CT and MR Imaging Findings in Athletes with Early Tibial Stress Injuries: Comparison with Bone Scintigraphy Findings and Emphasis on Cortical Abnormalities

Gaeta, Michele; Minutoli, Fabio; Scribano, Emanuele; Ascenti, Giorgio; Vinci, Sergio Lucio; Bruschetta, Daniele; Magaudda, Ludovico; Blandino, Alfredo

doi:10.1148/radiol.2352040406

Cited by 277 publications

(189 citation statements)

References 47 publications

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“…MRI evidence for excessive resorption at the site of atypical fractures also has been reported in a BP-treated patient, (12) and the same phenomenon has been seen in young athletes with early tibial stress injuries. (147,148) Somford and colleagues (11) also took the opportunity to assess the mineralization density of the bone tissue at the fracture site because some have suggested that prolonged BP treatment may lead to hypermineralized and, therefore, brittle bone matrix. There was no evidence of hypermineralization and no change in hydroxyapatite crystal size, although the crystals were more mature than in control subjects, consistent with the known effects of alendronate on bone turnover and secondary mineralization.…”

Section: Atypical Subtrochanteric and Femoral Shaft Fractures: Clinicmentioning

confidence: 99%

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Shane

Burr

Ebeling

et al. 2010

Journal of Bone and Mineral Research

998

679

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Reports linking long-term use of bisphosphonates (BPs) with atypical fractures of the femur led the leadership of the American Society for Bone and Mineral Research (ASBMR) to appoint a task force to address key questions related to this problem. A multidisciplinary expert group reviewed pertinent published reports concerning atypical femur fractures, as well as preclinical studies that could provide insight into their pathogenesis. A case definition was developed so that subsequent studies report on the same condition. The task force defined major and minor features of complete and incomplete atypical femoral fractures and recommends that all major features, including their location in the subtrochanteric region and femoral shaft, transverse or short oblique orientation, minimal or no associated trauma, a medial spike when the fracture is complete, and absence of comminution, be present to designate a femoral fracture as atypical. Minor features include their association with cortical thickening, a periosteal reaction of the lateral cortex, prodromal pain, bilaterality, delayed healing, comorbid conditions, and concomitant drug exposures, including BPs, other antiresorptive agents, glucocorticoids, and proton pump inhibitors. Preclinical data evaluating the effects of BPs on collagen cross-linking and maturation, accumulation of microdamage and advanced glycation end products, mineralization, remodeling, vascularity, and angiogenesis lend biologic plausibility to a potential association with long-term BP use. Based on published and unpublished data and the widespread use of BPs, the incidence of atypical femoral fractures associated with BP therapy for osteoporosis appears to be very low, particularly compared with the number of vertebral, hip, and other fractures that are prevented by BPs. Moreover, a causal association between BPs and atypical fractures has not been established. However, recent observations suggest that the risk rises with increasing duration of exposure, and there is concern that lack of awareness and underreporting may mask the true incidence of the problem. Given the relative rarity of atypical femoral fractures, the task force recommends that specific diagnostic and procedural codes be created and that an international registry be established to facilitate studies of the clinical and genetic risk factors and optimal surgical and medical management of these fractures. Physicians and patients should be made aware of the possibility of atypical femoral fractures and of the potential for bilaterality through a change in labeling of BPs. Research directions should include development of animal models, increased surveillance, and additional epidemiologic and clinical data to establish the true incidence of and risk factors for this condition and to inform orthopedic and medical management. ß

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Section: Atypical Subtrochanteric and Femoral Shaft Fractures: Clinicmentioning

confidence: 99%

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Shane

Burr

Ebeling

et al. 2010

Journal of Bone and Mineral Research

998

679

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“…This can lead to bone loss and subsequent micro-damage that can result in localised bone weakening, prompting stress fracture development (2). Stress fracture period prevalence in elite athletes and military recruits ranges from 14 to 21% (3,4), and most commonly manifests in the lower limbs (5).…”

Section: Introductionmentioning

confidence: 99%

RANK/RANKL/OPG pathway: Genetic associations with stress fracture period prevalence in elite athletes

Varley

Hughes

Greeves³

et al. 2015

Bone

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Context: The RANK/RANKL/OPG signalling pathway is important in the regulation of bone turnover, with single nucleotide polymorphisms (SNPs) in genes within this pathway associated with bone phenotypic adaptations.Objective: To determine whether four SNPs associated with genes in the RANK/RANKL/OPG signalling pathway were associated with stress fracture injury in elite athletes.Design, Participants, and Methods: Radiologically confirmed stress fracture history was reported in 518 elite athletes, forming the Stress Fracture Elite Athlete (SFEA) cohort. Data were analysed for the whole group, and were sub-stratified into male and cases of multiple stress fracture group. Genotypes were determined using proprietary fluorescence-based competitive allele-specific PCR assays.Results: SNPs rs3018362 (RANK) and rs1021188 (RANKL) were associated with stress fracture injury (p<0.05). 8.1% of stress fracture group and 2.8% of the non-stress fracture group were homozygote for the rare allele of rs1021188. Allele frequency, heterozygotes and homozygotes for the rare allele of rs3018362 were associated with stress fracture period prevalence (p<0.05). Analysis of the male only group showed 8.2% of rs1021188 rare allele homozygotes to have suffered a stress fracture while 2.5% of the non-stress fracture group were homozygous. In cases of multiple stress fractures, homozygotes for the rare allele of rs1021188, and individuals possessing at least one copy of the rare allele of rs4355801 (OPG) were shown to be associated with stress fracture injury (p<0.05). Conclusions:The data support an association between SNPs in the RANK/RANKL/OPG signalling pathway and the development of stress fracture injury. The association of rs3018362 (RANK) and rs1021188 (RANKL) with stress fracture injury susceptibility supports their role in the maintenance of bone health, and offers potential targets for therapeutic interventions.

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“…Banal et al reported 70% sensitivity for US compared to an MRI for the examination of fractures of the second metatarsal [12]. Several studies have described ultrasonographic findings of SF (11,14). Five US hallmarks have been described in SF: [1] cortical disruption which is a rare and late finding [2] posterior shadowing related to periosteal thickening.…”

Section: Discussionmentioning

confidence: 99%

“…MRI is the examination of choice in the early detection of SF but its use is limited by lack of access and associated cost [3]. In the past few years, various authors have reported ultrasound (US) as an inexpensive, non-invasive and ready modality with high sensitivity for the investigation of SF of the metatarsal [10,11]. Reports of SF affecting other bones then metatarsals diagnosed by US are rare [6].…”

Section: Introductionmentioning

confidence: 99%

Bilateral stress fracture of the tibia diagnosed by ultrasound. A case report

Khy

Wyssa

Bianchi

2012

Journal of Ultrasound

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KEYWORDSFatigue fracture; Sonography; Ultrasound; Stress fracture.Abstract We report the case of a 35 years old patient presenting with bilateral pain in the medial aspect of both knees. Ultrasound examination revealed hyperechoic appearance of the subcutaneous tissue and periarticular soft tissue bilateral. Color Doppler studies showed significant vascular signals at the surface of the tibial plateaux. US appearance, together with clinical findings, suggested a diagnosis of simultaneous bilateral fatigue fracture. An MRI confirmed the diagnosis and the patient's symptoms resolved with rest. US may be a useful imaging tool in the diagnosis of stress fracture.Sommario Presentiamo il caso di un paziente di 35 anni con dolore bilaterale nella parte mediale delle ginocchia. L'ecografia evidenziava ipoecogenicità del tessuto sottocutaneo e delle parti molli periarticolari bilateralmente. L'esame con color Doppler mostrava significativi segnali vascolari in corrispondenza del piatto tibiale. L'aspetto ecografico, associato ai segni clinici, suggeriva la diagnosi di simultanea frattura da fatica, bilaterale. La risonanza magnetica confermava la diagnosi e i sintomi del paziente regredivano con il riposo. L'ecografia può essere un'utile metodica nella diagnosi frattura da stress. ª

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CT and MR Imaging Findings in Athletes with Early Tibial Stress Injuries: Comparison with Bone Scintigraphy Findings and Emphasis on Cortical Abnormalities

Abstract: MR imaging is the single best technique in assessment of patients with suspected tibial stress injuries; in some patients with negative MR imaging findings, CT can depict osteopenia, which is the earliest finding of fatigue cortical bone injury.

Cited by 277 publications

References 47 publications

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

Atypical subtrochanteric and diaphyseal femoral fractures: Report of a task force of the american society for bone and mineral Research

RANK/RANKL/OPG pathway: Genetic associations with stress fracture period prevalence in elite athletes

Bilateral stress fracture of the tibia diagnosed by ultrasound. A case report

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