Updated: 1/29/2019

Stress Fracture

Topic
Review Topic
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Questions
4
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Evidence
3
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Snapshot
  • A 22-year-old woman presents with foot pain. She says that the pain worsens when running drills at her army base or when standing for prolonged periods of time. Her pain improves with rest. She denies any trauma to her foot or history of fracture. She recently joined the army and was mildly athletic before starting. On physical exam, there is pain upon palpation of the second and third metatarsal bone of the right foot.
Introduction
  • Clinical definition
    • overuse injury that commonly involves lower extremity structures such as
      • metatarsals
      • tibia
      • fibula
      • navicular bones
  • Epidemiology
    • incidence
      • more common in athletes and military recruits
    • risk factors
      • prior stress fractures
      • increasing intensity of physical activity
      • female gender
      • poor bone health
  • Etiology
    • repeated tensile or compressive stress
  • Pathogenesis
    • increased physical activity without adequate rest results in pathological bone changes
      • this disrupts the balance between bone resorption and formation, which increases the risk of microfractures
  • Prognosis
    • with early treatment, patients have a quicker recovery
Presentation
  • Symptoms 
    • pain that worsens with
      • activity
      • repeated loading
        • should be suspected with tenderness or edema following a recent intensification of activity
  • Physical exam
    • tenderness upon palpation of the affected bone
    • loading the affected bone may result in pain
Imaging
  • Radiography
    • incidence
      • an initial imaging modality in the evaluation of stress fractures 
        • specific but not sensitive
        • typically normal in the first 2-3 weeks after symptom onset
  • Magnetic resonance imaging (MRI)
    • incidence
      • obtained in patients with a negative stress fracture but symptoms are in a high-risk site
        • high-risk sites include
          • patella
          • talus
          • tarsal navicular
          • proximal 4th or 5th metatarsal
      • obtained in patients with negative stress fracture findings on repeat radiography with no symptom improvement
Studies
  • Making the diagnosis
    • clinical diagnosis supported by imaging 
Differential
  • Tendinopathy
    • differentiating factor
      • localized tenderness in the affected tendon
  • Nerve entrapment syndromes
    • differentiating factor
      • patients will experience pain and neurologic symptoms such as
        • paresthesias
        • numbness
        • weakness
      • Morton neuroma
        • compressive neuropathy of 3rd and 4th interdigital nerves of foot between metatarsal heads
        • can present similarly to stress fracture
Treatment
  • Conservative
    • activity reduction with or without analgesia  
      • indication
        • an initial conservative approach for low-risk fractures
    • rehabilitative exercise
      • indication
        • an initial conservative approach for low-risk fractures
  • Casting/splinting 
    • in particular needed for fractures of the 5th metatarsal
    • or following surgical intervention
    • should be performed in most stress fractures
  • Operative
    • orthopedic surgery
      • indication
        • recommended for high-risk fractures
Complications
  • Recurrent fractures
  • Malunion
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M2.OR.4752) A 17-year-old female presents to her primary care physician with right foot pain for the last 3 days. She states that the pain began gradually and is worse with weight bearing and activity. The patient states that she recently began to train for a marathon and is running much more than she did several months ago. She is healthy but has a 2-year history of irregular menstruation, with up to 3 months between periods. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 116/67 mmHg, pulse is 75/min, and respirations are 14/min. Her BMI is 17.1 kg/m^2, and she appears tired with a flat affect. Palpation of the dorsal surface of the right foot reveals point tenderness on the second metatarsal, though there is no redness, warmth, or swelling. The remainder of the exam is unremarkable. Plain radiograph of the right foot is performed and shown in Figure A. Which of the following is the best next step in management? Review Topic

QID: 108763
FIGURES:
1

Obtain right foot MRI

0%

(0/17)

2

Ice and rest the right foot

94%

(16/17)

3

Perform surgical intervention

6%

(1/17)

4

Prescribe oxycodone-acetaminophen

0%

(0/17)

5

Refer the patient to psychiatry

0%

(0/17)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(M2.OR.4672) A 25-year-old athlete comes into your office for pain in his right foot. He states that he has no prior medical history and takes no medications. He is an avid runner and runs in marathons, but recently switched to barefoot running from his normal shoes. He runs around 50 miles per week and states that his pain is getting worse and worse with each run. On exam, his vitals are within normal limits, but there is pain upon palpation of the second metatarsal of his right foot. His pulses and sensation are intact in all extremities. Figure A is an anteriorposterior (AP) radiograph of his right foot. What is the most likely diagnosis? Review Topic

QID: 107182
FIGURES:
1

Stress fracture

0%

(0/0)

2

Degenerative joint disease

0%

(0/0)

3

Septic arthritis

0%

(0/0)

4

Gout

0%

(0/0)

5

Plantar fasciitis

0%

(0/0)

M2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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