Case Discussion A recent history of atypical physical activity is antecedent to stress fractures in the absence of any trauma event or in presence of a trivial event. Most stress fractures involve the lower extremity and are actually fatigue fractures caused by muscle tension on normal bone.14,15,16Stress fractures have been reported most frequently in military recruits and athletes, though they also occur in children and adults in the general population.17,18,19. 1966;131:716-721. Occasionally, however, the diagnosis may not be as straight forward, and imaging may be indicated to differentiate among other significant etiologies. 1987;7(4):229-244. A stress fracture usually affects the second metatarsal, but it can happen in any of the five metatarsals in the foot. Initial Treatment If your metatarsal fracture is the result of a crush or twisting injury, the pain will likely be great enough to make you seek immediate medical attention. A stress response can occur either as a typical overuse injury on the normal bone (fatigue) or in a normal activity affecting weakened bone (insufficiency). This is followed by increased vascularity, which accompanies endosteal and periosteal callus formation. Smooth periosteal thickening is demonstrated at the medial border of the second metatarsal (arrowheads). Occasionally, MR imaging shows a hypointense, irregular line, typically contiguous with the cortex, within the area of edema and hyperemia consistent with a fracture line [Figure 8,9]. There might be may mild density changes in the trabecular bone due to effacement of the fatty marrow, often better appreciated on dual-energy CT. A stress response is characterized by a bone marrow edema like appearance with no obvious fracture cleft or cortical defect and with possible endosteal and/or periosteal edema. Bone marrow abnormalities of the foot and ankle: STIR versus T1-weighted contrast-enhanced fat-suppressed spin-echo MR imaging. You may decide to go to an emergency room or to your primary care doctor. Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Share Add to . 1983;146:339-346. Extensive marrow edema (asterisks) lies within the tarsal navicular bone with decreased signal intensity on the axial T1-weighted image (2a) and diffusely increased signal intensity on the coronal proton density-weighted fat-suppressed, fluid-sensitive series (2b). These result from the placement of abnormal stress on a normal bone. There is minimal soft tissue swelling and no discoloration or ecchymosis. Tarsal navicular stress fractures in athletes. During this period, in which bone strengthening as a reaction to stress has reached a plateau, bone marrow edema, hyperemia, and increased osteoclastic activity develop within the stressed area of the bone, translated on MR imaging as areas of poorly defined abnormal marrow signal, similar to a bone marrow contusion [Figure3, 4].29. A coronal T1-weighted image demonstrates normal marrow signal in the second, third and fourth metatarsals. During the first few weeks after the onset of symptoms, x-rays of the affected area may look normal. Sesamoiditis also more commonly involves both sesamoid bones, and may be associated with bursitis, tendinosis and tenosynovitis.48,49, Treatment typically involves avoidance of physical activity and attention to predisposing extrinsic factors such as footwear.50,51Hulkko and Orava4 reported 15 cases of stress fractures of the hallucal sesamoids in athletes. Report problem with Case; Contact user; Treatment Non-Surgical Treatment Most stress fractures can be treated non-surgically. Follow-up of athletes with MR imaging is feasible, although marrow edema can take up to 6 months to resolve with healing, especially in elderly patients.33 However, resolution of MR signal abnormalities within 4 weeks has been observed if aggressive rest programs are initiated with non-weight bearing at the start of symptoms in young athletes, lending support that marrow edema in this context represents recent or ongoing injury.24, Metatarsal stress fractures are among the most common stress fractures seen in athletes.34 Most metatarsal stress fractures involve the second and third metatarsal. Foot Ankle Int. This is accompanied by the development of edema and hyperemia, which is the stress reaction or stress response that can be demonstrated by MR imaging. 1985;13:87-94. When bone is challenged with repetitive, submaximal loading, a stress reaction will lead to physiologic and mechanical changes. Callus formation is seen at 4 weeks follow up. Occasionally, the patient may present with additional findings of redness, swelling, and obvious periosteal reaction at the site of stress fracture. 2nd to 4th metatarsals are commonly affected in the foot. Differential diagnosis avulsion fracture of the proximal 5 th metatarsal - pseudo-Jones fracture Jones fracture Prokuski LJ, Saltzman CL. ADVERTISEMENT: Supporters see fewer/no ads. Symptoms and Causes What causes a stress fracture? 34 Most metatarsal stress fractures involve the second and third metatarsal. Stress fracture. Diagnosis is made with plain radiographs of the foot. Stress fractures of the metatarsals occur with excessive training or repetitive stress in athletes or with a sudden increase in the level of exercise of any person. Skeletal Radiol. Sagittal fat-suppressed T2-weighted image in the same patient better demonstrates the marrow edema (asterisks) and a small joint effusion (arrowhead) associated with the sesamoid fracture (arrow). Stafford SA, Rosenthal KI, Gebhardt MC, et al. Metatarsal stress fractures: occur in the long, thin metatarsal bones of the front of the foot. Radiology 1996;199:1-12. Radiology 1988;169:217-220. AM J Sports Med 1986;14(6):486-490. Rubin DA, Dalinka MK, Kneeland JB. Goolsby MA, Boniquit N. Bone Health in Athletes. Bruckner P, Bradshaw C, Khan KM, et al. Initial treatment of choice for most stress fractures of the second metatarsal is nonoperative [6, 8-10], as they are considered to be low-risk and typically heal well with conservative treatment. One or both sesamoids may be involved. Coronal T1-weighted image in the same patient as figure 3. New periosteal bone formation may take up to 2 weeks to be detectable. Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Bilateral calcaneal stress fractures occur in up to 24% of patients.46Calcaneal stress fractures are less common in civilians and again related to footwear in many cases. A fatigue fracture is a stress fracture that results from the application of abnormal muscular stress or torque to a bone with normal elastic resistance.2 An insufficiency fracture, a subset of pathologic fractures, occurs in a nontumoral abnormal bone with a reduced elastic resistance to normal stress.2, Fatigue fracture. 2006;27:917-921. Symptoms and certain radiographic features (exuberant callus or periosteal reaction) may simulate infection, neoplasm, arthropathy, or ligament injury. Fatigue fractures of the foot and ankle in the athlete. This line is better visualized on fluid-sensitive images and is more visible after initiation of the healing process. Stress fractures of the femoral neck. Delayed union of Jones fractures may occur in up to 67% of cases treated non-operatively. However, marrow hyperintensity has progressed to the neck and head region, and surrounding soft tissue inflammation is also more distal. . A stress reaction might be difficult to differentiate from a stress fracture and in that case, should be called stress injury 1. If the athlete continues to exercise, the pain may become more severe or occur at an earlier stage of exercise.1 Typically, the pain resolves when the patient is non-weight bearing. 24 It is the longest metatarsal and resides in a mortise formed by the recess of the medial and lateral cuneiforms. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. A linear stress fracture (arrows) is seen within the distal aspect of the cuboid bone. In most cases, the diagnosis of a stress fracture is a clinical one. Unable to process the form. The frequency of metatarsal fractures is about ten times compared with that of Lisfranc fracture-dislocations. 2nd to 4th metatarsals are commonly affected in the foot. The surface you run on would also play a big role in developing a stress fracture . There is still a black in the gap where it was broken. Case contributed by Dr Maulik S Patel. Glossary of terms for musculoskeletal radiology. Stress fractures are caused by repetitive actions or impacts to the bones. Plain radiographs have poor sensitivity in detecting stress fractures, as positive findings may take months to appear. ADVERTISEMENT: Supporters see fewer/no ads. Thirteen year-old male with lateral foot pain. Stress fracture of the distal third of the right 2 nd metatarsal diaphysis with associated periosteal reaction and fracture line medially. Skeletal Radiol. Fractures of the base of the second metatarsal are common overuse injuries in ballet dancers. Increase their activity level suddenly. 2. The term stress fracture is used to describe fractures that occur after repetitive stress that is insufficient to cause an acute fracture. (2017) Sports health. Stress fractures in military recruits. Sports Med 1994;17:65-76. Mechanically, there is a decrease in ultimate strength, leading to an increased risk of microfracture. Muscles normally provide biomechanical dissipation of stress from the bones, but fatigued muscle may decrease this protective contribution, and this can result in the transmission of increased stress to the bones. Axial fat-suppressed proton-density weighted image of a 30 year-old female with lateral foot pain. Karasick D, Schweitzer ME. Treatment. Conservative management can be offered to undisplaced metatarsal fractures, including stress fractures which include adhesive strapping, short leg walking cast for 4 to 6 weeks, or a non-weight-bearing cast for 3 weeks followed by a walking cast for another 3 weeks, except in professional athletes to avoid long duration of immobilization. AJR 1986;147:553-556. Stress fractures. Metatarsal stress fractures are among the most common stress fractures seen in athletes. Clin J Sport Med 1996;6(2):85-89. Check for errors and try again. The failure point represents the mechanical load required for gross failure of the material. What are the findings? 8 (3): 278-283. A coronal plane fracture (arrow) involves the lateral hallucal sesamoid bone. (1a) Axial T1-weighted and (1b) coronal proton-density weighted fat-suppressed images are provided. ADVERTISEMENT: Supporters see fewer/no ads. The osteoclasts replace the circumferential lamellar bone with dense osteonal bone. The most location for a metatarsal fracture is the second metatarsal, especially in those whose second toe is longer than their big toe. Stress fractures most commonly develop in the 2nd and 3rd metatarsal bones of the foot. Steve DrSArbes Fellow American College of Foot & Ankle Surgeons Board Certified Foot & Ankle Surgery, ABPS 1. Download Free PDF View PDF. Radiol Clin North Am 1997;35:655-670. 40,45Operative intervention is also indicated for displaced and comminuted fractures. Chowchuen P, Resnick D. Stress fractures of the metatarsal heads. Stress fractures in children. Coronal T1-weighted image through the navicular bone in the same patient demonstrates a small cortical disruption dorsally (arrow) with no significant extension to the navicular body. Case Discussion. The mean patient age was 22.3 years old. Patients often become confused because when they stand up on their toes and apply a lot of force to the ball of the foot they also have pain if they have a metatarsal stress fracture. Subchondral linear hypointensity along the plantar aspect of the metatarsal head is compatible with insufficiency fracture. The marrow edema tends to be extensive and in the metatarsals often involves almost the whole shaft. Radiographs are usually normal in the acute phase. Swiss Surg 2002;8(1):3-6. Patient Data Age: 30 years Gender: Male mri Axial T2 Axial T1 Axial STIR Oblique STIR Oblique PD Coronal Gradient Echo Axial T1 C+ Axial T1 C+ fat sat Sagittal T1 C+ Coronal T1 C+ MRI Axial T2 Intramedullary fixation has been recommended as the treatment of choice for these fractures to achieve improved union rates.37More recently it has been suggested that intramedullary screw fixation alone does not always adequately address the torsional stress created by the insertion of the peroneus brevis on the proximal fragment of the fifth metatarsal in fifth metatarsal fractures. Lassus J, Tulikoura I, Konttinen Y, et al. A transverse fracture (arrow) involves the meta-diaphyseal junction of the fifth metatarsal base. Levy JM. Type III lesions have the longest average healing time with nonoperative care. Delayed union and nonunion may occur in a significant number of these injuries. As stress persists and a fracture develops, marrow signal alterations increase in extent and, unlike stress reaction, will be clearly depicted on both T1 and fluid-sensitive sequences. The second metatarsal is part of the Lisfranc complex, an S-shaped joint consisting of the articulations between the metatarsals, cuneiforms, and cuboid. Clin Sports Med 1997;16:275-290. Foot Ankle Int 2003;24(11):829-833. Note that the 2nd metatarsal is the longest, therefore bears the most weight. Stress fractures in the metacarpal bones were previously considered to be rare; however, this report showed a relatively high number of cases. With the increased use of MR imaging, the ability to detect marrow changes early has led to the concept of stress reaction and the grading of stress changes.24,25, Detection of stress fractures in the early stages on radiographs is difficult. A thorough physical examination begins with a detailed history followed by inspection, palpation, and testing of muscle strength, tone, reflexes, and . J Bone Joint Surg Br. Sports Med 1997;24(6):419-429. 17 (5): 309-25. Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries. Foot Ankle Int 2001;22(7):603-608. Greaney RB, Gerber FH, Laughlin RL. Patients with osseous stress injuries most commonly present with the insidious onset of activity-related local pain with weight bearing. Lucency at the adjacent third metatarsal is favored to represent a nutrient foramen. Stress response of bone is synonymously used with 'stress reaction' and is an early form of osseous 'stress injury', which also encompasses a stress fracture 1,2. Typical stress fracture of the distal shaft of the second metatarsal not seen on initial radiograph (left). The distal second metatarsal is the most common site for a stress fracture in the . This is the appearance of a Type I navicular stress fracture. Marrow edema of the first metatarsal head. In athletes, metatarsal stress fractures are most common during sprinting, hurdling, and jumping activities.20 Stress fractures in civilians are more commonly caused by new footwear or a new activity such as running or standing for long periods.13,14. 2006;40:692-695. Norfray JF, Schlacter L, Kernahan WT Jr, et al. O' Malley MJ, Hamilton WG, Munyak J et al. Shiraishi M, Mizuta H, Kubota K, et al. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . Terminology A pathological fracture, although a type of insufficiency fracture, is a term in general reserved for fractures occurring at the site of a focal bony abnormality. SoleScience can help, using footwear, off-the-shelf or custom-made orthotics . Coronal T1-weighted image obtained through the navicular bone in a 16 year-old female soccer player with 2 months of anterior and lateral foot pain. 1997;16:291-306. Foot Ankle. Acta Orthop Scand 2002;73:359-368. A fat-suppressed T2-weighted sagittal image through the fourth metatarsal reveals marrow edema (arrow) within the metatarsal diaphysis. Diagnosis, management and rehabilitation. Extensive marrow edema signal of the 2nd metatarsal base and diaphysis is compatible with bone stress. Pain is often medial or lateral, rather than on the plantar aspect of the foot. A recent history of atypical physical activity is antecedent to stress fractures in the absence of any trauma event or in presence of a trivial event. Stress fractures: Stress fractures of the metatarsals may occur distally at the metatarsal neck in runners. Sagittal proton-density weighted image through the third metatarsal. The average time for athletes to return to play after surgical intervention compared with nonoperative management using a nonweight-bearing cast is 3.8 months and 5.6 months, respectively.45 Typically, surgical intervention consists of screw fixation, with possible bone graft inlay. Extensive adjacent soft tissue edema and enhancement. Metatarsal stress fracture Case contributed by Dr Dalia Ibrahim Diagnosis almost certain Share Add to Citation, DOI & case data Presentation Mid-foot pain. 1994;29(2):176-193. Coris EE, Lombardo JA. It occurs when the bone itself is abnormal, as in osteoporosis, and the cycle of loading would otherwise not have led to a fracture. J Foot Ankle Surg. Sagittal T2-weighted fat-suppressed image in the same patient. Peris P. Stress fractures. Physical examination reveals pain when the examiner squeezes the patients heel from the sides. A fracture in this location is a true Jones fracture and may be complicated by delayed or non-union. In the acute setting, stress fractures are typically not well-seen on CT and, in these cases, the value of SPECT-CT lies in its ability to localize the uptake, as well as exclude other differential considerations (e.g., osteoarthritis, osteomyelitis, fracture). Injuries to the hallucal sesamoids in the athlete. These lesions may warrant more aggressive treatment and orthopedic referral for possible open reduction and internal fixation.43. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. Grade 1 demonstrates subtle periosteal edema without marrow changes. Therefore, if there is significant clinical evidence to suggest a navicular stress fracture, additional imaging with MR imaging should be obtained.40,41,42, A proposed CT-based classification system separates fractures into three groups: dorsal cortical break (type I)[FIGURES 13, 14], fracture propagation into the navicular body (type II) [Figures 1, 2], and fracture propagation into another cortex (type III)[Figures 15,16]. Stress fractures of the metatarsals occur most commonly in women. Case Discussion. Sagittal T1-weighted image in a 19 year-old female with two weeks of ankle pain. This is a classic location. Diagnosis certain Diagnosis certain . Stress fractures in military recruits. Stress fractures can also be seen in the heel (calcaneus), hip (proximal femur) and even the lower back. Treat insignificantly uprooted or non displaced breaks with immobilization without weight-bearing. Sagittal STIR image in the same patient better delineates the extensive marrow edema (asterisks) surrounding the fracture (arrows). Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes. The old fracture line, however, is not accompanied by marrow edema on fluid-sensitive images. It has been suggested that optimal internal fixation appears to require internal devices or fixation that also address the torsional stresses.38, Navicular stress fractures were once considered uncommon.25,39 However, more recent studies report the incidence at 14% to 35% of all stress fractures.20In athletes involved in track and field events, the incidence approaches 73%.39 Patients present with progressive pain over the dorsum of the midfoot. Case Discussion Initially in a stress fracture, the gross contour of the bone is normal and the damage is internal. Stress fracture of the distal third of the right 2nd metatarsal diaphysis with associated periosteal reaction and fracture line medially. Portland G, Kelikian A, Kodras S. Acute surgical management of Jones fractures. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Fatigue fractures of the femoral neck. Am Fam Phys. A stress fracture occurs when the rate of microcrack formation exceeds the repair capacity of the bone. Stress fractures: a review of 180 cases. Physical Examination of the Peripheral Nerves and Vasculature. J Bone Joint Surg Am. Sagittal T1-weighted image in a 78 year-old male with 2 months of ankle pain. Sagittal T1-weighted image in a 31 year-old male with ankle pain after lifting weights. A high level of suspicion and awareness of these injuries should be maintained when caring for physically active patients, in order to avoid misdiagnoses or delays in diagnosis. The diagnosis is usually made by taking x-rays. Kiss ZS, Khan KM, Fuller PJ. Stress fractures in sports are often caused by a repetitive force that is applied over a long time.-. thoughtful training, proper footwear, and controlled pathomechanics. Cortical/periosteal thickening is seen along its proximal portion. 9 (2): 108-117. Clin Orthop Relat Res 1998;348:72-78. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Am J Roentgenol. 2000;372:131-138. Diffuse marrow edema (asterisk) is seen within the navicular bone with no linear fracture identified. Treatment of navicular stress fractures may present a significant challenge. A stress fracture usually starts as a small crack in the outer shell (the cortex) of the bone. Radiol Clin North Am 2002;40:313-331. Progression to Grade 2 results in periosteal and marrow edema which is only identified on fluid sensitive imaging series. With Grade 4 stress reactions, a discrete fracture line is identified along with the marrow and periosteal changes. Stress response or stress reaction is the early result of bone failing to withstand a repetitive, cumulative loading force. Ideal treatment appears to involve a prolonged combination of non-weight bearing casting followed by weight-bearing casting.36The fifth metatarsal stress fracture may occur in the metatarsal shaft in contradistinction to the Jones fracture, which is a fracture through the meta-diaphyseal junction of the fifth metatarsal [Figures 11,12]. A fracture with surrounding marrow edema (arrows) lies within the posterior calcaneal body. Diffuse marrow edema (red asterisks) is seen within the diaphysis of the first, second, and third metatarsals. Creating Local Server From Public Address Professional Gaming Can Build Career CSS Properties You Should Know The Psychology Price How Design for Printing Key Expect Future. Clin Orthop. Tarsal navicular stress fractures. Metatarsal stress fracture also known as march fracture, first recognized as an entity in 1855 by Breithaupt is an overuse injury seen in the basketball players and in the military personnel. [ 18 ] However, some stress fractures may appear more proximally, especially in dancers; axial loads with torsion result in more proximal fractures. Blickenstaff LD, Morris JM. Marrow edema more anteriorly (blue asterisk) obscures the second linear fracture. A possible explanation of this abnormally expanded metatarsal could be a stress fracture. Jan 04 2022 Second And Third Metatarsal Stress Fractures As the name implies, a stress fracture occurs when a bone is overloaded by acute or chronic force, resulting in a small crack. The relative muscle groups, which are also experiencing the repetitive stresses, respond with hypertrophy and strengthening more rapidly than bone, and this force is transmitted to the periosteum at the muscle attachments, resulting in periostitis. Semin Roentgenol. Section snippets Anatomy. Lee JK, Yao L. Stress fractures: MR imaging. The second metatarsal is most commonly fractured in a metatarsal fracture, especially in those individuals who have a longer second toe when compared to their big toe. Raby 3rd Ed Chapter 17 Midfoot and forefoot. Imaging of stress injuries to bone: radiography, scintigraphy, and MR imaging. Challenging fractures of the foot and ankle. Less common stress fractures of the foot. Disuse osteopenia following a period of rest in a cam walker results in demineralization and loss of bone strength. Sagittal proton-density weighted image in a 15 year-old female with 3 months of pain in her forefoot. The appearance is compatible with grade 2 stress reaction. Am J Roentgenol. Surgical intervention also may be indicated in athletes who need quick healing to allow them to return to play. Stress fractures of the first metatarsal. (2020) Skeletal radiology. Egol KA, Koval KJ, Kummer F, et al. 1987;2:221-229. Physical examination may reveal tenderness and slight swelling. Brukner P, Bennell K. Stress fractures in female athletes. Periosteal thickening and elevation involving the distal third of the second metatarsal of the right foot, with a transverse fracture line. Extensive marrow edema is seen within the 3rd metatarsal diaphysis (asterisks) with marked surrounding periosteal and soft tissue edema (arrowheads). The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. Smooth periosteal thickening (arrowhead) at the medial aspect of the third metatarsal is again shown. Grade 0 is normal. Radiology 2002;224:463-469. Second metatarsal stress fracture in sport: comparative risk factors between proximal and non-proximal . The fracture itself is often not visible on the surface and only recognizable in x-ray images (Resnick and Niwayama, 1988 . Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Coronal STIR image at the same location demonstrates marked marrow edema in the navicular bone (asterisk) and the linear fracture (arrow), in this case of a Type III navicular stress fracture. Check for errors and try again. This true Jones fracture should be distinguished from the more common avulsion type fracture of the fifth metatarsal tuberosity which has a much better prognosis. Deutsch AL, Coel MN, Mink MH. In the series by Greaney et al.23, 77% of fractures were cancellous and 23% cortical. Peris P. Stress fractures in rheumatological practice: clinical significance and localizations. Gilbert RS, Johnson HA. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-28931. Khan KM, Brukner PD, Kearney C, et al. Signal characteristics Arendt EA, Griffiths HJ. Arch Orthop Trauma Surg. No distinct linear fracture. [9] Metatarsal fractures consist of 61% of all fractures of the foot in children. When two cortices are breached, operative intervention is frequently recommended. Radiographics. Posterior stress fractures are likely related to the muscle tension of the Achilles. Semin Roentgenol 1994;29:194-222. Metatarsal stress fractures are a common occurrence in athletes, particularly in runners, in whom they account for 20% of lower extremity stress fractures. Most metatarsal fractures in children occur at the fifth (41%) and the first (19% . {"url":"/signup-modal-props.json?lang=us\u0026email="}, Ling Y, Metatarsal fatigue and insufficiency (stress) fractures. Metatarsal fatigue and insufficiency (stress) fractures. Periosteal reaction is not common in this type of injury. (2016) Radiology. Fractures of the first metatarsal account for 7% to 8%, and fractures of the fourth and fifth metatarsals account for 3% of metatarsal stress fractures. Early confirmation of stress fractures in joggers. High-risk locations are the femoral neck, anterior cortex of the tibia, medial malleolus, navicular bone, talus, proximal 2nd and 5th metatarsal, patella, great toe sesamoid 3. Radiograph (top left) shows a fractured medial sesamoid (arrow) of the first metatarsophalangeal joint. Metatarsal stress fractures are often caused by being in the incorrect shoes. Same patient as figure 3. The relative lack of adjacent marrow edema suggests this is a more chronic injury and may reflect a delayed or non-union. The contour of the bone cortex of all bones must be checked carefully. Fracture of the medial sesamoid of the first metatarsophalangeal joint in a 49-year-old woman. Although insensitive, subtle loss of cortical density has been described as the grey cortex signof early-stage stress injury. Pathology confirmed fibrotic nonunion of the stress fractures.4, Up to 20% of stress fractures in athletes may occur in the tarsal bones.20 Stress fractures of the tarsal bones are too often a diagnostic challenge, because many providers do not consider tarsal stress fractures in the assessment of foot and ankle pain. 1981;54:1-7. A stress fracture is a break in a bone that is caused by repetitive stress. Occasionally, high-level ballet and modern dancers will generate stress fractures at the base of the metatarsal, near the midfoot. Rossi F, Dragoni S. Talar body fatigue stress fractures: three cases observed in elite female gymnasts. Check for errors and try again. A review of 12 years experience. Foot Ankle Intl 2004;25(9):650-565. Stress fractures occur as a result of excessive forces on normal bones as compared with insufficiency fractures that occur with normal forces on weak bones. Int J Sports Med 1987;8(3):221-226. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Fatigue fracture of the tarsal navicular bone. That's why you have a stress fracture of the second metatarsal, if in fact you really have a stress fracture. 2000;39:96-103. A prospective study showing an unusually high incidence. Palmer W, Bancroft L, Bonar F, Choi JA, Cotten A, Griffith JF, Robinson P, Pfirrmann CWA. Corresponding axial T1-weighted MR image (top right) demonstrates the fracture (arrow). Fractures often occur in the second and third metatarsal bones as they bear more relative . ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 2002;222:184-188. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Ibrahim D, Metatarsal stress fracture. Normal marrow signal is demonstrated without cortical abnormality (arrow). weight-bearing. Routine radiographs were more useful with cortical fractures. 1993;75:290-298. A metatarsal stress fracture most likely involves the second, third or fourth metatarsal bones. Axial fat-suppressed proton-density weighted image in a 46 year-old male with foot pain. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Stress Fractures of the Metatarsal Bones The second and third metatarsals of the foot, which are thinner (and often longer) than the adjacent first metatarsal, are most prone to stress fractures. Med Ztg 1855;24:169-171, 175-177. Plain films will most often be normal, and MR imaging is the imaging modality of choice for detection, localization, and characterization of tarsal bone stress fractures. When this occurs what should the physician report? Semin Roentgenol. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Extensive marrow edema is also seen within the navicular bone (blue asterisk). They are the second most common location for a stress fracture in sport, after tibia stress fracture (shin). Stress fractures of the tarsal navicular bone: CT findings in 55 cases. 9 the majority of second Hulkko A, Orava S, Pellinen P, et al. Radiol. Best Pract Res Clin Rheumatol 2003;17:1043-1061. . Vertullo C, Glisson R, Nunley J. Torsional strains in the proximal fifth metatarsal: implications for Jones and stress fracture management. Periosteal callous formation begins shortly after the onset of fracture, and can be seen on MR images as a hypointense line, peripheral to the bright signal periosteal edema and parallel to the cortex, representing the elevated periosteum and periosteal reaction [Figure 10].29 Periosteal reaction commonly accompanies stress fractures of the metatarsals but is typically not seen in the tarsal bones. Same patient as figure 3. Am J Roentgenol. The first metatarsal is injured in 10% of metatarsal stress fractures; such fractures involve a different kind of reaction (the endosteal variety), with liner sclerosis. Figure 4: Stress fracture of the 2nd metatarsal. Sagittal T1-weighted image in a 56 year-old female runner with lateral foot pain. Bone changes are usually not evident on radiographs for 10 to 21 days following injury.23, MR imaging is extremely sensitive in the detection of pathophysiologic soft tissue, bone, and marrow changes associated with stress injuries.26It allows depiction of abnormalities weeks before the development of radiographic abnormalities and has comparable sensitivity and superior specificity in relation to scintigraphy.27,28Apart from bone response, it also provides information about the surrounding soft tissues and may demonstrate the muscular or ligamentous insults associated with or responsible for the symptoms.29,30 MR imaging is noninvasive, nonionizing, and more rapidly performed than bone scintigraphy. Nine patients were male and 6 were female. Unable to process the form. It also commonly occurs in those individuals who over pronate . Focal pressure over the navicular reproduces the symptoms.19,39,40 Initial radiographs are normal. Foot and ankle disorders: radiographic signs. In this case, the linear fracture (arrow) extends somewhat obliquely from the dorsal cortex to the lateral cortex of the navicular bone. Any process that can affect these parameters could also alter bone resistance and favor the development of fractures.8,9 Conditions predisposing to insufficiency fracture include metabolic disorders, inflammatory conditions, bone dysplasias, neurologic disorders and drug therapy.8 Osteoporosis and rheumatoid arthritis are the most common underlying conditions in patients with insufficiency fractures of the foot and ankle.10. Stress fractures of the talus [Figure 27, 28] and calcaneus also occur in athletes.53,54. Bone undergoes a constant cycle of reabsorption and regeneration. Sports-related injuries are common and the current focus on fitness and competitive athletics has resulted in many individuals undertaking increased levels of physical activity. 1998;27:22-25. Foot Ankle International Journal (1996); 17: 89-94. Extensive surrounding periosteal and soft tissue edema (arrowheads) is also demonstrated. Changes are more defined with Grade 3 injuries with marrow edema identified on T1-weighted images. Magnetic resonance imaging of lower extremity injuries. Stress fractures refer to fractures occurring in the bone due to a mismatch of bone strength and chronic mechanical stress placed upon the bone. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Heyworth P, Second metatarsal stress fracture. In fact, in the series of Greaney et al., calcaneal stress fractures were more common than metatarsal stress fractures.23 Associated upper tibial stress fractures were noted in 60% of military recruits. 3. Radiology 121. Koulouris G, Morrison WB. Breithaupt MDS. Immediate intramedullary screw fixation of Jones fractures and proximal shaft fifth metatarsal fractures has been reported to have nearly 100% union rates, with an average time to union being approximately 6 to 8 weeks. Goergen TG, Rossman DJ, Gerber KH. Skeletal Radiol. Hontas MJ, Haddad RJ, Schlesinger LC. Radiography Radiographs have a sensitivity of 15-35% for detecting stress fractures on initial examinations, increasing to 30-70% at follow up due to more overt bone reaction. Sagittal T1-weighted image through the 3rd metatarsal of the same patient demonstrates a dorsal fracture of the cortex (arrow) with the linear low signal line extending into the medullary cavity of the bone. 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