Stress Fractures in the Juvenile Skeletal System

Abstract

Stress fractures affecting the juvenile skeletal system are rare and are described as having a good prognosis. Precisely because these fractures are so rare, studies allowing clear and generally applicable conclusions are lacking. The object of the present study was a systematic analysis of patients with stress fractures in an immature skeletal system, with special reference to the frequently difficult and delayed diagnosis and to the forms of therapy considered appropriate. Twenty-five patients with a total of 27 stress fractures affecting bones with the growth plates still open were examined according to a standardized procedure. The average duration of follow-up was 4.8 years (SD +/- 2.3) and the average age at occurrence 12.9 years (SD +/- 4.31). The risk factors were largely the same as those in adults. The most frequent site was the tibia (48% of cases; n = 13), followed by the metatarsal bones. Most (26/27) fractures were treated conservatively, with an average duration of therapy of 8.9 weeks (SD 8.2 weeks). Ultimately, 17 (63%) of the fractures healed in such a way as to allow the patients to return to full athletic activity with no restrictions within 3 months after diagnosis. In 9 cases (33%) it was not possible to achieve complete absence of symptoms within 12 months after diagnosis was made. No pseudarthroses were observed. There was a significant correlation between clinical outcome recorded as "free of symptoms" and an early diagnosis (less than 2 weeks after first symptoms (p = 0.033) and a fracture line seen on MR tomography in contrast to a stress reaction with merely increased signal intensity (p = 0.037). Overall, a strikingly high proportion of these patients had a prolonged course. This is attributable partly to the delay in diagnosis and to inappropriate initial treatment. When stress fractures were recognizable by a demonstrable fracture line--in contrast to just an edema--on MR tomography and their diagnosis was followed by an adequate form of therapy the chances of complete healing seemed to be better. It is essential to carry out targeted imaging investigations, e.g., by means of MR tomography, when there is a reason to consider a stress reaction. Furthermore, stress fractures should be adequately treated until all symptoms have disappeared.

Stress fractures in children

“…The observations of other authors are similar: in the material presented by Papadimitriou, this time was 25 days on average [6]. From among 27 patients with stress fractures presented in the study published by Niemeyer, in 13 persons the diagnosis was established within 2 weeks, while this period was over 2 weeks in the remaining group of patients [14].…”

“…In ni au to rzy ma ją po dob ne ob ser wa cje: w ma te ria le Pa pa di mi triou by ło to śred -nio 25 dni [6]. Spo śród 27 cho rych ze zła ma nia mi zmę cze nio wy mi przed sta wio ny mi w pra cy Nie mey era roz po zna nie u 13 z nich po sta wio no przed upły wem 2 ty go dni, zaś u po zo sta łych po wy żej 2 ty go dni [14].…”

Anisotropy of the fatigue behaviour of cancellous bone

“…Thus, damage due to repeated loading is of considerable interest for biological tissues as cracking is observed for loads far below the static strength. Cyclic failures of bones due to the accumulation of fatigue damage are clinically known as overuse injuries or stress fractures which are observed in athletes (Snyder et al, 2006;Niemeyer et al, 2006) and military recruits (Sormaala et al, 2006) and are also associated with age related fragility fractures (Burr et al, 1997). Cyclic loading induced damage accumulation is also reported to weaken vertebrae (Burr et al, 1997) and is often associated with loosening of implants (Bauer and Schils, 1999).…”

National Athletic Trainers' Association Position Statement: Prevention of Pediatric Overuse Injuries

“…In another Japanese study 29 of stress fractures in 208 athletes under the age of 20 years, the researchers found that the peak age of occurrence was 16 years, the most frequent site was the tibial shaft, and basketball was the sport most commonly associated with stress fractures. A 2006 retrospective study 47 of stress fractures among 25 juveniles demonstrated that the age of onset was 12.9 6 4.3 years (range, 3-17 years) and the tibia was most often affected (48%, n 5 13), followed by the metatarsals (18.5%, n 5 5). Using data from the High School Report Injuries Online (RIO) injury surveillance system, Fernandez et al 48 reported that 4350 athletic injuries occurred among athletes participating in 9 high school sports during 1 academic year.…”