Bilateral stress fracture of the tibia diagnosed by ultrasound. A case report

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study

OBJECTIVE

To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI).

METHODS

A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv²² criteria were applied to classify MRI findings.

RESULTS

Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77).

CONCLUSIONS

USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

Preliminary image findings of lower limb stress fractures to aid ultrasonographic diagnoses: A systematic review and narrative synthesis

INTRODUCTION

This systematic review investigates which image appearances are most common when diagnosing lower limb stress fractures using ultrasound imaging, with the aim of outlining an image critique guideline for operators to support confident diagnoses.

METHOD

A comprehensive literature search of medical databases and handsearching was undertaken to identify relevant studies. All studies were critically examined for quality using the CASP critical appraisal tool. Results from eight studies were combined and interpreted using a narrative synthesis.

FINDINGS

A clear outline of common stress fracture appearances using ultrasound were identified in a combined total of 119 participants. Each finding was ranked according to its popularity. Periosteal thickening (78/119) and cortical disruption/irregularity (83/119) were noted in all eight studies. Hypervascularity of the periosteum visualised by colour Doppler imaging (66/119) was reported in six of the eight studies. Soft tissue hypervascularity (13/119), bony callus formation (5/119) and cortical break (22/119) were seen in three studies.

CONCLUSIONS

Based on the findings, we offer a guideline of the most significant preliminary image findings to be utilised by operators when examining athletes suspected of having lower limb stress fractures. The results show a gap in research for evaluating changes in appearance depending on the injury severity. Further research into distinguishing stress fractures from pathological involvement may in future reduce reliance on plain film radiography.

Ultrasound and bone: a pictorial review

The assessment of bone mainly relies on standard radiographs, CT, MRI, and bone scintigraphy depending on the anatomic region complexity and clinical scenario. Ultrasound (US), due to different acoustic impedance between soft tissues and the bone cortex, only allows the evaluation of the bone surfaces. Nevertheless, US can be useful in the evaluation of several bone disorders affecting the limbs as a result of its tomographic capabilities and high definition. This pictorial review article summarises our clinical experience in adults and reviews the literature on US bone examination. We first present the US appearance of normal bone and the main congenital anatomic variations, after which we illustrate the US findings of a variety of bone disorders. Although US has limits in bone assessment, its analysis must be a part of every musculoskeletal US examination.

Ultrasound Features of the Normal and Pathologic Periosteum

Thickening and elevation of the periosteum from the underlying bone cortex, defined as a periosteal reaction, can be associated with several bone disorders. Although ultrasound (US) has limited possibilities in assessing bones, it can depict a periosteal reaction earlier than plain radiography, thus indicating underlying bone disorders. This pictorial essay aims to illustrate the normal and pathologic US appearances of the periosteum in both children and adults. Several disorders are discussed, such as pediatric bone trauma, infections and tumors, as well as trauma, overuse, including medial tibial stress syndrome, and finally certain seronegative spondyloarthropathies in adults. Whenever US depicts a periosteal reaction, a correlation with clinical and laboratory data is mandatory to differentiate different bone disorders. Computed tomography or magnetic resonance imaging must be performed when an infection or a tumor is suspected based on both US and the clinical presentation.

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

Occult isolated fracture of the trapezoid diagnosed by ultrasonography

PURPOSE

To describe a patient with an occult isolated trapezoid fracture of the wrist. Isolated trapezoid fractures are very difficult to detect without advanced radiological imaging, since the fragment displacement does not occur in the sagittal plane. A discussion regarding the investigation of trapezoid fractures utilizing multiple imaging modalities includes the first demonstration of its detection via ultrasonography (US).

METHODS

A 26-year-old male presented to a chiropractic teaching clinic with pain involving the left wrist, after vaulting over the handlebars of his bicycle 2 days prior. The mechanism of injury was hyperflexion of the left wrist. Left wrist pain, reduced range of motion, and dorsal soft tissue edematous changes were identified at examination. Although the initial radiographic examination was negative, elevated clinical suspicion triggered an US examination 4 days later. The US exam demonstrated an isolated 1.8 mm dorsal trapezoid fracture, which was minimally displaced by 0.7 mm.

RESULTS

Following the US diagnosis of an isolated trapezoid fracture, the wrist was immobilized. The patient elected to not pursue an orthopedic consultation. Conservative care included ice and Class IV therapeutic laser therapy. The patient reported complete alleviation of clinical symptoms after approximately 2 weeks of splinting and treatment.

CONCLUSION

We emphasize the limitations of radiography in the diagnosis of this fracture. To our knowledge, this is the first case to describe the use of US in the diagnosis of an isolated trapezoid fracture.

Stress Fractures of the Calcaneus Diagnosed by Sonography: Report of 8 Cases

We present a retrospective review of 8 patients (6 women and 2 men, with an age range of 46-80 years; mean age, 60.2 years) in whom sonography was used to diagnose a calcaneal stress fracture. Sonography was performed because of a clinical suspicion of soft tissue injuries. Two patients were first assessed by standard radiography; for the remaining patients, sonography was the first imaging technique used. Patients were subsequently examined by magnetic resonance imaging, except for 1 patient in whom the diagnosis was made only on a clinical-sonographic correlation. On sonography, there was thickening of the periosteum and subcutaneous edema in all patients; a calcified bone callus was evident in none of the 8 patients. Cortical irregularities were found in 6 of 8 patients. Color Doppler imaging showed local hypervascular changes of the periosteum in all patients. Sonography, together with clinical findings, can be used to diagnose a calcaneal stress fracture. We suggest that sonologists should include a calcaneal stress fracture in their differential diagnosis in cases of mechanical hind foot pain. They must also include, as a part of every sonographic examination of the ankle, an examination of the calcaneus and be aware of the sonographic appearance of stress fractures. If the diagnosis is still uncertain after the sonographic examination, magnetic resonance imaging should be prescribed.

A repetitive spontaneous distal tibial insufficiency fracture: an unusual case report

Stress fractures typically occur, when cyclic loading to the healthy bone exceeds the normal carrying range capacity. These fractures are most commonly seen in athletes and military recruits who are engaged with intensive physical exercise in their daily lives. Stress fractures can also occur in a variety of conditions, in which the mineral content or the elasticity of bone is abnormal and defined as an insufficiency fracture. The tibia is the most frequent location for stress fractures, while bilateral tibial fractures are extremely rare. Herein, we report a repetitive spontaneous distal tibial insufficiency fracture in the right and left distal tibia and discuss predisposing factors, diagnosis, and treatment in the light of the current literature.

Ultrasound-Diagnosed Tibia Stress Fracture: A Case Report

Stress fractures are a frequent cause of lower extremity pain in athletes, and especially in runners. Plain imaging has a low sensitivity. Magnetic resonance imaging (MRI) or bone scan scintigraphy is the criterion standard, but expensive. We present the case of a young female distance runner with left shin pain. Plain radiography was unremarkable. Ultrasound showed focal hyperechoic elevation of the periosteum with irregularity over the distal tibia and increased flow on Doppler. These findings were consistent with a distal tibia stress fracture and confirmed by MRI. Examination of our case will highlight the utility of considering an ultrasound for diagnosis of tibial stress fracture.

Bilateral Synchronous Stress Fracture of the Tibia in a Young Female Basketball Player

We present a case of a bilateral synchronous stress fracture of the tibia in a young female basketball player. The patient was initially referred for ultrasound and radiographs of the knees to exclude Osgood-Schlatter disease. Radiographs and subsequent MRI revealed bilateral stress fractures of the proximal tibia. A synchronous and symmetrical occurrence of stress fractures in the lower limbs is unusual. As clinical presentation is often nonspecific, appropriate imaging (plain films and MRI) plays a pivotal role in the correct diagnosis of this uncommon entity.

DISTAL FIBULAR STRESS FRACTURE IN A FEMALE RECREATIONAL RUNNER: A CASE REPORT WITH MUSCULOSKELETAL ULTRASOUND IMAGING FINDINGS

BACKGROUND AND PURPOSE

This case report describes a physical therapist's use of diagnostic ultrasound imaging in the decision making process used to refer a patient to a physician for a suspected fibular stress fracture. The purpose of this case report is to 1) describe the history, subjective examination, and objective examination findings of a fibular stress fracture, 2) describe the ultrasound findings associated with a fibular stress fracture, and 3) describe the decision making process of a physical therapist in the decision to refer the patient to a medical physician for further work-up.

CASE DESCRIPTION

A 52-year-old female recreational runner with a recent increase in running intensity self-referred to a physical therapist with a 19-day history of lateral lower leg pain. Examination revealed relatively normal ankle range of motion, mild weakness of ankle invertors and evertors, no increase in pain with resisted muscle tests of the ankle, and tenderness to palpation over the fibularis brevis muscle and distal fibula. Diagnostic ultrasound examination of the fibularis muscles revealed cortical irregularity of the distal third of the fibula in the location of tenderness.

OUTCOMES

The physical therapist used the abnormal ultrasound findings, running history, symptoms, and physical examination for differential diagnosis, and decided to refer the patient to a physician for further examination. Radiographs revealed a fibular stress fracture. Follow-up ultrasound imaging demonstrated a mixed hypoechoic-hyperechoic appearance of the fibular cortex typical of healing fracture and the presence of bony callus.

DISCUSSION

Diagnostic ultrasound imaging is increasingly being used by physical therapists to guide rehabilitation. Ultrasound imaging of musculotendinous structures may display adjacent bone. Physical therapists should be knowledgeable of normal and abnormal bony ultrasound imaging findings. Abnormal ultrasound findings may be one sign indicating the need to refer a patient for consultation by a physician.

Ultrasonography of fractures in sports medicine

High-resolution ultrasound is emerging as an important imaging modality in fracture assessment due to its availability, ease of use and multiplanar capabilities. Its usefulness includes injury assessment for the presence of a fracture when obtaining radiographs is not immediately available, detecting occult fractures not revealed on radiographs, and diagnosing bone stress injury before radiographic changes. Sonographic evaluation of bone, however, has limitations and should always be coupled with radiographs and possibly advanced imaging modalities such as CT and MR when clinically indicated.

An unusual stress fracture: Bilateral posterior longitudinal stress fracture of tibia

INTRODUCTION

Stress fractures (SF) occur when healthy bone is subjected to cyclic loading, which the normal carrying range capacity is exceeded. Usually, stress fractures occur at the metatarsal bones, calcaneus, proximal or distal tibia and tends to be unilateral.

PRESENTATION OF CASE

This article presents a 58-year-old male patient with bilateral posterior longitudinal tibial stress fractures. A 58 years old male suffering for persistent left calf pain and decreased walking distance for last one month and after imaging studies posterior longitudinal tibial stress fracture was detected on his left tibia. After six months the patient was admitted to our clinic with the same type of complaints in his right leg. All imaging modalities and blood counts were performed and as a result longitudinal posterior tibial stress fractures were detected on his right tibia.

DISCUSSION

Treatment of tibial stress fracture includes rest and modified activity, followed by a graded return to activity commensurate with bony healing. We have applied the same treatment protocol and our results were acceptable but our follow up time short for this reason our study is restricted for separate stress fractures of the posterior tibia.

CONCLUSION

Although the main localization of tibial stress fractures were unilateral, anterior and transverse pattern, rarely, like in our case, the unusual bilateral posterior localization and longitudinal pattern can be seen.

Stress fractures of the ankle malleoli diagnosed by ultrasound: a report of 6 cases

OBJECTIVE

To present the ultrasound appearance of stress fractures (SF) of the ankle malleoli.

MATERIAL AND METHODS

We present a retrospective review of 6 patients (4 women and 2 men, with an age range of 24-52 years, mean age of 39 years) in which ultrasound diagnosed, together with the clinical findings, an SF of the ankle malleoli. For all of these patients ultrasound was the first imaging technique applied because of a clinical suspicion of soft tissue injuries following excessive exertion. Patients were subsequently examined using standard radiographs and/or MRI.

RESULTS

At ultrasound patients showed thickening of the periosteum in all patients, calcified bone callus was evident in 3 out of 6 patients. Cortical irregularities and subcutaneous oedema were found in all but one patient. Colour Doppler showed local hypervascular changes in all patients. Local compression with the transducers during real-time scanning increased pain in all cases.

CONCLUSION

Ultrasound, together with the clinical findings, can diagnose an SF of the ankle malleoli. We suggest that sonologists should include malleolar SF in their differential diagnosis, particularly in the case of perimalleolar pain from over-solicitation. They must also include, as part of every ultrasound examination of the ankle, the evaluation of both malleoli and should be aware of the ultrasound appearance of malleolar SF. If the diagnosis remains uncertain, an MRI should be prescribed.