Fatigue fracture
Updates to Article Attributes
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was changed:
Fatigue fractures are a type of stress fracture due to abnormal stresses on normal bone. They should not be confused with an insufficiency fracture, which occurs due to normal stresses on abnormal bone. Plain filmsradiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. MRI is the most sensitive and specific modality. Bone scans are sensitive but not specific.
Terminology
Some authors 3 use the term stress fracture synonymously with fatigue fractures, and thus some caution with the term is suggested.
Epidemiology
The demographics are usually young active patients, with specific locations having different demographics in keeping with the associated activity 2.
Pathology
The abnormal stresses result in repeated microfractures at sites of structural weakness and incomplete healing results with repeated injury. These are typical in athletes.
Location
In many cases of lower limb fractures, bilateral abnormalities are present, whereas in the upper limb they are more frequently unilateral.
-
pelvis and lower
lowerlimb (most common)- medial neck of femur
- compressive forces
- ballet, running, gymnastics
- pubic rami / obturator ring
- : bowling, gymnastics, stooping
- medial neck of femur
-
tibia
- proximal in children
- mid to distal in adults 2
-
calcaneum
- bilateral in up to 27% of cases
- jumping/landing on heels/prolonged standing
-
navicular
- : marching/running
-
metatarsals
- : marching/prolonged standing/ballet
- sesamoid of great toe
- : prolonged standing
- upper limb
- spinous processes of C6, C7, T1, T2
- : shovelling
-
coracoid process
- : trap shooting
- ribs
-
chronic: chronic cough, golf, carrying heavy pack
-
-
humerus
- : throwing
- coronoid process of ulna
- : propelling wheelchair, throwing javelin
- hook of hamate
- : racket sports, golf
Radiographic features
Early diagnosis is best made with MRI (near 100% sensitive) or bone scan or(less specific than MRI,) as plain filmsradiographs may appear normal for some time - the sensitivity for early-stage injuries is ~25% (range 15-35%) and late-stage injuries is ~50% (range 30-70%) 4.
Plain filmradiograph
- initially normal
- earliest changes is the gray cortex sign: cortical lucency at the site of microfracture
- periosteal reaction progressing to callus formation in diaphyseal fractures
- linear sclerosis and cortical thickening more common in metaphyseal and epiphyseal fractures 2
MRI
MRI is as sensitive as bone scanning but is of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or infection.
MRI signal characteristics
-
T1
- low marrow signal
-
enhancement canvery hypointense linear fracture line may beprominentpresent - hypointense periosteal/endosteal new bone formation
- T2: high marrow signal with extension into adjacent soft tissues
- T1C+: enhancement can be prominent
Bone scanNuclear medicine
There is increased activity at the site of the fracture on bone scans.
Treatment and prognosis
Treatment depends on the location and whether the fracture is complete or incomplete.
Options include conservative management, plaster cast, internal fixation. Most importantly change in behaviour to reduce the activity which has lead to the fracture is needed. In some instances, an altered technique may be sufficient to prevent re-occurrence.
-<p><strong>Fatigue fractures</strong> are a type of <a href="/articles/stress-fractures">stress fracture</a> due to abnormal stresses on normal bone. They should not be confused with an <a href="/articles/insufficiency-fracture">insufficiency fracture</a>, which occurs due to normal stresses on abnormal bone. Plain films typically demonstrate a linear sclerotic region. MRI is the most sensitive and specific modality. <a href="/articles/bone-scan">Bone scans</a> are sensitive but not specific.</p><h4>Terminology</h4><p>Some authors <sup>3</sup> use the term stress fracture synonymously with fatigue fractures, and thus some caution with the term is suggested.</p><h4>Epidemiology</h4><p>The demographics are usually young active patients, with specific locations having different demographics in keeping with the associated activity <sup>2</sup>.</p><h4>Pathology</h4><p>The abnormal stresses result in repeated microfractures at sites of structural weakness and incomplete healing results with repeated injury. These are typical in athletes.</p><h5>Location</h5><p>In many cases of lower limb fractures, bilateral abnormalities are present, whereas in the upper limb they are more frequently unilateral.</p><ul><li>-<a href="/articles/pelvis-1">pelvis</a> and lower lower limb (most common)<ul><li>medial neck of femur<ul>- +<p><strong>Fatigue fractures</strong> are a type of <a href="/articles/stress-fractures">stress fracture</a> due to abnormal stresses on normal bone. They should not be confused with an <a href="/articles/insufficiency-fracture">insufficiency fracture</a>, which occurs due to normal stresses on abnormal bone. Plain radiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. MRI is the most sensitive and specific modality. <a href="/articles/bone-scan">Bone scans</a> are sensitive but not specific.</p><h4>Terminology</h4><p>Some authors <sup>3</sup> use the term <strong>stress fracture</strong> synonymously with <strong>fatigue fractures</strong>, and thus some caution with the term is suggested.</p><h4>Epidemiology</h4><p>The demographics are usually young active patients, with specific locations having different demographics in keeping with the associated activity <sup>2</sup>.</p><h4>Pathology</h4><p>The abnormal stresses result in repeated microfractures at sites of structural weakness and incomplete healing results with repeated injury. These are typical in athletes.</p><h5>Location</h5><p>In many cases of lower limb fractures, bilateral abnormalities are present, whereas in the upper limb they are more frequently unilateral.</p><ul>
- +<li>
- +<a href="/articles/pelvis-1">pelvis</a> and lower limb (most common)<ul>
- +<li>medial neck of femur<ul>
-</li></ul>-<ul><li>pubic rami / obturator ring<ul><li>bowling, gymnastics, stooping</li></ul>-</li></ul>-</li></ul><ul><li>- +</li>
- +<li>pubic rami / obturator ring: bowling, gymnastics, stooping</li>
- +<li>
-</li></ul><ul><li>- +</li>
- +<li>
-</li></ul><ul><li>-<a href="/articles/navicular">navicular</a><ul><li>marching/running</li></ul>-</li></ul><ul><li>-<a href="/articles/metatarsals">metatarsals</a><ul><li>marching/prolonged standing/ballet</li></ul>-</li></ul><ul><li>sesamoid of great toe<ul><li>prolonged standing</li></ul>-</li></ul><ul><li>upper limb</li></ul><ul>-<li>spinous processes of C6, C7, T1, T2<ul><li>shovelling</li></ul>-<a href="/articles/coracoid-process">coracoid</a> process<ul><li>trap shooting</li></ul>-</li>-<li>ribs<ul><li>chronic cough, golf, carrying heavy pack</li></ul>-</li>- +<a href="/articles/navicular">navicular</a>: marching/running</li>
-<a href="/articles/humerus">humerus</a><ul><li>throwing</li></ul>-</li>-<li>coronoid process of <a href="/articles/ulna">ulna</a><ul><li>propelling wheelchair, throwing javelin</li></ul>- +<a href="/articles/metatarsals">metatarsals</a> : marching/prolonged standing/ballet</li>
- +<li>sesamoid of great toe: prolonged standing</li>
- +</ul>
-<li>hook of <a href="/articles/hamate">hamate</a><ul><li>racket sports, golf</li></ul>- +<li>upper limb<ul>
- +<li>spinous processes of C6, C7, T1, T2: shovelling</li>
- +<li>
- +<a href="/articles/coracoid-process">coracoid</a> process: trap shooting</li>
- +<li>ribs: chronic cough, golf, carrying heavy pack</li>
- +<li>
- +<a href="/articles/humerus">humerus</a>: throwing</li>
- +<li>coronoid process of <a href="/articles/ulna">ulna</a>: propelling wheelchair, throwing javelin</li>
- +<li>hook of <a href="/articles/hamate">hamate</a>: racket sports, golf</li>
- +</ul>
-</ul><h4>Radiographic features</h4><p>Early diagnosis is best made with bone scan or MRI, as plain films may appear normal for some time.</p><h5>Plain film</h5><ul>- +</ul><h4>Radiographic features</h4><p>Early diagnosis is best made with MRI (near 100% sensitive) or bone scan (less specific than MRI) as plain radiographs may appear normal for some time - the sensitivity for early-stage injuries is ~25% (range 15-35%) and late-stage injuries is ~50% (range 30-70%) <sup>4</sup>.</p><h5>Plain radiograph</h5><ul>
-<li>periosteal reaction progressing to callus formation in diaphyseal fractures</li>- +<li>earliest changes is the <a title="Gray cortex sign (stress fracture)" href="/articles/grey-cortex-sign-stress-fracture-1">gray</a><a title="Gray cortex sign (stress fracture)" href="/articles/grey-cortex-sign-stress-fracture-1"> cortex sign</a>: cortical lucency at the site of microfracture</li>
- +<li>
- +<a title="Periosteal reaction" href="/articles/periosteal-reaction">periosteal reaction</a> progressing to callus formation in diaphyseal fractures</li>
-</ul><h5>MRI</h5><p>MRI is as sensitive as bone scanning but is of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or infection.</p><ul>- +</ul><h5>MRI</h5><p>MRI is as sensitive as bone scanning but is of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or infection.</p><h6>MRI signal characteristics</h6><ul>
-<li>enhancement can be prominent</li>- +<li>very hypointense linear fracture line may be present</li>
- +<li>hypointense periosteal/endosteal new bone formation</li>
-</ul><h5>Bone scan</h5><p>There is increased activity at the site of the fracture.</p><h4>Treatment and prognosis</h4><p>Treatment depends on the location and whether the fracture is complete or incomplete.</p><p>Options include conservative management, plaster cast, internal fixation. Most importantly change in behaviour to reduce the activity which has lead to the fracture is needed. In some instances, altered technique may be sufficient to prevent re-occurrence.</p>- +<li>
- +<strong>T1C+:</strong> enhancement can be prominent</li>
- +</ul><h5>Nuclear medicine</h5><p>There is increased activity at the site of the fracture on bone scans. </p><h4>Treatment and prognosis</h4><p>Treatment depends on the location and whether the fracture is complete or incomplete.</p><p>Options include conservative management, plaster cast, internal fixation. Most importantly change in behaviour to reduce the activity which has lead to the fracture is needed. In some instances, an altered technique may be sufficient to prevent re-occurrence.</p>
References changed:
- 4. Marshall R, Mandell J, Weaver M, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018;38(7):2173-92. <a href="https://doi.org/10.1148/rg.2018180073">doi:10.1148/rg.2018180073</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30422769">Pubmed</a>
Tags changed:
- rg_37_7_edit
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