Tibial Stress Fractures

 

 

Etiology

 

Repetitive high impact exercises

- athletes - runners / gynmasts / dancers / soccer players / basketball

- military

 

Predisposing factors

 

- female triad - amenorhea, disordered eating, low bone mineral density 

- nutritional deficiencies

- Vitamin D deficiency

 

Locations

 

Posteromedial cortex Anterior cortex Tibial plateau

 

Most common

 

4% of tibial stress fractures  

 

Compression side

Better prognosis

 

Tension side

More problematic

May develop dreaded black line / fracture

 

 

Signs

 

Pain with activity

Point tenderness on tibia

 

Differential diagnosis

 

Shin splints / medial tibial stress syndrome

- medial tibial periosteitis

 

Exertional compartment syndrome

 

Xray

 

Cortical thickening

 

Look for "dreaded black line" - sign of fracture

 

Tibial Stress FractureTibial Stress Fracture 2

Periosteal thickening with possible "dreaded black line"

 

Tibial Stress Fracture

Anterior cortical thickening with dreaded black line

 

Bone scan

 

Posteromedial Tibial Stress Fracture

Increased uptake tibial plateau

 

MRI

 

MRI stressMRI tibia stress

 

Fredericson Classification of Medial Tibial Stress Fractures on MRI

 

Grade 1:  Periosteal edema

Grade 2:  Bone marrow edema on T2

Grade 3:  Bone marrow edema on T1 and T2

Grade 4a: Intra-cortical stress changes

Grade 4b: Frank tibial stress fracture

 

CT

 

CT stressCT stress

 

Nonoperative management

 

Options

 

Rest

Air cast brace

Extra-corporeal shock wave

Low intensity pulsed ultrasound / Exogen /bone stimulator

 

Air cast brace

 

Allen et al Military Med 2004

- RCT of 31 patients with tibial stress fracture air cast v no air cast

- no difference in outcomes

 

Low intensity pulsed ultrasound

 

Results

 

Ditmars et al Pediatr Radiol 2020

- 42 tibial stress fractures < 19

- mean return to play with no pain 55 days

- no correlation to Fredericson grading

 

Schundler et al Arthrosc Sports Med 2023

- systematic review of operative v nonoperative management tibial stress fractures

- 22 studies and 340 patients

- failure rate nonoperative: 0 - 25%

- failure rate operative: 0 - 6%

 

Operative Management

 

Indication

 

High risk - anterior stress fractures

 

Options

 

Intra-medullary nail

Anterior tension band plating

 

Liimatainen et al Scand J Surg 2009

- drilling of stress fracture in 20 patients

- union rate 50%

- fixation union rate 93%

- isolated drilling not recommended

 

Anterior tension band plating

 

Technique

 

Fluoroscopy to identify fracture

- debride fracture +/- bone graft

- anterolateral 3.5 mm dynamic compression plate

 

Results

 

Intramedullary nail

 

Chang et al AJSM 1996

- five cases of chronic tibial stress fractures in military treated with IM reamed nail

- minimum 1 year nonoperative treatment

- 2 excellent results (unlimited pain free running)

- 3 good results (occasional pain with vigorous exercise)

 

Varner et al AJSM 2005

- 7 athletes with chronic tibial stress fracture treated with IM reamed nail

- symptoms 1 year, nonoperative treatment 4 months

- return to sport by 4 months

- one patient developed bursitis at nail insertion site which settled with HCLA

- one patient developed a distal tibial traumatic fracture which healed non operatively

 

Anterior tension band plating

 

Zbeda et al AJSM 2015

- 13 athletes undergoing anterior plating for chronic tibial stress fractures

- return to training 11 weeks

- 92% return to competition

- 38% required plate removal

 

IM nail v anterior plate

 

Randall et al Arch Orthop Trauma 2025

- systematic review of IMN v plate

- 8 studies and 37 athletes

- nail: return to sport 100%, mean time 20 weeks, 14% chronic anterior knee pain

- plate: return to sport 95% (19/20, mean time 11 weeks, 30% hardware removal