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May 22-24, 2013

Saltsjöbaden

Difficult stress fractures through

the ATPC lens

Courtesy of Dr Stuart Houston

Normal reference

2 year oldLeft leg postoperative Left leg after 3 years

Before we go all ‘negative’ on bone!!

1. Stress

fracture in the Jones’ position

• Percutaneous screw fixation?

• 6 weeks plaster cast?

Stress fracture in the

Jones’ position

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8 weeks vs 16 weeks /

44% non-union rate

• Avulsion – 59 days to get back to football training

• Type II fracture – better success rate with surgery (75% compared with 33%)

• About 80 days +/- 20 days to get back to sport

• 25% recurrence rate

• Surgical options? Aim for lateral compression?

Sport-specific Stress FracturesClassic cases…

Others include:

1. Insidious medial foot pain

2. Groin pain in a marathon runner

3. Anterior shin pain in a jumper

4. Base of 2nd MT in a dancer

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1. Navicular stress fractures1. Navicular stress fracture

• Can be a career-stopping injury

• 8 weeks non-weightbearing cast is best supported by the literature (Torg, Khan, Scott Burne)

• Very inconvenient treatment

• Worked well for Michael Jordan

• Results of weightbearing rest are poor

• Surgery data are not encouraging

Classic cases…

Others include:

1. Insidious medial foot pain

2. Groin pain in a marathon runner

3. Anterior shin pain in a jumper

4. Base of 2nd MT in a dancer

2. Femoral neck (tension side)

Femoral neck (tension side)

• Undisplaced; initial bed rest for 1 week, then gradual weightbearing

• Displaced; surgical fixation

Classic cases…

Others include:

1. Insidious medial foot pain

2. Groin pain in a marathon runner

3. Anterior shin pain in a jumper

4. Base of 2nd MT in a dancer

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3. Anterior

tibial cortexAnterior tibial cortex

Controversial at present (too few to do a nice large RCT)

Clinical practice includes:

• 6-8 weeks non-weightbearing on

crutches

• 6-8 weeks walking in AirCast boot

• Intramedullary screw fixation

Classic cases…

Others include:

1. Insidious medial foot pain

2. Groin pain in a marathon runner

3. Anterior shin pain in a jumper

4. Base of 2nd MT in a dancer

4. Base of 2nd MT

(Ballet)

Base of 2nd MT stress fracture

• Non-weightbearing for 2 weeks

• Partial weightbearing for 2 weeks

What about pars defect?

• Managed symptomatically today – no longer a ‘difficult’ stress fracture

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Summary table – key is to

think of itMEMORABLE QUOTES