Ultrasound-Diagnosed Tibia Stress Fracture: A Case Report

Ultrasound ability in early diagnosis of metatarsal stress fractures

Stress fractures are common in young and active individuals, associated with aggressive or repetitive physical activity and their early detection is fundamental to optimise patient care, decrease complications and avoid unnecessary exams. Currently, magnetic resonance imaging is the standard of care for detecting these lesions. Recently, ultrasound has been getting an increasing interest for the detection of stress fractures. In this article, we describe a clinical case that involved a second metatarsal stress fracture diagnosed by ultrasound and review the literature regarding the use of ultrasound in the diagnosis of stress fractures, particularly of the metatarsals.

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.

Tibia stress injury and the imaging appearance of stress fracture in juvenile dermatomyositis: six patients' experiences

BACKGROUND

Tibial stress injuries are frequent injuries of the lower extremity and the most common causes of exercise-induced leg pain among athletes and military recruits. They sometimes occur in patients with pathological conditions of bone metabolism such as osteoporosis or rheumatoid arthritis, but there are previously no cases reported in juvenile dermatomyositis (JDM). Here we report 6 JDM patients who presented with shin pain, and the imaging appearance of tibial stress fractures or stress reactions.

CASE PRESENTATION

All 6 patients with JDM presented with shin pain or tenderness in the anterior tibia without any evidence of excessive exercise or traumatic episode. They were diagnosed with tibial stress injuries based on a combination of radiographs, three-phase bone scans, and magnetic resonance imaging (MRI), and 5 out of 6 patients had been treated with prednisone and/or methotrexate at onset of tibial stress injuries. In one patient, we could not find any abnormalities in his radiograph, but the subsequent MRI showed tibial stress reaction. In all 6 patients, the tibial stress injuries improved with only rest and/or analgesics.

CONCLUSION

We experienced 6 children with JDM who presented with shin pain, and who were diagnosed with tibial stress fractures or stress reactions. Their underlying disease and weakness, treatment with glucocorticoid and methotrexate, or inactivity may have resulted in these tibial injuries, and made these patients more predisposed than other children. In addition to preventing JDM patients from getting osteoporosis, we need to consider stress reactions when children with JDM complain of sudden shin pain.

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.