border of the tibia often heal uneventfully. Fibular fractures may also occur as the result of repetitive loading and in this case they are referred to as stress fractures. It typically occurs in runners and other athletes that are exposed to intensive weight-bearing activities such as jumpers [1]. PMC Tibia fractures are usually caused by a sudden injury such as a fall, collision while playing sports, automobile accident or cycling accident. PMC The underlying etiology is not known in this case. Now, if you do break your leg, that is actually one of the very worst . Management and prognosis of tibial shaft fractures are influenced by their location in the bone (proximal, middle, or distal third) and their orientation (transverse, oblique, spiral, or comminuted). Bethesda, MD 20894, Web Policies Further A common story is a runner who is increasing his or her training over a short period of time. A common type of tibia fracture, the tibial shaft fracture, occurs below the knee joint. Stress fracture of the tibia after arthrodesis of the ankle or the hindfoot. Key words: stress fracture, tibia, bilateral, distal tibia. Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. This is the inner border of the tibia (closest to the midline of the body) toward the back of the leg. The most common locations for stress fractures are weight-bearing bones of the lower extremities. Chronic anterior midtibial stress fractures in athletes treated with reamed intramedullary nailing. However, on multivariate regression analysis the only significant factor was a high angle of tibia fracture. Insufficiency fractures of this area have been reported. Due to the shape of the tibia . Stress fractures after total knee arthroplasty. Decide if you should see one, find one suited for you and get the most from your visit. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Distal tibial stress fracture. Conclusion: Distal tibial stress fractures at the metaphysis are uncommon as most frequently they are in the diaphysis. Please enable it to take advantage of the complete set of features! This kind of injuries can easily be missed because they usually do not follow an acute injury in a fit young athlete, and plain radiographs usually appear normal. This site needs JavaScript to work properly. and transmitted securely. The tibia is the larger of these. Tibial stress fractures (also known as fatigue fractures) are generally uncomplicated and respond well to conservative treatment. Treatment of a tibial stress fracture can be either surgical or nonsurgical. To. A tibial stress fracture is a crack or micro-fracture in the lower shinbone. HHS Vulnerability Disclosure, Help The reason that's better is that it's far less likely to actually break. A fatigue fracture is a focal failure of normal bone caused by repetitive applied stress ( 1, 3, 4 ). Typical stress fracture of the distal shaft of the second metatarsal not seen on initial radiograph (left). These activities usually involve excessive weight bearing activity such as running, sprinting or jumping. 2013 Dec 21;48(6):574-577. doi: 10.1016/j.rboe.2013.12.008. 30. 2008 Mar-Apr;10(2):183-90. de Paiva Luciano A, Filho NF, Adami F, de Abreu LC. The https:// ensures that you are connecting to the In addition,there is a moderate ankle joint effusion, a type 2 os naviculare and the spring ligament recess is noted. Her bone density scan, bone profile, and biochemistry were all normal. 2008 Mar-Apr;10(2):183-90. In this paper, a case of an amateur triathlete who suffered from a bilateral distal tibial stress fracture is presented. A tibial stress fracture is a fortunately uncommon cause of leg pain in athletes, especially running athletes or those who participate in repetitive landing from a jump, such as gymnastics. Stress fractures of the tibia, metatarsals, and fibula are the most frequently reported sites. This program offers a comprehensive Q&A collection on tibia fractures, ankle fractures, navicular and tibial stress fractures, calcaneus stress fractures and more. The patient was put in a boot. A tibial stress fracture is a hairline fracture of the tibia bone. Intended for healthcare professionals Acute fractures Stress tests: Tap test- tibia, fibula, talus, or calcaneus Calf squeezes/ compression- tibia or fibula Tx: RICE Referral for x-ray Be prepared to activate an emergency action plan (EAP) if open fractures or signs of shock. 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