Management of common stress fractures ; When to apply conservative therapy, when to take an aggressive approach

BW Perron — 2005-05-09T13:08:38-00:00

Postgraduate Medicine, Vol. 111, No. 2. (February 2002), 95.

Metatarsal stress fractures (march fractures) were the first type of stress fracture described and characterized radiographically.6 (Reference) The typical fracture involves the second and third metatarsals and is most common in athletes and military recruits, who are on their feet often. Patients present with pain on ambulation and point tenderness over the affected metatarsal. If the injury is chronic, fracture callus may be palpated along the metatarsal shaft. Plain films may reveal the fracture, most often evidenced by fluffy fracture callus around the painful area (figure 1). Definitive diagnosis can be made on bone scans, which show the fracture as early as 48 to 72 hours from onset of symptoms. Primarily found in runners, tibial stress fractures most often occur in the distal third of the bone and respond well to rest followed by a gradual return to weight-bearing activities.10 (Reference) Stress fractures in the middle third of the bone along the anterior tibial cortex are of much more concern because they are prone to nonunion. Typically, patients complain of pain that occurs in the region after running and resolves with rest. Pain progresses, lasting longer after running and finally occurring even at rest. Patients often relate a recent history of increased training intensity or mileage with inadequate rest. Physical examination reveals localized pain to palpation, and periosteal thickening may be appreciable. Plain films may be diagnostic if symptoms have been present for 4 to 6 weeks (figure 3). Bone scanning reveals a stress fracture and helps to differentiate this entity from medial tibial stress syndrome (shin splints), which can mimic a stress fracture in this region (figure 4).3,10 (Reference) Illustration: Figure 1. Stress fracture of the third metatarsal with exuberant healing callus.; Illustration: Figure 2. Technetium Tc 99m bone scan of fifth metatarsal stress fracture.; Illustration: Figure 3. Tibial stress fracture with callus formation; fracture line is faintly visible.; Illustration: Figure 4. Technetium Tc 99m bone scan of tibial stress fracture in a runner who had persistent pain. Plain films were normal.; Illustration: Figure 5. Femoral neck stress fracture (distraction type) in a long-distance runner.; Illustration: Figure 6. Fibular stress fracture in a recreational runner who had recently increased total mileage from 15 to 35 miles a week.; Illustration: Figure 7. Humeral stress fracture of right (throwing) arm in a 15-year-old pitcher; transverse fracture line is plainly visible.; Illustration: Figure 8. "Scottish terrier's collar" (shaded area) seen on oblique view of lumbar spine. Adapted, with permission, from Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am 1999;30(3):488.

Insufficiency fractures of the tibia and fibula.

P Alonso-Bartolomé — 2005-05-04T20:25:47-00:00

Semin Arthritis Rheum, Vol. 28, No. 6. (June 1999), pp. 413-420.

OBJECTIVE: Insufficiency fractures (IF) occur when normal or physiological muscular activity stresses a bone that is deficient in mineral or elastic resistance. IF of the tibia and fibula are probably less common than IF of the ribs, vertebrae, hip, pelvis, and distal ulna, and therefore they are frequently underrecognized and mistaken for other conditions. Our aim was to analyze the main features and outcome of IF of the tibia and fibula in patients attending our Rheumatology Service. METHODS: IF was considered when occurring spontaneously or with minimal trauma. Between January 1984 and July 1997, 25 patients were diagnosed as having IF of the tibia and fibula. The main predisposing factors, clinical features, therapy, and outcome were retrospectively reviewed. RESULTS: All the patients except four were women (mean age, 66+/-12 years). Three cases were diagnosed between 1984 and 1990 (0.42 cases/year) and 22 between 1991 and 1997 (three cases/year). Eighteen patients had an underlying CONDITION: rheumatoid arthritis (RA, 13 cases), psoriatic arthritis (2), systemic lupus erythematosus (SLE) (1), kidney transplant (1), and Crohn's disease (1). Eleven patients had osteoporotic fractures in other locations. Risk factors for osteoporosis were corticosteroids (13 cases), prolonged immobilization (10), early menopause (2), and methotrexate therapy (10). All patients had pain on weight bearing and marked functional impairment, 16 had local inflammatory signs, and 10 had deformity. In only five patients the diagnosis of IF was considered at the first examination. The diagnostic delay was 76+/-117 days (median, 21). The initial radiograph was diagnostic in 20 patients, and in the remaining the diagnosis was made by computed tomography (CT) scan (three cases), magnetic resonance imaging (MRI) (1), and bone scan (1). IF were located as follows: tibia (10 cases), fibula (seven), tibia and fibula (eight). Nineteen patients were treated with conservative management, four received no specific treatment, and two required surgery. Sixteen patients were hospitalized for a mean period of 12+/-8 days. Most patients had complete recovery. The high frequency of IF seen in RA patients is probably due to the severe disease in patients treated by our Service and that such patients have a higher risk for osteoporosis and its complications. CONCLUSIONS: IF of the tibia and fibula are probably more common than previously thought. They usually occur in patients with underlying rheumatic diseases, mainly RA, and are frequently mistaken for other joint and bone conditions. Despite a frequent delay in diagnosis, they have a good prognosis with conservative management. Nonetheless, a higher index of suspicion may avoid unnecessary investigations and treatments.

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Management of common stress fractures ; When to apply conservative therapy, when to take an aggressive approach

Insufficiency fractures of the tibia and fibula.