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Stress Fractures. Presented by M.A. Kaeser, DC Summer 2009. General considerations. Term is applied to a bone injury incurred as the result of repetitive stress of lower magnitude than required for an acute traumatic fracture Occurs in normal or abnormal bone Radiographs are

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Stress fractures

Stress Fractures

Presented by M.A. Kaeser, DC

Summer 2009

General considerations
General considerations

  • Term is applied to a bone injury incurred as the result of repetitive stress of lower magnitude than required for an acute traumatic fracture

  • Occurs in normal or abnormal bone

  • Radiographs are

    insensitive in the early


  • Bone scans are modality

    of choice

  • MRI will depict neoplasm

    versus stress fracture


  • Fatigue fracture

    • Occurs secondary to an abnormal

      amount of stress or torque applied

      to a normal bone

    • Examples: military recruits,

      runners, dancers, people who

      inadequately train

  • Insufficiency Fracture

    • Occurs with normal stress placed on abnormal bone

    • Examples: Paget’s, osteoporosis, osteomalacia or rickets, osteopetrosis, fibrous dysplasia, OI


  • Major cause is abnormal degree of repetitive trauma

  • Related to increased physical trauma

  • May be related to muscular imbalance or altered biomechanics (rigid supination of foot, varus deformities of foot, LLI)

  • May follow certain surgical procedures (bunionectomies, hip replacement, knee surgery, fusion of the lumbosacral junction)

  • Deformity from OA, esp. at knee

  • Menstrual irregularities may predispose women to stress fractures

Common sites
Common sites

  • Metatarsals are M/C, esp.

    middle and distal portions of

    the shaft of the second and

    third metatarsals

    • Frequent in military recruits (march fracture, Deutschlander’s disease)

      • Due to fatigue of the peroneus longus muscle leading to instability of the foot

    • Stress fractures of the 2nd and 3rd metatarsals may complicate Morton’s syndrome (congenitally shortened first metatarsal)

Common sites continued
Common sites continued

  • Proximal tibia

    • High incidence in joggers, marchers and ballet dancers

  • Calcaneus

    • Found in military recruits and long-distance runners

  • Proximal or distal metaphyses of the fibula

    • Runners and ballet dancers

  • Ribs

    • Rowers (12%)

Common sites continued1
Common sites continued

  • Pars interarticularis of the

    lower L/S

    • M/C site for stress fracture

      of the entire skeleton

    • May be found w/ or w/o


  • Sacrum

    • M/C in elderly women with osteoporosis

    • Associated with neural compromise (paraesthesias and sphincter dysfunction)

Clinical features
Clinical Features

  • More common in women than men

  • Pain, related to activity and relieved by rest

  • Soft tissue swelling with localized tenderness over the area of stress

  • Bones of lower extremity are most frequently involved

  • More than one site can be present

Radiologic features
Radiologic Features

  • Initial radiographic examination

    may fail to reveal the fracture line

  • Minimum radiographic latent period is 10-21 days

  • CT may be helpful in demonstrating the fracture line

  • Bone scan is modality of choice

    • Focal uptake at the site of fracture on

      delayed images is characteristic but

      not specific

    • Scan may be active for up to 12

      months after healing

Radiologic features continued
Radiologic Features continued

  • Combination bone scan with tomography (SPECT) is useful for active stress in pars

  • CT is useful when diagnosis is in doubt

  • MRI

    • Low signal on T1

    • High signal on T2 if local

      hemorrhage is present

      (if not the signal is low on T2)

Roentgen signs
Roentgen Signs

  • Periosteal response

    • Most frequently seen and reliable signs are

      periosteal and endosteal cortical thickening

    • Solid pattern of periosteal response

    • Cortical thickening is localized to the area of

      stress fracture

  • Fracture line

    • Exuberant periosteal new bone will obscure the radiolucent fracture line

    • Fracture may be too thin to see

    • Oblique fractures are most common, transverse and longitudinal may occur

    • CT will depict fracture when plain film doesn’t

Transverse opaque bands
Transverse opaque bands

  • Enface

    • Periosteal callus forms a linear, transverse, radiopaque band

    • Margins are hazy and pooly defined (this differentiates it from growth lines)

Differential diagnosis
Differential Diagnosis

  • Osteomyelitis

    • Creates a significant periosteal


    • Lytic bone destruction adjacent to

      periosteal callus confirms osteomyelitis

  • Osteosarcoma

    • Both produce a periosteal response

      (stress fracture = solid,

      o-sarc = spiculated)

    • Bone destruction will be seen with


    • CT depicts a linear radiolucent fracture line which diagnoses a stress fracture

Differential diagnosis continued
Differential Diagnosis continued

  • Osteoid Osteoma

    • Oval radiolucent nidus of

      osteoid oseoma vs

      radiolucent fracture line

  • Growth Arrest Lines

    • Discrete radiopaque lines through the metaphysis (growth arrest lines)

    • Radiopaque line is broad, hazy,

      ill-defined margin to its edge

      in stress fractures

    • GALs are usually found in

      other bones as bilateral,

      symmetrical, well-defined radiopaque bands

Calcaneus parachuting

Clavicle persistent tic

First rib backpacker

7th-9th ribs coughing, golfing,


Scapula (coracoid) trap shooting

Ulna pitchfork work,


Phalanx tuft guitar playing

5th metatarsal running on banked track fields

Hook of hamate equipment holding (tennis, golf, baseball)