March Fracture of the Tibia

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Abstract
Although “march fractures” of the metatarsals have been encountered with increasing frequency (2, 6, 12, 13), similar “stress”, fractures in the other weight-bearing bones are apparently much less common. More than 200 metatarsal march fractures have been observed at the authors' station, but until recently none had been seen in other bones. Three instances of march fracture in the tibia were then encountered within two months, and a search of the files revealed a fourth case. Pfahler (10) reported a single instance of this type of fracture of the tibia at the meeting of the American Roentgen Ray Society in 1939. This “insufficiency fracture” had occurred in a high-school athlete. The fracture line was narrow, incomplete, and extended only through the thickness of the cortex. The callus resembled an osteogenic sarcoma, and Pfahler stated that up to that time he had never seen a fracture of this kind. Barth, in discussing the report, remarked that no such case had been seen in his clinic. Pfahler commented that such fractures had not been seen in this country because, up to that time, we had not had compulsory military training. In the European literature, on the other hand, as might be expected, a number of reports of march fractures of the tibia were to be found. Aleman (1) stated that about 100 instances of periostitis ab exercitio are reported yearly in the Swedish army. He objected to the name and designated these cases as insufficiency fractures, although he had not observed the fracture line, but only the callus formation. Ollonqvist (8), basing his report on twelve years of observation, stated that “march fractures” of the tibia occurred at the rate of 60 a year in the Finnish army. He called it osteopathic itineraria tibiae and noted the presence of the fracture line. (It is possible that the extensive use of skis and snowshoes in the Northern European armies may have some relation to this large number of incomplete fractures in the tibia.) Brandt (3) stated that march fractures of the tibia are usually located in the middle third and are next in frequency to those occurring in the metatarsals. He attributed this high incidence in the tibia to the rigid marching step used in the German army. Hansson (4) reported a case of incomplete fracture of the tibia of this type and two similar fractures in the femur. In 1942 Peterson (9) recorded a single instance of this type of fracture in the femur, and stated that the only similar cases in the English literature had been reported by Nordentoft (7) in 1941. The latter had described two march fractures in the tibia and two in the femur. Roberts and Vogt (11), in 1939, described 12 cases of “pseudofracture” of the upper third of the tibia, without a history of trauma, in children ranging from four to sixteen years of age.

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