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Int Orthop. 2009 April; 33(2): 585.
Published online 2008 August 12. doi:  10.1007/s00264-008-0635-7
PMCID: PMC2899052

Dilemma in stress fractures

We read with interest the article by Fottner et al. [3], concerning stress fractures presenting as tumours, where the authors described pain as the first symptom as well as the index finding for their inclusion criteria. But it is worth mentioning that atypical presentations of stress fractures are known and pain may be preceded by swelling/fullness or other signs of inflammation [1, 5].

The article emphasises the detection of a fracture line either on MRI or CT to differentiate between a tumourous condition and a stress fracture. Cortical abnormalities or fatigue lines only appear in advanced stages of stress fractures (Fredericson’s MR imaging classification of osseous stress injury; grade 4) and are not present in early grades 1–3 [4], where the diagnosis is primarily clinical. Moreover, as the authors have themselves mentioned, pathological fractures in tumour lesions do occur and in such cases the diagnostic dilemma deepens. Correlation to the clinical setting, sequential radiographs, and a careful study of the fracture characteristics (fracture line continuous with the cortex, extending into the intramedullary space, orientated perpendicular to the cortex and the major weight-bearing trabeculae [2]) help avoid this pitfall.

Footnotes

Concerning the article by Fottner A, Baur-Melnyk A, Birkenmaier C, Jansson V, Dürr HR (2008) Stress fractures presenting as tumours: a retrospective analysis of 22 cases. Int Orthop. doi:10.1007/s00264–007–0488–5.

A reply on this paper is available at doi:10.1007/s00125-008-1040-x.

References

1. Daffner RH, Martinez S, Gehweiler JA, Harrelson JM. Stress fractures of proximal tibia in runners. Radiology. 1982;142:63–65. [PubMed]
2. Deutsch AL, Coel MN, Mink JH. Imaging of stress injuries to bone: radiography, scintigraphy, and MR imaging. Clin Sports Med. 1997;16:275–90. doi: 10.1016/S0278-5919(05)70022-3. [PubMed] [Cross Ref]
3. Fottner A, Baur-Melnyk A, Birkenmaier C, Jansson V, Dürr HR (2008) Stress fractures presenting as tumours: a retrospective analysis of 22 cases. Int Orthop. doi:10.1007/s00264–007–0488–5 [PMC free article] [PubMed]
4. Fredericson M, Bergman G, 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;23:472–481. doi: 10.1177/036354659502300418. [PubMed] [Cross Ref]
5. Lam HS, Wong WC. Stress fracture of tibia that simulates malignancy: a case report. J Hong Kong Med Assoc. 1993;45(4):302–304.

Articles from International Orthopaedics are provided here courtesy of Springer-Verlag