Stress Fractures

STRESS FRACTURES

Stanley R. Kalish, D.P.M. Marc R. Bernbach, D.P.M.

Stress f ractures have been described byavarietyof terms Symptoms and Differential Diagnosis including march fracture, bone exhaustion, fatigue frac- There is usually no history of acute trauma. Symptoms ture, and insufficiency f racture. Previously, the Iiterature willvarydepending on the location of the stress fracture. has focused on stress f ractu res and their prevalence among Localized edema and pain exacerbated by activity and m ilitary person nel. However, stress f ractu res are not selec- tive and recent literature documents the occurrence in relieved by rest are the classical presentation. However, those ranging from athletes (professional and amateur) symptoms may be similar to those associated with sesa- to housewives. moiditisorshin splints depending on the location of com- plaint. Diagnosis of a stress fracture requires a high de- lncidence gree of suspicion.

The incidence of stress f ractu re varies. Tibial, calcaneal, Pathogenesis and metatarsal fractures represent almost 80% of those documented. The second and third metatarsals are the A stressf ractu re has been described asa partialor incom- lete fractu re resu ltingf rom inabilityof the bonetowithstand most com mon metatarsal s effected. Stress f ractu res of the first, fourth, and fifth metatarsals have been reported; low intensity stress that is applied in a rythmic subthresh- however, these fractures were noted to be rare (1). The old fash ion. Bone responds to stress in excess of the accus- tomed amount by a process known as osteonal remodel- tarsal bones are i nf req uently i nvolved except the calcaneu s. A few reports have been published documenting stress ing or osteonization. Circumferential lamellar bone is resorbed replaced by dense osteonal fractures of talus and navicular (2, Devas, 1975, 4). Stress and subsequently fractures of the cuneiform bones, although infrequent, bone as descri bed by Sweet and Al I man, 192. Th u s, fol low- may not be as rare as some earlier literature indicates. ing the onset of stress there is a time when the cortical bone is weakened prior to osteonal new bone formation. Meu rman (1, 5) has reported several stress f ractu res of the These sites resorption are more likely to cuneiforms. Occasionally, the sesamoids are involved as cortical of bony micro-f racturesand continued stress mayencour- reported by several authors (3, 6) (Fig. 1). become age gross fractures.

This sequence occurs since bone replacement is a slow process, whereas resorption occurs quickly producing a cortex temporarily weakened. This process can be inter- rupted if stress is eliminated ordecreased enough to allow bone formation to occu r at a greater rate than resorption. Utilizingthis concept it is thought stress f ractu res are part ofacontinuu m and notan isolated occu rrenceasan acute, traumatic fracture would be described. Stress fractures resu lt d u ri ng remodel ing of normal bonewhen resorption of bone exceeds repair, making it a process not an event.

The forces which act on bone to produce stress have been described as either bending or compression forces. Stress fractures of cortical bone (metatarsals) are usually

secondary to bend i ng forces; whereas, com pression forces are most f requently responsible for f ractu res of soft, can- cellous bone (tarsal bones). Diagnosis

Diagnosis of a stress f ractu re depends on clinicalas well as radiographic findings. Symptoms as previously de- Fig. 1. Fibular sesamoid stress f racture. Note radiolucent Iine scribed are usually classic, but may be misleading. A high extend i ng f rom proxi mal, Iateral cortex to d istal, med ial cortex.

253 degree of clinical suspicion as well as appropriate use of radiographic modalities will increase the rate of proper diagnosis.

A conf irmed d iagnosis of a stress f ractu re is dependent on one or more of the following radiographic findings: periosteal new bone formation, endosteal thickening or a radiolucent line extending through at least one cortex. More specifically, as outlined by Savoca (2) cortical de{ect and periosteal new bone formation are seen in the shaft of long bones. Medullary sclerosis is classically seen in short bones such as the calcaneus and in the metaphysis of long bones such as the first metatarsal. These findings usuallyappear severalweeks after inju ry. Tibialand f ibu lar stress fractures commonly appear Iater radiographically than is true in the bones of the foot. A delay in diagnosis may not necessarily be a problem since conservative ther- apy focused at reducing bone stress will usually relieve the symptoms while awaiting the results of serial radiographs performed on a weekly basis. : ) :,::, : :. : :: :, :4.:::a):: : : :.,: :a ;-::.,:.) : ::

) However, athletes in training and those individuals who :..:.:. : :.) ::.. :: ?..:.1 t.t.. :t : ;:..)) t: t ::. are unable to reduce activity may continue to produce ,::i;:i;ii.iii,;i:ii;;;i.,

. :) ::: :a) :4. :..t stress so that symptoms continue or overtf ractu re occu rs. t::. ::.. it.... ;:..:: :...; : '-:r rt:i r,;:::tri:t ,i! i iart;!,:jri r:l:::r al

:.:;:a:::an,:,:.:.::l:tr:,:::a.a::::l::,.;:. Consideringthis scenario, rapid identification of anypath- '-,,i-::r",,:r,::i!:i:,::,.. ... r. :!. ologic changes in bone would seem important.

Conventional radiography was found to be positive in only 22-40% (at acute presentation) by several major stud ies (Fig.2A). It has been well documented with scintigraphic conf irmation of a stress f racture, that even several weeks after in ju ry continued negative conventional rad iography is estimated to be at a rate of 20-50%.

Radionuclide bone scanning has become the def initive diagnostic exam for stress injuries (Fig.28). Wilcox states that a normal bone scan excludes the diagnosis of stress f ractu re. Following acute f ractu re Matin (7)concluded B0% were positive within 24 hours and 95% within 72 hours. When evaluating stress fractures there is usually a later clinical presentation by which time the scan is consis- tently positive.

Thetechnique of choice involves the use of technetiu m, 99m methylene diphosphonate in atriphasic manner. The three phase exam should include: 1. the radionuclide angiogram 2. blood pool images Fig.2. Navicular stress f racture. A. Note questionable cortical 3. delayed image for complete evaluation. break on medial navicular surface. B. Technetium-99m MDP bone scintigraphydemonstrating increased uptake in the tomography (CT) pro- Although a positive bone scan has become the defini- region of the Ieft navicular. C. Computed vides f urther detail and identif ies specif ic location of navicular Roub (8) warns that diagnoses tive diagnostic modality, stress fractu re. other than stress fracture must be considered. These include osteoid osteoma, Ewing's sarcoma/ hematogenous osteomyelitis, periostitis, and focal metastases. Since bone scanning is extremely sensitive for stress f racture but not specific for detail or location, conventional radiographic

254 correlation shou ld be performed several weeks after clini- bearing if necessary and compression to reduce edema. cal presentation. These modalities are individualized to type and location of the f ractu re as well as the patient. Treatment plans can I n most cases the d iagnosis of a f is stress ractu re evident be summarized according to anatomic location. based on bone scans or plain radiographs with clin icalcor-

relation. As stated p reviou sly, conf i rmatory rad iograp h s are seen in less than 50% of those caseswith positive bone scans. Thus when painful symptoms continue and radiographic or clin ical correlation is non-conf irmatory, f u rther Forefoot d iag nostic exam i natio n may be necessary. Routi ne tomography may be utilized to add further specificity to a diag- Sesamoids nosis. However, where suff icient dou bt concerning the d i- Reduce activity. agnosis exists orf u rther detail is desired computed tomog- 1. raphy (CT) is most appropriate (Fig. 2C). 2. Applycompression:Jonescompressiondressing or Gelocast/Unna boot. CTd iagnosis of a stress f ractu re is based upon the visual- 3. Dancers cut-out pad forfirst metatarsophalangeal ization of cortical fracture lines and marked endosteal joint, or cal I u s formation. E rosions and periosteal new bone formation below 1-2 mm are not visible on CT. Conventional 4. Wearsurgical shoewith half inchfeltliner(cutout radiographs are more appropriate for slight periosteal for f i rst metatarsophalangeal joint). callus or minor cortical fissures. CT reveals subtle differ- ences in tissue density especially useful when ruling out Metatarsals malignancy. Although CT is usuallyableto makeadiagnosis Essentially same as above. When pain persists or frac- where u ncertainty exists f u rther evaluation may be neces- tu re is q u estio nable a below-knee non-weight-beari ng cast sa ry s u ch as b io psy o r arte riography. Co m p u te rized tom og- may be necessary in the treatment of metatarsal stress f rac- raphy should be used when sufficient doubt concerning tu res. Fifth metatarsal stress fractures of the shaft(Jones f rac- the diagnosis still exists. Table 1 summarizes an organized may require internal fixation as described by Delee approach for the diagnosis of stress fractures. ture) (9) due to a high incidence of nonunion (Fig. 3). However, Treatment avulsion fractures involving the tuberosity of the fifth metatarsal usually heal well with a non-weight-bearing Treatment consists of a few fundamental principles. below-knee cast (Fig. 4). Rarely is i nternal f ixatio n req u i red Reductio n of activity, I i m ited weightbeari ng o r non-weight- for this type of fifth metatarsal f racture (Fig. 5).

R/O Stress Fracture tI StressOPlainOSerial OStress Fractures+ Radiographs + Radiographs+ Fracture

"lI I "-/Nesative Bone Scan-+ Stress loI rracture + Stress Fracture Detail \ 1. Detail & Location & \ 2. R/O Bone Lesion/ Location \ Malignancy / \ Conventional Computerized Tomography Tomography

Table 1 Fig. 3. Jones f ractu res of f ifth metatarsal are successfully f ixated with either A. AO screw fixation or B. Tension band technique.

255 A trffi, s

ffl ,',:

Fig.4. A. Jones f ractures are located at proximal diaphyseal- metaphyseal ju nction and are susceptible to nonunion. B. Avu l- sion f ractu res involve tuberosity and usually heal without complication.

Cuneiforms

1. Reduce activity. 2. Apply compression initially. 3. May require partialor non-weight-bearing below- knee cast.

Rearfoot

Navicu larlCalcaneus:

1. Reduce activity. ) Apply compression initially.

3. Apply below-knee cast with non-weightbearing for six weeks or evidence of healed f ractu re.

4. May req u i re open red uction with i nte rnal f ixation of fracture if displacement exists.

Summary

Fig. 5. A. Avu I sion i nj u ries of f ifth metatarsal base usual ly do The pathogenesis, diagnosis, and treatmentof stressf rac- not require f ixation, however severely displaced avulsion f ractu res have been reviewed.Appropriate rad iographic stud ies ture requires open reduction internal f ixation to prevent malu- with clinical correlation shou ld make the d iagnosis straight nion or nonunion. B. Tension band technique was utilized for forward in most cases. Treatment consists of reduction of internal fixation. activity, com pression, and non-weightbeari ng if necessary.

References 3. Devas M: Stress Fractures. London, Churchill Liv- ingstone, 1975, p 56. 1. Meurman KOA: Less common stress fractures in the 4. Pavlov H,Torg.lS, Freiberger RH: Tarsal navicular stress fool. Br J Radiol 54:1,1981. f ractures. Radiographic evaluation . Radiology14S:641, 2. Savoca CJ: Stress fractures. Radiology100:519,1971. 1983.

256 5. Merman KOA, Elfving S: Stress f ractu re of the cu neiform Keene J S, Lange RH : D iagnostic d i lem mas i n foot and an kle bones. Br J Radiol53:157, 1980. i nju ries. JA MA 256:247, 1986.

6. VanHal ME, Keene JS, Lange TA: Stress fractures of the Levy J M : St res s f ract u res of t h e f i rst metata rsal. AJ R 130:679, great toe sesamoids. Am J Sports Med 10:122,1982. 1978.

7. Matin P: The appearance of bone scans following f rac- Micheli LJ, Sohn RS, Solomon R: Stress fractures of the se- tu res, i ncl ud i ng i m med iate and long term stud ies./ Nuc/ cond metatarsal involving Lisf ranc's joint in balletdancers. Med 20:12A,1979- I Bone Joint Surg 674:1372,1985. 8. Rou b LW, Gu merman LW, Hanley EN, Clark MW, Cood- Miller HC: Stressfractureof thefibula: secondaryto pro- man LW, Herbert DL: Bone stress: a radionuclide imag- nation? J Am Podiatry Assoc 75:211,1985. i ng pers pective. Rad i o I ogy 132:431, 1979. Miller JW Poulos PC: Fatigue stress fracture of the tarsal 9. Delee JC, Evans JB Julian J: Stress fracture of the fifth navicular. J Am Podiatry Assoc 75:437,1985. metatarsal. Am J Sports Med 11:349,1983. Montalbano MM, Hugar DW: Metatarsal stress fractures in ru nners. / Am Podiatry Assoc 72:581, 1982. Additional References MurciaM, Brennan RE, Edeiken J: Computed tomography Acker JH, Drez D: Non-operative treatment of stress f rac- of stress f ractu re. Skeletal Radiol 8:193, 1982. tu res of the proximalshaftof thef ifth metatarsal(ones Frac- NewbergAH, Kalisher L: Case report: an unusual stressf racture). Foot Ankle 7:152-155, 1986. tu re in a jogger. J Trauma 18:816,1978.

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