Fibular mid-shaft stress fractures in a 4-year-old child: A case report and literature review of the first decade of children with fibular stress fracture

Mid-fibular stress fractures are rare in the pediatric population and frequently present a diagnostic dilemma due to their subtle clinical presentation. In young, active children, the localized pain and associated periosteal reaction can closely mimic aggressive pathologies, such as primary bone malignancies or osteomyelitis, often leading to unnecessary parental anxiety and invasive diagnostic procedures. We report the case of a 4-year-old boy presenting with a 2-week history of an antalgic gait and localized tenderness over the left fibular shaft in the absence of acute trauma. While initial plain radiography revealed a reactive cortical lesion suspicious for malignancy, subsequent cross-sectional imaging with computed tomography and magnetic resonance imaging identified a subtle fracture line and circumferential periosteal thickening, confirming a mid-fibular stress fracture. The patient was managed conservatively with restricted weight-bearing and analgesics, with complete clinical recovery and radiographic bone remodeling documented at 2-month follow-up. This case underscores the necessity of maintaining a high index of suspicion for stress-related injuries in the pediatric population, even in the absence of a high-impact mechanism. A comprehensive diagnostic approach utilizing multimodal imaging is essential to differentiate benign stress fractures from more ominous conditions, ensuring appropriate conservative management and avoiding the risks associated with unnecessary biopsy or over-treatment.