Diagnostic Imaging Pathways - Stress Fracture (Suspected)
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This pathway provides guidance on the imaging of adult patients with suspected stress fractures.
Date reviewed: August 2013
Date of next review: 2017/2018
Published: August 2013
Quick User Guide
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Suspected Stress Fracture Image 1a (Plain Radiography): Normal x-ray in 18 yo male with medial tibial pain. |
| 1b |  |
Image 1b (Bone Scan): Delayed phase of bone scan showing focal uptake in the posteromedial cortex typical of a stress fracture (arrow). |
Teaching Points
Teaching Points
- Plain radiographs are the initial imaging modality of choice, but are limited due to their inability to detect bony changes early in the development of a stress fracture
- Early radiographs are often normal. Consider repeat plain radiography at 10-14 days
- MRI is the most sensitive and specific investigation to diagnose a stress fracture when radiographs are normal or equivocal and can best evaluate for other differential diagnoses
- Scintigraphy has high sensitivity for stress fracture but poorer specificity, and is associated with ionising radiation exposure. It is an alternative when MRI is contraindicated or unavailable
- CT can be helpful as an alternative to MRI to demonstrate bony changes but is less sensitive
xray
Plain Radiographs
- Initial imaging modality of choice for detection of suspected stress fractures 3
- Highly specific (~96%) but poorly sensitive (~56%), limiting accuracy (~67%) 4
- When plain radiographs demonstrate changes consistent with stress fracture, such as linear cortical radiolucency or localised periosteal reaction 5-7, no further imaging is indicated 3
- Early radiographs are often normal or nonspecific. The lag time between manifestation of initial symptoms and detection of radiographic findings ranges from 1 week to several months 8
- Radiographs may be negative initially in 60-90% of patients and remain negative in 40-60% of stress fractures 5-7,9
- If the plain radiographs are normal or non-diagnostic, options include
- Treat the patient for a presumed fracture and repeat radiography in 2-3 weeks. The American College of Radiology Expert Panel suggest repeat radiography in 10-14 days 3
- If definitive diagnosis is needed, further investigate with MRI (preferred over bone scan due to higher specificity and absence of ionising radiation)
mri
Magnetic Resonance Imaging
- Comparable sensitivity and superior specificity to that of bone scan for detection of bone abnormalities 4,7,15-20
- Aids in differentiating pathologic fractures from stress and insufficiency fractures 21 and superior soft tissue visualisation aids in differential diagnosis of pain
- Multiple classification systems for stress fractures have been developed to evaluate stress fractures and a ‘gold standard’ is yet to be developed 22 Two four-stage grading scales using MRI have been published
- Arendt and Griffiths’ scale has been used for the femur, tibia, fibular, navicular, calcaneus and forefoot and has prognostic implications regarding time of healing 23
- Fredericson and colleagues’ scale was developed using tibia data, and found presence of a fracture or cortical abnormality opposed to oedema alone predicted a longer symptomatic period in runners. 7 These findings were not replicated in a more heterogeneous study population 24
threephase
Three-Phase Bone Scintigraphy
- A radiotracer (e.g. 99-Technetium-MDP) is injected into a vein after which a series of images are taken immediately (dynamic phase, demonstrating perfusion to a lesion), shortly after the injection (blood pool phase) and again 3-4 hours later (demonstrating relative bone turnover associated with a lesion)
- High sensitivity (~100%) for stress fractures. 4,12,25,26 80% of all fractures show some scan abnormality 24 hours post-injury and 95% at 72 hours. 26 Classical findings include focally intense and fusiform cortical uptake
- The addition of SPECT to planar scintigraphy improves accuracy 27
- Less specific than MRI. False positives can occur in osteoid osteoma, osteomyelitis, or metastatic disease 4,17
- Not as useful in follow-up care as uptake can persist for months after clinical healing 28
- Due to the radiation exposure and poorer specificity, the role of bone scintigraphy should be reserved to exclude a radiographically occult fracture in patients unable to undergo MRI or after an inconclusive MRI examination 19
ct
Computed Tomography
- Less sensitive than bone scintigraphy or MRI in the detection of stress fractures 17,29,30, but may better define an abnormality discovered with another modality 13 and have played a role in the diagnosis of longitudinal fractures 31
- CT may occasionally depict osteopaenia, the earliest finding of a cortical stress injury, in symptomatic patients with normal MRI findings17
- May be useful in follow-up evaluation of healing in radiographically-occult fractures
Ultrasound
- While less accurate than MRI, use of ultrasound to evaluate stress fractures in the metatarsal bones has been evaluated with a reported 83% sensitivity and 76% specificity, compared to MRI as the gold standard 32
- Performance has been poor in more common sites of stress fracture 33,34
- Further studies are needed to determine the role of ultrasound in the evaluation of stress fracture
References
References
Date of literature search: April 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Boden BP, Osbahr DC. High-risk stress fractures: evaluation and treatment. J Am Acad Orthop Surg. 2000;8(6):344-53. (Review article)
- Kaeding CC, Yu JR, Wright R, Amendola A, Spindler KP. Management and return to play of stress fractures. Clin J Sport Med. 2005;15(6):442-7. (Review article)
- Expert Panel on Musculoskeletal Imaging:, Daffner RH, Weissman BN, Appel M, Bancroft L, Bennett DL, et al. ACR appropriateness criteria: stress (fatigue/insufficiency) fracture, including sacrum, excluding other vertebrae. American College of Radiology; 2011 [cited 2013 April 1]. (Evidence based guideline) View the reference
- Kiuru MJ, Pihlajamaki HK, Hietanen HJ, Ahovuo JA. MR imaging, bone scintigraphy, and radiography in bone stress injuries of the pelvis and the lower extremity. Acta Radiologica. 2002;43(2):207-12. (Level II/III evidence)
- Kijowski R, Choi J, Mukharjee R, de Smet A. Significance of radiographic abnormalities in patients with tibial stress injuries: correlation with magnetic resonance imaging. Skeletal Radiol. 2007;36(7):633-40. (Level III evidence)
- Giladi M, Ziv Y, Aharonson Z, Nili E, Danon YL. Comparison between radiography, bone scan and ultrasound in the diagnosis of stress fractures. Mil Med. 1984;149(8):459-61. (Review article)
- Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners - correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472-81. (Level III evidence)
- Anderson MW, Greenspan A. Stress fractures. Radiology. 1996;199(1):1-12. (Review article)
- Zwas ST, Elkanovitch R, Frank G. Interpretation and classification of bone scintigraphic findings in stress fractures. J Nucl Med. 1987;28(4):452-7. (Level III evidence)
- Geslien GE, Thrall JH, Espinosa JL, Older RA. Early detection of stress fractures using 99mTc-polyphosphate. Radiology. 1976;121(3 Pt. 1):683-7. (Level III evidence)
- Greaney RB, Gerber FH, Laughlin RL, Kmet JP, Metz CD, Kilcheski TS, et al. Distribution and natural history of stress fractures in United States marine recruits. Radiology. 1983;146(2):339-46. (Level II evidence)
- Courtenay BG, Bowers DM. Stress-fractures - clinical features and investigation. Med J Aust. 1990;153(3):155-6. (Level IV evidence)
- Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloydsmith DR, Macintyre JG. Stress fractures in athletes - a study of 320 cases. Am J Sports Med. 1987;15(1):46-58. (Level III evidence)
- Prather JL, Nusynowitz ML, Snowdy HA, Hughes AD, McCartney WH, Bagg RJ. Scintigraphic findings in stress fractures. J Bone Joint Surg Am. 1977;59(7):869-74. (Level III/IV evidence)
- Shin AY, Morin WD, Gorman JD, Jones SB, Lapinsky AS. The superiority of magnetic resonance imaging in differentiating the cause of hip pain in endurance athletes. Am J Sports Med. 1996;24(2):168-76. (Level III evidence)
- Rizzo PF, Gould ES, Lyden JP, Asnis SE. Diagnosis of occult fractures about the hip - magnetic-resonance imaging compared with bone-scanning. J Bone Joint Surg Am. 1993;75A(3):395-401. (Level II evidence)
- Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553-61. (Level II evidence)
- Deutsch AL, Mink JH, Waxman AD. Occult fractures of the proximal femur - MR imaging. Radiology. 1989;170(1):113-16. (Level III evidence)
- Dobrindt O, Hoffmeyer B, Ruf J, Seidensticker M, Steffen IG, Zarva A, et al. MRI versus bone scintigraphy. Evaluation for diagnosis and grading of stress injuries. Nuklearmedizin. 2012;51(3):88-94. (Level II/III evidence)
- Ishibashi Y, Okamura Y, Otsuka H, Nishizawa K, Sasaki T, Toh S. Comparison of scintigraphy and magnetic resonance imaging for stress injuries of bone. Clin J Sports Med. 2002;12(2):79-84. (Level III evidence)
- Fayad L, Kawamoto S, Kamel I, Bluemke D, Eng J, Frassica F, et al. Distinction of long bone stress fractures from pathologic fractures on cross-sectional imaging: how successful are we? AJR Am J Roentgenol. 2005;185(4):915-24. (Level II/III evidence)
- Miller T, Kaeding CC, Flanigan D. The classification systems of stress fractures: a systematic review. Phys Sportsmed. 2011;39(1):93-100. (Level I/II evidence)
- Arendt EA, Griffiths HJ. The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes. Clin Sports Med. 1997;16(2):291-306. (Review article)
- Yao L, Johnson C, Gentili A, Lee JK, Seeger LL. Stress injuries of bone: analysis of MR imaging staging criteria. Acad Radiol. 1998;5(1):34-40. (Level III evidence)
- Shikare S, Samsi AB, Tilve GH. Bone imaging in sports medicine. J Postgrad Med. 1997;43(3):71-2. (Level IV evidence)
- Matin P. Appearance of bone scans following fractures, including immediate and long-term studies. J Nucl Med. 1979;20(12):1227-31. (Level II evidence)
- Bryant LR, Song WS, Banks KP, Bui-Mansfield LT, Bradley YC. Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. 2008;191(4):1010-5. (Level III evidence)
- Diehl J, Best T, Kaeding C. Classification and return-to-play considerations for stress fractures. Clin Sports Med. 2006;25(1):17-28, vii. (Review article)
- Groves AM, Cheow HK, Balan KK, Housden BA, Bearcroft PWP, Dixon AK. 16-Detector multislice CT in the detection of stress fractures: a comparison with skeletal scintigraphy. Clin Radiol. 2005;60(10):1100-5. (Level III evidence)
- Cabarrus MC, Ambekar A, Lu Y, Link TM. MRI and CT of insufficiency fractures of the pelvis and the proximal femur. AJR Am J Roentgenol. 2008;191(4):995-1001. (Level III evidence)
- Shearman CM, Brandser EA, Parman LM, El-Khoury GY, Saltzman CL, Pyevich MT, et al. Longitudinal tibial stress fractures: a report of eight cases and review of the literature. J Comput Assist Tomogr. 1998;22(2):265-9. (Review article)
- Banal F, Gandjbakhch F, Foltz V, Goldcher A, Etchepare F, Rozenberg S, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 2009;36(8):1715-9. (Level III evidence)
- Boam WD, Miser WF, Yuill SC, Delaplain CB, Gayle EL, MacDonald DC. Comparison of ultrasound examination with bone scintiscan in the diagnosis of stress fractures.. J Am Board Fam Pract. 1996;9(6):414-7. (Level III evidence)
- Schneiders AG, Sullivan SJ, Hendrick PA, Hones BDGM, McMaster AR, Sugden BA, et al. The ability of clinical tests to diagnose stress fractures: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2012;42(9):760-71. (Level I evidence)
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