We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Stress Fractures (Main)

From WikiSM
Jump to: navigation, search

Other Names

  • Stress Reaction

Background

  • This page acts as the main page for all stress fractures

History

  • First reported by Breithaupt, a Prussian military surgeon, in 1855[1]

Epidemiology

  • Stress fractures represent between 0.7% and 20% of all sports medicine injuries[2]
    • Wentz et al estimate 2% of all sports injuries in athletes[3]
    • In runners, stress fractures represent 16% of all injuries
  • The most common site overall is the tibia[4]
  • Estimated that 80-95% of stress fractures occur in the lower extremities
  • Breakdown of extremity[5]
    • Tibia (23.6%)
    • Tarsal navicular (17.6%)
    • Metatarsals (16.2%)
    • Femur (6.6%)
    • Pelvis (1.6%).

Pathophysiology

  • General
    • Occur as a result of repetitive submaximal mechanical load across the bone
    • Universally, there will be a sudden increase in training intensity, duration and/or frequency
    • Inadequate rest is also frequently cited
    • Training surface, footwear are also factors
  • Bone remodeling
    • Bone remodels due to mechanical stress
    • Bone absorption exceeds mechanical repair and formation during remodeling
    • Wolff's Law: Rate and remodeling depends on number, frequency of loading cycles
    • Continued loading may propagate microfractures into stress fractures
    • Vast majority of cases occur in individuals with normal bone and excessive forces
    • Starts with a "crack" but can propagate with inadequate healing time
  • Types
    • Fatigue fracture: repetitive stress on abnormal bone
    • Insufficiency fracture: repetitive stress on abnormal bone
  • Early detection is important
    • Increased awareness has been shown to improve early detection

Risk Factors

Clinical Features

  • History
    • Onset is universally insidious
    • Localized pain related to activity and worsened by activity
    • Early in disease state, pain occurs towards the end of exercise
    • Can progress to pain with less activity and eventually with normal ambulation/ rest
    • Eventually pain can even occur at night
  • Physical Examination
    • Typically point tender on bone depending on the area affected
    • May have soft tissue swelling, erythema or bony callus
  • Special Tests

Location

Upper Extremity

Torso/ Pelvis

Lower Extremity

Evaluation

Radiographs

  • Poor sensitivity[13]
    • Early stages as low as 10%, periosteal elevation not seen for 2-3 weeks
    • At follow up ranges from 30-70%
  • Findings when abnormal
    • Periosteal elevation
    • Cortical thickening
    • Sclerosis
    • Fracture line

MRI

  • Study of choice
  • Shows increased signal intensity, bone edema, soft tissue edema
  • Sensitivity, specificity and accuracy rated as high as 100%[14]

Bone Scan

  • 91m Technetium-methylene diphosphonate bone scintigraphy
  • Sensitive (74-84%), not specific (33%)[15]
  • Has fallen out of use in favor of MRI
  • False positives: due to increased bone metabolism (tumors, infections)[16]
  • Doesn't distinguish well between stress fracture and stress reaction[17]

CT Scan

  • Single Photon Emission Computed Tomography (SPECT)
  • Useful for
    • Sacrum and pubic stress fractures as MRI has reduced sensitivity

Ultrasound

  • Growing but less well defined utility in the diagnosis of stress fractures
  • In a case-control study of MRI-confirmed metatarsal stress fractures[18]
    • Sensitivity 83%, specificity 76%
  • Also useful to evaluate other surrounding soft tissue structures

Laboratory Evaluation

  • May not be necessary in first time stress fractures
  • If the athlete has had a previous stress fracture, consider the following:
    • Complete Blood Count
    • ESR (Erythrocyte Sedimentation Rate)
    • CRP (C-reactive Protein)
    • Kidney function tests
    • Liver function tests
    • Calcium levels
    • Albumin
    • Vitamin D level
    • Hormone Profile (females)
    • Thyroid studies
    • Parathyroid hormone (PTH)
    • Phosphorous
    • Alkaline Phosphatase

Management

Prevention

  • Among army recruits, a reduction in running distance resulted in fewer injuries and lower injury severity[19]
  • Among female long distance runners, increased calcium, vitamin D, and protein intake correlated with increased bone mineral density and protection from stress fractures[20]
    • Potassium intake was associated with increased bone mineral density only
  • Insoles reduced stress fractures in the military population [21]

Prognosis

  • Some fractures are high risk for propagation
    • Require prompt treatment, careful monitoring to prevent progression
  • High Risk
    • Anterior tibial diaphysis
    • Lateral femoral neck
    • Patella
    • Medial malleolus
    • Navicular
    • Fifth metatarsal base
    • Proximal second metatarsal
    • Sesamoids (great toe tibial)
    • Talus
    • Femoral head
  • Low Risk
    • Posteromedial tibial
    • Metatarsals
    • Calcaneus
    • Cuboid
    • Cuneiform
    • Fibula
    • Medial femoral neck
    • Femoral shaft
    • Pelvis

Nonoperative

General

  • Depends on location, imaging
  • Early intervention to prevent propagation and full cortical break
  • Cessation of all provocative activities
    • Must decide whether to make patient weight-bearing or non-weight bearing
  • Conservative management
    • Reduced weight bearing
    • Splinting
    • Activity modification

Medications

  • NSAIDS
    • One study found delayed stress fracture healing[22]
    • Meta-analysis: no significant risk of nonunion with nonsteroidal anti-inflammatory exposure[23]
    • Overall, NSAIDS are controversial and typically not recommended
  • Bisphosphonates
    • Use is not supported by any strong evidence for treatment or prophylaxis[24][25]
    • One case series showed accelerated recovery among 5 runners
  • Vitamin D
    • Deficiency should be suspected in elderly patient stress fractures
  • Calcium
  • Calcitonin
    • Role in stress fractures is unknown
  • Raloxifene
    • Role in stress fractures is unknown
  • Strontium Ranelate
    • Role in stress fractures is unknown
  • Teriparatide
    • Role in stress fractures is unknown

Treatment Modalities

Opeative

Rehab and Return to Play

Rehabilitation

  • Gradual resumption of activities

Return to Play

  • Slow, controlled return to play once pain free

Complications

  • Premature return to sport
    • Associated with recurrence, progression
  • Full cortical break
  • Re-fracture
  • Inability to return to sport

See Also

References

  1. ↑ Breithaupt ZVR . Pathologie monschuchew fusser. Med Zeittung 1855;24:169, 170–5
  2. ↑ Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–481.
  3. ↑ Wentz L , Liu PY , Haymes E , Ilich JZ . Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Mil Med 2011;176:420–30
  4. ↑ Brukner P, Bradshaw C, Khan K.et al Stress fractures: a review of 180 cases. Clin J Sport Med 1996685–89
  5. ↑ Kahanov, Leamor, et al. "Diagnosis, treatment, and rehabilitation of stress fractures in the lower extremity in runners." Open access journal of sports medicine 6 (2015): 87.
  6. ↑ Wright AA Taylor JB Ford KR Siska L Smoliga JM. Risk factors associated with lower extremity stress fractures in runners: A systematic review with meta‐analysis. Br J Sports Med.
  7. ↑ Warden SJ Burr DB Brukner PD. Stress fractures: Pathophysiology, epidemiology, and risk factors. Curr Osteoporos Rep. 2006;4(3):103‐109.
  8. ↑ Zeni AI, Street CC, Dempsey RL, Staton M. Stress injury to the bone among women athletes. Phys Med Rehabil Clin N Am. 2000;11(4):929-947
  9. ↑ Rousière, Mickaël, André Kahan, and Chantal Job-Deslandre. "Postpartal sacral fracture without osteoporosis." Joint Bone Spine 68.1 (2001): 71-73.
  10. ↑ Friberg O. Leg length asymmetry in stress fractures: clinical and radiological study. J Sports Med Phys Fitness. 1982;22(4):485-488
  11. ↑ Simkin A, Leichter I, Giladi M, Stein M, Milgrom C. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle. 1989;10(1):25-29
  12. ↑ Burge MR, Lanzi RA, Skarda ST, Eaton RP. Idiopathic hypogonadotropic hypogonadism in a male runner is reversed by clomiphene citrate. Fertil Steril. 1997;67(4):783-785
  13. ↑ Fredericson, Michael, et al. "Stress fractures in athletes." Topics in Magnetic Resonance Imaging 17.5 (2006): 309-325.
  14. ↑ Shin A Y, Morin W D, Gorman J D, Jones S B, Lapinsky A S. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24:168–176.
  15. ↑ Gaeta M, Minutoli F, Scribano E, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553-561
  16. ↑ Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Macintyre JG. Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures: the concept of bone strain. Sports Med. 1987;4(1):65-75
  17. ↑ Monteleone GP. Stress fractures in the athlete. Orthop Clin North Am. 1995;26(3):423-432
  18. ↑ Banal F, Gandjbakhch F, Foltz V, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 2009;36(8):1715-1719
  19. ↑ Rudzki SJ. Injuries in Australian Army recruits: part I. Decreased incidence and severity of injury seen with reduced running distance. Mil Med. 1997;162(7):472-476
  20. ↑ Nieves JW, Melsop K, Curtis M, et al. Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners. PM R. 2010;2(8):740-750
  21. ↑ Rome K, Handoll HH, Ashford R. Interventions for preventing and treating stress fractures and stress reactions of bone of the lower limbs in young adults. Cochrane Database Syst Rev. 2005;(2):CD000450.
  22. ↑ Li J, Waugh LJ, Hui SL, Burr DB, Warden SJ. Low-intensity pulsed ultrasound and nonsteroidal anti-inflammatory drugs have opposing effects during stress fracture repair. J Orthop Res. 2007;25(12):1559-1567
  23. ↑ Dodwell ER, Latorre JG, Parisini E, et al. NSAID exposure and risk of nonunion: a meta-analysis of case-control and cohort studies. Calcif Tissue Int. 2010;87(3):193-202
  24. ↑ Milgrom C, Finestone A, Novack V, et al. The effect of prophylactic treatment with risedronate on stress fracture incidence among infantry recruits. Bone. 2004;35(2):418-424
  25. ↑ Stewart GW, Brunet ME, Manning MR, Davis FA. Treatment of stress fractures in athletes with intravenous pamidronate. Clin J Sport Med. 2005;15(2):92-94
  26. ↑ Rue JP, Armstrong DW 3rd, Frassica FJ, Deafenbaugh M, Wilckens JH. The effect of pulsed ultrasound in the treatment of tibial stress fractures. Orthopedics. 2004;27(11):1192-1195
Created by:
John Kiel on 13 June 2019 07:23:58
Authors:
Last edited:
31 October 2021 13:53:03
Categories:

Retrieved from "https://wikism.org/w/index.php?title=Stress_Fractures_(Main)&oldid=15209"