Stress Fracture (Hairline Fractures) Treatment in Singapore 2023

Introduction

Hairline fractures, also referred to as stress fractures. One-sided loads on the skeleton can, when intensity and load are too high, lead to stress fractures or fatigue fractures if the adaptive ability of the body is insufficient to cope. Stress fractures can affect children who begin athletic training as early as the age of 7 years. The frequency of stress fractures in adolescents is increasing. The injury can be caused by frequently repeated movements under normal load, e.g. longdistance running, or by movements of a lower frequency but with a higher load, e.g. weightlifting. The most dangerous combination, however, is a high load and a high frequency.

In principle, stress fractures can occur in any bone of the body, but are most common in the lower limbs. They occur mainly in the metatarsal bones, and in the tibia, fibula, femur, hip and pelvic bones, and vertebral bodies. Stress fractures should always be suspected in people who are subjected to repeated movements or heavy loads and who complain of pain on exertion. Usually there is no pain or discomfort at rest. Local tenderness and swelling over the painful area are found and a clinical examination usually leads to the diagnosis. If no fracture is discovered on X-ray examination, it should be repeated 3–4 weeks later if the symptoms persist. The diagnosis can then be confirmed. A bone scan can confirm the diagnosis at an early stage.

The risk of stress fracture can be reduced primarily by increasing training gradually but also by varied training alternating with regular rest so that the body has time to recover. The surface that athletes use in training can also be of importance, and the construction of the shoes is vital. Anyone running on a hard surface should always wear shoes with good shock-absorbing properties. When there is a change from a hard to a soft surface or vice versa, the intensity of training should be reduced during the transition period.

Basics

Description

  • A stress (microscopic) fracture occurs when:
    • Repetitive stresses are applied to a bone faster than it is able to remodel to withstand this challenge.
      • As the stressing force continues, the bone gradually fatigues and eventually breaks.
      • Remodeling occurs in response to the stress but does not happen quickly enough to prevent the break.
    • Suddenly increased forces are applied to a normal bone (e.g., a metatarsal stress fracture that occurs in a military recruit who marches 20 miles without adequate conditioning).
  • Related to the stress fractures is the insufficiency fracture, in which normal forces cause a fracture of weakened bone (e.g., a femoral neck fracture in an osteopenic elderly woman).
  • Weightbearing bones of the lower extremity are affected, most commonly:
    • Metatarsus
    • Calcaneus
    • Tibia
    • Fibula
    • Femoral neck
  • Classification/radiographic grading:
    • Grade I: Normal radiograph, positive STIR
    • Grade II: Normal radiograph, positive STIR, positive T2-weighted MRI
    • Grade III: Periosteal reaction on radiograph, positive T1- and T2-weighted MRI, STIR without definite cortical break
    • Grade IV: Fracture line or periosteal reaction, fracture line on T1- and T2-weighted MRI
  • Synonyms: March fracture; Fatigue fracture

General Prevention

  • Avoid sudden increases in physical activity levels, especially when involving walking or running.
  • Runners should be educated to reduce mileage and to rest when they have acute, new-onset pain with activity.

Epidemiology

  • Can occur at any age:
    • Typically, people <60 years old develop stress fractures after sustained or cyclic exertion.
    • Persons >60 years old develop stress fractures from normal stress to a weak bone.

Incidence

  • Stress and insufficiency fractures occur more often in females than in males.
  • Commonly occur in:
    • Running and jumping athletes
    • 5% of military recruits
    • In a recent study, elite tennis players had a 12% rate of stress fracture .

Prevalence

Femoral stress fractures occur at a rate of 20 per 100,000 person-years; 1/2 are within the femoral neck.

Risk Factors

  • Female triad (eating disorder, amenorrhea, stress fracture [osteoporosis])
  • Rapid change in conditioning program:
    • >10% increase in running mileage per week
    • Military recruit in boot camp
  • Skeletal malalignment:
    • Pes cavus, pes planus
    • Excessive external rotation of the hip
  • Muscle fatigue: as muscles fatigue, they absorb less shock, which is transmitted to the bone (e.g., marathon running).
  • Low bone density
  • Gender: Female recruits have higher rates of stress fracture than do male recruits.
  • Low aerobic fitness is a predictor of stress fracture in recruits.

Etiology (Cause)

  • Sudden increase in strenuous activity in young people
  • Minimal stress in people with weak or osteopenic bone

Associated Conditions

  • Osteopenia
  • Metabolic bone disease
  • Female triad

Diagnosis

Signs and Symptoms

  • The patient initially presents with a 2-3-week history of a vague, dull ache with exertion or impact loading.
  • As the injury progresses, the pain becomes sharper and localized and begins earlier in training.
  • If a stress fracture progresses to complete (macroscopic) fracture, pain occurs at rest.

Physical Exam

  • Antalgic gait may be present.
  • Point tenderness is noted in the affected bone.
  • Observe swelling and thickening of the soft tissues over the affected bone.
  • Pain in the hip with resisted active straight-leg raise (Stinchfield sign).

Tests

Lab

No serum laboratory tests

Imaging

  • Radiography:
    • Plain radiographs (AP and lateral views) typically do not show findings until 2 weeks after the onset of symptoms.
    • What usually is observed is healing, periosteal callus, or sclerosis at the fracture site.
  • Bone scan:
    • Very sensitive
    • Findings may be delayed 48-72 hours in elderly patients with insufficiency fractures.
  • MRI:
    • Very sensitive
    • Allows for classification and prognosis
    • Can rule out other soft-tissue injuries in the differential diagnosis

Differential Diagnosis

  • Infection
  • Fracture
  • Soft-tissue injury
  • Exertion or chronic compartment syndrome
  • Tumor

Treatment of Stress Fracture (Hairline Fractures) in Singapore

General Measures

  • In general, the patient must reduce activity below the threshold of pain.
    • If the patient has pain with walking, crutches should be used.
    • If the patient has pain with motion, or at rest, the injured part should be immobilized in a cast or fracture splint.

Activity

  • After initial treatment, activity should be increased gradually.
  • Once the patient is pain free, low-impact training can be started and advanced as tolerated.
  • Once running is resumed, mileage should be increased slowly.

Special Therapy

Physical Therapy

  • Identify training errors that led to the stress fracture.
  • Identify and correct mechanics and muscle imbalance.
  • Core strengthening

Medication

NSAIDs can be given, but they have an inhibitory effect on bone healing, making them a controversial intervention.

First Line

Acetaminophen

Surgery

  • For high-risk stress fractures:
    • Fractures whose displacement would cause catastrophic complications:
      • Femoral neck fractures require emergent internal fixation because a complete, displaced femoral neck fracture is associated with a high incidence of AVN .
    • Fractures associated with a high rate of delayed union or nonunion: Patella, tarsal navicular, talus

Follow-up

Disposition

Issues for Referral

High-risk fractures (see what has been determined previously)

Prognosis

  • Stress fractures in young people have a good prognosis.
  • Older patients or those with metabolic bone disease typically continue to develop insufficiency fractures in other bones.
  • Time to return to full activity :
    • Grade I: 3+ weeks
    • Grade II: 5+ weeks
    • Grade III: 11+ weeks
    • Grade IV: 14+ weeks

Complications

  • Completion of fracture, the most common complication of stress fractures, substantially prolongs healing and may require internal fixation.
  • Continued pain even after fracture healing may occur.

Patient Monitoring

Radiographs are obtained every 4-6 weeks to monitor progress to healing.

Miscellaneous

Codes

ICD9-CM

733.11 Stress fracture
 

Patient Teaching

Gradual increase in training intensity (e.g., <10% in running mileage per week)

Prevention

  • Patient education:
    • With new-onset pain with activity, the patient should rest and reduce training.
    • The patient should try to identify and correct any training errors.

Stress Fracture (Hairline Fractures) FAQ

No. These fractures can be treated with prolonged nonweightbearing and immobilization. However, they are associated with a high risk of nonunion. Surgical fixation allows earlier weightbearing, less immobilization, improved predictable healing, and earlier return to activity.
Any bone subjected to an increased mechanical load (including repetitive muscle use) can develop stress fractures. For example, overhead athletes, such as pitchers, can develop stress fractures in the humerus and olecranon, and rowers can develop stress fractures of the ribs.
Athletes with stress fractures can participate in active rest, decreasing their activity below the threshold of pain. If an athlete has a stress fracture in a weightbearing bone, then core strengthening and balancing exercises and aquatic (or hydroaerobic) exercises can be done. Once pain-free, an athlete can begin low-impact aerobics, such as stationary cycling or elliptical training. If the athlete is pain free with these activities, jogging and sports-specific activities can be begun.
You may continue to rely on crutches or a cane. Typically, it's safe to resume placing your full weight on the affected area approximately two weeks after the onset of your symptoms. This weight-bearing activity can facilitate the healing of the stress fracture. However, refrain from engaging in any activities that cause discomfort or pain.

If you would like an appointment / review with our stress/hairline fractures specialist in Singapore, the best way is to call +65 3135 1327 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first, then please contact contact@orthopaedicclinic.com.sg or SMS/WhatsApp to +65 3135 1327

Rest assured that the best possible care will be provided for you.

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