Review Question - QID 98

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.