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A 20 year-old distance runner developed proximal tibial pain 6 weeks ago. Initially it was only painful while running, but she now has pain with walking. There is no knee effusion. The radiographs are normal. The MRI is shown. Which of the following is the most appropriate initial management?
Protected weight-bearing with crutches
Switch to elliptical for lower impact exercise
Prescription anti-inflammatory medicines
Open reduction and internal fixation
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Tibial stress fractures are relatively common overuse injuries that can often be difficult to treat. Differential includes medial tibia stress syndrome (shin splints), periostitis, infection, bursitis, neoplasm, exertional compartment syndrome, or nerve entrapment. Other comorbid medical conditions, including the female athlete triad, need to be carefully evaluated and treated. As Young describes, nonoperative treatment with protected weightbearing is the standard, but surgical intervention may be necessary if symptoms are not responsive to initial nonoperative treatment. For shaft fractures, intramedullary nailing may allow return to sport but does not guarantee healing. Plain radiographs are usually normal early on but with time may show periosteal reaction, new bone formation, or even a distinct fracture line. The typical posteromedial stress fracture is considered lower risk, whereas the anterior or “dreaded black line” stress fractures are considered higher risk. Ishibashi showed that MRI was better than bone scan for evaluating these injuries.
Young AJ, McAllister DR.
Clin Sports Med. 2006 Jan;25(1):117-28, x. PMID: 16324978 (Link to Abstract)
Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S.
Clin J Sport Med. 2002 Mar;12(2):79-84. PMID: 11953553 (Link to Abstract)
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A college football player has progressive leg pain for over 6 months, is no longer able to run and has failed non-operative treatment. His radiograph shows a linear lucency over the anterior tibia. What is the next most appropriate step to quickly return him to play?
Tibial intramedullary nailing
Posterior tibial plate with bone graft
Bone grafting alone
The patient has a stress fracture of the tibia. Nonoperative treatment with protected weight bearing, cessation of running, and possible use of a bone stimulator is useful early. Once the radiographs show the fracture especially in the anterior cortex of the tibia, surgical treatment is often recommended. This location is uncommon, but at increased risk for nonunion and propagation to complete fracture. An IM nail would allow for fastest weight bearing and return to activity. Anterior tension band plating has also been described, but not posterior.
The paper by Varner et al reports on a series of 11 athletes treated with a reamed IM tibial nail for chronic anterior stress fracture. The average return to sports was 4 months.
Varner KE, Younas SA, Lintner DM, Marymont JV
Am J Sports Med. 2005 Jul;33(7):1071-6. PMID: 15888719 (Link to Abstract)
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Which of the following stress fracture locations has the greatest likelihood of delayed healing or developing a nonunion?
Anterior cortex of tibia
Posteromedial cortex of tibia
Inferior femoral neck
The anterior tibial cortex is a tension side stress fracture and reportedly in the article below it is a problematic area to heal. Conversely, compression side tibial stress fractures usually heal without a problem. This is true on the femoral neck as well. While 2nd and 5th metatarsals can have problems with delayed or nonunions, 3rd metatarsals generally heal well.
Illustration A shows a tibial stress fracture on biplanar radiographs.
Boden BP, Osbahr DC.
J Am Acad Orthop Surg. 2000 Nov-Dec;8(6):344-53. PMID: 11104398 (Link to Abstract)
Boden BP, Osbahr DC, Jimenez C.
Am J Sports Med. 2001 Jan-Feb;29(1):100-11. PMID: 11206247 (Link to Abstract)
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A 17-year-old collegiate female track runner reports left leg pain for 3 months that was insidious in onset. Radiographs were unremarkable, and an MRI demonstrates increased marrow edema. A bone scan is shown in Figure A. What is the next appropriate step in management?
protected weight-bearing for 4-6 weeks
immediate return to sport
tibia intramedullary nailing
long leg casting
biopsy of the tibial lesion
The history of an athlete with an insidious onset of pain is highly suspicious of a stress fracture. The incidence of stress fractures in runners may be as high as 20%.
Stress fractures result from excessive, repetitive, submaximal loads on bones that cause an imbalance between bone resorption and formation. An abrupt increase in the duration, intensity, or frequency of physical activity without adequate periods of rest may lead to an escalation in osteoclast activity. Technetium bone scan is highly sensitive for detecting stress fractures but lacks specificity. An MRI is also valuable in identifying stress fractures when the clinical diagnosis is in doubt. If plain films are normal but the level of clinical suspicion is high, a trial of rest and evaluation with serial radiographs is appropriate. A rest period of 4 to 6 weeks of limited weight bearing progressing to full weight bearing may be necessary.
Boden et al reviewed stress fractures in adults, including appropriate diagnosis and treatment methods. They reported that failure of symptom improvement with rest is highly suggestive of the need for operative intervention.
Ohta-Fukushima et al reviewed 370 athletes with stress fractures, and found that the tibia was the most commonly involved bone (49.1% cases) followed by the tarsals (25.3%) and the metatarsals (8.8%). Patients who waited more than three weeks after onset of pain to be evaluated had prolonged recoveries.
Figure A is a representative bone scan that shows increased uptake in a tibial diaphysis.
Answer 2: Immediate return is not indicated, as activities should be limited.
Answer 3: Intramedullary nailing is not indicated without initial conservative treatment with this patient's findings.
Answer 4: Casting is not indicated for this stress fracture.
Answer 5: No indications for biopsy are noted in this scenario.
Ohta-Fukushima M, Mutoh Y, Takasugi S, Iwata H, Ishii S.
J Sports Med Phys Fitness. 2002 Jun;42(2):198-206. PMID: 12032416 (Link to Abstract)
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