IMAGING OF STRESS INJURIES TO BONE: Radiography, Scintigraphy, and MR Imaging

doi:10.1016/S0278-5919(05)70022-3

Clinics in Sports Medicine

Volume 16, Issue 2, 1 April 1997, Pages 275-290

https://doi.org/10.1016/S0278-5919(05)70022-3 Get rights and content

The term stress fracture refers to the failure of the skeleton to withstand submaximal forces acting over time.1, 5, 6, 18, 19, 20, 23 Two types of stress fractures have been identified: (1) fatigue fractures, such as have been classically described in military recruits and runners in which normal bone is subjected to repeated abnormal stresses, and (2) insufficiency fractures, in which normal stresses are applied to a bone whose skeletal composition reflects deficient elastic resistance.1, 5, 6, 18, 19, 20, 23 Fatigue fractures represent common problems in the sports medicine population, and insufficiency fractures, particularly in osteoporotic patients, represent common orthopedic problems and frequent diagnostic challenges. Although conventional radiographs continue to be used as a primary method for diagnosis, the limitations of radiography in the early detection of these injuries have been increasingly recognized.* Advanced imaging techniques, including radionuclide methods, and more recently, MR imaging, have increasingly been employed in the assessment of stress fractures, and have provided valuable insights into the spectrum of stress-related changes to bone.* This article reviews the diagnostic methods available to the clinician for detection of stress injuries of bone.

Section snippets

BACKGROUND

A stress fracture may be considered as the final consequence in a series of preceding events. Prior to actual fracture, a number of pathologic alterations occur that are associated with symptoms and which place the patient “at risk” for fracture development. The term stress response refers to those prefailure events at the cellular level that result in structural weakening of bone.20, 23

As elucidated by Robb and colleagues,²³ when bone is stressed there is gradual and progressive resorption of

Conventional Radiographs

Radiographic abnormalities are affected by both the location of the fracture and the time interval between the injury and radiographic examination.20, 23, 25 It has become increasingly recognized that many significant injuries to bone may be initially, and in some cases, forever radiographically occult.* The initial manifestation of a stress fracture in a long bone may be that of localized periosteal reaction (Fig. 1).

CONCLUSION

Both scintigraphy and MR imaging represent robust diagnostic techniques for the evaluation of stress injuries to bone. When performed with state-of-the-art methodology, both modalities demonstrate the ability to detect stress injuries well prior to their radiographic depiction. The three-phase bone scan offers physiologic information from which both the age of the injury as well as the status of healing of the fracture can be inferred. MR demonstrates higher specificity as a consequence of its

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View all citing articles on Scopus

: Address reprint requests to Andrew L. Deutsch, MD, Tower Imaging, 444 San Vicente Boulevard, Suite 106, Los Angeles, CA 90048

^*: References 4, 6, 7, 8, 9, 10, 14, 15, 16, 20, 24, 28, 29

^*: References 4, 6, 7, 8, 9, 10, 14, 15, 16, 20, 24, 28, 29

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IMAGING OF STRESS INJURIES TO BONE: Radiography, Scintigraphy, and MR Imaging

Section snippets

BACKGROUND

Conventional Radiographs

CONCLUSION

Stress fractures

Radiology

Conservative management of distraction type stress fractures of the femoral neck

J Bone Joint Surg

Low-back pain in adolescent athletes: Detection of stress injury to the pars interarticularis with SPECT

Radiology

Difficult to detect osseous injuries

The Physician and Sports Medicine

Stress fractures: Current concepts

AJR Am J Roentgenol

Stress lesions of bone

Current Imaging

Traumatic injuries of bone and osteonecrosis

Occult fractures of the proximal femur: MR imaging

Radiology

Comparison of MRI with bone scanning for suspected hip fracture in elderly patients

J Bone Joint Surg

Imaging of fractures: Stress and occult

J Rheumatol

The effects of ice on blood flow and bone metabolism in knees

Am J Sports Med

The specific scintigraphic pattern of shin splints in the lower leg: Concise communication

J Nucl Med

Bone contusions of the knee: Increased lesion detection with fast spin echo MR imaging with spectroscopic fat saturation

Radiology

Stress fracture: MRI

Orthopedics