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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)