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Workup

Imaging Studies

Stress fractures may not show up on radiographs for the first 2-4 weeks after injury. (See the image below.) The first radiographic finding may be a localized periosteal reaction or an endosteal cortical thickening. The low sensitivity of radiography for stress fractures makes bone scanning, magnetic resonance imaging (MRI), and computed tomography (CT) the preferred tests for diagnosis.

$Fifth metatarsal stress fracture.$ Fifth metatarsal stress fracture.

Technetium-99m 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. Conventional radiography and bone scanning have been compared for the initial detection of stress fractures; positive findings were reported in 96% of bone scans but on only 42% of radiographs.

MRI is also useful in the diagnosis of stress fractures. It provides information about bone integrity and fracture orientation, and it can demonstrate focal tissue damage and edema.

The MRI findings of stress fractures typically follow one of two patterns. In the first pattern, a hypointense, bandlike fracture line is visible with surrounding bone or tissue edema. The second MRI pattern represents an amorphous stress fracture or response pattern. In this pattern, there is no obvious fracture line or band; instead, the fracture may have diffuse or scattered areas of hypointensity on T1-weighted images, with increased signal intensity on T2-weighted images.^[38]

Short-tau inversion recovery (STIR) imaging sequences suppress the normal fat signal intensity in bone marrow, allowing better visualization of intramedullary bone.^{[39, 40, 41]}

Wright et al carried out a systematic review of published studies with the aims of assessing the diagnostic accuracy of imaging modalities used to diagnose lower-extremity stress fractures and formulating evidence-based recommendations for clinical practice.^[42] Reported sensitivities and specificities (with 95% confidence interval) for these modalities were as follows:

Conventional radiography - Sensitivity, 12% (0-29%) to 56% (39-72%); specificity, 88% (55-100%) to 96% (87-100%)
Nuclear scintigraphy - Sensitivity, 50% (23-77%) to 97% (90-100%); specificity, 33% (12-53%) to 98% (93-100%)
MRI - Sensitivity, 68% (45-90%) to 99% (95-100%); specificity, 4% (0-11%) to 97% (88-100%)
CT - Sensitivity, 32% (8-57%) to 38% (16-59%); specificity, 88% (55-100%) to 98% (91-100%)
Ultrasonography (US) - Sensitivity, 43% (26-61%) to 99% (95-100%); specificity, 13% (0-45%) to 79% (61-96%)

The investigators found MRI to be the most sensitive and specific imaging test for diagnosing stress fractures of the lower extremity.^[42] They concluded that when MRI is available, nuclear scintigraphy is not recommended, because of its low specificity, high dosage of ionizing radiation, and other limitations. They also noted that radiography is likely to yield false-negative results at initial presentation, particularly in the early stages of fracture, and sometimes fails to identify an existing stress fracture at any time.

Grading

Several grading systems for stress fractures based on MRI or scintigraphic findings have been proposed for correlating imaging findings with clinical findings and providing treatment guidelines (see Table 2 below).^[39]

Table 2. Grading of Stress Fractures According to Radiologic Findings^[39] (Open Table in a new window)

Grade	Radiographic Finding	Bone Scan Finding	MRI Finding
1	Normal	Poorly defined area	Increased activity on STIR image
2	Normal	More intense	Poor definition on STIR and T2-weighted images
3	Discrete line	Sharp area of uptake	No focal or fusiform cortical break on T1- and T2-weighted images
4	Fracture or periosteal reaction	More intense localized transcortical uptake	Fracture line on T1- and T2-weighted images

Treatment & Management

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Fifth metatarsal stress fracture.

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Table 1. Epidemiologic Features of Stress Fractures According to Location and Activity

Location of Fracture	Activity Involved
Metatarsals, general	Football, basketball, gymnastics, ballet, military training^[21]
Metatarsal, base of the second	Ballet
Metatarsal, fifth	Tennis,^{[22, 23]} ballet
Sesamoids of the foot	Running, ballet, basketball, skating
Navicular	Sprinting,^[24] jumping, basketball, football
Talus	Pole vaulting
Calcaneus	Military drills, running, aerobics
Fibula	Running, jumping, ballet, repeated heavy lifting^[24]
Tibia	Running sports, dancing, ballet
Patella	Running, hurdling
Femoral neck	Distance running, military training^[25]
Pubic rami	Military drills, distance running
Pars articularis	Gymnastics, ballet, cricket, volleyball, diving, football
Chest, ribs	Swimming,^[26] golf,^[27] rowing,^[28] overhead throwing sports^[29]
Sternum	Wrestling^[30]
Ulna	Racquet sports, volleyball
Olecranon	Baseball, throwing sports

Table 2. Grading of Stress Fractures According to Radiologic Findings ^[39]

Grade	Radiographic Finding	Bone Scan Finding	MRI Finding
1	Normal	Poorly defined area	Increased activity on STIR image
2	Normal	More intense	Poor definition on STIR and T2-weighted images
3	Discrete line	Sharp area of uptake	No focal or fusiform cortical break on T1- and T2-weighted images
4	Fracture or periosteal reaction	More intense localized transcortical uptake	Fracture line on T1- and T2-weighted images

Table 3. Healing Times for Various Stress Fractures* ^[43]

Site of Stress Fracture	Percentage Healed at 2-4 wk, %	Percentage Healed at 1-2 mo, %	Percentage Healed at > 2 mo, %
Tibia, proximal third	0	43	57
Tibia, middle third	0	48	52
Tibia, distal third	0	53	47
Fibula	7	75	18
Metatarsals	20	57	23
Sesamoids	0	0	100
Femur, shaft	7	7	86
Femur, neck	0	0	100
Pelvis	0	29	75
Olecranon	0	0	100
*Adapted from Hulkko et al.^[44] 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.

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Author

Stefanos F Haddad, MD Resident Physician, Department of Orthopedic Surgery, Albany Medical Center

Stefanos F Haddad, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, New York State Society of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Cory M Czajka, MD Orthopedic Surgeon, Capital Region Orthopedic Group

Cory M Czajka, MD is a member of the following medical societies: Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

John M Martinez, MD Staff Physician, Kaiser Permanente

John M Martinez, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine

Disclosure: Nothing to disclose.

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