Updated: 6/1/2021

Tibial Shaft Stress Fractures

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https://upload.orthobullets.com/topic/3112/images/xray with dreaded black line.jpg
https://upload.orthobullets.com/topic/3112/images/mri - shows edema.jpg
https://upload.orthobullets.com/topic/3112/images/stress fx tibia proximal.jpg
https://upload.orthobullets.com/topic/3112/images/tibial 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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(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?

QID: 494
FIGURES:
1

Protected weight-bearing with crutches

91%

(3355/3672)

2

Switch to elliptical for lower impact exercise

4%

(130/3672)

3

Prescription anti-inflammatory medicines

2%

(76/3672)

4

Arthroscopic surgery

2%

(70/3672)

5

Open reduction and internal fixation

1%

(26/3672)

L 1 C

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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 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?

QID: 223
1

Tibial intramedullary nailing

75%

(1281/1708)

2

Posterior tibial plate with bone graft

1%

(20/1708)

3

Bone grafting alone

1%

(21/1708)

4

Cast treatment

5%

(80/1708)

5

Protected weight-bearing with crutches

18%

(300/1708)

L 2 D

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

QID: 262
1

Anterior cortex of tibia

74%

(1927/2588)

2

Posteromedial cortex of tibia

4%

(114/2588)

3

Distal fibula

1%

(36/2588)

4

Inferior femoral neck

13%

(330/2588)

5

3rd metatarsal

7%

(171/2588)

L 2 D

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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?

QID: 98
FIGURES:
1

protected weight-bearing for 4-6 weeks

89%

(3503/3923)

2

immediate return to sport

0%

(8/3923)

3

tibia intramedullary nailing

6%

(227/3923)

4

long leg casting

2%

(74/3923)

5

biopsy of the tibial lesion

3%

(100/3923)

L 1 D

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Evidence (19)
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EXPERT COMMENTS (6)
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