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Injuries and medical problems in sport > Foot stress fractures > Flashcards

Foot stress fractures Flashcards

1
Q

Stresses on foot of running

A
  • heel weight bearing = 110%
  • Running = 250%
  • forefoot running = 300%
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2
Q

RF for foot stress fractures

A
  • Female athletes
  • Extrinsic factors (inc env)
  • Intrinsic factors
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3
Q

Female quintuple

A
  • low BMD
  • low BMI
  • oligo/a-menorrhoea
  • inc age
  • poor nutrition
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4
Q

How does menstrual irregularity increase stress fracture risk?

A
  • delayed menarche 4x risk

- amenorrhoea = 2x

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5
Q

How does poor nutrition increase stress fracture risk?

A
  • elevated dietary restraint
  • no calcium supplementation 2x
  • previous ED diagnosis 5x
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6
Q

How does BMI affect risk of stress fracture

A

2-3x inc in underweight

less soft tissue to re-distribute force

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7
Q

Risk of stress fracture in female + BMI<19 + late menarche + previous fracture

A

35% yearly risk

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8
Q

Risk of stress fracture in female triad + >12h a week training

A

46% annual

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9
Q

Which athletes with stress fractures require a BMD assessment?

A
  • Female quintuple
  • > 50yrs

otherwise, DEXA not required

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10
Q

Extrinsic factors inc risk of SF

A
  • training regime
  • type- running, ballet
  • training surface
  • footwear
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11
Q

Intrinsic risk factors for stress fracture

A
  • bony anatomy
  • stiff joints
  • leg length discrepency
    muscle + BMI
  • fitness and experience
  • FHx
  • smoking
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12
Q

How are stress fractures classified?

A
  • Fatigue (normal bone, abnormal stress)
  • Insufficiency (abnormal bone, normal stress)
  • Pathological
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13
Q

classification of BSIs

A

Fredericson

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14
Q

Grading of stress fractures and implications for Mx

A

Grade 4+5 will need surgical intervention + early referral

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15
Q

Hx stress fracture

A
  • localised crescendo pain
  • progressive pain
  • eventually day-to-day activities/night
  • female quintuple
  • ask about training
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16
Q

Stress fracture O/E

A
  • localised tenderness

- swelling with delayed presentations

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17
Q

imaging for stress fractures

A
  • plain radiograph- often normal till 2-3 months
  • CT
  • MRI - gold standard
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18
Q

Low risk bones of non-union

A
  • Distal 2-5 metatarsal
  • Cuboid
  • Cuneiform
  • Calcaneum

Good blood supply

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19
Q

High risk bones of non-union

A
  • Proximal second metatarsal (forces through midfoot)
  • 5th metatarsal dia/meta-physeal junction (watershed area for blood supply)
  • Navicular
  • Talus
  • Sesamoid
  • Ant process of calcaneum

Need early aggressive Tx

20
Q

Fracture features on radiograph indicating increased risk of non-union

A
  • sclerotic or cystic appearance
  • MRI appearance of complete fracture on T1/2
  • Displaced fracture
21
Q

How are foot fractures managed based on non-union risk?

A

Risk stratification is done by age (>50) + presence of female quintuple

  • Low risk non-union = activity modification (prolonged if high risk)
  • High risk non-union = immobilise/surgical stabilsation
22
Q

Grade 4-5 grade fracture Mx

23
Q

non-surgical Mx principles

A
  1. Analgesia
  2. Mobilisation based on underlying symptoms- crutches, boot- make sure ADL are pain free. if not pain free, won’t heal as microfractures
  3. Correcting underlying bone health/deficiencies
  4. Maintaining VO2 max- treadmills, antigravity treadmill, swimming
24
Q

Rules for RTP stress fracture

A

FWB for 2 weeks

Follow 30:10 rule

  • 1/3rd normal pace
  • 1/3rd typical distance
  • Increasing in 10% weekly increments
25
prevention stress fracture
- periodisation (every 4 weeks relative rest) - orthotics - diet- crucial - BMD screening
26
stress fractures which behave differently
- metatarsal - calcaneal - navicular - talar - sesamoid
27
most common foot stress fracture
metatarsal fractures
28
2 types of metatarsal fractures and differences in Mx
Distal 2-5th = low risk of non-union - manage based off pain - walking boot/stiff shoes Proximal 2-5th = high risk of non-union - strictly NWB- early, aggressive Tx as take longer to heal (3/12) - if sign of non-union, early referral for surgery
29
features of non-union on xray
- cysts | - sclerosis
30
2 overriding things that help bone heal
- Biology (calcium, vit D, not smoking) | - Stability (imobilisation)
31
which sports increase the risk of calcaneal fractures?
- jumping sports | nb can be mistaken for arthritis/tendionpathy/bursitis
32
2 types of calcaneal stress fracture
1) Body of calcaneum- Mx based on underlying pain with partial/NWB 2) Anterior process of calcaenium
33
Anterior process of calcaneus fracture- Mx and associations
- rare - associated with incomplete coalition (?genetic) - strict NWB 6/52- high risk of non-union - K wire decompression can reduce RTP time
34
which athletes are affected by navicular bone fractures?
- runners | - basketball players
35
Why are navicular fractures at high risk of non-union?
- covered by cartilage on 3 sides - retrograde blood supply - 70% risk non-union (similar to scaphoid)
36
Which imaging modality is preferred in navicular stress fracture and why?
CT- quantifies degree of fracture MRI- shows high signal diagnostic of stress fracture
37
Types of navicular stress fracture and Mx
Type 1: cortex only- strict NWB 6/52 Type 2: body- poor bloody supply Type 3: body + both cortices For types 2+3, early stabilisation (percutaneous screws) + strict NWB to reduce risk of non-union
38
Further features to consider early surgical intervention for navicular stress fractures
- cystic changes - sclerosis - avascular necrosis Use CT to detect
39
Talar stress fractures - what increases risk?
- more common in military personnel | - repetitive axial loading and plantar flexion
40
Talar risk fractures- types and prognosis
Blood supply from posterior tibial artery is small (no soft tissue attachments) so high risk of non-union - 1/3 are neck - 2/3rds head 6/52 NWB (neck an extra 6/52 protected)
41
Use of MRI in suspected sesamoid fractures
differentiate bi-partite sesamoid from fracture/AVN
42
Mx of sesamoid fractures
- offloading brace - steroid injection in chronic case - surgical fixation (high risk)
43
Why is surgery not often indicated in sesamoid stress fractures
- very small screw to fix | - excision of sesamoid leaves risk of hallux abductus (worse off)
44
Best imaging for sensitivity and diagnosis of stress fracture?
MRI | if cler clinical features but x-ray negative
45
What bones in the foot additionally benefit from CT scan?
NAVICULAR- quantify degree (type 2/3 for early surgical Intervention) Most of the time CT is not indicated
46
conclusions of stress fractures lecture

Injuries and medical problems in sport (17 decks)

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