Stress Fractures in the Juvenile Skeletal System

Abstract

Stress fractures affecting the juvenile skeletal system are rare and are described as having a good prognosis. Precisely because these fractures are so rare, studies allowing clear and generally applicable conclusions are lacking. The object of the present study was a systematic analysis of patients with stress fractures in an immature skeletal system, with special reference to the frequently difficult and delayed diagnosis and to the forms of therapy considered appropriate. Twenty-five patients with a total of 27 stress fractures affecting bones with the growth plates still open were examined according to a standardized procedure. The average duration of follow-up was 4.8 years (SD ± 2.3) and the average age at occurrence 12.9 years (SD ± 4.31). The risk factors were largely the same as those in adults. The most frequent site was the tibia (48 % of cases; n = 13), followed by the metatarsal bones. Most (26/27) fractures were treated conservatively, with an average duration of therapy of 8.9 weeks (SD 8.2 weeks). Ultimately, 17 (63 %) of the fractures healed in such a way as to allow the patients to return to full athletic activity with no restrictions within 3 months after diagnosis. In 9 cases (33 %) it was not possible to achieve complete absence of symptoms within 12 months after diagnosis was made. No pseudarthroses were observed. There was a significant correlation between clinical outcome recorded as “free of symptoms” and an early diagnosis (less than 2 weeks after first symptoms (p = 0.033) and a fracture line seen on MR tomography in contrast to a stress reaction with merely increased signal intensity (p = 0.037). Overall, a strikingly high proportion of these patients had a prolonged course. This is attributable partly to the delay in diagnosis and to inappropriate initial treatment. When stress fractures were recognizable by a demonstrable fracture line - in contrast to just an edema - on MR tomography and their diagnosis was followed by an adequate form of therapy the chances of complete healing seemed to be better. It is essential to carry out targeted imaging investigations, e.g., by means of MR tomography, when there is a reason to consider a stress reaction. Furthermore, stress fractures should be adequately treated until all symptoms have disappeared.

Key words

Stress fracture - adolescents - juvenile skeletal system - overuse injury

References

• 1 Bahk Y W, Kim S H, Chung S K, Kim J H. Dual-head pinhole bone scintigraphy.  J Nucl Med. 1998;  39 1444-1448
• 2 Bennell K L, Brukner P D. Epidemiology and site specificity of stress fractures.  Clin Sports Med. 1997;  16 179-196
• 3 Brill P A, Macera C A. The influence of running patterns on running injuries.  Sports Med. 1995;  20 365-368
• 4 Brudvig T J, Gudger T D, Obermeyer L. Stress fractures in 295 trainees: a one-year study of incidence as related to age, sex, and race.  Mil Med. 1983;  148 666-667
• 5 Brukner P, Bennell K. Stress fractures in female athletes. Diagnosis, management and rehabilitation.  Sports Med. 1997;  24 419-429
• 6 Brukner P, Bradshaw C, Khan K M, White S, Crossley K. Stress fractures: a review of 180 cases.  Clin J Sport Med. 1996;  6 85-89
• 7 Brunet M E, Cook S D, Brinker M R, Dickinson J A. A survey of running injuries in 1505 competitive and recreational runners.  J Sports Med Phys Fitness. 1990;  30 307-315
• 8 Connolly L P, Connolly S A, Treves S T. Differentiation of anterior tibial stress fracture from osteoid osteoma.  Clin Nucl Med. 2001;  26 54-56
• 9 Dalton S E. Overuse injuries in adolescent athletes.  Sports Med. 1992;  13 58-70
• 10 de la Cuadra P, Albinana J. Pediatric stress fractures.  Int Orthop. 2000;  24 47-49
• 11 Devas M B. Stress fractures in children.  J Bone Joint Surg Br. 1963;  45 528-541
• 12 Flinn S D. Changes in stress fracture distribution and current treatment.  Curr Sports Med Rep. 2002;  1 272-277
• 13 Fredericson M, Bergman A G, Hoffman K L, Dillingham M S. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system.  Am J Sports Med. 1995;  23 472-481
• 14 Fredericson M, Bergman A G, Matheson G O. [Stress fractures in athletes].  Orthopäde. 1997;  26 961-971
• 15 Hulkko A, Orava S. Stress fractures in athletes.  Int J Sports Med. 1987;  8 221-226
• 16 Iwamoto J, Takeda T. Stress fractures in athletes: review of 196 cases.  J Orthop Sci. 2003;  8 273-278
• 17 Lassus J, Tulikoura I, Konttinen Y T, Salo J, Santavirta S. Bone stress injuries of the lower extremity: a review.  Acta Orthop Scand. 2002;  73 359-368
• 18 Li G P, Zhang S D, Chen G, Chen H, Wang A M. Radiographic and histologic analyses of stress fracture in rabbit tibias.  Am J Sports Med. 1985;  13 285-294
• 19 Matheson G O, Clement D B, McKenzie D C, Taunton J E, Lloyd-Smith D R, MacIntyre J G. Stress fractures in athletes. A study of 320 cases.  Am J Sports Med. 1987;  15 46-58
• 20 Mulligan M E. The “gray cortex”: an early sign of stress fracture.  Skeletal Radiol. 1995;  24 201-203
• 21 Orava S. Stress fractures.  Br J Sports Med. 1980;  14 40-44
• 22 Orava S, Puranen J. Exertion injuries in adolescent athletes.  Br J Sports Med. 1978;  12 4-10
• 23 Protzman R R, Griffis C G. Stress fractures in men and women undergoing military training.  J Bone Joint Surg Am. 1977;  59 825
• 24 Rossmuller B, Hahn K, Fischer S. Bone scintigraphy in non-neoplastic diseases in children.  Q J Nucl Med. 1998;  42 133-147
• 25 Savoca C J. Stress fractures. A classification of the earliest radiographic signs.  Radiology. 1971;  100 519-524
• 26 Stanitski C L, McMaster J H, Scranton P E. On the nature of stress fractures.  Am J Sports Med. 1978;  6 391-396
• 27 Steingruber I E, Wolf C, Gruber H, Gabriel M, Czermak B V, Mallouhi A, Jaschke W. (Stress fractures in athletes.)  Radiologe. 2002;  42 771-777
• 28 Waisman Y, Varsano I, Grunebaum M, Mimouni M. Stress fractures: a diagnostic problem.  Arch Dis Child. 1987;  62 847-848
• 29 Walker R N, Green N E, Spindler K P. Stress fractures in skeletally immature patients.  J Pediatr Orthop. 1996;  16 578-584
• 30 Watkins J, Peabody P. Sports injuries in children and adolescents treated at a sports injury clinic.  J Sports Med Phys Fitness. 1996;  36 43-48
• 31 Yoon T R, Rowe S M, Song E K, Mulyadi D. Unusual osteonecrosis of the femoral head misdiagnosed as a stress fracture.  J Orthop Trauma. 2004;  18 43-47