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Observation with continuation of physical activity
1%
63/5561
Discontinuation of running with weightbearing in CAM walker
10%
543/5561
Intramedullary nailing of the tibia
48/5561
Casting of the affected lower extremity
72/5561
Discussion of eating habits and training regimens
86%
4800/5561
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Based on the history, clinical presentation and the radiographs presented, the patient has developed a stress reaction of her anterior tibia. This is consistent with a diagnosis of female athletic triad. The next step needs to include a multifaceted treatment approach that includes psychological counseling, review of dietary intake and addressing her training habits that put her at risk for developing a stress fracture. The female athletic triad consists menstrual dysfunction, disordered eating, and premature osteoporosis, and is most commonly seen in female athletes involved in running and gymnastics. Elite runners carry an incidence of amenorrhea that is close to 50%. Hormonal dysfunction, particularly with estrogen/progesterone, leads to a loss of the protective effect against osteoporosis, and stress fractures can subsequently occur. Khan et al. discuss injuries that affect ballet dancers, with turnout and forcing turnout being two of the most important physical attributes of ballet that lead to stress related injuries. Common injuries include stress fractures of 2nd metatarsal, patellofemoral issues, and shin pain from stress fractures or chronic exertional compartment syndrome. Nonoperative modalities are usually effective, including therapy to maintain strength/range of motion as well as nutritional advising sessions. Brukner et al. discuss the management of stress fractures in female athletes. They indicate the importance of delineating the history of pain and its relation to exercise. MRI is often the advancing imaging test of choice. Most stress fractures will heal with rest from aggravating activity. Activity should be maintained during this rest period, in the form of non weight bearing activities. Figures A and B demonstrate AP and lateral radiographs of the right tibial shaft in a skeletally mature individual. Note the thickening of the anterior cortex of the tibia on the lateral xray; this is consistent with a stress reaction. Illustrations A and B demonstrate a tibia AP and lateral radiograph with a stress fracture of the anterior tibial cortex. The "dreaded black line" that is seen on the lateral xray, often carries a poor prognosis. The patient with this radiograph, would likely benefit from surgical intervention. Incorrect answers Answer 1: The patient should be asked to discontinue the activity that precipitated the injury Answer 2, 4: Patient specific rehabilitation should include protected weight bearing rehabilitative regimens as the healing process takes place. Casting would lead to stiffness of immobilized joints Answer 3: Initial treatment in a patient without a clear fracture line should be non-surgical.
2.4
(31)
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