Medication Summary
The goals of pharmacotherapy are to reduce patient discomfort, minimize associated morbidity, and to prevent complications. Medications used in the management of stress fractures include the nonsteroidal anti-inflammatory drugs (NSAIDs) celecoxib, ibuprofen, and naproxen and the analgesic acetaminophen.
A study by Yoo et al suggested that in elderly patients with sacral insufficiency fractures and preexisting comorbidities, treatment with teriparatide may shorten healing time and lead to faster functional improvement and better pain reduction. [42]
Nonsteroidal anti-inflammatory drugs
Class Summary
Have analgesic, anti-inflammatory, and antipyretic activities. Mechanism of action is not known, but they may inhibit COX activity and prostaglandin synthesis. Other mechanisms may include inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Celecoxib (Celebrex)
Inhibits primarily COX-2, which is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID-related GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited, thus GI toxicity may be decreased. Seek lowest dose for each patient.
Ibuprofen (Motrin, Excedrin IB, Advil, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Naproxen (Aleve, Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of COX, which is responsible for prostaglandin synthesis.
NSAIDs decrease intraglomerular pressure and decrease proteinuria.
Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
May be a reasonable alternative for symptom management in individuals who cannot tolerate NSAIDs or if the practitioner is concerned that NSAIDs may interfere with bone healing.
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This image is of a 17-year-old male wrestler with a 2-month history of left-sided low back pain, worse with extension. Total body scintigraphy findings were unremarkable. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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Same patient as in the above image. Single-photon emission computed tomography (SPECT) images demonstrate abnormal delayed uptake in the posterior elements of L5. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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Same patient as in the above 2 images. Subsequent MRI revealed an area of bright signal in the left pars interarticularis of L5 on T2-weighted images, confirming the diagnosis of acute unilateral spondylolysis. The patient was treated successfully with activity restriction and bracing with a lumbar corset for 3 months, at which point he was asymptomatic. Plain film imaging at follow-up (not shown) was unremarkable, with no evidence of spondylolysis on oblique views. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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A 17-year-old female dancer with a 2-week history of left shin pain. Plain film imaging was unremarkable. Three-phase bone scanning demonstrated an area of linear uptake in the posterior medial aspect of the left tibia on blood pool images, but delayed images were considered normal. This scintigraphic pattern is consistent with medial tibial stress syndrome (shin splints), but not with stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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This is a 55-year-old female industrial worker with a 1-week history of right foot pain. Plain film imaging was unremarkable. Bone scanning revealed a stress fracture of the second metatarsal. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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This image is of an 18-year-old female soccer player with a 3-week history of left leg pain, which was worse at night and with activity. Upon examination, she reported tenderness in response to palpation over the midtibia. Bilateral pes planus was noted. Plain film radiography failed to demonstrate a fracture. Bone scanning revealed a focal area of delayed uptake on the posterior medial aspect of the proximal third of the left tibia, confirming the diagnosis of stress fracture. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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A 63-year-old man with metastatic thyroid carcinoma went for a walk and awoke the following morning with left hip girdle pain. Plain film imaging revealed a subtle area of linear cortical lucency at the proximal left femoral metadiaphysis, consistent with an insufficiency fracture through pathologic bone. The patient subsequently underwent internal fixation. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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Enlarged view of the fracture shown in the above image. Plain film imaging revealed a subtle area of linear cortical lucency at the proximal left femoral metadiaphysis, consistent with an insufficiency fracture through pathologic bone. The patient subsequently underwent internal fixation. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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This case involves a 16-year-old female basketball player with a 2-year history of left foot pain refractory to casting and reduced weight bearing. Bone scanning revealed a focal area of delayed uptake lateral to the left first metatarsal phalangeal joint, which corresponded to a bipartite sesamoid on plain films. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
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Sesamoid stress fractures are prone to nonunion, and sesamoidectomy is indicated for patients who do not respond to conservative management. Some clinicians recommend bone grafting as an alternative to complete or partial sesamoidectomy. Courtesy of Michael Spieth, MD, and Nandita Bhattacharjee, MD, MHA; Marshfield Clinic Department of Radiology.
