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| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Bilateral Anterior Tibial Pain in a Football Player1 (continued) |
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| Answer: Bilateral stress fractures of the anterior tibia. | ||
| The patient was managed with modification of his training regimen, physical therapy modalities, strengthening exercises for the muscles of the leg, and foot orthoses. | ||
 Fig. 2 For larger view, click on image | With resumption of running at the beginning of the next season, he again experienced moderate tenderness along the middle third of the anteromedial border of the right tibia. Plain radiographs showed four distinct radiolucent areas in the anterior part of the tibial cortex (Fig. 2). | |
 Fig. 3 For larger view, click on image | Sagittal T2-weighted magnetic resonance imaging scan of the right tibia showed three transverse fracture lines in the anterior part of the cortex without any evidence of bone-marrow edema (Fig. 3). | |
| Discussion | ||
| Stress fractures of the anterior part of the cortex of the middle third of the tibia apparently were first described in 1956 by Burrows2, who reported on five ballet dancers who had such a lesion. Multiple stress fractures of the anterior part of the tibial cortex and simultaneous bilateral fractures have not been frequently reported. Previous reports have indicated that these fractures do not heal with nonoperative treatment3-7, but those reports included very small numbers of patients. Blank3, in a study of five patients who had had symptoms for one to nine years, reported that none of the fractures healed despite prolonged rest, immobilization in a cast, and cessation of all physical activity. Similarly, Green et al.6, in a study of six patients, reported that none of the fractures healed despite immobilization in a cast for three to fifteen months. One patient went on to have a complete fracture, one was managed with electromagnetic stimulation but continued to have symptoms two years after the time of presentation, and three were managed with excision of the lesion followed by bone-grafting. There was no information on the sixth patient. | ||
| The most remarkable feature in the case of our patient was the progression to radiographic nonunion in the absence of the typical symptoms of an acute stress fracture. In the case of a typical stress fracture, pain initially develops during the latter part of the exercise period and then gradually develops earlier during the exercise period. Eventually, the pain develops at the onset of exercise and persists after exercise. The pain that is caused by a typical stress fracture can become sufficiently severe to limit participation in sports activities. In contrast, our patient was able to participate in competitive sports activities for five years without extensive limitations. This course of events was very different from that associated with a typical stress fracture. While we recognize that generalizations should not be made on the basis of a single case, we believe that this difference should be noted and should encourage the physician to exercise vigilance when determining the definitive diagnosis and treatment. In the case of our patient, the diagnosis of nonunion was based on the long duration of symptoms and the appearance of the lesions on radiographs. | ||
| We were able to find only one report that described the results of bone-scanning in patients who had tibial stress fractures. Blank3, in a report in which three such fractures were evaluated with bone scans, noted minimum uptake at the fracture site and suggested that this finding was consistent with nonunion. In that study, the blood-flow and blood-pool image revealed normal findings and the delayed image demonstrated only slight uptake. In the case of our patient, we believed that the findings on bone scans and the presence of radiolucent areas in the anterior part of the tibial cortex as seen on radiographs were consistent with nonunion. It is not known whether stress fractures of the anterior part of the tibial cortex follow the same clinical course as typical stress fractures or whether they are associated with a different underlying mechanism. | ||
| In the case of our patient, treatment with an intramedullary rod led to satisfactory clinical and radiographic healing of the four fractures in the right tibia. | ||
| Stress fractures of the anterior part of the tibial cortex have unique features in terms of both clinical presentation and outcome. The subacute nature of the symptoms often permits the patient's continued participation in sports activities and belies the propensity for progression to nonunion. In order to provide appropriate treatment, the physician should be aware of this lesion and its surprisingly small impact on the ability of the patient to participate in sports. Because the plain radiographs of patients who have pain in the shin usually reveal normal findings, there is an inclination to perform bone-scanning or to obtain magnetic resonance imaging as the initial investigation of choice. We found follow-up plain radiographs to be extremely helpful, and we believe that they should always be made when a patient reports pain over the middle third of the tibia. | ||
| References | ||
| 1. Brukner P, Fanton G, Bergman AG, Beaulieu C, Matheson GO. Bilateral stress fractures of the anterior part of the tibial cortex. A case report. J Bone Joint Surg Am. 2000;82:213-8. 2. Burrows HJ. Fatigue infraction of the middle of the tibia in ballet dancers. J Bone Joint Surg Br. 1956;38:83-94. 3. Blank S. Transverse tibial stress fractures. A special problem. Am J Sports Med. 1987;15:597-602. 4. Brahms MA, Fumich RM, Ippolito VD. Atypical stress fracture of tibia in a professional athlete. Am J Sports Med. 1980;8:131-2. 5. Friedenberg ZB. Fatigue fractures of the tibia. Clin Orthop. 1971;76:111-5. 6. Green NE, Rogers RA, Lipscomb B. Nonunions of stress fractures of the tibia. Am J Sports Med. 1985;13:171-6. 7. Stanitski CL, McMaster JH, Scranton PE. On the nature of stress fractures. Am J Sports Med. 1978;6:391-6. |
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