Ultrasound ability in early diagnosis of metatarsal stress fractures.

Stress fractures are common in young and active individuals, associated with aggressive or repetitive physical activity and their early detection is fundamental to optimise patient care, decrease complications and avoid unnecessary exams. Currently, magnetic resonance imaging is the standard of care for detecting these lesions. Recently, ultrasound has been getting an increasing interest for the detection of stress fractures. In this article, we describe a clinical case that involved a second metatarsal stress fracture diagnosed by ultrasound and review the literature regarding the use of ultrasound in the diagnosis of stress fractures, particularly of the metatarsals.

Bone health and the masters runner.

Masters runners are often defined as those ages 35 years and older who train and compete in running events. These runners represent a growing population of the overall running community and experience running-related injuries including bone stress injuries (BSIs). Similar to younger runners, health considerations in masters runners include the goal to optimize bone health with focus on mitigating age-associated loss of bone strength and preventing BSIs through a combination of ensuring appropriate physical activity, optimizing nutrition, and correcting faulty biomechanics. Importantly, BSIs in masters runners may include characteristics of both overuse injury from insufficient recovery and failure of bone weakened by age-related loss of bone (insufficiency fractures). This narrative review covers the limited available research on strategies to optimize bone health in masters runners. Applying knowledge on masters athletes and extrapolating from other populations, we propose strategies on treatment and prevention of BSIs. Finally, the review highlights gaps in knowledge that require further age-specific discoveries to advance treatment and prevention.

[Diagnostics and treatment of insufficiency fractures of the pelvis]. / Diagnostik und Therapie von Beckeninsuffizienzfrakturen.

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X­rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

[Stress fractures in the military context]. / Stressfrakturen im militärischen Kontext.

BACKGROUND: Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist. OBJECTIVE: Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities. MATERIAL AND METHODS: A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options. RESULTS: There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated. CONCLUSION: Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.

Shin pain in athletes.

BACKGROUND: Both serious athletes and patients attempting to maintain or improve their health through exercise are at risk of a number of conditions that are not frequently mentioned during medical training. Most of these are related to overuse. OBJECTIVE: The aim of this article is to improve general practitioners' knowledge of a specific group of exercise-related conditions that occur in the anterior aspect of the lower limb below the knee, commonly referred to as the shin region. DISCUSSION: Many having been previously grouped under the relatively meaningless term 'shin splints', these conditions include, among others, bone stress reactions and fractures and chronic exertional compartment syndromes. Some resolve with rest and a gradual return to activity, whereas others are difficult to treat conservatively and might benefit from early referral.

[Contemporary imaging examinations for (suspected) stress fractures]. / Zeitgemäße bildgebende Untersuchung bei (vermuteter) Stressfraktur.

Stress fractures belong to the group of atraumatic fractures. A low-impact and repetitive load is the underlying cause and no fracture would occur under physiological circumstances. The conventional X­ray examination remains the initial imaging modality when a stress fracture is suspected. In contrast, magnetic resonance imaging (MRI) is the gold standard and is also used to rule out other pathological changes. Computed tomography (CT) should be included if the MRI findings are unclear. New techniques, such as dual energy computed tomography (DECT) and magnetic resonance bone imaging (MR bone) should be used more frequently in practice in the future and become increasingly more important for the correct diagnosis.

[Sacral H-shaped fractures between traumatic, insufficiency and fatigue fractures : Similarities, differences and controversies]. / Die Sakrum-H-Fraktur zwischen traumatischer, Insuffizienz- und Ermüdungsfraktur : Gemeinsamkeiten, Unterschiede und Kontroversen.

In the basic entirety of stress fractures, insufficiency fractures are defined as fractures caused by prolonged normal or physiological loading of a bone with insufficient elastic resistance. This clearly distinguishes it from fatigue fractures, in which excessive loads are continuously applied to a bone with normal elastic resistance. According to Pentecost (1964) both entities of stress fracture result from "the inherent inability of the bone to withstand stress applied without violence in a rhythmical, repeated, subthreshold manner". This distinguishes them from acute traumatic fractures. In the clinical routine these differences are not always so clearly presented. The example of the H­shaped sacral fracture is used to illustrate the relevance of a clear terminology. In this context, current controversies in the treatment of sacral insufficiency fractures are discussed.

[High-risk stress fractures in competitive athletes]. / High-risk-Stressfrakturen beim Leistungssportler.

Bone stress injuries are chronic overload reactions of the bone, which are characterized by the load-dependent occurrence of locally perceived pain and tenderness on palpation at the site of the injury. Structurally normal bone becomes fatigued as a result of repetitive submaximal loading and/or inadequate regeneration. Certain stress fractures of the femoral neck (tension side), patella, anterior tibial cortex, medial malleolus, talus, tarsal navicular bone, proximal fifth metatarsal, and sesamoid bones of the great toe tend to develop complications (complete fractures, delayed union, pseudarthrosis, dislocation, arthrosis). These injuries are classified as high-risk stress fractures. Aggressive diagnostics and treatment are recommended when a high-risk stress fracture is suspected. Treatment is frequently different from low-risk stress fractures, including prolonged non-weight-bearing immobilization. In rare cases, surgery is indicated when conservative treatment fails, when a complete or non-healing fracture develops, or in cases of dislocation. The outcomes of both conservative and operative treatment are described as less successful compared with low-risk stress injuries.

Current risks factors and emerging biomarkers for bone stress injuries in military personnel.

INTRODUCTION: Bone stress injuries (BSIs) have plagued the military for over 150 years; they afflict around 5 to 10% of military recruits, more so in women, and continue to place a medical and financial burden on defence. While the tibia generally adapts to the rigours of basic military training, the putative mechanisms for bone maladaptation are still unclear. METHODS: This paper provides a review of the published literature on current risk factors and emerging biomarkers for BSIs in military personnel; the potential for biochemical markers of bone metabolism to monitor the response to military training; and, the association of novel biochemical 'exerkines' with bone health. RESULTS: The primary risk factor for BSI in military (and athletic) populations is too much training, too soon. Appropriate physical preparation before training will likely be most protective, but routine biomarkers will not yet identify those at risk. Nutritional interventions will support a bone anabolic response to training, but exposure to stress, sleep loss, and medication is likely harmful to bone. Monitoring physiology using wearables-ovulation, sleep and stress-offer potential to inform prevention strategies. CONCLUSIONS: The risk factors for BSIs are well described, but their aetiology is very complex particularly in the multi-stressor military environment. Our understanding of the skeletal responses to military training is improving as technology advances, and potential biomarkers are constantly emerging, but sophisticated and integrated approaches to prevention of BSI are warranted.

How Advancement in Bone Science Should Inform the Examination and Treatment of Femoral Shaft Bone Stress Injuries in Running Athletes.

Stress fractures likely have a 1-2% incidence in athletes in general. In runners, a more vulnerable population, incidence rates likely range between 3.2 and 21% with female runners having greater susceptibility. The incidence of femoral shaft stress fractures is less well known. New basic and translational science research may impact the way clinicians diagnose and treat femoral stress fractures. By using a fictitious case study, this paper applies bone science to suggest new approaches to evaluating and treating femoral shaft stress fractures in the running population.

Stress fractures in the forefoot after arthrodesis of the hindfoot in a patient with rheumatoid arthritis: A case report.

Rheumatoid arthritis (RA) is an autoimmune disease that attacks multiple joints throughout the body. Ankle arthrodesis (AA) has been the gold standard surgery for end-stage ankle arthritis in patients with RA. Here, we report the case of a 67-year-old woman with RA who had displacement and loosening of total ankle arthroplasty. The ankle was converted to AA using a metal spacer and an intramedullary nail. The patient had no complications in perioperative terms of arthrodesis. However, multiple fractures were found in the metatarsal bones at the routine 3-year follow-up. Although the patient did not remember any symptoms, the clinical outcome deteriorated compared to that a year before. The hindfoot in this case report was fixed completely by an intramedullary nail, while the midfoot had already involved ankylosis because of severe joint destruction present before the surgery. As a result, the range of motion in the joints of the midfoot and hindfoot was lost, and it is probable that an excessive load was applied to the forefoot during push-off by the toes, resulting in a stress fracture. Patients with RA remain at risk of future progressive joint destruction in every joint of their body. Therefore, surgeons should choose a surgery that preserves ankle motion to decrease the rate of adjacent joint degeneration for severe ankle arthropathy in patients with RA.

A review of equine tibial fractures.

Equine tibial fractures are relatively infrequent in racing and non-racing sport horses, but limitations in successful treatment of tibial fractures in adult horses result in relatively high mortality compared with other musculoskeletal injuries. The aetiology of tibial fracture can be classified into two general categories: traumatic impact or fatigue failure. Tibial stress fractures, also known as fatigue fractures, are often rated as the second most common stress fracture in racing Thoroughbreds; young age, early stage in race training, and initiation of training after a period of rest are the reported risk factors. Both impact and fatigue fracture propagation are dependent on the magnitude of force applied and on the local composition/alignment of mineralised collagen in the tibial lamella. Extensive research has characterised the pattern of strain distribution and stress remodelling within the equine tibia, but in vivo measurement of load and angular moments are currently not feasible. Further research is warranted to correlate biomechanical theory of tibia fatigue fracture propagation with current histopathological data. Preventative measures for fatigue fractures aim to optimise diagnostic efficiency, reduce the interval between injury and diagnosis and modify racing and training conditions to reduce non-specific fracture risk. Treatment options for complete tibial fractures in adult horses are limited, but with careful case selection, successful outcomes have been reported after open reduction and internal fixation. On the other hand, tibial stress fractures and minimally displaced incomplete fractures are typically treated conservatively and have good prognosis for athletic recovery. This review aims to describe the current literature regarding tibial fracture aetiology, prevalence, risk factors, fracture biomechanics, treatment, prognosis and prevention.

Stress fractures.

Stress fractures (SF) represent 10%-20% of all injuries in sport medicine. An SF occurs when abnormal and repetitive loading is applied on normal bone: The body cannot adapt quickly enough, leading to microdamage and fracture. The etiology is multifactorial with numerous risk factors involved. Diagnosis of SF can be achieved by identifying intrinsic and extrinsic factors, obtaining a good history, performing a physical exam, and ordering laboratory and imaging studies (magnetic resonance imaging is the current gold standard). Relative energy deficiency in sport (RED-S) is a known risk factor. In addition, for women, it is very important know the menstrual status to identify long periods of amenorrhea in the past and the present. Early detection is important to improve the chance of symptom resolution with conservative treatment. Common presentation involves complaints of localized pain, with or without swelling, and tenderness on palpation of bony structures that begins earlier in training and progressively worsens with activity over a 2- to 3-week period. Appropriate classification of SF based on type, location, grading, and low or high risk is critical in guiding treatment strategies and influencing the time to return to sport. Stress injuries at low-risk sites are typically managed conservatively. Studies have suggested that calcium and vitamin D supplementation might be helpful. Moreover, other treatment regimens are not well established. Understanding better the pathophysiology of SFs and the potential utility of current and future bone-active therapeutics may well yield approaches that could treat SFs more effectively.

A Review on Management of Insufficiency Fractures of the Pelvis and Acetabulum.

"Insufficiency fractures of the pelvis and acetabulum are occurring at increasing rates. Osteoporosis is the most prevalent risk fracture. Diagnosis begins with plain radiographs followed by advanced imaging with computed tomography and/or MRI. Pelvic ring fragility injuries are classified by the Fragility fractures of the pelvis system. Elderly acetabular fractures may be classified by the Letournel system. Management of these injuries is primarily nonoperative with early immobilization when allowed by fracture characteristics. When warranted, percutaneous fixation and open reduction internal fixation are options for both. Both acute and delayed total hip arthroplasty are options for acetabular fractures."

Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries.

BACKGROUND: Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. QUESTIONS/PURPOSES: We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? METHODS: We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. RESULTS: We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). CONCLUSION: The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. LEVEL OF EVIDENCE: Level III, prognostic study.

Sacral Insufficiency Fractures.

¼: Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. ¼: The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. ¼: Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. ¼: Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. ¼: The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Navicular Fracture.

The tarsal navicular is an essential component of the Chopart joint and crucial for most of hindfoot motion. Most fractures are low-energy dorsal avulsions that may be treated nonoperatively. Displaced comminuted fractures require open reduction and internal fixation, sometimes with external fixation, bridge plating, and bone grafting. Diagnosis of stress fractures is commonly delayed. Conservative treatment is associated with good results, but surgery allows for quicker return-to-play in athletes. Nonunion in acute and stress fractures needs open debridement, grafting, and stable fixation. Müller-Weiss disease may present with a fragmented navicular and mimic an acute or a stress fracture.

Bone stress injuries.

Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.

Unusual presentation of atraumatic insufficiency pelvic fractures unmasking pregnancy-related osteoporosis: A case report.

We describe the case of a young 27-year-old Caucasian female who presented in the third trimester of her first pregnancy with sudden and severe suprapubic and left-sided hip pain without history of trauma. She was eventually diagnosed with two insufficiency fractures of the pelvis. The underlying diagnosis was pregnancy-related osteoporosis. Her baby was delivered successfully at term, with an elective caesarean section. The diagnosis was eventually made using a magnetic resonance imaging scan. Pregnancy-related osteoporosis is relatively rare, and cases of patients presenting with insufficiency fractures of this condition are rarer still. Our case raises the importance of considering this diagnosis in females in the later stages of pregnancy, with severe sudden hip or pelvis pain. The patient gave informed written consent for the publication of this case.