Stress Fractures of the Foot

Anatomy of the Naviculocuneiform Joint Complex

Background

The purpose of this study was to quantify the articular surfaces of the naviculocuneiform (NC) joint to help clinicians better understand common pathologies observed such as navicular stress fractures and arthrodesis nonunions.

Methods

Twenty cadaver NC joints were dissected and the articular cartilage of the navicular, medial, middle, and lateral cuneiforms were quantified by calibrated digital imaging software. Statistical analysis included calculating the mean cartilage surface area dimensions of the distal navicular and proximal cuneiform bones. Length measurements on the navicular were obtained to estimate the geographic location of the interfacet ridges. Lastly, all facets of the articular surfaces were described in regard to the shape and location of cartilaginous or fibrous components. Results were compared using Student t tests.

Results

Navicular cartilage was present over 75.4% of the surface area of the proximal NC joint, compared with 72.6% of combined cuneiform cartilage distally. The mean height of the deepest (dorsal-plantar) measurement of navicular articular cartilage was 18 ± 3 mm. The mean heights of the distal medial, middle, and lateral cuneiform articular facets were 15 ± 1 mm, 17 ± 2 mm, and 15 ± 2 mm, respectively.

Conclusion

There is significant variation among the articular surfaces of the NC joint. Additionally, the central third of the navicular was calculated to lie in the inter-facet ridge between the medial and middle articular facets of the navicular.

Clinical Relevance

Surgeons may consider this study data when performing joint preparation for NC arthrodesis as cartilage was present to a mean depth of 18 mm at the NC joint. Additionally, this study demonstrates that the central third of the navicular, where most navicular stress fractures occur, lies in the interfacet ridge between the medial and middle articular facets of the navicular.

[Stress fractures in the military context]

BACKGROUND

Soldiers, especially as recruits, are exposed to significantly elevated stress patterns of the foot due to occupation-related marching and excessive running. This can lead to military-specific stress fractures of the metatarsals, i.e., marching fractures. The treatment and prevention of stress fractures are of particular importance in the military context due to the impact on operational capability and treatment costs. A uniform classification of these fractures does not yet exist.

OBJECTIVE

Review of stress fractures in the military setting with presentation of the incidence, risk factors, classification, treatment and prevention possibilities.

MATERIAL AND METHODS

A PubMed®-based review of the current literature on stress fractures in the military context was conducted and the results were discussed with a focus on specific military medical treatment options.

RESULTS

There are several possibilities to classify stress fractures, the most well-known being a 4-level magnetic resonance imaging (MRI)-based classification. Prevention and treatment possibilities are multifaceted but so far insufficiently validated.

CONCLUSION

Military-specific stress fractures should be grouped according to a 4-level and MRI-based classification. The treatment options include both conservative and surgical measures and should be implemented taking the patient's individual requirements into account. Preventive measures play a key role in the military context. They include the adaptation of screening tools, training and equipment and require continuous evaluation and development.

Treatment of Navicular Stress Fracture Accompanied by Os Supranaviculare: A Case Report

Navicular stress fractures (NSFs) are relatively uncommon, and predominantly affect athletes. Patients complain of vague pain, bruising, and swelling in the dorsal aspect of the midfoot. Os supranaviculare (OSSN) is an accessory ossicle located above the dorsal aspect of the talonavicular joint. There have been few previous reports of NSFs accompanied by OSSN. Herein we report the case of a patient with OSSN who was successfully treated for an NSF. A 34-year-old Asian man presented with a 6-month history of insidious-onset dorsal foot pain that occasionally radiated medially toward the arch. The pain worsened while sprinting and kicking a soccer ball with the instep, whereas it was temporarily relieved by rest for a week and analgesics. Plain radiographs of the weight-bearing foot and ankle joints revealed a bilateral, well-corticated OSSN. Computed tomography (CT) revealed a sagittally oriented incomplete fracture that extended from the dorsoproximal cortex to the center of the body of the navicular. The OSSN was excised and the joint was immobilized with a non-weight-bearing cast for 6 weeks, followed by gradual weight bearing using a boot. The 5-month follow-up CT scan demonstrated definite fracture healing. At the 1-year follow-up, the patient’s symptoms had resolved, the American Orthopedic Foot and Ankle Society midfoot score had improved from 61 to 95 points, and the visual analog scale pain score had improved from 6 to 0. We describe a rare case of NSF accompanied by OSSN. Because of the fracture gap and biomechanical properties of OSSN, OSSN was excised and the joint was immobilized, leading to a successful outcome. Further research is required to evaluate the relationship between NSFs and OSSN, and determine the optimal management of NSFs in patients with OSSN.

Vitamin D and Stress Fractures in Sport: Preventive and Therapeutic Measures-A Narrative Review

There are numerous risk factors for stress fractures that have been identified in literature. Among different risk factors, a prolonged lack of vitamin D (25(OH)D) can lead to stress fractures in athletes since 25(OH)D insufficiency is associated with an increased incidence of a fracture. A 25(OH)D value of <75.8 nmol/L is a risk factor for a stress fracture. 25(OH)D deficiency is, however, only one of several potential risk factors. Well-documented risk factors for a stress fracture include female sex, white ethnicity, older age, taller stature, lower aerobic fitness, prior physical inactivity, greater amounts of current physical training, thinner bones, 25(OH)D deficiency, iron deficiency, menstrual disturbances, and inadequate intake of 25(OH)D and/or calcium. Stress fractures are not uncommon in athletes and affect around 20% of all competitors. Most athletes with a stress fracture are under 25 years of age. Stress fractures can affect every sporty person, from weekend athletes to top athletes. Stress fractures are common in certain sports disciplines such as basketball, baseball, athletics, rowing, soccer, aerobics, and classical ballet. The lower extremity is increasingly affected for stress fractures with the locations of the tibia, metatarsalia and pelvis. Regarding prevention and therapy, 25(OH)D seems to play an important role. Athletes should have an evaluation of 25(OH)D -dependent calcium homeostasis based on laboratory tests of 25-OH-D₃, calcium, creatinine, and parathyroid hormone. In case of a deficiency of 25(OH)D, normal blood levels of ≥30 ng/mL may be restored by optimizing the athlete’s lifestyle and, if appropriate, an oral substitution of 25(OH)D. Very recent studies suggested that the prevalence of stress fractures decreased when athletes are supplemented daily with 800 IU 25(OH)D and 2000 mg calcium. Recommendations of daily 25(OH)D intake may go up to 2000 IU of 25(OH)D per day.

Navicular Stress Fractures

Navicular stress fractures are multifactorial injuries due to chronic overload on the navicular, particularly in young athletes. The navicular is subject to unique stresses and has a complex blood supply, making it susceptible to stress fractures and potentially delayed union or nonunion. Expeditious diagnosis is critical to prevent a delay in treatment and a poor outcome. Advanced imaging is essential in making the diagnosis and monitoring healing. Both nonsurgical and surgical treatments have demonstrated good results. Nonsurgical management consists of a period of immobilization and nonweight bearing, and surgical management typically involves open reduction and internal fixation. Patients need to be appropriately counseled regarding expectations for these challenging injuries.

Arthroscopically Assisted Internal Fixation of Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Patients undergoing fixation for foot and ankle fractures may experience poor outcomes despite achieving apparent anatomic reduction. Adjunct arthroscopy to identify missed concomitant injuries and subtle displacements has been proposed as a vehicle to enhance functional results for these patients. The purpose of this review is to provide an overview of the literature regarding arthroscopically assisted open reduction and internal fixation (AAORIF) methods for commonly encountered foot and ankle injuries including pilon, ankle, and calcaneus fractures published to date.

METHODS

A systematic review of the literature was performed using the PubMed database to access all studies reporting on arthroscopically assisted internal fixation methods for pilon, ankle, and calcaneus fractures. Relevant publications were analyzed for details on their respective study designs, the operative technique used, clinical outcomes, outcome instruments used, and reported complications.

RESULTS

A total of 32 studies were included in this review. Two studies on pilon fractures, a randomized controlled trial (RCT) and case series with a total of 243 patients, met inclusion criteria. Postoperative articular reductions, bone union, and Mazur scores were found to be significantly better for those using adjunct arthroscopy when compared to those with no arthroscopy use. Patient-reported outcomes were overall reported as excellent for most patients, with no difference in patient-reported outcomes reported in the RCT. For ankle fractures, a total of 17 studies comprising of 2 systematic reviews, 1 meta-analysis, 2 RCTs, 5 retrospective comparative studies, 6 case series, and 1 case-control study met inclusion criteria for this review. Results were mixed, though the overall consensus was that arthroscopy use may help to better visualize concomitant intra-articular injuries and is generally considered safe with at least comparable outcomes to conventional methods. For the calcaneus, 13 studies met the criteria. Two studies were review papers, 8 were case series, and 3 were retrospective comparative studies. A total of 308 patients with 316 fractures formed the basis of analysis. In general, the studies found comparable functional outcomes between with or without arthroscopy use, but found that anatomical reductions were significantly improved with the use of arthroscopy.

CONCLUSIONS

Arthroscopy shows promise as a valuable adjunct tool for internal fixation of foot and ankle fractures, though definitive conclusions as to its clinical significance have yet to be drawn because of limited evidence. Potential advantages related to the direct visualization of the fracture site and minimally invasive nature of arthroscopy were suggested throughout studies examined in this review. The presence of intra-articular pathology may lead to unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with an otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions with arthroscopy, therefore, has the potential to improve patient outcomes. To date, however, available literature has not shown that significant improvements in anatomical reductions and treatment of these intra-articular injuries provide any improvement in outcomes over standard fixation methods. Few prospective randomized controlled studies have been performed comparing these 2 operative techniques, rendering any suggestion that AAORIF improves clinical outcomes over traditional open fixation difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct prior to advocating for its routine use in patients.

Approaching Foot and Ankle Injuries in the Ambulatory Setting

Foot and ankle injuries account for a significant volume of primary care office visits each year. Given the incidence of injury and concern for long-term sequelae, it is imperative that primary care physicians familiarize themselves with commonly encountered foot and ankle injuries. Coupling a sound understanding of key anatomic structures with an appropriately gathered history can help to quickly narrow the differential diagnosis in this clinical presentation. This article focuses on key elements from the history and physical examination as well as provides a concise review of imaging modalities and recommended treatment strategies.

Is Use of Bone Cement for Treatment of Second Metatarsal Stress Fractures Safe? A Case Report

Metatarsal stress fractures are common injuries of the foot and can be a source of chronic pain without appropriate management. Conservative management is first line, but surgery may be indicated in athletes, cases of nonunion, and fractures of the fifth metatarsal. We report a case of a 34-year-old female who presented to clinic for intractable pain of the left foot secondary to a stress fracture of the left second metatarsal, which had been previously treated with injectable acrylic bone cement. Calcium sulfate hydroxyapatite cement has a multitude of applications in orthopedic surgery, but to our knowledge no studies have documented its use in the treatment of metatarsal stress fractures. Our findings suggest that injectable calcium sulfate hydroxyapatite cement is not a suitable stand-alone treatment in fractures of the second metatarsal.

Stress fracture of the second proximal phalanx of the foot in teenage athletes: Unrecognized location of stress fracture

Background

Adolescent athletes are a high-risk population for stress fractures. We report four cases of stress fractures of the second proximal phalanx, which had not been previously diagnosed as the location of the stress fracture of the foot, in teenage athletes.

Case report

All fractures were on the plantar side of the proximal phalangeal base, and the oblique images of the plain radiograph clearly depicted the fractures. Notably, three out of the four patients had histories of stress fracture of other locations. While three athletes with acute cases were able to make an early return to play with simple conservative management, the chronic case required surgical treatment for this rare injury.

Conclusion

Although a rare injury, it is important that clinicians be aware of this type of stress fracture, as a timely diagnosis can avoid the need for surgical treatment and allow an early return to play.

Metatarsal Stress Fractures

Metatarsal stress fractures are also called "march fractures" or "marcher's foot." They most commonly occur in the distal second and third metatarsals. The second and third metatarsals receive the majority of stress during ambulation and are less mobile compared with the other metatarsals. The predominant risk factor is excessive overuse with repetitive motions with little recovery time such as marching activities in the military. Any element that has a detrimental effect on bone density can predispose an individual to stress fractures. There is often a delay of 2 or more weeks from the onset of symptoms until visible fractures are able to be seen on radiographs. Initial treatment strategies involve rest, ice, nonweight bearing, and avoidance of exercise to prevent fracture displacement, nonunion, and other complications. Orthopedic referral will guide definitive care.

Tarsal navicular stress fractures

PURPOSE OF REVIEW

Navicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures.

RECENT FINDINGS

Various operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports. The author's preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.