Stress/Fatigue fractures are discussed in detail. Their causes, most common sites, investigation, management.

1. STRESS
FRACTURES

2. TOPICS
• DEFINITION
• EPIDEMIOLOGY
• PATHOGENESIS
• RISK FACTORS
• CLINICAL FEATURES
• EXAMINATION
• INVESTIGATION
• DIFFERENTIAL DIAGNOSIS
• PREVENTION
• TREATMENT
• DISCUSSING INDIVIDUAL SITES

3. DEFINITION
• Stress fractures/Fatigue fractures: Normal
bone is subjected to repeated episodes of
stress, less severe than that necessary to
produce an acute fracture
• Different from Insufficiency fractures

4. EPIDEMIOLOGY
• Common in elite athletes & military recruits.
• 1% incidence in athletes, 20% in runners.
• Weight bearing lower limb bone prone
• Tibia – [50%] most common
• Neck femur, Tarsals & metatarsals
• Females are more prone
– Female athlete triad- eating disorder,
amenorrhea/oligo, decreased bone mineral
density

5. PATHOGENESIS
Rapid increases in the frequency, duration, or intensity of an athletic
activity without adequate periods of rest
Disrupts normal bone remodeling
Osteoclast-mediated bone resorption in the haversian canals
and interstitial lamellae
Small cracks appear at the cement lines of the haversian systems,
which propagate into microfractures
New bone formation occurs as a result of increased periosteal
osteoblastic activity.

6. RISK FACTORS
• Extrinsic risk factors
– Training regimen
– Training surface
• Intrinsic risk factors
– Malalignment*, Limb
length discrepency
– Nutrition
– Overweight
– Smoking
– Non-steroidal anti-
inflammatory drugs
*Malalignment: Anatomic and alignment factors such as tibia vara, pronation, cavus,
limited joint motion, and decreased vascularity may be contributing factors in stress
fractures of the lower leg and foot

7. CLINICAL FEATURES
• History of unaccustomed & repeated activity.
• Pain on exertion is the hallmark (worsens with
activity and improves with rest)
• General health, medications, diet, and
menstrual history in women
• Increase in training volume or intensity, a
change in technique or surface, or an
alteration of footwear

8. EXAMINATION
• Limb biomechanics - leg length discrepancy,
or muscle imbalance, excessive subtalar
pronation.
• Tenderness
• Pain often can be elicited by percussion over
a distant site of the involved bone.
• Soft-tissue swelling can be seen(esp.-foot)
• Inaccessible sites – femoral neck - movts

9. INVESTIGATION
• X Ray
• Scintigraphy
• MRI
• CT Scan

10. X- RAY
• Normal – 1st 2-3 wks after the onset of
symptoms
• Periosteal response – 3 months after onset of
symptoms.
• Periosteal bone formation, sclerosis, endosteal
callus, and a frank fracture line.

11. Tibia Stress Fracture

12. Femur Neck Stress Fracture

13. March fractures

14. Scintigraphy
• Sensitive method
• It detects the osteoblastic activity associated
with remodelling.
• Acute stress fractures are depicted as discrete,
localized, areas of increased uptake of a Tc-
99m
• Lacks specificity.

16. MRI
• Both sensitive and specific
• It is extremely sensitive in the detection of
pathophysiological soft-tissue, bone and
marrow changes associated with stress
fractures
• Soft tissue- collection in infection, mass in
tumor can be well visualised

20. CT-scan
• Disruption in normal cortical pattern is better
seen then xray
• Less sensitive then MRI or Bone scan

21. DIFFERENTIAL DIAGNOSIS
• Periostitis, Bursitis, infection
• Avulsion injuries, muscle strain
• Neoplasm
• Exertional compartment syndrome

22. PREVENTION
• Training errors - most frequent culprit and should
be corrected.
• Assessment of the type and condition of the
running shoes
• Viscoelastic insoles, may help reduce the
incidence of lower-extremity stress fractures.
• Education – parents, coaches, military personnel
– periodic rest.
• Female athletes – alerted , eating disorders,
hormonal abnormalities.

23. TREATMENT
• Rest
• Surgical treatment is needed for certain
fractures

24. DISCUSSING INDIVIDUAL SITES
Femoral neck
Tibia
Metatarsal
Navicular

25. FEMORAL NECK
• Complaint of groin pain associated with
activity
• Pain with movement of the hip and often a
reduction in range of motion.
• T/t is based on the prevention of
displacement. If displacement occurs,
nonunion, varus deformity, and osteonecrosis
can result.

27. Treatment
The Stable Compression-type Fracture
• Avoid weight bearing
• Serial radiographs to ensure that displacement is not
occurring and that healing is progressing.
• Fracture healing may require up to 2 months from the time of
diagnosis.
• Return to activity requires
- resolution of pain,
- a full range of motion of the hip,
- restoration of muscle strength and endurance,
- radiographic evidence of a healed fracture.
Fracture on tensile surface
• Internal fixation with CCS

28. TIBIA
• Progress to nonunion or complete fracture despite rest
• BECAUSE-tensile forces and hypovascularity
Treatment:
• Electrical stimulation is combined with immobilization
• Non-wt bearing for 8-12 wks
• Monitor clinically, radiologically for healing
• If this regimen is unsuccessful, and the patient remains
symptomatic, surgical treatment is indicated.
• If a single fracture exists, excision of the fracture site
with cancellous bone grafting can be used, but for
multiple fracture lines, intramedullary nailing is
preferred

29. METATARSAL FRACTURES
Treatment:
• Strict avoidance of weight
bearing for 6 to 8 weeks.
• Limb elevation
• Ice fomentation
• Cycling / aquatic therapy
• Once healed- increase
intensity of exercise
gradually (10% per week)

30. Treatment
• Dancer and jones usually
present as acute
traumatic event but
usually has h/o pain prior
to traumatic incident
• Avulsion injuries usually
heal without the need for
surgical treatment,
• Fracture of the proximal
diaphysis often requires
operative treatment,
especially in the active
patient.

31. TARSAL NAVICULAR
• The initial treatment of non-displaced navicular
stress fractures is avoidance of weight bearing
and immobilization in a short leg cast for 8 weeks.
• Surgical treatment is indicated for fractures that
are displaced at initial presentation or fail to heal
with immobilization.
• The preferred method of surgical treatment is
open reduction and internal fixation with lag
screws.