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Injuries and medical problems in sport > Bone stress injuries > Flashcards

Bone stress injuries Flashcards

1
Q

Epidemiology

A

Difficult diagnosis- mimic other overuse injury + not often findings on x-ray
Majority of sports overuse injuries in track and field
20-60% incidence

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2
Q

Main 3 locations for overuse bone stress injuries

A

tibia
metatarsals
navicular

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3
Q

State the locations of the low risk bone stress injuries

A

LOW RISK

  • posteromedial border of tibia
  • femur
  • 1-4th metatarsals
  • ribs
  • ulnar
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4
Q

State the locations of the high risk bone stress injuries

A

HIGH RISK

  • anterior edge of tibia
  • neck of femur
  • navicular
  • 5th metatarsal
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5
Q

What are the issues associated with high risk bone stress injuries?

A
  • Delayed diagnosis
  • Delayed Tx

Leading to:

  • increased healing time
  • non-union
  • surgery
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6
Q

Role of Hx in BSI Dx

A
  • Sport
  • Event
  • Training intensity
  • Previous BSI
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7
Q

What specific questions should you ask about symptoms for a bone stress injury?

A
  • exercise related
  • progressively worse
  • intermediate
  • night pain
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8
Q

How are BSIs graded according to Sx frequency?

A

Grade 1: end of training
Grade 2: mid-training
Grade 3: whole training
Grade 4: Daily ctivities

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9
Q

What clinical tests are used for LL BSI

A
  • one leg hop test
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10
Q

DDx for BSI

A
  • bone contusion
  • osteomyelitis
  • neoplasm (lymphoma, leukaemia)
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11
Q

First line investigation for suspected BSI

A

Therapeutic USS
Most symptomatic point spotted at 2w/cm2 and decreased if painful by 0.1w/cm
80% sensitivity and 67% specificity

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12
Q

Second line Investigations for BSI

A

If therapeutic USS is positive –> MRI

If therapeutic USS negative –> x-ray

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13
Q

Gold standard investigation for bone stress injuries

A

MRI

Sensitive and specific, can be used to grade

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14
Q

MRI BSI grading system

A 
Grade 0 = normal
Grade 1 = endosteal marrow oedema
Grade 2 = periosteal and endosteal marrow oedema
Grade 3=  Grade 2 and soft tissue oedema
Grade 4 = fracture line
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15
Q

What grade of BSI does the following MRI show

A

Grade 1: endosteal marrow oedema

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16
Q

What grade of BSI does the following MRI show

A

endoteal and periosteal marrow oedema

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17
Q

What grade of BSI does the following MRI show?

A

Grade 3- endosteal, periosteal and soft tissue oedema

18
Q

What grade of BSI does the following MRI show?

A

Grade 4: stress fracture

19
Q

Main objective assessment tool in the diagnosis of BSI

A

Diagnostic imaging

20
Q

Limitations of radiographs for BSI

A

often appear normal despite clinical Sx and signs suggestive of BSI

21
Q

what are the benefits and negatives of radioisotope bone scanning in diagnosis of BSI?

A

very high sensitivity 84-100%

HOWEVER:

  • low specificity (high false positive)
  • high radiation dose
22
Q

How does diagnosis and severity of BSI correlate with regards to Sx onset?

23
Q

Mx of BSI

A
  • Majority is conservative
  • Modify training- not rest
  • Medication
  • Physio modalities
  • Rehabilitation + dealing with predisposing factors
24
Q

Extrinsic risk factors for BSI

A

mileage
number of training cycles
inadequate recovery periods and training fatigued muscles
pace
downhill running
sports- track, basketball, gymnastics, running
harder running surface

25
Intrinsic risk factors for BSI
External rotation of LL Bony anatomy: leg length discrepancy, femoral anteversion, genu varum/valgum, narrow tibia Muscle- small calf girth ``` Female Nutrition- low calcium/vit D, calorie deficit Older age >20 aerobic fitness + sporting experience Previous BSI Smoking FHx ```
26
Phase 1 Mx BSI- Grade 1-3
- control pain - NWB- swimming, core, stability - Local Tx- low intensity pulsed TUS TILL AT LEAST ONE WEEK WITHOUT PAIN WALKING
27
Phase 2 Mx BSI- Grade 1-3
Training modification: - local Tx- low intensity pulsed TUS- EWST - cycling, XT, stair stepper - deal with modifiable RF
28
Phase 3 Mx BSI- Grade 1-3
Functional- RTP - Functional rehab - Sport specific - 10% increase every 10 days aim to be free of symptoms on therapeutic USS
29
Which stress fractures are low risk of non-union?
- Femoral neck fractures of medial cortex - Tibial shaft fractures of the posteromedial cortex - distal 2-4 metatarsals - calcaneal fractures - fractures of fibula - fractures of pubic ramus
30
Mx low risk stress fractures
conservative management increase impact loading once ambulation and dat to day activity are pain free treat underlying RF and modify training regimen
31
Which stress fractures are at high risk of non-union?
- femoral neck - tibial shaft anterior cortex - navicular - talus/medial malleolus/sesamoids
32
How are stress fractures with high risk managed?
- often require operative management | - risk of non-union or delayed union
33
What grade BSI does this MRI show and what is the Mx?
Grade 3 BSI fracture of navicular bone Start conservative: non-weight bearing cast 6 weeks, then depends on pain- 86% rate of healing + boot If this fails, surgical Mx
34
Sx femoral stress fractures
pain in anterior inguineal area
35
How are femoral stress fractures diagnosed?
70% with the hop test
36
How are femoral stress fractures managed?
Compression-type fractures: conservative (RTP 8-16wks) | Tension-type fractures/displaced: internal fixation
37
Mx of metatarsal fractures
2nd-4th: - 20% all lower extremity BSF - 4-6wks limited activities or casting 4-6wks 5th: - 6-8wks non-weight bearing cast - 70% healing without surgical fixation
38
what is the highest demographic affected by tibial stress fractures
40-50% in athletes
39
Mx tibial stress fractures
Can be posteromedial or anterior 1) conservative (ant) 2) aircast splinting if more severe Sx /not resolved conservatively 3) casting for mid-shaft fracture until pain free and radiographic evidence of healing 4) Surgery (intramedullary nailing +/- grafting) if no improvement after 6 months
40
BSI grade and time to RTP
Grade 1: 3-4 weeks Grade 2: 5-8 weeks Grade 3: 9-16 weeks Grade 4: 16+ weeks
41
prophylaxis BSI
training is key prevention - periodisation- inc training over 3 weeks and follow with 1 week relative rest, allowing met adaptation - monitor loading and intensity - deal with modifiable RF - optimal nutriotion calcium vit D
42
Summary BSI points

Injuries and medical problems in sport (17 decks)

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