http://upload.orthobullets.com/topic/3112/images/mri - shows edema.jpg
Introduction
  • An overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures 
  • Epidemiology
    • commonly seen in runners and military recruits
    • seen after change in training routine
  • Mechanism
    • linear microfractures in trabecular bone from repetitive loading
  • Pathophysiology
    • callus formation
    • woven bone
    • endochondral bone formation
Presentation
  • History
    • change in exercise routine
  • Symptoms
    • onset of symptoms often insidious
    • symptoms initially worse with running, then may develop symptoms with daily activities
  • Physical exam
    • pain directly over fracture
Imaging
  • Radiographs
    • recommended views
      • AP and lateral
    • findings
      • lateral xray may show "dreaded black line" anteriorly indicating tension fracture from posterior muscle force 
      • endosteal thickening
      • periosteal reaction with cortical thickening
  • Technetium Tc 99m bone scan
    • findings
      • focal uptake in cortical and/or trabecular region
  • MRI
    • replacing bone scan for diagnosis and is most sensitive 
    • findings
      • marrow edema 
      • earliest findings on T2-weighted images 
        • periosteal high signal
      • T1-weighted images show linear zone of low signal
Treatment
  • Nonoperative
    • activity restriction with protected weightbearing q q
      • indications
        • most cases
      • technique
        • avoids NSAIDs (slows bone healing)
        • consider bone stimulator
  • Operative
    • intramedullary tibial nailing q
      • indications
        •  if "dreaded black line" is present, especially if it violates the anterior cortex
          • fractures of anterior cortex of tibia have highest likelihood of delayed healing or non-union q
 

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Questions (4)

(OBQ08.108) 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? Review Topic

QID:494
FIGURES:
1

Protected weight-bearing with crutches

92%

(1992/2159)

2

Switch to elliptical for lower impact exercise

4%

(81/2159)

3

Prescription anti-inflammatory medicines

2%

(35/2159)

4

Arthroscopic surgery

1%

(28/2159)

5

Open reduction and internal fixation

1%

(16/2159)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ06.212) 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? Review Topic

QID:223
1

Tibial intramedullary nailing

61%

(175/288)

2

Posterior tibial plate with bone graft

1%

(4/288)

3

Bone grafting alone

2%

(6/288)

4

Cast treatment

9%

(26/288)

5

Protected weight-bearing with crutches

27%

(77/288)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ06.251) Which of the following stress fracture locations has the greatest likelihood of delayed healing or developing a nonunion? Review Topic

QID:262
1

Anterior cortex of tibia

77%

(797/1033)

2

Posteromedial cortex of tibia

5%

(50/1033)

3

Distal fibula

1%

(11/1033)

4

Inferior femoral neck

10%

(105/1033)

5

3rd metatarsal

6%

(67/1033)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

ILLUSTRATIONS:

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(OBQ04.37) 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? Review Topic

QID:98
FIGURES:
1

protected weight-bearing for 4-6 weeks

89%

(859/962)

2

immediate return to sport

0%

(3/962)

3

tibia intramedullary nailing

6%

(60/962)

4

long leg casting

2%

(18/962)

5

biopsy of the tibial lesion

2%

(22/962)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

Incorrect Answers:
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.


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