Unusual Presentation of Hip Pain in a Pregnant Woman Due to Bilateral Cervical Neck Stress Fractures: A Case Report.

CASE: We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes. CONCLUSION: Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

Multifocal stress fractures in a patient with rheumatoid arthritis.

Stress fractures are often associated to activities that requires repetitive stress such as running. However, insufficiency-type stress fractures can also occur in patients with risk factors such as rheumatoid arthritis. Diagnosis of stress fracture would require a thorough clinical evaluation along with radiological imaging. However, this may be difficult due to how it mimics other musculoskeletal problems. The case of a woman in her 60s presenting with 2 months of severe ipsilateral right knee and ankle pain is used as an example. Based on initial clinical assessment and plain radiograph, her provisional diagnosis was osteoarthritis or inflammatory arthritis secondary to rheumatoid disease. However, MRI scan revealed that she had multifocal stress fractures in her knee, ankle and foot. Hence, we hope that this case study can allow clinicians to consider multifocal stress fracture as a possible diagnosis in patients with risk factors and to have lower threshold in performing MRI scans.

Stress fractures of the hand and wrist in athletes.

Stress fractures of the upper extremity are reported less often than their lower extremity counterpart. This review aims to provide a comprehensive overview of an important and often missed diagnosis in pediatric athletes: hand and wrist stress fractures.

Sacral insufficiency fractures are a frequent and painful consequence of pubic symphysis osteomyelitis.

BACKGROUND: Pubic symphysis osteomyelitis can result from urosymphyseal fistula formation. High rates of sacropelvic insufficiency fractures have been reported in this population. The aim of this study was to describe the presentation and risk factors for sacral insufficiency fractures (SIF) associated with surgical treatment of pubic symphysis osteomyelitis. METHODS: A retrospective review was performed for 54 patients who underwent surgery for pubic symphysis osteomyelitis associated with a urosymphyseal fistula at a single institution from 2009 to 2022. Average age was 71 years and 53 patients (98%) were male. All patients underwent debridement or partial resection of the pubic symphysis at the time of fistula treatment. Average width of the symphyseal defect was 65 mm (range 9-122) after treatment. RESULTS: Twenty patients (37%) developed SIF at a mean time of 4 months from osteomyelitis diagnosis. Rate of sacral fracture on Kaplan-Meier analysis was 31% at 6 months, 39% at 12 months, and 41% at 2 years. Eleven patients developed SIF prior to pubic debridement and 12 patients developed new or worsening of pre-existing SIF following surgery. Width of pubic resection was higher in patients who developed SIF (76 mm vs. 62 mm), but this did not meet statistical significance (p = 0.18). CONCLUSION: Sacral insufficiency fracture is a common sequela of pubic symphysis osteomyelitis. These fractures are often multifocal within the pelvis and can occur even prior to pubic resection. Pubectomy further predisposes these patients to fracture. Clinicians should maintain a high index of suspicion for these injuries in patients with symphyseal osteomyelitis.

Operative Technique for Sacral Insufficiency Fractures Causing Spinopelvic Dissociation: A Case Report.

CASE: We present a case of a 54-year-old man with atraumatic, U-type sacral insufficiency and L5 compression fractures leading to spinopelvic dissociation, inability to ambulate, and bowel/bladder compromise. The patient underwent L3-4 percutaneous pedicle screw fixation with bilateral iliac bolts and percutaneous iliosacral screw fixation. Postoperatively, the patient had return of bowel/bladder function and independent ambulation at 2.5 years. CONCLUSION: Atraumatic spinopelvic dissociation is an underappreciated pathology in older patients. Here, we describe the result of our preferred treatment strategy, triangular osteosynthesis, to preserve function and independence. Despite optimal, prompt treatment, these injuries pose a difficult rehabilitation process for patients.

Subchondral Insufficiency Fractures of the Knee: A Clinical Narrative Review.

¼ Subchondral insufficiency fractures of the knee (SIFKs) are subchondral plate fractures with a prevalence of 2% to 4% of all knee injuries.¼ Magnetic resonance imaging is the gold standard for evaluating SIFK, while plain radiographs have limited the use in the diagnosis of SIFK.¼ Among patients with SIFK, 50% to 100% have meniscal pathology.¼ Medical therapies and standard treatments traditionally used in the management of knee osteoarthritis differ from recommended management of SIFK patients.¼ Randomized controlled trials and cohort studies with long-term follow-up are needed to determine the optimal rehabilitation protocol, interventional therapy, and prognosis of SIFK patients.

Stress Fractures of the Distal Phalanx in Skeletally Immature Sport Climbers.

Stress fractures in the distal phalanx of skeletally immature patients are rare and previously unreported clinical occurrences. We report on 2 adolescent sport climbers with such fractures of the dorsal metaphysis of the distal phalanx at the point where parts of the extensor tendon insert. A conservative treatment approach alone was sufficient in healing this fracture type in both patients after 12 wk. Clinicians should be informed of the existence of this rare clinical phenomenon and counsel patients that a conservative treatment approach may result in complete healing without the need for an invasive procedure.

Weight-Bearing CT with Maximum Ankle Dorsiflexion to Identify Impingement and Tibial Plafond Stress Fracture: A Case Report.

CASE: A 25-year-old male pole vaulter presented with several months of right ankle pain. Radiographs showed an anterior tibial osteophyte with a small intra-articular body suggesting impingement. Weight-bearing computed tomography (CT) revealed an associated tibial plafond stress fracture. Subsequent arthroscopy with osteophyte resection and loose body removal significantly improved symptoms, and he gradually resumed training. CONCLUSION: Stress fractures should always be considered in athletes with ankle pain. A unique aspect of this case was the use of weight-bearing CT in diagnosis and surgical planning. To our knowledge, this is the first described case in which weight-bearing CT was used in this fashion.

Bilateral femoral neck stress fractures in elderly individuals: A case report and literature review.

RATIONALE: Bilateral femoral neck stress fractures are relatively rare injuries that occur frequently in military recruits, athletes and patients with osteoporosis, renal bone disease, metabolic bone disease, and chronic steroid use. Herein, a case of an elderly patient with bilateral femoral neck stress fractures is reported. PATIENT CONCERNS: A 65-year-old man presented to the author's hospital with right hip pain for over a month. The patient was a farmer, had a long history of field labor before the onset of pain, denied any history of trauma. DIAGNOSIS: The patient was diagnosed with a right subcapital fracture of the femoral neck after examination. The patient complained of only right hip symptoms, and hip computed tomography showed no abnormalities in the left hip. A tension fracture of the left femoral neck was missed due to unawareness of the abnormal signal of the left femoral neck seen on right hip magnetic resonance imaging. INTERVENTIONS: During the first hospitalization, the patient underwent total hip arthroplasty (THA) on the right hip. Two months after the operation, the patient started to have pain in the left hip and underwent left THA again for a displaced left femoral neck fracture. OUTCOMES: The patient eventually underwent bilateral THA surgery and had a satisfactory functional recovery. But the oversight in the diagnostic process led to the patient undergoing left THA that could have been avoided. LESSONS: For patients who complain of hip pain but deny a history of trauma, we should be concerned about the presence of a hip fracture even if the patient's radiograph does not report a positive result. The most sensitive method is bilateral magnetic resonance imaging examination of the hip. Femoral neck stress fractures require early diagnosis and treatment to prevent complications.

Outcomes of conservative treatment of acromial and scapular spine stress fracture post reverse shoulder arthroplasty: a systematic review with meta-analysis.

INTRODUCTION: Acromial and scapular spine stress fractures are common complications post reverse shoulder arthroplasty. A systematic review with meta-analysis was conducted to evaluate the clinical outcomes of conservatively treated acromial and scapular spine stress fractures post reverse shoulder arthroplasty in comparison to nonfracture control. METHODS: Embase, MEDLINE, and Web of Science were searched on September 9, 2022, using various terms related to fracture, acromion, scapula, and reverse shoulder arthroplasty. Meta-analysis using a random effects model was performed on common outcome scores. Risk of bias was assessed using the Joanna Briggs Institute tools for case-controlled studies. Sensitivity analysis was performed for imputed standard deviations and studies with <20 participants. RESULTS: Thirteen studies with a total of 339 fracture and 3142 control patients were included in the systematic review. Meta-analysis was performed on 12 studies assessing active forward flexion, abduction, external rotation, Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, pain score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Fracture patients experienced significantly poorer functional outcome compared with control patients when the fractures were managed conservatively. Levy III fractures tend to experience worse outcomes. Pain score did not demonstrate a statistically significant difference between the fracture and nonfracture cohort. DISCUSSION: Currently, literature regarding surgical management is lacking, partially because of a dearth of high-quality literature but also hindered by a lack of standardized techniques. This review was limited by inclusion of studies of low evidence, small sample sizes, and inconsistency in outcome measurement and follow-up period. Overall, patients with acromial and scapular spine stress fractures treated conservatively are expected to have reduced shoulder function compared to nonfracture patients, with the spine of scapula fracture patients suffering the poorest outcomes. Future studies should aim to use the same sets of outcomes parameters to assess the patients at fixed time intervals and report outcomes stratified by Levy classification. This will enable interinstitutional collaboration and pooling of results.

Total Hip Arthroplasty is the Most Effective Treatment for Atraumatic Subchondral Insufficiency Fractures of the Femoral Head.

BACKGROUND: Subchondral insufficiency fracture of the femoral head (SIFH) is a relatively newly used diagnosisfollowing an insidious onset of hip pain in individuals without apparent antecedent trauma. The aim of this study was to investigate the outcomes of a consecutive series of patients with SIFH treated at one institution. METHODS: A total of 93 patients aged 23 to 91 years who were treated for SIFH in the outpatient clinics at one academic, urban medical center between August 2012 and August 2019 were identified. The diagnosis was made by magnetic resonance imaging or radiograph of the hip and was confirmed by a radiologist specialized in orthopedic surgery. Patient demographics, injury history, duration of pain, treatment type, and persistence of pain were recorded. RESULTS: Sixty-five (69.9%) patients with a mean age of 64.2 ± 9.4 years ultimately underwent total hip arthroplasty (THA). Twenty-eight (30.1%) patients chose no surgical intervention. Patients who underwent THA had less pain at their final follow-up appointment than patients who elected non-operative treatment (p < 0.001). At their final follow-up appointments, 92.9% of patients treated non-operatively reported pain, compared to only 13.8% of patients who underwent THA who had pain. Age, body mass index, and duration of pain prior to initial complaint did not affect presence of continued pain at final follow-up appointments, regardless of treatment type (p > 0.05). CONCLUSION: In the majority of patients, SIFH is often not sufficiently managed with non-operative treatments. Pain reported among patients with confirmed or suspected SIFH is usually severe and interferes with patients' ability to perform their activities of daily life. Total hip arthroplasty seems to be the most reliable method of treatment for this condition. Physicians who treat patients with SIFH should counsel them as to the expectations of recovery and the potential for poorer outcome if treated without THA.

Late Periprosthetic Femoral Stress Fracture Associated with Extra-articular Deformity in a Patient with Fibrous Dysplasia: A Case Report.

CASE: In the setting of a total hip arthroplasty performed in a patient with a proximal femoral deformity, atraumatic periprosthetic femoral stress fracture may arise as a complication. We report a rare case of a late periprosthetic femoral stress fracture around a cemented stem in a patient with a history of fibrous dysplasia of the proximal femur. After a 10-year uneventful period, the patient complained about a subtle, subacute pain in his left thigh induced by exercise but not with daily axial load. Diagnosis of a nondisplaced, incomplete (i.e., only compromising the lateral femoral cortex) periprosthetic femoral stress fracture was made with plain radiographs, blood work, and bone scintigraphy. Surgical treatment consisted of a minimally invasive plate osteosynthesis bridging the femoral deformity plus percutaneous osteoperiosteal decortication. At 5-year follow-up, the patient was asymptomatic with full return to physical activity, with radiographs evidencing callus formation. CONCLUSION: Stress fractures around well-fixed femoral stems, while infrequent, should be addressed in patients with a history of severe proximal femur deformity experiencing atraumatic thigh pain.

Tarsal Navicular Bone Stress Injuries: A Multicenter Case Series Investigating Clinical Presentation, Diagnostic Approach, Treatment, and Return to Sport in Adolescent Athletes.

BACKGROUND: Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes. PURPOSE: To describe the characteristics of tarsal navicular BSIs in adolescents. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed. RESULTS: Among 110 patients (mean age, 14.7 ± 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 ± 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 ± 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery. CONCLUSION: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.