Navicular stress fractures in identical twin runners: high-risk fractures require structured treatment

Treatment and Rehabilitation Approaches for Stress Fractures in Long-Distance Runners: A Literature Review

Stress fractures (SFs) result from repetitive mechanical stress on bones, leading to an imbalance in osseous tissue adaptation and resulting in cortical fractures. The majority of SFs occur in the lower limb due to excessive mechanical loads. Long-distance runners are highly susceptible to SFs, especially when there is a significant increase in the load or intensity of their activity. Various intrinsic and extrinsic factors contribute to the development of SFs. Common SF locations in long-distance runners include the tibial shaft, femur, metatarsal, and pelvic region. Diagnosis may be delayed due to mild symptoms and unremarkable imaging tests. However, the chronicity and recurrence of misdiagnosed SFs may lead to debilitating complete fractures that are even more challenging to treat. In this review, we present data revealed from published case reports and case series studies obtained through PubMed and Embase databases focusing on the management of SFs in long-distance runners and correlate treatment outcomes with rehabilitation and return to high-level athletic performance.

Evaluation of tarsal navicular stress fracture fixation using intraoperative O-arm computed tomography

Stress fractures of the tarsal navicular are high-risk injuries that can result in displacement, avascular necrosis, malunion, and nonunion. Delayed diagnosis and improper treatment can lead to long-term functional impairments and poor clinical outcomes. Increased shear stress and decreased vascularity in the central third of the navicular can complicate bony healing with often unpredictable return times to activity using conservative management in a non-weight-bearing cast. There recently has been increasing debate regarding the effectiveness of treatment options with a trend toward surgical management to anatomically reduce and stabilize navicular stress fractures in athletes. However, anatomic reduction and fixation of the navicular can be difficult despite direct visualization and intraoperative fluoroscopy. We report a case of a chronic navicular stress fracture in a high-level teenage athlete treated with open reduction internal fixation (ORIF) and calcaneus autograft using intraoperative computed tomography (CT) (O-arm®, Medtronic, Minneapolis, MN) for real-time evaluation of fracture reduction and fixation. Intraoperative CT was fast, reliable, and allowed for confirmation of guide wire orientation, alignment, and length across the fracture site. Anatomic fixation of navicular stress fractures can be challenging, and it is important for surgeons to be aware of the potential advantages of using intraoperative CT when treating these injuries.

LEVELS OF EVIDENCE

Therapeutic, Level IV: Case Report.

The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis

STUDY DESIGN

Systematic literature review and meta-analysis.

OBJECTIVES

To evaluate the diagnostic accuracy of clinical tests to identify stress fractures in the lower limb.

BACKGROUND

Stress fractures are a bone-related overuse injury primarily occurring in the lower limb and commonly affecting running athletes and military personnel. Physical examination procedures and clinical tests are suggested for diagnosing stress fractures; however, data on the diagnostic accuracy of these tests have not been investigated through a systematic review of the literature.

METHODS

A systematic review was conducted in 8 electronic databases to identify diagnostic accuracy studies, published between January 1950 and June 2011, that evaluated clinical tests against a radiological diagnosis of lower-limb stress fracture. Retrieved articles were evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool, and a meta-analysis was performed where appropriate.

RESULTS

Nine articles investigating 2 clinical procedures, therapeutic ultrasound (n = 7) and tuning fork testing (n = 2), met the study inclusion criteria. Meta-analysis was used to statistically analyze the data extracted from the ultrasound articles and demonstrated a pooled sensitivity of 64% (95% confidence interval [CI]: 55%, 73%), specificity of 63% (95% CI: 54%, 71%), positive likelihood ratio of 2.1 (95% CI: 1.1, 3.5), and negative likelihood ratio of 0.3 (95% CI: 0.1, 0.9). Tuning fork test data could not be pooled; however, sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio ranged from 35% to 92%, 19% to 83%, 0.6 to 3.0, and 0.4 to 1.6, respectively.

CONCLUSION

The results of this systematic review do not support the specific use of ultrasound or tuning forks as standalone diagnostic tests for lower-limb stress fractures. As the overall diagnostic accuracy of the tests investigated is not strong, based on the calculated likelihood ratios, it is recommended that radiological imaging should continue to be used for the confirmation and diagnosis of stress fractures of the lower limb.

LEVEL OF EVIDENCE

Diagnosis, level 1a-.J Orthop Sports Phys Ther 2012;42(9):760-771, Epub 19 July 2012. doi:10.2519/jospt.2012.4000.

Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis

PURPOSE

This study was conducted to provide a statistical analysis of previously reported tarsal navicular stress fracture studies regarding the outcomes and effectiveness of conservative and surgical management.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the published literature was conducted utilizing MEDLINE through Ovid, PubMed, ScienceDirect, and EBSCOhost. Reports of studies that provided the type of tarsal navicular stress fracture (ie, complete or incomplete), type of treatment, result of that treatment, and the time required to return to full activity were selected for analysis. Using a mixed generalized linear model with study as a random effect and treatment as a fixed effect, cases were separated and compared based on 3 different types of treatment: conservative, weightbearing permitted (WBR); conservative, non-weightbearing (NWB); and surgical treatment. The outcome of the treatment was recorded as either successful or unsuccessful based on radiographic and/or clinical healing of the fracture and time from onset of treatment to return to activity.

RESULTS

There was no statistically significant difference between NWB conservative treatment and surgical treatment regarding outcome (P = .6441). However, there is a statistical trend favoring NWB management (96% successful outcomes) over surgery (82% successful outcomes). Weightbearing as a conservative treatment was shown to be significantly less effective than either NWB (P = .0001) or surgical treatment (P <.0003).

CONCLUSION

Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. The authors could find no advantage for surgical treatment compared with NWB immobilization. However, there is a statistical trend favoring NWB over surgery. Rest or immobilization with weightbearing was inferior to both other treatments analyzed. The authors concluded that conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular.