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

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ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

An

unusual

stress

fracture:

Bilateral

posterior

longitudinal

stress

fracture

of

tibia

Melih

Malkoc

_,

_Ozgur

_Korkmaz

_,

_Tugrul

_Ormeci

_,

_Ismail

_Oltulu

_,

Mehmet

Isyar

_,

_Mahir

_{Mahirogulları}

a_{DepartmentofOrthopedicsandTraumatology,IstanbulMedipolUniversity,SchoolofMedicine,Turkey} b_{DepartmentofRadiology,IstanbulMedipolUniversity,SchoolofMedicine,Turkey}

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Articlehistory: Received24April2014

Receivedinrevisedform2June2014 Accepted2June2014

Availableonline11June2014 Keywords:

Tibialstressfracture Longitudinaltibialfracture

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INTRODUCTION:Stressfractures(SF)occurwhenhealthyboneissubjectedtocyclicloading,whichthe normalcarryingrangecapacityisexceeded.Usually,stressfracturesoccuratthemetatarsalbones, calcaneus,proximalordistaltibiaandtendstobeunilateral.

PRESENTATIONOFCASE:Thisarticlepresentsa58-year-oldmalepatientwithbilateralposterior longi-tudinaltibialstressfractures.A58yearsoldmalesufferingforpersistentleftcalfpainanddecreased walkingdistanceforlastonemonthandafterimagingstudiesposteriorlongitudinaltibialstressfracture wasdetectedonhislefttibia.Aftersixmonthsthepatientwasadmittedtoourclinicwiththesametype ofcomplaintsinhisrightleg.Allimagingmodalitiesandbloodcountswereperformedandasaresult longitudinalposteriortibialstressfracturesweredetectedonhisrighttibia.

DISCUSSION:Treatmentoftibialstressfractureincludesrestandmodifiedactivity,followedbyagraded returntoactivitycommensuratewithbonyhealing.Wehaveappliedthesametreatmentprotocoland ourresultswereacceptablebutourfollowuptimeshortforthisreasonourstudyisrestrictedforseparate stressfracturesoftheposteriortibia.

CONCLUSION:Althoughthemainlocalizationoftibialstressfractureswereunilateral,anteriorand trans-versepattern,rarely,likeinourcase,theunusualbilateralposteriorlocalizationandlongitudinalpattern canbeseen.

©2014TheAuthors.PublishedbyElsevierLtd.onbehalfofSurgicalAssociatesLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction

Stress fractures (SF) occur when healthy bone is subjected to cyclic loading, which the normal carrying range capacity is exceeded.1,2_{SFmostlyseenathletesormilitaryrecruitsbecauseof}

intensivephysicalexercise.2–4_{Usually,stressfracturesoccuratthe}

metatarsalbones,calcaneus,proximalordistaltibiaandtendstobe unilateral.1,2_{Inthisstudy,weaimedtoreporta58-year-oldmale}

patientwithbilateralposteriorlongitudinaltibialstressfractures.

2. Casepresentation

A58yearsoldmalesufferingforpersistentleftcalfpainand decreasedwalkingdistanceforlastonemonth.Hewas complain-ingtheprogressionofpainthroughonhisleftleg.Inhismedical historythere wasnochanges atthedailywalkingandexercise

∗ Correspondingauthorat:IstanbulMedipolUniversity,SchoolofMedicine, DepartmentofOrthopedicandTraumatology,TemAvrupaOtoyoluGoztepeCıkısi, No:1Bagcilar,34214Istanbul,Turkey.Tel.:+902124607777;fax:+902124607070.

E-mailaddress:[email protected](M.Malkoc).

habits for last one year.Localization of theprogressive pain is mostly posterior of the wholeleg and culf. The pain he suffer was existing both with motionand rest. He was checked and hadatherapyforchronicosteomyelitisforthreemonthsandno recoveryhasbeenacquired.Thestandardlastinfectiontitleshave beenstudiedsuchassedimentationrates,C-reactiveprotein,ASO, rheumatoid factor,white blood cellvalue, redblood cellvalue. Allthevaluesofthetestswerenormal.X-ray(Fig.1)and mag-neticresonanceimaging(MRI)(Figs.4and5)havebeenobtained andthree-phasedbonescintigraphywasstudied(Fig.6).Especially withMRIandbonescintigraphyposteriorlongitudinaltibialstress fracturewasdetectedonhislefttibia.Thepatientwasinstructedto restrictactivitytononweight-bearingexerciseforfourtosixweeks, followedbyaperiodofgradualincreaseinweight-bearing activ-ityandanti-inflammatorytreatmentapplied.Aftersixmonthsthe patientwasadmittedtoourclinicwiththesametypeofcomplaints in his rightleg. Allimaging modalities and blood counts were performedandasaresultlongitudinalposteriortibialstress frac-turesweredetectedonhisrighttibia(Figs.2,3and7)Thepatient wasinstructedtorestrictactivitytononweight-bearingexercise forfourtosixweeks,followedbyaperiodofgradualincreasein weight-bearingactivityandanti-inflammatorytreatmentapplied http://dx.doi.org/10.1016/j.ijscr.2014.06.002

2210-2612/© 2014TheAuthors.Published byElsevier Ltd.onbehalf of SurgicalAssociatesLtd. Thisis an openaccessarticle underthe CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Fig.1. Bilateralantero-posteriorX-raygraphyoftibias.

again.Attheendofsixweeks,patienthadpainlessandfree move-mentofthebothlowerextremity.14monthsoffollow-upperiod, patientgainedthepainfreeweight-bearingandfulloflegmotion. 3. Discussion

Sportsinjurieshavesignificantlyincreasedinfrequencyinthe pastfewyears,especiallyamongindividualswhoselevelofphysical fitnessisillsuitedtotheintensityortheverynatureofthe activ-ityundertaken.Althoughdataontheprevalenceofsportsinjuries seemtobedifficulttocollect,itisestimatedthatapproximately 6%ofthosewhoengageinsportsrequiremedicalcarefortheir injuries.5,6_{Themostcommonlocationsforstressfracturesarein}

Fig.2.TransverseMRIsectionofrighttibia.

Fig.3.CoronalMRIsectionofrighttibia.

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Fig.5. CoronalMRIsectionoflefttibia.

thetibia(23.6%),tarsalnavicular(17.6%),metatarsal(16.2%),fibula (15.5%), femur(6.6%), pelvis(1.6%), and spine (0.6%).7,8 _{A bone}

scanisasensitivemethodforearlydiagnosisofafatiguefracture. Theradioactivetracerisincorporatedintothecellsresponsiblefor boneremodellingwithin24hfollowingthefracture.However,this techniqueisnotsufficientlyspecificbecauseboneturnovercanbe increasedinawidevarietyofothersconditionsincludingtumours, infectionsorinflammations.8–10_{At3-DCT-scan,thebonerepair}

reactionappearsasbonysclerosissurroundingthelineoffracture. Insomestudies,thistechniqueisevenmoresensitiveandspecific

thanMRI.11,12_{Duetoitsmutiplanarcapabilitiesandhightissue}

contrast,MRIistheimagingmodalityofchoicefordiagnosingan SF.MRIissensitiveandspecific,revealingintramedullaryoedema, theperiostealreactionandthefractureline.

Khyetal.reporteda35yearsoldpatientpresentingwithpain inthemedialaspectofbothknees.Ultrasonography(USG) appear-ance and with clinicalfindings together,suggested a diagnosis ofsimultaneousbilateralfatiguefracture.AnMRIconfirmedthe diagnosisand thepatient’s symptoms resolvedwith rest.They reportedUSGmaybeausefulimagingtoolinthediagnosisofstress fracture.13_{InourcasewedidnotperformedUSGtoourpatient.}

Kilcoyneetal.wererandomizedthepatientswithtibialstress frac-tures topulsedultrasound orplacebo treatment.Theresultsof placeboversuspulsedultrasoundwerenodifferentwithrespectto healingtimeandreturntoduty.14_{Inourcase,restrictionof}

weight-bearingandanti-inflammatorymedicationwerelimitedthepain andincreasedtherangeofmotion.Liimatainenetal.treated sur-gically49anteriormid-tibialstressfracturesin45patientsduring theyears1985–2005.Allthepatientswereathletes,mainly run-ners.Themeanageofthepatientswas26years.34ofthefractures occurredinmenand15inwomen.Thefirstmethodoftreatment, anteromedialandlateraldrilling,wasusedin20operationsand thesecondmethod,laminofixation,in29operations.Surgical treat-mentwithlaminofixationprovedtobesuperiortotibialfracture sitedrilling.15_{Wetreatedourcasewithoutsurgeryandallthetibial}

stressfracturesaremidtibialinLiimatainenetal.studybutinour casethetibialstressfracturesarebilaterallyandintheposterior

Fig.7.Bonescanofrighttibia.

longitudinalformation.AccordingtovanderVelde’sstudythree patientssufferedfromexercise-relatedlowerlegpain,clinical fea-tures,andriskfactorsspecificforposteriortibialstressfracture. Diagnosiswasconfirmedforallthreeindividualsbyradiographic imaging.Treatmentincludedrestandmodifiedactivity,followed byagradedreturntoactivitycommensuratewithbonyhealing. Thisapproachwassuccessfulfortwooftheindividualsdiagnosed withposteriortibialstressfracture.Inthethirdindividual treat-mentrecommendationswerenot adheredto,resultingin three

separatestressfracturesoftheposteriortibiaover27months.16

Wehaveappliedthesametreatmentprotocolandourresultswere acceptablebutourfollowuptimeshortforthisreasonourstudyis restrictedforseparatestressfracturesoftheposteriortibia.

4. Conclusion

Althoughthemainlocalizationoftibialstressfractureswas uni-lateral,anteriorandtransversepattern,rarely,likeinourcase,the

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unusualbilateralposteriorlocalization and longitudinalpattern canbeseen.Themajorityoftibialstressfracturesareeffectively managewithanappropriatebalanceofrelativerestandtherapy withoutanysurgery.

Conflictofinterest None.

Funding None.

Ethicalapproval

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages. Authorcontributions

MelihMalkoc:studydesign;TugrulOrmeci:datacollectionand figurepreparation;Ozgur Korkmaz:writing;IsmailOltulu:data collection; Mehmet Isyar: datacollection; Mahir Mahirogulları: analysis.

Keylearningpoint

• Unusualandbilateralplacementoftibialstressfracture.

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