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 indications most cases technique avoids NSAIDs (slows bone healing) consider bone stimulator Operative intramedullary tibial nailing 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
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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: A 1 Protected weight-bearing with crutches 92% (2630/2867) 2 Switch to elliptical for lower impact exercise 4% (102/2867) 3 Prescription anti-inflammatory medicines 2% (52/2867) 4 Arthroscopic surgery 2% (52/2867) 5 Open reduction and internal fixation 1% (22/2867) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ06.212) A college football player has progressive leg pain for over 6 months, is no longer able to run and has failed all modalities of 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 77% (825/1078) 2 Posterior tibial plate with bone graft 1% (12/1078) 3 Bone grafting alone 1% (10/1078) 4 Cast treatment 4% (46/1078) 5 Protected weight-bearing with crutches 17% (182/1078) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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 76% (1670/2184) 2 Posteromedial cortex of tibia 4% (95/2184) 3 Distal fibula 1% (29/2184) 4 Inferior femoral neck 11% (246/2184) 5 3rd metatarsal 6% (136/2184) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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: A 1 protected weight-bearing for 4-6 weeks 90% (2621/2906) 2 immediate return to sport 0% (6/2906) 3 tibia intramedullary nailing 6% (161/2906) 4 long leg casting 2% (51/2906) 5 biopsy of the tibial lesion 2% (62/2906) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1