Fracture
Stress Fracture
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Stress Fracture
Epidemiology
Relative Risk
s
Women > Men
Relative Risk
= 3.5
White males > Black males
Relative Risk
= 4.7
White females > Black females
Relative Risk
= 8.5
Mechanisms of Injury
Weight bearing
Muscle forces
Muscle Strength
increases faster than bone strength
Muscle
Fatigue
Risk factors
Repetitive activity
Military recruits
Sports (e.g. distance
Running
, track and field sport)
Running
(>25 miles per week)
Track and Field
Basketball
Soccer
Dance
Increases in intensity, frequency, and loading
Too fast
Too far
Too soon
Biomechanical forces
Over pronators or Supinators
Hallux Valgus
Genu Varum
or genu valgus
Leg Length Discrepancy
External hip rotation
Changes in foot gear or training surface
Muscle
Fatigue
Systemic Diseases that weaken bone
Rheumatoid Arthritis
Systemic Lupus Erythematosus
Osteoarthritis
Pyrophosphate
Arthropathy
Renal Disease
Osteoporosis
(
Female Athlete Triad
)
Joint Replacement
Nutritional deficiency (e.g. dieting)
Vitamin D Deficiency
Other Associated risk factors
Tobacco Abuse
Alcohol
>10 drinks per week
Female Athlete Triad
Pathophysiology
Common Stress Fracture Sites
Tibia Stress Fracture
(23% of Stress Fractures)
Metatarsal Stress Fracture
(16% of Stress Fractures)
Fibula Stress Fracture
(15% of Stress Fractures)
Tarsal Navicular Stress Fracture
Calcaneal Stress Fracture
Medial Malleolus Stress Fracture
Femoral Neck Stress Fracture
(6%)
Femoral Shaft Stress Fracture
Pubic Ramus Stress Fracture
Pelvic Stress Fracture (1-2%)
Seen almost exclusively in women
Lumbar Stress Fracture
Coracoid process Stress Fracture
Humerus Stress Fracture
Olecranon Stress Fracture
Symptoms
Deep ache following rapid training change
Pain progression
Start: Pain after activity
Next: Pain with activity
Next: Pain with walking (at presentation in 81% of patients)
Last: Pain at rest
Night pain rarely occurs
Consider another diagnosis
Signs
Fracture
site intense localized pain
Tenderness to palpation (present in most cases)
Edema
at
Fracture
site may be present
Compression induces pain
Percussion of bone distant from symptomatic site
Vibrating tuning fork (128 Hz) at suspected site
Mediocre
Test Sensitivity
and
Specificity
Lesho (1997) Mil Med 162(12): 802-3 [PubMed]
Specific Tests for leg or pelvis Stress Fracture
Fulcrum Test
Hop Test
Poor
Specificity
(common finding in
Shin Splints
)
Batt (1998) Med Sci Sports Exerc 30(11): 1564-71 [PubMed]
Differential Diagnosis
Primary benign
Bone Neoplasm
Osteoid Osteoma
Osteoblast
oma
Eosinophilic Granuloma
Infections
Chronic or
Subacute Osteomyelitis
Chronic Musculoskeletal
Soft Tissue Injury
Tendonitis
Muscle Strain
Chronic Compartment Syndrome
Metastatic Neoplasm to bone
Breast Cancer
Prostate Cancer
Primary Malignant
Bone Neoplasm
s
Osteosarcoma
Ewing Sarcoma
Nerve Compression Syndrome
s
Tarsal Tunnel Syndrome
Carpal Tunnel Syndrome
Ulnar Tunnel
Syndrome
Hernia
ted Intervertebral Disc
Osteoarthritis
Hypertrophic Pulmonary
Osteoarthropathy
Imaging
Overall imaging approach (preferred)
Step 1: XRay negative and Stress Fracture suspicion persists
Step 2: Repeat XRay in 2-3 weeks is negative and Stress Fracture suspicion persists
Step 3: Obtain MRI (preferred) or bone scan
Imaging modalities
Stress Fracture XRay
Stress Fracture Bone Scan
Stress Fracture CT
Stress Fracture MRI
Ultrasound
is being investigated for specific Stress Fracture sites (e.g.
Metatarsal Stress Fracture
)
Banal (2009) J Rheumatol 36(8): 1715-9 [PubMed]
Management
Rest for 4-7 weeks (may require up to 3 months)
Activity should be pain-free only
Non-weight bearing until pain free while walking
Tibia Stress Fracture
Femoral Stress Fracture
Analgesia
Acetaminophen
is preferred over
NSAID
S
NSAID
S may delay healing
Immobilization
Short-leg
Casting
or CAM-Walker Indications
Non-compliance
High-risk for non-union
Navicular Stress Fracture
Metatarsal Stress Fracture
Pneumatic brace (Air cast)
Support results in quicker recovery and less pain
Indicated in tibial and fibular Stress Fractures
Active rest (cross training)
Consider formal rehabilitation program with physical therapy for strength and
Stretching
Goals
Cardiovascular conditioning
Flexibility
Proprioception
Strength
Activities
Swimming
Pool
Running
with float vest
Biking
Stair climbing machines (later stages)
Surgery
Indications
High Risk Fracture
s for non-union
Non-healing
Fracture
s
Specific high risk sites
Tarsal Navicular Stress Fracture
Proximal anterior
Tibia Stress Fracture
Base of fifth
Metatarsal Stress Fracture
Femoral Neck Stress Fracture
Experimental: Electromagnetic field devices
Questionable efficacy
High cost
Prevention
Do not increase
Exercise
intensity >10% per week
Stretch and warm-up before
Exercise
Choose level
Running
surfaces
Shoes should be light weight and in good condition
Consider
Orthotic
s for biomechanical factor correction
Shock
-absorbing insoles may be beneficial
Osteoporosis Prevention
(unclear efficacy)
Consider
Calcium
supplement 1000 mg orally daily
Consider
Vitamin D
800 IU orally daily
Reference
Simmons (1997) AAFP Sports Med Review
Buckwalter (1997) Am Fam Physician, 56(1):175-182 [PubMed]
Patel (2011) Am Fam Physician 83(1): 39-46 [PubMed]
Sanderlin (2003) Am Fam Physician 68:1527-32 [PubMed]
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