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Stress and Insufficiency Fracture
Umesh D. Oza, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Stress reaction in bone leading to fracture
            • Skeletal trauma secondary to repetitive loading overcoming intrinsic repair rates, resulting in spectrum of progressive bone disruption ranging from micro damage stress reaction to complete fracture
            • Stress fracture: Abnormal stress or overuse imposed on otherwise normal bone
            • 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. Bancroft LW: Wrist injuries: a comparison between high- and low-impact sports. Radiol Clin North Am. 51(2):299-311, 2013
                                        2. Liong SY et al: Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 85(1016):1148-56, 2012
                                        3. Murthy NS: Imaging of stress fractures of the spine. Radiol Clin North Am. 50(4):799-821, 2012
                                        4. 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
                                        5. Campbell SE et al: Imaging of stress injuries of the pelvis. Semin Musculoskelet Radiol. 12(1):62-71, 2008
                                        6. 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
                                        7. Lee E et al: Role of radionuclide imaging in the orthopedic patient. Orthop Clin North Am. 37(3):485-501, viii, 2006
                                        8. Sofka CM: Imaging of stress fractures. Clin Sports Med. 25(1):53-62, viii, 2006
                                        9. 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
                                        10. 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
                                        11. 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
                                        12. 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
                                        13. 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

                                                TERMINOLOGY

                                                • Definitions

                                                  • Stress reaction in bone leading to fracture
                                                  • Skeletal trauma secondary to repetitive loading overcoming intrinsic repair rates, resulting in spectrum of progressive bone disruption ranging from micro damage stress reaction to complete fracture
                                                  • Stress fracture: Abnormal stress or overuse imposed on otherwise normal bone
                                                  • 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. Bancroft LW: Wrist injuries: a comparison between high- and low-impact sports. Radiol Clin North Am. 51(2):299-311, 2013
                                                                              2. Liong SY et al: Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 85(1016):1148-56, 2012
                                                                              3. Murthy NS: Imaging of stress fractures of the spine. Radiol Clin North Am. 50(4):799-821, 2012
                                                                              4. 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
                                                                              5. Campbell SE et al: Imaging of stress injuries of the pelvis. Semin Musculoskelet Radiol. 12(1):62-71, 2008
                                                                              6. 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
                                                                              7. Lee E et al: Role of radionuclide imaging in the orthopedic patient. Orthop Clin North Am. 37(3):485-501, viii, 2006
                                                                              8. Sofka CM: Imaging of stress fractures. Clin Sports Med. 25(1):53-62, viii, 2006
                                                                              9. 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
                                                                              10. 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
                                                                              11. 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
                                                                              12. 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
                                                                              13. Oza UD et al: Multiple insufficiency fractures in a young woman with anorexia nervosa and bulimia. Clin Nucl Med. 28(3):250-1, 2003