Stress fractures in children: a review of 37 cases

Healing of patellar fractures in two kittens

Two kittens aged between four and five months were presented having sustained patellar fractures. In both cases, healing was subsequently documented radiographically; this has not been reported previously in the literature.

One kitten had bilateral patellar fractures – the symptomatic right stifle was treated with a pin and tension-band-wire which later failed, at which point partial patellectomy was performed. The fracture of the left patella was minimally displaced and was treated conservatively. A radiograph of the left patella taken eleven months after initial presentation showed complete healing of the fracture. The second case was treated surgically with a circumferential wire; healing of the fracture was demonstrated radiographically at twelve weeks postoperatively. Radiographic images taken five weeks postoperatively had shown some narrowing of the fracture gap.

These two cases demonstrate that bony union of patellar fractures can be documented, given a long enough duration of radiographic follow-up; circumferential wire was an effective treatment in a displaced fracture, and conservative treatment resulted in complete healing of a minimally displaced fracture.

Femoral Neck Stress Fractures in Children Younger Than 10 Years of Age

BACKGROUND

Femoral neck stress fractures are rare in healthy children, with only 9 cases previously reported. The present article reviews our institutional experience with femoral neck stress fractures in children younger than 10 years of age, to highlight the unique features of this condition.

METHODS

We undertook a retrospective review of clinical records of patients who had been treated at our institution for an idiopathic femoral neck stress fracture between 2000 and 2014. To focus on children rather than adolescents, the World Health Organization's definition of adolescent as a person between 10 and 19 years of age was used; we thereby limited our analysis to patients younger than 10 years of age.

RESULTS

The study included 6 patients (3 males, 3 females) treated for an idiopathic femoral neck stress fracture, with a mean age at diagnosis of 7.7 years (range, 5.2 to 8.9 y). All patients presented with a limp, which worsened with activity and had persisted for a mean of 5 weeks (range, 2 to 9 wk). None of the patients had experienced an increase in activity level or sporting volume before symptom onset. On examination, 3 patients experienced pain with terminal hip flexion and 3 patients demonstrated pain-free hip range of motion. Plain radiography demonstrated inferior femoral neck cortical disruption, suggesting a compression-type stress fracture mechanism. The diagnosis was confirmed by cross-sectional imaging in all cases. All patients were initially treated with 6 to 8 weeks of non-weight-bearing followed by 4 to 6 weeks of partial weight-bearing, leading to complete healing in 4 patients. Two patients demonstrated incomplete healing and were managed with spica casting for an additional 6 weeks.

CONCLUSIONS

Our case series illustrates the unique features of this rare condition in children, with a history and examination profile distinct from those of adolescents and adults. Compliance with weight-bearing restrictions is difficult in this population and hip spica casting may be required to permit complete healing.

LEVEL OF EVIDENCE

Level IV-case series.

False-positive In-111 DTPA octreotide scintigraphy in bilateral tibial insufficiency fracture

We present a case of bilateral tibial insufficiency fracture in which indium (In)-111 diethylenetriamine pentaacetic acid (DTPA) octreotide scan showed increased activity in the region of the fracture. The scan was performed in a 5-year-old girl with severe refractory hypertension and elevated plasma metanephrines for evaluation of possible neuroendocrine tumor. Octreotide scan is usually positive in neuroendocrine and some other tumors but also shows positive results in a number of other conditions. However insufficiency fracture has not been reported as a positive finding on octreotide scan in children. This may relate to the expression of somatostatin membrane receptor in activated white blood cells or expression of somatostatin receptors by bone cells.

Intra-epiphyseal stress injury of the proximal tibial epiphysis: preliminary experience of magnetic resonance imaging findings

Stress induced injuries affecting the physeal plate or cortical bone in children and adolescents, especially young athletes, have been well described. However, there are no reports in the current English language literature of stress injury affecting the incompletely ossified epiphyseal cartilage. We present four cases of stress related change to the proximal tibial epiphysis (PTE) along with their respective magnetic resonance imaging (MRI) appearances ranging from subtle oedema signal to a pseudo-tumour like appearance within the epiphyseal cartilage. The site and pattern of intra-epiphyseal injury is determined by the type of tissue that is affected, the maturity of the skeleton and the type of forces that are transmitted through the tissue. We demonstrate how an awareness of the morphological spectrum of MRI appearances in intra-epiphyseal stress injury and the ability to identify concomitant signs of stress in other nearby structures can help reduce misdiagnosis, avoid invasive diagnostic procedures like bone biopsy and reassure patients and their families.

Femoral neck stress fracture in children: a case report, up-to-date review, and diagnostic algorithm

Stress fracture of the femoral neck in skeletally immature individuals is a rare condition and generally seen as compressive type. Because the condition may lead to disastrous complications, femoral neck stress fracture must also be kept in mind in the differential diagnosis of pediatric hip pain. We present a case of compressive-type stress fracture of the femoral neck in a 10-year-old girl with left hip pain that was sustained for 4 weeks and emphasize the difficulty of early diagnosis with only a radiographic evaluation and put forward an algorithm for diagnosis and treatment.