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Stress Injuries
A. Carlson Merrow, Jr., MD, FAAP
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Clinical Issues

          TERMINOLOGY

          • Synonyms

            • Stress fracture: Fatigue fracture, insufficiency fracture, march fracture, exhaustion fracture, crack fracture, pseudofracture
            • Chronic repetitive physeal injury: Traction apophysitis, little leaguer elbow, little leaguer shoulder, gymnast wrist
          • Definitions

            • Fatigue fracture: Fracture due to abnormal stresses applied (over time) to normal bone
              • Normal bone subjected to repetitive stresses that in isolation would not lead to fracture but gradually result in mechanical failure
            • Insufficiency fracture: Fracture due to normal stresses applied to abnormal bone
              • Demineralized or otherwise weakened bone from focal or systemic process
                • Osteoporosis, osteogenesis imperfecta, rickets/osteomalacia, hyperparathyroidism
                • Pathologic fracture: Underlying lesion weakens bone, predisposing to fracture
            • Stress response/reaction: Result of stresses upon bone prior to development of macroscopic fracture
              • Microtrabecular fracture + some degree of healing
            • Chronic physeal stress injury: Repetitive stress to metaphyseal vasculature & cartilaginous growth plate interrupts normal endochondral ossification

          IMAGING

          • General Features

            • Radiographic Findings

              • CT Findings

                • MR Findings

                  • Nuclear Medicine Findings

                    • Imaging Recommendations

                      DIFFERENTIAL DIAGNOSIS

                        PATHOLOGY

                        • General Features

                          • Microscopic Features

                            CLINICAL ISSUES

                            • Presentation

                              • Demographics

                                • Natural History & Prognosis

                                  • Treatment

                                    Selected References

                                    1. Boyle MJ et al: Femoral neck stress fractures in children younger than 10 years of age. J Pediatr Orthop. ePub, 2016
                                    2. Bedoya MA et al: Overuse injuries in children. Top Magn Reson Imaging. 24(2):67-81, 2015
                                    3. Swischuk LE et al: Tibial stress phenomena and fractures: imaging evaluation. Emerg Radiol. 21(2):173-7, 2014
                                    4. Rauck RC et al: Pediatric upper extremity stress injuries. Curr Opin Pediatr. 25(1):40-5, 2013
                                    5. Jaimes C et al: Taking the stress out of evaluating stress injuries in children. Radiographics. 32(2):537-55, 2012
                                    6. Galbraith RM et al: Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2(3):127-33, 2009
                                    7. Hébert KJ et al: MRI appearance of chronic stress injury of the iliac crest apophysis in adolescent athletes. AJR Am J Roentgenol. 190(6):1487-91, 2008
                                    8. Laor T et al: Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol. 186(5):1260-4, 2006
                                    9. Lee SH et al: Stress fractures of the femoral diaphysis in children: a report of 5 cases and review of literature. J Pediatr Orthop. 25(6):734-8, 2005
                                    10. Ahovuo JA et al: Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol. 14(3):500-5, 2004
                                    11. Biedert R et al: Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. 24(2):137-41, 2003
                                    12. Craig JG et al: Longitudinal stress fracture: patterns of edema and the importance of the nutrient foramen. Skeletal Radiol. 32(1):22-7, 2003
                                    13. Iwamoto J et al: Stress fractures in athletes: review of 196 cases. J Orthop Sci. 8(3):273-8, 2003
                                    14. Parr TJ et al: Overuse injuries of the olecranon in adolescents. Orthopedics. 26(11):1143-6, 2003
                                    15. Ishibashi Y et al: Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 12(2):79-84, 2002
                                    16. Laor T et al: Local physeal widening on MR imaging: an incidental finding suggesting prior metaphyseal insult. Pediatr Radiol. 27(8):654-62, 1997
                                    17. Umans HR et al: Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging. Skeletal Radiol. 25(4):319-24, 1996
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Terminology

                                      • Imaging

                                        • Top Differential Diagnoses

                                          • Clinical Issues

                                            TERMINOLOGY

                                            • Synonyms

                                              • Stress fracture: Fatigue fracture, insufficiency fracture, march fracture, exhaustion fracture, crack fracture, pseudofracture
                                              • Chronic repetitive physeal injury: Traction apophysitis, little leaguer elbow, little leaguer shoulder, gymnast wrist
                                            • Definitions

                                              • Fatigue fracture: Fracture due to abnormal stresses applied (over time) to normal bone
                                                • Normal bone subjected to repetitive stresses that in isolation would not lead to fracture but gradually result in mechanical failure
                                              • Insufficiency fracture: Fracture due to normal stresses applied to abnormal bone
                                                • Demineralized or otherwise weakened bone from focal or systemic process
                                                  • Osteoporosis, osteogenesis imperfecta, rickets/osteomalacia, hyperparathyroidism
                                                  • Pathologic fracture: Underlying lesion weakens bone, predisposing to fracture
                                              • Stress response/reaction: Result of stresses upon bone prior to development of macroscopic fracture
                                                • Microtrabecular fracture + some degree of healing
                                              • Chronic physeal stress injury: Repetitive stress to metaphyseal vasculature & cartilaginous growth plate interrupts normal endochondral ossification

                                            IMAGING

                                            • General Features

                                              • Radiographic Findings

                                                • CT Findings

                                                  • MR Findings

                                                    • Nuclear Medicine Findings

                                                      • Imaging Recommendations

                                                        DIFFERENTIAL DIAGNOSIS

                                                          PATHOLOGY

                                                          • General Features

                                                            • Microscopic Features

                                                              CLINICAL ISSUES

                                                              • Presentation

                                                                • Demographics

                                                                  • Natural History & Prognosis

                                                                    • Treatment

                                                                      Selected References

                                                                      1. Boyle MJ et al: Femoral neck stress fractures in children younger than 10 years of age. J Pediatr Orthop. ePub, 2016
                                                                      2. Bedoya MA et al: Overuse injuries in children. Top Magn Reson Imaging. 24(2):67-81, 2015
                                                                      3. Swischuk LE et al: Tibial stress phenomena and fractures: imaging evaluation. Emerg Radiol. 21(2):173-7, 2014
                                                                      4. Rauck RC et al: Pediatric upper extremity stress injuries. Curr Opin Pediatr. 25(1):40-5, 2013
                                                                      5. Jaimes C et al: Taking the stress out of evaluating stress injuries in children. Radiographics. 32(2):537-55, 2012
                                                                      6. Galbraith RM et al: Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med. 2(3):127-33, 2009
                                                                      7. Hébert KJ et al: MRI appearance of chronic stress injury of the iliac crest apophysis in adolescent athletes. AJR Am J Roentgenol. 190(6):1487-91, 2008
                                                                      8. Laor T et al: Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol. 186(5):1260-4, 2006
                                                                      9. Lee SH et al: Stress fractures of the femoral diaphysis in children: a report of 5 cases and review of literature. J Pediatr Orthop. 25(6):734-8, 2005
                                                                      10. Ahovuo JA et al: Fatigue stress fractures of the sacrum: diagnosis with MR imaging. Eur Radiol. 14(3):500-5, 2004
                                                                      11. Biedert R et al: Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. 24(2):137-41, 2003
                                                                      12. Craig JG et al: Longitudinal stress fracture: patterns of edema and the importance of the nutrient foramen. Skeletal Radiol. 32(1):22-7, 2003
                                                                      13. Iwamoto J et al: Stress fractures in athletes: review of 196 cases. J Orthop Sci. 8(3):273-8, 2003
                                                                      14. Parr TJ et al: Overuse injuries of the olecranon in adolescents. Orthopedics. 26(11):1143-6, 2003
                                                                      15. Ishibashi Y et al: Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sport Med. 12(2):79-84, 2002
                                                                      16. Laor T et al: Local physeal widening on MR imaging: an incidental finding suggesting prior metaphyseal insult. Pediatr Radiol. 27(8):654-62, 1997
                                                                      17. Umans HR et al: Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging. Skeletal Radiol. 25(4):319-24, 1996