This has been a highly informative discussion for me. I have a query
though. I have a patient whom I am absolutely convinced has a stress
fracture to the anterior crest of the right tibia. Plain films have shown
nothing and I wonder if anyone knows just how reliable the plain films are,
especially in terms of false negatives.
Many thanks
Dave Cashley
----------
>From: Ben Yates <[log in to unmask]>
>To: [log in to unmask]
>Subject: Re: anterior tibial pain
>Date: Mon, Aug 19, 2002, 2:22 am
>
>Kevin you wrote:
>Grahame wrote:
>><<Sounds like a stress fracture to me also - plain film first then MRI would
>>be
>>more helpful than bone scan.>>
>>
>>The problem with the approach that Grahame mentions above is that both the
>>plain film radiograph and MRI are likely to be negative unless there is
>>actually a stress fracture in the tibia. However, the bone scan has enough
>>sensitivity to detect periostitis (or a "pre-stress fracture") which may be
>>difficult or impossible to detect on plain films or MRI. In addition, the
>>bone scan is about 1/2 to 1/3 the cost of an MRI here in the US.
>>
>>Cheers,
>>
>>Kevin
>Both MRI and bone scans can be used to detect both stress fractures and
>bone stress reactions such as medial tibial stress syndrome or anterior
>tibial stress syndrome. The problem is that both techniques can produce
>both false positive and false negative results.
>There are grading systems for both MRI and bone scans for medial tibial
>stress syndrome based upon the appearance of the scans. Pre stress
>fractures show up as marrow oedema on an MRI, best seen in a T2 image.
>As for the diagnosis I would agree with you that this is likely to be
>heading towards a stress fracture.
>Andrew most tibial stress fractures occur on the posterior medial border
>and are graded as low risk stress fractures because they heal easily with
>rest. Tibial Stress fractures on the anterior crest are high risk due to
>the very high incidence of non-union. They often require bone grafting or
>intramedullary nailing and can take 6-9 months to heal.
>If the pain is localised to a 1-2.5 cm area on the bone then it is likely
>to be a stress fracture. Stress reactions like MTSS usually cover at least
>5cm area of the bone. If his pain persists I would recommend getting either
>scan done. If it an anterior crest stress # put him in a non weight bearing
>BK cast for 6 weeks. If a stress # elsewhere then relative rest as Kevin
>suggests or place him in a CAM walker. Post # treatment obviously requires
>addressing the risk factors which produced the fracture whether this is
>biomechanical or other.
>
>For those interested in imaging techniques for shin splints you might be
>interested in the references below.
>
>6. Arendt EA, Griffiths HJ: The use of MR imaging in the assessment and
>clinical management of stress reaction in high performance athletes. Clin.
>Sports Med. 16:291-306, 1997
>
>7. Bachmann-Nielsen M, Hansen K, Holmer P, et al: Tibial periosteal
>reaction in soldiers. Acta Orthop. Scand. 62:531-534, 1991
>
>8. Batt M, Ugalde V, Anderson M, et al: A prospective controlled study of
>diagnostic imaging for acute shin splints. Med Sci Sports Exercise.
>30:1564-1571, 1998
>3. Anderson MW, Greenspan A: Stress fractures. Radiology. 199: 1-12, 1996
>
>4. Anderson M, Ugalde V, Batt M, et al: Shin splints: MR Appearance in a
>Preliminary Study. Radiology. 204:177-180, 1997
>
>55. Zwas ST, Elkanovitch R, Frank G: Interpretation and classification of
>bone scintigraphic findings in stress fractures. J Nucl Med. 28:452-457,
>1987
>
>Cheers
>Ben
>
>
>
>
>
>>*****************************************************
>>Kevin A. Kirby, DPM
>>Assistant Clinical Professor of Biomechanics
>>California College of Podiatric Medicine
>>
>>Private practice:
>>107 Scripps Drive, Suite #200
>>Sacramento, CA 95825
>>
>>Voice: (916) 925-8111 Fax: (916) 925-8136
>>e-mail: [log in to unmask]
>>*****************************************************
>>
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>>
>Ben Yates MSc, BSc (Hons), FCPod (Surg)
>Head of Podiatry & Podiatric Surgeon
>La Trobe University
>Melbourne, 3086
>Victoria
>Australia
>Tel: + 61 3 9479 5839
>Fax: + 61 3 9479 5784
>
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