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Stress and Insufficiency Fracture
Fathima Fijula P. Manzil, MD; Umesh D. Oza, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          • Scanning Tips

            TERMINOLOGY

            • Definitions

              • Stress fracture: Abnormal stress or overuse imposed on otherwise normal bone
                • Stress reaction in bone leading to fracture
                • Skeletal trauma secondary to repetitive loading overcoming intrinsic repair rates → progressive bone disruption ranging from microdamage stress reaction to complete fracture
              • Stress fracture differs from insufficiency fracture: Physiologic stress overwhelming abnormal (insufficient) bone
                • Underlying metabolic or other bony deficiency
              • Partial or complete fracture
                • Grade I: < 25% of cortex
                • Grade II: 25-50% cortical involvement
                • Grade III: 50-75% cortical involvement
                • Grade IV: > 75% cortical involvement

            IMAGING

            • General Features

              • Nuclear Medicine Findings

                • Radiographic Findings

                  • CT Findings

                    • MR Findings

                      • Imaging Recommendations

                        DIFFERENTIAL DIAGNOSIS

                          PATHOLOGY

                          • General Features

                            • Microscopic Features

                              CLINICAL ISSUES

                              • Presentation

                                • Demographics

                                  • Natural History & Prognosis

                                    • Treatment

                                      DIAGNOSTIC CHECKLIST

                                      • Consider

                                        • Image Interpretation Pearls

                                          Selected References

                                          1. Rogers NB et al: Improving the diagnosis of ipsilateral femoral neck and shaft fractures: A new imaging protocol. J Bone Joint Surg Am. ePub, 2019
                                          2. Bancroft LW: Wrist injuries: a comparison between high- and low-impact sports. Radiol Clin North Am. 51(2):299-311, 2013
                                          3. Liong SY et al: Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 85(1016):1148-56, 2012
                                          4. Murthy NS: Imaging of stress fractures of the spine. Radiol Clin North Am. 50(4):799-821, 2012
                                          5. Bryant LR et al: Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. 191(4):1010-5, 2008
                                          6. Campbell SE et al: Imaging of stress injuries of the pelvis. Semin Musculoskelet Radiol. 12(1):62-71, 2008
                                          7. Berger FH et al: Stress fractures in the lower extremity The importance of increasing awareness amongst radiologists. Eur J Radiol. 62(1):16-26, 2007
                                          8. Lee E et al: Role of radionuclide imaging in the orthopedic patient. Orthop Clin North Am. 37(3):485-501, viii, 2006
                                          9. Sofka CM: Imaging of stress fractures. Clin Sports Med. 25(1):53-62, viii, 2006
                                          10. Tins B et al: Marrow changes in anorexia nervosa masking the presence of stress fractures on MR imaging. Skeletal Radiol. 35(11):857-60, 2006
                                          11. Fayad LM et al: Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: how successful are we? AJR Am J Roentgenol. 185(4):915-24, 2005
                                          12. Gaeta M et al: CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 235(2):553-61, 2005
                                          13. Connolly LP et al: Young athletes with low back pain: skeletal scintigraphy of conditions other than pars interarticularis stress. Clin Nucl Med. 29(11):689-93, 2004
                                          14. Oza UD et al: Multiple insufficiency fractures in a young woman with anorexia nervosa and bulimia. Clin Nucl Med. 28(3):250-1, 2003
                                          Related Anatomy
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                                          Related Differential Diagnoses
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                                          References
                                          Tables

                                          Tables

                                          KEY FACTS

                                          • Terminology

                                            • Imaging

                                              • Pathology

                                                • Clinical Issues

                                                  • Scanning Tips

                                                    TERMINOLOGY

                                                    • Definitions

                                                      • Stress fracture: Abnormal stress or overuse imposed on otherwise normal bone
                                                        • Stress reaction in bone leading to fracture
                                                        • Skeletal trauma secondary to repetitive loading overcoming intrinsic repair rates → progressive bone disruption ranging from microdamage stress reaction to complete fracture
                                                      • Stress fracture differs from insufficiency fracture: Physiologic stress overwhelming abnormal (insufficient) bone
                                                        • Underlying metabolic or other bony deficiency
                                                      • Partial or complete fracture
                                                        • Grade I: < 25% of cortex
                                                        • Grade II: 25-50% cortical involvement
                                                        • Grade III: 50-75% cortical involvement
                                                        • Grade IV: > 75% cortical involvement

                                                    IMAGING

                                                    • General Features

                                                      • Nuclear Medicine Findings

                                                        • Radiographic Findings

                                                          • CT Findings

                                                            • MR Findings

                                                              • Imaging Recommendations

                                                                DIFFERENTIAL DIAGNOSIS

                                                                  PATHOLOGY

                                                                  • General Features

                                                                    • Microscopic Features

                                                                      CLINICAL ISSUES

                                                                      • Presentation

                                                                        • Demographics

                                                                          • Natural History & Prognosis

                                                                            • Treatment

                                                                              DIAGNOSTIC CHECKLIST

                                                                              • Consider

                                                                                • Image Interpretation Pearls

                                                                                  Selected References

                                                                                  1. Rogers NB et al: Improving the diagnosis of ipsilateral femoral neck and shaft fractures: A new imaging protocol. J Bone Joint Surg Am. ePub, 2019
                                                                                  2. Bancroft LW: Wrist injuries: a comparison between high- and low-impact sports. Radiol Clin North Am. 51(2):299-311, 2013
                                                                                  3. Liong SY et al: Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 85(1016):1148-56, 2012
                                                                                  4. Murthy NS: Imaging of stress fractures of the spine. Radiol Clin North Am. 50(4):799-821, 2012
                                                                                  5. Bryant LR et al: Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. 191(4):1010-5, 2008
                                                                                  6. Campbell SE et al: Imaging of stress injuries of the pelvis. Semin Musculoskelet Radiol. 12(1):62-71, 2008
                                                                                  7. Berger FH et al: Stress fractures in the lower extremity The importance of increasing awareness amongst radiologists. Eur J Radiol. 62(1):16-26, 2007
                                                                                  8. Lee E et al: Role of radionuclide imaging in the orthopedic patient. Orthop Clin North Am. 37(3):485-501, viii, 2006
                                                                                  9. Sofka CM: Imaging of stress fractures. Clin Sports Med. 25(1):53-62, viii, 2006
                                                                                  10. Tins B et al: Marrow changes in anorexia nervosa masking the presence of stress fractures on MR imaging. Skeletal Radiol. 35(11):857-60, 2006
                                                                                  11. Fayad LM et al: Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: how successful are we? AJR Am J Roentgenol. 185(4):915-24, 2005
                                                                                  12. Gaeta M et al: CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 235(2):553-61, 2005
                                                                                  13. Connolly LP et al: Young athletes with low back pain: skeletal scintigraphy of conditions other than pars interarticularis stress. Clin Nucl Med. 29(11):689-93, 2004
                                                                                  14. Oza UD et al: Multiple insufficiency fractures in a young woman with anorexia nervosa and bulimia. Clin Nucl Med. 28(3):250-1, 2003