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Updated: Jun 5 2023

Tibial Shaft Stress Fractures

Images with dreaded black line.jpg - shows edema.jpg fx tibia proximal.jpg stress fx bone scan.jpg
  • Summary
    • A tibial shaft stress fracture is an overuse injury where normal or abnormal bone is subjected to repetitive stress, resulting in microfractures.
    • Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.
    • Treatment is activity restriction with protected weight-bearing in most cases. Surgical intramedullary nailing is recommended in the presence of an anterior tibia tension-sided stress fracture ("dreaded black line").
  • Epidemiology
    • Demographics
      • commonly seen in runners and military recruits
      • seen after change in training routine
  • Etiology
    • 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
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