STRESS FRACTURE

Wenas Arjanggi Hartas (07700239)

Sisar Priya Nur Zaman (07700023)

Tutor :
dr. Maksum Pandelima, Sp.OT

Overview

The stressfractureis a common overuse

injury seen in athletes and military
recruits. [1,2]

Definition

A stress fracture is caused by repetitive and

submaximal loading of the bone, which
eventually becomes fatigued and leads to a
true fracture. [4,5]

PATHOPHYSIOLOGY

Normal bone remodeling occurs secondary

to increased compressive or tensile loads or
increased load frequency. In the normal
physiologic response, minor microdamage
of the bone occurs.
This is repaired through remodeling. Stress
fractures
develop
when
extensive
microdamage occurs before the bone can
be adequately remodeled. [6,7]

ETIOLOGY

Stress fracture result from reccurent and

repetitive loading of bone.
The 3 factors that can predispose an inviduals
to the development of stress fracture are :
1. An increase in the applied load
2. An increase in the number of applied stress
3. A decrease in the surface area of the
applied load. [8]

Risk Factors

Menstrual disturbance
Caloric restriction
Decreased bone density
Muscle weakness
Leg lenght difference [10,11]

Epidemiology

Based on location and activity

Location of Fracture

Activity Involved

Metatarsals, general

Football, basketball, gymnastics, ballet, military training [20]

Metatarsal, base of the second

Ballet

Metatarsal, fifth

Tennis,[21, 22]ballet

Sesamoids of the foot

Running, ballet, basketball, skating

Navicular

Basketball, football, running

Talus

Pole vaulting

Calcaneus

Military drills, running, aerobics

Fibula

Running, aerobics, ballet, race-walking

Tibia

Running sports, dancing, ballet

Patella

Running, hurdling

Femoral neck

Distance running, military training[23]

Pubic rami

Military drills, distance running

Pars articularis

Gymnastics, ballet, cricket, volleyball, diving, football

Chest, ribs

Swimming,[24]golf,[25]rowing[26]

Sternum

Wrestling[27]

Ulna

Racquet sports, volleyball

Olecranon

Baseball, throwing sports

 Based on sex
-Studies of US military recruits revealed a
higher percentage of stress fractures in
female recruits than in male recruits.
- Bennell et al also found a 45% incidence of
stress fractures in competitive female
runners [1,28,29,30]

 Based on race
- In a study of military recruits, Markey found
no difference in the incidence of stress
fractures between recruits of various racial
backgrounds. [33]

Clinical Presentation

History
- With stress fractures, the typical complaint
is that of an insidious onset of pain with
activity or a complaint of pain in the
affected extremity with repeated loading.
- The pain subsides at rest, but symptoms
return when the patient resumes the
original activity.

 Physical Examination
- The common findings on physical
examination may include tenderness or
pain on palpation or percussion of the
bone.
- Erythema or edema may be present at the
site of the stress fracture.

Diagnostic Testing

Radiography
- Stress fractures may not show up on
radiographs for the first 2-4 weeks after
injury. The first radiographic finding may be
a localized periosteal reaction or an
endosteal cortical thickening.

 Techtenium-99m bone scanning

- Technetium bone scan findings may be
positive in the case of a stress fracture
after 72 hours; however, a positive bone
scan finding is nonspecific, and it may be
indicative of another diagnosis, such as an
infection or a neoplastic process.

 Magnetic Resonance Imaging

- The MRI findings of stress fractures typically
follow 1 of 2 patterns.
- In the first pattern, a hypointense, bandlike
fracture line is visible with surrounding bone or
tissue edema.
- The second MRI finding represents an amorphous
stress fracture or response pattern. [35,36,37]

 Grading of Stress Fractures on the Basis of

Radiologic Findings [35]
Grade

Radiographic
Finding

Bone Scan Finding

MRI Finding

Normal

Poorly defined area

Increased activity on
STIR image

Normal

More intense

Poor definition on
STIR and T2-weighted
images

Discrete line

Sharp area of uptake

No focal or fusiform
cortical break on T1and
T2-weighted
images

Fracture or periosteal More

intense Fracture line on T1reaction
localized transcortical and
T2-weighted
uptake
images

Treatment

- Most stress fractures can be treated by

having patients stop or significantly
decrease their activity for approximately
4-6 weeks.
- Patients with pain with walking may be
placed in a short leg cast with crutches, a
walking boot, or a brace for 4-6 weeks. [38]

Healing times for various stress fractures

[39]

Site of Stress Fracture Percentage Healed at Percentage Healed at Percentage Healed at

2-4 wk, %
1-2 mo, %
> 2 mo, %
Tibia, proximal third

43

57

Tibia, middle third

48

52

Tibia, distal third

53

47

Fibula

75

18

Metatarsals

20

57

23

Sesamoids

100

Femur, shaft

86

Femur, neck

100

Pelvis

29

75

Olecranon

100

*Adapted from Hulkko (Findings were from a case series of 368 stress fractures in athletes, in
which the healing times of stress fractures in different locations were assessed.)

Prevention

- Nutitional measures :
calcium and vitamin D rich food [40]
- Biomechanical measures :
The use of orthotic devices and shoe
inserts has been studied as a preventive
measure for lower-extremity stress
fractures. [41]

Complications

High risk stress fractures

- Nonunion of stress fractures is uncommon,
but it can occur. These include stress
fractures of the neck of the femur, the
anterior cortex of the tibia, the tarsal
navicular, and the bases of the second and
fifth metatarsals. [39]

 Low risk stress fracture

- Low-risk stress fractures include most
upper- extremity stress fractures, with the
possible exception of fractures through the
physis of the humeral head (little leaguer's
shoulder) and fractures through the medial
epicondyle (little leaguer's elbow). [39]

- Other low-risk stress fractures include

stress fractures of the ribs, pelvis, femoral
shaft, fibula, calcaneus, and the metatarsal
shafts.

THANK YOU