Management of common stress fractures ; When to apply conservative therapy, when to take an aggressive approach
Postgraduate Medicine, 111 (2):
95+ (февраля 2002)Аннотация
Metatarsal stress fractures (march fractures) were the first type of stress fracture described and characterized radiographically.6 (Reference) The typical fracture involves the second and third metatarsals and is most common in athletes and military recruits, who are on their feet often. Patients present with pain on ambulation and point tenderness over the affected metatarsal. If the injury is chronic, fracture callus may be palpated along the metatarsal shaft. Plain films may reveal the fracture, most often evidenced by fluffy fracture callus around the painful area (figure 1). Definitive diagnosis can be made on bone scans, which show the fracture as early as 48 to 72 hours from onset of symptoms. Primarily found in runners, tibial stress fractures most often occur in the distal third of the bone and respond well to rest followed by a gradual return to weight-bearing activities.10 (Reference) Stress fractures in the middle third of the bone along the anterior tibial cortex are of much more concern because they are prone to nonunion. Typically, patients complain of pain that occurs in the region after running and resolves with rest. Pain progresses, lasting longer after running and finally occurring even at rest. Patients often relate a recent history of increased training intensity or mileage with inadequate rest. Physical examination reveals localized pain to palpation, and periosteal thickening may be appreciable. Plain films may be diagnostic if symptoms have been present for 4 to 6 weeks (figure 3). Bone scanning reveals a stress fracture and helps to differentiate this entity from medial tibial stress syndrome (shin splints), which can mimic a stress fracture in this region (figure 4).3,10 (Reference) Illustration: Figure 1. Stress fracture of the third metatarsal with exuberant healing callus.; Illustration: Figure 2. Technetium Tc 99m bone scan of fifth metatarsal stress fracture.; Illustration: Figure 3. Tibial stress fracture with callus formation; fracture line is faintly visible.; Illustration: Figure 4. Technetium Tc 99m bone scan of tibial stress fracture in a runner who had persistent pain. Plain films were normal.; Illustration: Figure 5. Femoral neck stress fracture (distraction type) in a long-distance runner.; Illustration: Figure 6. Fibular stress fracture in a recreational runner who had recently increased total mileage from 15 to 35 miles a week.; Illustration: Figure 7. Humeral stress fracture of right (throwing) arm in a 15-year-old pitcher; transverse fracture line is plainly visible.; Illustration: Figure 8. "Scottish terrier's collar" (shaded area) seen on oblique view of lumbar spine. Adapted, with permission, from Smith JA, Hu SS. Management of spondylolysis and spondylolisthesis in the pediatric and adolescent population. Orthop Clin North Am 1999;30(3):488.