Bone Stress Injury (Tenforde article) Flashcards
What are biologic risk fractures of BSI?
Genetics Medications Calcium & Vitamin D def Female athlete triad Female sex
What medications increase BSI risk?
Steroids
Anticonvulsants
Antidepressants
Antacids
What is the female athlete triad?
Energy availability (eating disorder) Menstrual function (amenorrhea) Bone mineral density (osteoporosis)
What are biomechanical risk factors of BSI?
Training patterns (volume or intensity) Bone char (thinner cortex, lower BMD) Leg length discrepancy Lean Mass Cavus or planus foot type Smaller calf cross-sectional area Higher peak hip ADD Knee IR Knee ABD Tibial IR Rear foot eversion Running >20 miles/week
What should be asked on history when evaluating BSI?
complete running hx Freq of racing Changes in running volume Shoe type and duration of use Change in foot strike pattern Dietary restriction behavior Foods high in vit D & Ca Medications (hormones, steroids) Personal or family hx of Low BMD
What maneuvers should be done to evaluate sacral/pelvic BSI?
Focal tenderness SI joint provovcation Thigh thrust Pelvic distraction/compression FABER Eval for leg length discrepancy
What maneuvers should be done to evaluate Femoral neck BSI?
Hip IR
FADIR (for FAI eval)
What maneuvers should be done to evaluate Lesser trochanter BSI?
Hip IR
FADIR (for FAI eval)
Iliopsoas tendonopathy
What maneuvers should be done to evaluate Femoral shaft BSI?
Fulcrum test to localize pain at injury site
What maneuvers should be done to evaluate Calcaneus BSI?
Calcaneal squeeze test
What are LOW risk anatomic locations of BSI?
Posteriomedial tibia
Fibula/lateral malleolus
Calcaneus
Diaphysis of 2nd-4th metatarsals
What are MODERATE risk anatomic locations of BSI?
Pelvis (sacrum and pubic rami) Femoral shaft Proximal tibia Cuboid Cuneiform
What are HIGH risk anatomic locations of BSI?
Femoral neck Patella Anterior tibial diaphysis Medial malleolus Talus (lateral process)
What is a MRI Grade 1 for BSI?
Mild marrow or periosteal edema on T2; normal T1
Mild to moderate periosteal edema on T2; Normal marrow on T2 and T1
What is a MRI Grade 2 for BSI?
Moderate marrow or periosteal edema plus + T2
Moderate to severe periosteal edema on T2; Marrow edema on T2 but not T1
What is a MRI Grade 3 for BSI?
Severe marrow or periosteal edema on T1 and T2
Moderate to severe periosteal edema on T2; Marrow edema on T2 and T1
What is a MRI Grade 4 for BSI?
Severe marrow or periosteal edema on T1 and T2 plus fx line on T1 or T2
Moderate to severe periosteal edema on T2; Marrow edema on T2 and T1; fx line present
Recommended intake of Vitamin D
Ages 9-70: 600 IU
>71: 800 IU
Recommended intake of Ca
Ages 9-18: 1300 mg
Women 19-50 yo & Men 19-70 yo: 1000 mg
Women >51 yo & Men >71 yo: 1200 mg
What should be done for females with BSI?
Referral to Sports Dietitian
Ensure proper menstration
What should be done for males with BSI in pelvis, sacrum or femoral neck?
DEXA scan (using Z-scores) Endocrine work up
Tx for Tension side femoral neck fx
Bed rest if no widening of cortical fx
Ortho referral for failure to achieve interval bony healing
Cross-training exercises when pain free
2-3 mo to heal
Tx for femoral neck compression side and Lesser trochanter fx
NWB on crutches
Repeat imaging to ensure bone healing
Cross-training exercises when pain free
2-3 mo to heal
What is the dreaded black line?
Horizontal radiolucency localized to tension side of tibia
Anterior Tibial cortex fx tx
Assess for “dreaded black line”
Repeat imaging to ensure bone healing prior to WB
IM rod for nonunion
Medial malleolus fx tx
Initial trial of immobilization
Surgery for fx displacement or involvement of talocural joint
Base of 2nd metatarsal fx tx
High risk, esp if Lisfranc join (metatarsal-cuneifrom) involved
Min 4 wks immobilization
Repeat x-ray & exam to ensure pain free before WB
What is a Morton’s toe?
2nd toe extending past the great toe
RF for 2nd metatarsal fx d/t inc force through 2nd ray of foot
Custom foot orthosis w/ metatarsal pad beneath 2nd metatarsal to dec risk
What is a Jone’s fx?
5th metatarsal diaphysis fx
High risk injury d/t avascularity of the bone distal to the tuberosisty which can result in nonunion
Tx of a Jone’s fx tx
CAM walker boot
Surgery: IM screw fixation & bone grafting l/t RTP in 12 wks
Tarsal Navicular fx tx
Strict NWB
CT to assess for healing in chronic process
Surgery: high grade, AVN, cystic changes or sclerosis
What can appear as a sesamoid fx on xray?
Bipartite sesamoid w/ sesamoiditis
Get xr-ray of asx foot to compare
Tx of seasamoid fx
Delayed healing response
Cushioned orthosis w/ accomodative insole to offload
Tx of sacrum & pelvis fx
Crutches to NWB
WB when ambulation pain free
RTFA in 12 weeks
Tx of Cuboid & Cuneiform fx
Immobilization for pain free ambulation
Progression to neutral shoe
PT for strength & biomechanical factors
Tx of Femoral Shaft fx
Injuries w/o displacement or cortical break heal & RTR in 8-12 wks
Tx of Tibia fx
Injuries typically at distal 1/3 posterior medial aspect
more severe: focal pain, tenderness with direct/indirect palpation
MRI grade prognosticates for recovery in 3-12 wks
Tx of Fibula fx
Easy to exam due to surface bony anatomy
Prompt RTR when asx
Tx of Calcaneus fx
Walking boot
Possibly crutches for pain-free mobility
Tx of 2-4 metatarsal shaft fx
Low risk & good response to healing
No fx line: metatarsal pad w/ firm shoe to ambulate w/o pain
Fx line: repeat x-rays in 4 wks to ensure healing
Cross train 7 RTR progression when ambulating pain free
6-8 wks RTR
