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CURRENT CONCEPTS
Management of High-Risk Stress Fractures
Treatment decision-making for high-risk stress fractures should be based on radiographic findings with less consideration given to symptom severity. The immediate goal of treatment of a high-risk stress fracture is to avoid progression and get the fracture to heal. Typically this requires either complete elimination of loading of the site or surgical stabilization. Ideally while the fracture is healing, one works to avoid deconditioning of the athlete while minimizing the risk of a significant complication of fracture healing. While over-treatment of a low-risk stress fracture may result in unnecessary deconditioning and loss of playing time, under-treatment of a high-risk injury puts the athlete at risk of significant complications. In this case relative rest may be achieved with alternative training options such as aquatic training which may include an aquatic treadmill or suspended treadmill training.
The presence of a visible fracture line on a plain radiograph in a high-risk stress fracture should prompt serious consideration of operative management. If an incomplete fracture is present on plain films with evidence of fracture on MRI or CT in a high-risk location, immobilization and strict non-weight bearing is indicated. Worsening symptoms or radiographic evidence of fracture progression despite non- operative treatment is an indication for surgical fixation.
All complete fractures at high-risk sites should receive serious consideration for surgical treatment. In summary, surgical fixation should be considered for high risk stress fractures for several reasons. These include expediting healing of the fracture to allow earlier return to full activity as well as to minimize the risk of non-union, delayed union and re-fracture. Finally, surgical intervention may be necessary to prevent catastrophic fracture progression such as in the case of a tension-sided femoral neck fracture.
Return to Sports Participation
Generally in athletes, return to play should only be recommended after proper treatment and complete healing of the injury. Because of the significant complications associated with progression to complete fracture, it is not recommended that an individual be allowed to continue to participate in their activity with evidence of a high-risk stress fracture. Return to play decision-making for a low grade injury at a high-risk location should be predicated on the patient’s compliance level, healing potential, and risk of worsening of the injury. A key difference between a low- grade stress fracture at a high-risk location versus a low-risk location is that with the low-risk site the athlete or patient can be allowed to continue to train, whereas the high-risk site needs to heal prior to full return to activity.
Regardless of the grade and location, the risk of continued participation should be discussed with each athlete, and the management of each fracture should be individualized. Cross-training while resting from the inciting activity allows maintenance of cardiovascular fitness while decreasing stresses at the healing fracture site.
07 Return to participation should be a joint decision between the physician, athletic trainer, coach, and athlete. If a stress fracture is diagnosed in the non-competitive season, most athletes seek to achieve complete healing prior to return to training or competition. If the injury occurs at mid-season or in the championship season, elite athletes may limit the volume and intensity of their training while continuing to compete. Complete healing of the fracture is then sought
once the season is over.
Summary
Stress fractures are common injuries in highly active individuals. An understanding of the pathophysiology coupled with a clinically relevant classification system aids the clinician in their treatment decision-making. The authors’ suggest using the grade of the fracture and it’s location (high vs low risk) as the classification system for stress fractures. Stress fracture management and return to play considerations should employ a wholistic approach and be individualized to the patient taking into consideration injury site (low vs. high risk), grade (extent of structural failure), the individual’s activity level, competitive situation, and risk tolerance.
01 Table 1 02 Table 2 03 Fig 1
04 Fig 2 05 Fig 3 06 Fig 4 07 Fig 5
Anatomic Sites for High-Risk Stress Fractures Kaeding-Miller Stress Fracture Classification System Oblique radiograph of a healing nondisplaced Grade 3 distal fibular stress fracture in a 19 year old female military recruit. Callus formation is evident after 6 weeks of activity modification.
Nuclear bone scintigraphy image of a 22 year old male distance runner with ongoing distal thigh pain. A grade 2 stress fracture is present of the left distal femur.
Coronal CT scan of a Grade 5 tarsal navicular stress fracture in an 18 year old high school football player. Evidence of a nonunion is present.
Coronal T2 MRI of a 36 year old professional golfer with medial knee pain. A grade 3 stress fracture is present at the medial proximal tibia.
Lateral radiograph of the elbow of a 24 year-old semi- professional baseball pitcher with a displaced (Grade 4) olecranon stress fracture.
ISAKOS NEWSLETTER 2015: Volume I 27