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Normal Tibia-Fibula X-Ray Report Template (2-View)

Normal tibia and fibula radiograph report template: AP and lateral views including the knee and ankle joints, alignment, cortices and medullary cavities, proximal and distal articulations and soft tissues, with notes on the Maisonneuve injury, stress fractures, toddler's fracture and compartment syndrome.

EXAMINATION: [Right / Left] tibia and fibula radiograph, 2 views.

CLINICAL HISTORY: [indication, e.g. “Direct blow to the left shin,
pain and swelling” / “Fall, lower leg pain” / “Anterior shin pain in
a runner, evaluate for stress fracture”]

COMPARISON: None available.

TECHNIQUE: AP and lateral views of the [right / left] tibia and
fibula, including the knee and ankle joints.

FINDINGS:
Alignment: Normal alignment of the tibia and fibula. No angulation
or rotational deformity.
Tibia: The tibia is intact from the plateau to the plafond. The
cortices are smooth without a fracture line, cortical step-off,
periosteal reaction or focal sclerosis. Normal medullary cavity
without a focal lytic or sclerotic lesion.
Fibula: The fibula is intact from the head to the lateral malleolus,
including the proximal fibular neck. No fracture.
Knee (visualized): The tibial plateau, intercondylar eminence and
fibular head are intact. The proximal tibiofibular joint is normally
aligned. No joint effusion. [The distal femur is unremarkable.]
Ankle (visualized): The tibial plafond, medial malleolus and lateral
malleolus are intact. The ankle mortise is congruent with a normal
tibiofibular clear space and medial clear space. No talar dome
abnormality.
Joint spaces: Preserved at the knee and ankle.
Mineralization: Normal.
Soft tissues: No soft tissue swelling, radiopaque foreign body, soft
tissue gas or calcification. [Mild anterior soft tissue swelling of
the mid-tibia.]
Growth plates: [Not applicable, skeletally mature. / The proximal
and distal tibial and fibular physes are open and normal.]

IMPRESSION:
1. No acute fracture or dislocation of the [right / left] tibia or
fibula.
2. [Soft tissue swelling without underlying fracture.]

Dictation notes

Both joints on the film: an isolated medial malleolar fracture or widened medial clear space with a proximal fibular neck fracture is a Maisonneuve injury, an unstable ankle with a torn syndesmosis, and the proximal fibula is the part cut off the ankle series.
An isolated fibular shaft fracture is not isolated until the ankle mortise and the proximal tibiofibular joint have been cleared; a tibial shaft fracture carries a fibular fracture in most cases, often at a different level.
Stress fractures appear as a focal area of cortical thickening, periosteal new bone or a faint transverse lucency two to three weeks after symptoms begin; a negative radiograph in a runner with focal tenderness is reported as such with MRI as the next test, and an anterior mid-tibial “dreaded black line” is a high-risk stress fracture.
In a toddler who will not bear weight, look for the faint spiral or oblique distal tibial fracture (toddler's fracture); a negative film is followed by a repeat in 10-14 days, when the periosteal reaction shows.
Report soft tissue gas, foreign bodies and any communication of a fracture with a wound; compartment syndrome is a clinical diagnosis, but a tibial shaft fracture with marked soft tissue swelling is the setting in which the report should prompt the clinician to check.

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This is a reference implementation of a published guideline, for use by qualified clinicians. It does not account for patient-specific factors and is not a substitute for clinical judgment or a formal radiology consultation. Templates are generic scaffolds for licensed radiologists; verify wording against your own practice standards. See our full disclaimer.