2003;67:85-90. Case Discussion These are classic appearances of a stress fracture of the second metatarsal, sometimes known as a "march fracture" or a fatigue fracture, and is caused by abnormal stresses on normal bone. J Bone Joint Surg Br 1985;67:732-735. 1983;146:339-346. Sagittal STIR image in the same patient better delineates the extensive marrow edema (asterisks) surrounding the fracture (arrows). Before a stress fracture takes place, a frequently painful condition termed stress reaction occurs. Kiss ZS, Khan KM, Fuller PJ. 1978;130:679-681. 1966;48:1031-1047. Rob Rinaldi,DPM. Smooth periosteal thickening is demonstrated at the medial border of the second metatarsal (arrowheads). Arendt EA, Griffiths HJ. (2020) Skeletal radiology. Rodney asked about a non-displaced fifth metatarsal fracture. Stress fractures refer to fractures occurring in the bone due to a mismatch of bone strength and chronic mechanical stress placed upon the bone. 1987;7(4):229-244. ADVERTISEMENT: Supporters see fewer/no ads. Anderson MW, Greenspan A. 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. Bruckner P, Bradshaw C, Khan KM, et al. Stress fractures in children. That is why its called a stress fracture. Stress fractures in sports are often caused by a repetitive force that is applied over a long time.-. Diagnosis is made with plain radiographs of the foot. There is minimal soft tissue swelling and no discoloration or ecchymosis. Spitz DJ, Newberg AH. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Radiology 1988;169:217-220. Unable to process the form. 1998;27:22-25. Imaging findings may be found in compact bone or trabecular bone. 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. Pain is often medial or lateral, rather than on the plantar aspect of the foot. A linear low signal fracture (arrows) parallels the posterior cortex. 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. The contour of the bone cortex of all bones must be checked carefully. Koulouris G, Morrison WB. Fatigue fractures of the femoral neck. Although insensitive, subtle loss of cortical density has been described as the grey cortex signof early-stage stress injury. Marrow edema more anteriorly (blue asterisk) obscures the second linear fracture. 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. Sagittal T2-weighted fat-suppressed image in the same patient. Radiology 121. Clin Orthop. Associated Conditions Compartment syndrome (rarely) Lisfranc dislocation Diagnosis A stress fracture is a break in a bone that is caused by repetitive stress. The fracture callous is best appreciated medially (arrowheads) where the low signal callus lies superficial to the periosteal edema. A prospective study showing an unusually high incidence. Metatarsal fractures are common in the paediatric population and rarely require operative management. 3. Devas MB. MR imaging can be particularly helpful for the diagnosis and characterization of osseous stress injuries in the foot and ankle. Crutches should be provided and weight bearing allowed as tolerated, with follow-up in three to five days. Fatigue fracture of the tarsal navicular bone. Diagnosis, management and rehabilitation. Skeletal Radiol. 1966;131:716-721. thoughtful training, proper footwear, and controlled pathomechanics. Gilbert RS, Johnson HA. However, some stress fractures may appear more proximally, especially in dancers; axial loads with torsion result in more proximal fractures. Clin J Sport Med 1996;6(2):85-89. 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). A healing stress fracture of the second metatarsal is demonstrated with extensive marrow and soft tissue edema. [ 18 ] Sagittal proton-density weighted image in a 15 year-old female with 3 months of pain in her forefoot. Metatarsal stress fractures are often caused by being in the incorrect shoes. Fractures often occur in the second and third metatarsal bones as they bear more relative . Occasionally, the patient may present with additional findings of redness, swelling, and obvious periosteal reaction at the site of stress fracture. Injuries to the hallucal sesamoids in the athlete. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. Radiographics. The distal second metatarsal is the most common site for a stress fracture in the . In 1855, Breithaupt first reported stress fractures in soldiers associated with marching, which was later radiographically confirmed in 1897.2,3Previously reported in military recruits, sports and recreational injuries now account for up to 10% of patients in a typical sports medicine practice.4Prospective studies indicate an incidence of stress fractures that reaches 31% in soldiers5 and 21% in athletes.6The foot and ankle are the most commonly injured and imaged parts of the musculoskeletal system, accounting for 25% of athletic injuries,7 with runners and dancers constituting the majority.6, Insufficiency fracture. This is the appearance of a Type I navicular stress fracture. 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. A metatarsal stress fracture most likely involves the second, third or fourth metatarsal bones. Foot Ankle International Journal (1996); 17: 89-94. 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 Potter NJ, Brukner PD, Makdissi M, et al. 1998;27:411-418. Have a bone condition such as osteoporosis (thin, weak bones) or arthritis (inflamed joints). Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 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. 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. 1. Foot Ankle Int 2001;22(7):603-608. Differential diagnosis avulsion fracture of the proximal 5 th metatarsal - pseudo-Jones fracture Jones fracture 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. Treatment. The fracture callous from the healing second metatarsal fracture is partially imaged (arrow). 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. Non-steroidal anti-inflammatory drugs should be avoided as these may impair bone healing 3. Clin Orthop Relat Res 1998;348:72-78. Often a radiologist will use the radiology equipment, which is known as the technical component, and the physician will provide the second half of the CPT code by supervising and interpreting the study. During the first few weeks after the onset of symptoms, x-rays of the affected area may look normal. Smooth periosteal thickening (arrowheads) is seen with no linear fracture identified. Levy JM. A thorough physical examination begins with a detailed history followed by inspection, palpation, and testing of muscle strength, tone, reflexes, and . Tarsal navicular stress fractures in runners. Clin Sports Med. Management includes activity restriction, stiff-soled shoes [9], rest, ice, compression, elevation, and in some cases immobilization. AM J Sports Med 1986;14(6):486-490. Nondisplaced and noncomminuted tarsal bone fractures may be treated with non-operative management with casting and non-weight bearing for 6 weeks. 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. Stress fractures of the femoral neck. Early confirmation of stress fractures in joggers. 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. An incomplete linear sagittal plane defect within the dorsal aspect of the bone extends from the dorsal cortex to the navicular body (arrows). A possible explanation of this abnormally expanded metatarsal could be a stress fracture. 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. 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. These lesions may warrant more aggressive treatment and orthopedic referral for possible open reduction and internal fixation.43. Foot Ankle Int 2003;24(11):829-833. When two cortices are breached, operative intervention is frequently recommended. Conversely, persistence of the fracture line may be noted even after complete healing has occurred. (1a) Axial T1-weighted and (1b) coronal proton-density weighted fat-suppressed images are provided. Twenty year-old male with foot pain after the start of football practice. Fredericson M, Jennings F, Beaulieu C, Matheson GO. Tarsal navicular stress fractures. You can use Radiopaedia cases in a variety of ways to help you learn and teach. (2017) Sports health. Download as PowerPoint Open in Image Viewer 4. 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. 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. Metatarsal stress fracture is the most common location for a stress fracture after the tibial stress fractures. Radiograph (top left) shows a fractured medial sesamoid (arrow) of the first metatarsophalangeal joint. Battaglia H, Simmen HP, Meier W. Stress fractures of the cuboid bone: an easy to treat rarity. Osteoporosis Etiology The injury usually is a result of a direct blow, inversion injury, or overuse. . Fracture of the medial sesamoid of the first metatarsophalangeal joint in a 49-year-old woman. Clin Sports Med 2006;25:1-16. Skeletal Radiol. Improving Diagnostic Accuracy and Efficiency of Suspected Bone Stress Injuries. Foot and ankle disorders: radiographic signs. This is followed by increased vascularity, which accompanies endosteal and periosteal callus formation. Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. This is sometimes described as a stress reaction. Stress fracture of the distal third of the right 2nd metatarsal diaphysis with associated periosteal reaction and fracture line medially. 1985;13:87-94. Axial fat-suppressed proton-density weighted image of the foot in a 20 year-old male with two months of foot pain. The first metatarsal head bears double the heaviness of other metatarsal heads. Metatarsal stress fractures: occur in the long, thin metatarsal bones of the front of the foot. Fit and healthy runner with midfoot pain. Imaging of stress injuries to bone: radiography, scintigraphy, and MR imaging. That is why runners who run long distances often suffer from metatarsal fractures. Steve DrSArbes Fellow American College of Foot & Ankle Surgeons Board Certified Foot & Ankle Surgery, ABPS 2000;372:131-138. (2006) Topics in magnetic resonance imaging : TMRI. Share Add to . Same patient as figure 3. 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. Marrow edema of the first metatarsal head. The osteoclasts replace the circumferential lamellar bone with dense osteonal bone. Surgical intervention also may be indicated in athletes who need quick healing to allow them to return to play. 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. Florid surrounding soft tissue inflammation. Same patient as figure 3. Management of stress fractures is non-operative with functional treatments and early weight-bearing 2 . Occasionally, high-level ballet and modern dancers will generate stress fractures at the base of the metatarsal, near the midfoot. They are the second most common location for a stress fracture in sport, after tibia stress fracture (shin). Am J Roentgenol. An oblique fracture (arrow) involves the medial aspect of the proximal phalangeal base. MR imaging signal alterations of stress response of sesamoids and sesamoiditis overlap. 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. Delayed union of Jones fractures may occur in up to 67% of cases treated non-operatively. Sagittal T1-weighted image in the same patient reveals the low signal fracture (arrow) at the fifth metatarsal base. Stress fractures: Stress fractures of the metatarsals may occur distally at the metatarsal neck in runners. Stress fractures in the metacarpal bones were previously considered to be rare; however, this report showed a relatively high number of cases. A fat-suppressed T2-weighted sagittal image through the fourth metatarsal reveals marrow edema (arrow) within the metatarsal diaphysis. 4B 68-year-old woman with forefoot pain referred for evaluation of possible stress fracture. Blickenstaff and Morris22described the phases of stress fractures that at least partially explain the changes seen with imaging. Br J Radiol. Type III lesions have the longest average healing time with nonoperative care. Axial STIR image in the same patient demonstrates the marrow edema (asterisk) and oblique fracture (arrow) in the proximal phalangeal base. Peter Gonzalez. Curr Orthop 2003;17:150-155. A stress fracture can also come from a sudden increase in physical activity or a change in your exercise routine. Brukner P, Bennell K. Stress fractures in female athletes. Stress fractures and the female athlete. Approximately 1% of running injuries involve the sesamoids; 40% of these are stress fractures and 30% are sesamoiditis.47 Sesamoiditis/osteochondritis, osteonecrosis, stress response of the synchondrosis of partite sesamoids bones, traumatic fractures, osteomyelitis, and bursitis between the tibial sesamoid and the flexor halluces brevis tendon may all occur in this location. Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes. 2002;222:184-188. Delay in diagnosis for up to 4 months is not uncommon.44Treatment with cast immobilization may be effective for fractures involving only the dorsal cortex (type I). Increased STIR signal intensity and low T1 signal have been described with sesamoid stress response, as opposed to increased STIR signal intensity and normal T1 signal, which favor sesamoiditis. Delayed union and nonunion may occur in a significant number of these injuries. SoleScience can help, using footwear, off-the-shelf or custom-made orthotics . Lee JK, Yao L. Stress fractures: MR imaging. Shiraishi M, Mizuta H, Kubota K, et al. Axial T1-weighted (A) and sagittal STIR (B) MR images through second metatarsal show flattening, subchondral sclerosis, and rounded area of cystic change without surrounding marrow edema-like pattern (arrow). Greaney RB, Gerber FH, Laughlin RL. Do activities that put a lot of pressure on their feet, such as running, dancing, jumping, or marching (as in the military). Periosteal reaction is not common in this type of injury. 1993;14(1):28-34. This appearance is diagnostic of a stress reaction. Symptoms of fractures of the second or third metatarsals include: Toe pain Swelling Tenderness Walking with a limp The presence of a callus under the toe in question Inhibited range of motion Diagnosing and Treating March Fractures Diagnosing these injuries begins with a clinical examination from a foot specialist like Dr. Silverman. Different Types of Metatarsal Fracture There are two types of metatarsal fractures: acute and stress fractures. Rubin DA, Dalinka MK, Kneeland JB. 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]. Stafford SA, Rosenthal KI, Gebhardt MC, et al. They most commonly develop in the second and third metatarsals in your foot, because these bones tend to be longer and thinner than adjacent metatarsals. Magnetic resonance imaging of lower extremity injuries. Check for errors and try again. Physical examination reveals pain when the examiner squeezes the patients heel from the sides. The diagnosis is usually made by taking x-rays. A stress fracture occurs when the rate of microcrack formation exceeds the repair capacity of the bone. Treat insignificantly uprooted or non displaced breaks with immobilization without weight-bearing. Epidemiology Incidence Diffuse marrow edema (red asterisks) is seen within the diaphysis of the first, second, and third metatarsals. A transverse fracture (arrow) involves the meta-diaphyseal junction of the fifth metatarsal base. Skeletal Radiol. Semin 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. [9] Metatarsal fractures consist of 61% of all fractures of the foot in children. What are the findings? 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. ADVERTISEMENT: Supporters see fewer/no ads. Foot Ankle Int. ADVERTISEMENT: Supporters see fewer/no ads. This is a classic location. Surgery is not often required. The second type of stress fracture is an insufficiency fracture. Navicular stress fractures; outcomes of surgical and conservative management. Bone marrow edema throughout the second metatarsal diaphysis. In fact, today's episode is based on a question sent in by listener. 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.35Most military stress fractures are caused by marching in new recruits. 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. 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. The head of the second metatarsal and, occasionally, the third metatarsal are commonly affected. Uprooted cracks as a rule require open decrease and inside fixation. Fractures may be primarily cortical or medullary, depending on the fracture site. Goolsby MA, Boniquit N. Bone Health in Athletes. Subsequent reloading of the foot resulted in a subchondral insufficiency fracture at the metatarsal head - normal load but in abnormal, weakened bone. A discrete fracture line, however, is not always seen. Best Pract Res Clin Rheumatol 2003;17:1043-1061. Pathria MN, Chung CB, Resnick DL. 11. The emphasis today on the importance of exercise and weight loss has led an increasing number of people to begin new activities, including running, cycling, aerobics and many others. Daffner RH. The fracture itself is often not visible on the surface and only recognizable in x-ray images (Resnick and Niwayama, 1988 . This is the area of greatest impact on your foot when you push off to walk or run. Coronal T1-weighted image in the same patient as figure 3. Adjacent low signal marrow (asterisks) is compatible with marrow edema. Umans H, Pavlov H. Stress fractures of the lower extremities. Bone undergoes a constant cycle of reabsorption and regeneration. Stress fractures in military recruits. A smaller linear fracture (arrowheads) is demonstrated more anteriorly, without significant adjacent T1 signal abnormality. A stress fracture usually starts as a small crack in the outer shell (the cortex) of the bone. 2001;21:425-440. Lassus J, Tulikoura I, Konttinen Y, et al. Stress fracture at the 2nd metatarsal proximal diaphysis is healing, with more mature cortical and periosteal new bone. Mechanically, there is a decrease in ultimate strength, leading to an increased risk of microfracture. Schmid MR, Hodler J, Vienne P, et al. Check for errors and try again. Stress fractures most commonly develop in the 2nd and 3rd metatarsal bones of the foot. Chowchuen P, Resnick D. Stress fractures of the metatarsal heads. Most metatarsal fractures can be treated with an initial period of elevation and limited weight bearing. Metatarsal Foot Fractures - Emergency Department. Clin Sports Med 1997;16:275-290. Case study, Radiopaedia.org (Accessed on 12 Dec 2022) https://doi.org/10.53347/rID-69345. Stress fractures are tiny cracks that form in a bone after repetitive stress. Foot Ankle Intl 2004;25(9):650-565. Summary. Radiology Cases of Stress Fracture AP and lateral radiographs of the femur show on the AP view a transverse non-displaced healing fracture through the distal femoral diaphysis that on the lateral view has periosteal reaction and marked cortical thickening along the posterior aspect of the femur. Most metatarsal fractures in children occur at the fifth (41%) and the first (19% . You can use Radiopaedia cases in a variety of ways to help you learn and teach. 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. Metabolic changes at the site of fracture allow isotope bone scans to detect the injury as early as 24 hours after injury. A stress reaction might be difficult to differentiate from a stress fracture and in that case, should be called stress injury 1. Peris P. Stress fractures in rheumatological practice: clinical significance and localizations. Radiol Clin North Am 1997;35:655-670. Axial fat-suppressed proton-density weighted image of the foot. Fig. 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. If the excessive stress on the bone continues, mechanical failure may occur through these microfracture sites, resulting in a stress fracture.11,12, Daffner13reported that most stress fractures are caused by muscular activity rather than direct osseous trauma. Patients may continue to be symptomatic even after 3 months of rest and immobilization. Metatarsal stress fractures are among the most common stress fractures seen in athletes. We found many metacarpal stress fractures because we could use MRI relatively easily. One or both sesamoids may be involved. In this case, the linear fracture (arrow) extends somewhat obliquely from the dorsal cortex to the lateral cortex of the navicular bone. a. Stress injuries are more common in the foot and the lower leg though can occur anywhere. 34 Most metatarsal stress fractures involve the second and third metatarsal. Semin Roentgenol 1994;29:194-222. In an overuse situation, the weight-bearing parts of bone are affected, whereas in insufficiency related stress reactions the trabecular bone tends to be involved 1,2. It occurs when the bone itself is abnormal, as in osteoporosis, and the cycle of loading would otherwise not have led to a fracture. 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. A fracture in this location is a true Jones fracture and may be complicated by delayed or non-union. A low signal intensity fracture (arrows) within the talus parallels the posterior subtalar facet. Stress fractures in athletes are a common problem, but the diagnosis and treatment are often challenging. Evaluate the TCO of your PACS download >, 750 Old Hickory Blvd, Suite 1-260Brentwood, TN 37027, Focus on Musculoskeletal and Neurological MRI, Developmental Talocalcaneal Coalitions and Associated Conditions, Hammer, Mallet, and Claw Toe Deformities of the Lesser Toes. Sagittal T1-weighted image in a 78 year-old male with 2 months of ankle pain. Marked marrow edema (red asterisks) and a linear fracture (arrows) are seen within the posterior aspect of the calcaneus. 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. 20,29,30 The extreme plantar flexion of the foot and ankle for en pointe position and the unique locking configuration of the second metatarsal and cuneiforms have been proposed as causes of this injury. Grade 1 demonstrates subtle periosteal edema without marrow changes. A stress fracture usually affects the second metatarsal, but it can happen in any of the five metatarsals in the foot. 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. Radiology 1996;199:1-12. Fatigue, insufficiency, and pathologic fractures. 1987;2:221-229. Corresponding axial T1-weighted MR image (top right) demonstrates the fracture (arrow). A coronal T1-weighted image demonstrates normal marrow signal in the second, third and fourth metatarsals. Plain radiographs have poor sensitivity in detecting stress fractures, as positive findings may take months to appear. 2007 Shaw Bronner. 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. Occasionally, however, the diagnosis may not be as straight forward, and imaging may be indicated to differentiate among other significant etiologies. Even though the x-ray doesn't look like it's healed. second metatarsal stress fractures are at a lower risk to cause permanent damage due to inherent compressive forces and amenability to conservative treatment. The pathophysiology of stress fractures. The majority of tarsal bone stress fractures occur in the navicular.34, Rarely, stress fractures may occur in the cuboid bone [Figure 25, 26]. Routine radiographs were more useful with cortical fractures. MTPJ spacing preserved. If you are dealing with a typical "stress" fracture, say 2nd metatarsal, that hardly even shows up on an xray, then yes, if it's been 3 or 4 weeks and the patient still has inflammation, then I would inject a short acting cortisone. Stress fractures of the great toe have been reported in runners, soccer players, and volleyball players. Case Discussion. . It also commonly occurs in those individuals who over pronate . Periosteal edema may be seen, manifested as high signal outside the cortex on fluid-sensitive images [Figures 5, 6, 7]. 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. Fractures of the proximal fourth metatarsal bone are less common than distal fourth metatarsal fractures, and have a longer healing time. Karasick D, Schweitzer ME. Less common stress fractures of the foot. Am J Roentgenol. Michael RH, Holder LE. 1963;45:528-541. Radiol. 1. This line is better visualized on fluid-sensitive images and is more visible after initiation of the healing process. Figure 4: Stress fracture of the 2nd metatarsal. Eight fractures involved the medial sesamoid, six involved the lateral sesamoid, and in 1 patient both sesamoids were involved. Challenging fractures of the foot and ankle. Focal pressure over the navicular reproduces the symptoms.19,39,40 Initial radiographs are normal. 8 (3): 278-283. Health care providers caring for recreational and professional athletes must be knowledgeable of the signs and symptoms of these injuries and maintain high suspicion when seeing active patients seeking care for foot and ankle pain, as the signs and symptoms are often vague and overlap with other diagnoses. Prokuski LJ, Saltzman CL. Initially in a stress fracture, the gross contour of the bone is normal and the damage is internal. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators . PATIENT ASSESSMENT The old fracture line, however, is not accompanied by marrow edema on fluid-sensitive images. Chuckpaiwong B, et al. Extensive marrow edema is seen within the 3rd metatarsal diaphysis (asterisks) with marked surrounding periosteal and soft tissue edema (arrowheads). Int J Sports Med 1987;8(3):221-226. Stress fracture of the proximal phalanx of the great toe. Stress fractures: a review of 180 cases. Portland G, Kelikian A, Kodras S. Acute surgical management of Jones fractures. 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. Case Discussion Stress fractures are caused by repetitive actions or impacts to the bones. Calcaneal stress fractures [Figures 17 20] are nearly as common as metatarsal stress fractures. This anatomical arrangement is termed the "keystone" and enables the second metatarsal to . Breithaupt MDS. 24 It is the longest metatarsal and resides in a mortise formed by the recess of the medial and lateral cuneiforms. 1997;16:291-306. Clinical outcomes of edema-like bone marrow abnormalities in the foot. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. Radiographs are usually normal in the acute phase. Miller JH. Axial T1-weighted image in a 15 year-old female with 3 months of pain in the forefoot. Am J Roentgenol. A fracture with surrounding marrow edema (arrows) lies within the posterior calcaneal body. Download Free PDF View PDF. Foot Ankle. There is a spectrum of osseous stress injuries that occurs, beginning with stress reaction or stress response and eventually leading to stress fracture. You may decide to go to an emergency room or to your primary care doctor. Coris EE, Lombardo JA. 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. Stress fractures of the talus [Figure 27, 28] and calcaneus also occur in athletes.53,54. No distinct linear fracture. 1994;29(2):176-193. 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