Multiple Tibial Insufficiency Fractures in the Same Tibia

Abstract

Stress fractures were first described by Briethaupt in 1855. Since then, there have been many discussions in the literature concerning stress fractures, which have been described in both weight-bearing and non-weight-bearing bones. Currently, the tibia is the most frequent location, but multiple stress fractures in the same tibia are rare. This paper presents an unusual case of a 60-year-old woman with multiple tibial stress fractures of spontaneous onset.Keywords stress fracture, tibia, multiple, aged population Case ReportA 60-year-old woman was seen and followed at our department for right leg pain. The medical history of this woman included multiple depression episodes, resection of a benign left breast cancer tumor, morbus Parkinson, thyroid dysfunction after intake of lithium, and rib fractures after a fall. Her medication chart mentioned an antidepressant (imipramine), analgetics (paracetamol and tramadol), her Parkinson medication (prolopa and levodopa), and a sleeping tablet (lormetazepam).Her initial symptoms of lower right leg pain with associated redness of the overlying skin were experienced since June 2005. She first consulted the department of neurology, where she was admitted for further investigation. An ultrasound was helpful to exclude deep-venous thrombosis. Radiographic images confirmed the absence of any osseous pathology. Empiric antibiotics (amoxicillin) for possible erysipelas were commenced, without any result. Evoked potentials as well as EMG were normal. Laboratory analyses showed slightly elevated LDH but normal CRP and sedimentation rates, normal calcium levels and alkaline phosphatise, and normal vitamin D and PTH levels. Kidney and liver functions were also within normal range. Discharge with NSAIDs and observation.Fourteen days after discharge, the patient was readmitted with immense pain, inability to walk, mild swelling of her lower leg, and redness. Ultrasound showed some edema in the lower leg, while radiography revealed slight periosteal reaction on the dorsal side of the distal tibial metaphysis (Figure 1). Magnetic resonance imaging (MRI) confirmed the edema of the distal half of the tibia with concomitant inflammation of the surrounding soft tissue (arrow). Additionally, the MRI showed a fracture line in the distal tibia (arrowhead; Figure 2). All the above-mentioned signs and findings were in favor of a stress fracture (insufficiency fracture); however, infection or any malignant pathology still had to be ruled out. To complete the technical investigation, a bone scan was performed. Hyperemia of the middle and distal tibia suggestive of osseous pathology was found, no evidence of malignancy, however indicative for stress fracture versus osteomyelitis (Figures 3 and 4). The latter was ruled out by a leucocyte scan and renewal of laboratory analysis, which were normal and comparative to previous results. The diagnosis of insufficiency fracture at multiple sites of the same tibia was determined, despite no evidence of trauma or raised activity level of any kind. Tr...

A repetitive spontaneous distal tibial insufficiency fracture: an unusual case report

“…A positive bone scan shows an increased uptake at the affected area. [2,5] Similarly, in our case, plain radiography showed typical course of the fracture and the diagnosis was able to be made on Day 15.…”

“…[1][2][3] Two types of SFs have been described according to etiology: fatigue fractures and insufficiency fractures. [5] A fatigue fracture occurs, when the healthy bone is exposed to abnormal muscular stress or torque. Many conditions leading an abnormal bone mineral content or elasticity such as osteoporosis, fibrous dysplasia, Paget's disease, rheumatoid arthritis, systemic lupus erythematosus, calcium pyrophosphate deposition and, diabetes mellitus may lead to the formation of insufficiency fractures.…”

“…In addition, heavy smoking, inhaled steroid use, and amenorrhea are the other predisposing factors. [3][4][5] Our case was working as a guard, before he got retired and he had no predisposing condition which would cause overloading of the distal tibia. However, osteopenia, vitamin D deficiency, the use of inhaled steroids, and heavy smoking may have led to a spontaneous distal tibial insufficiency fracture.…”

“…[2] Since plain radiographic findings may not be obvious initially, the delay from onset to diagnosis ranges from 15 days to 18 months. [5] Chronic stress leads to periosteal reaction and cortical thickening at the injury site, which make the fracture visible on the plain radiographs over time. A positive bone scan shows an increased uptake at the affected area.…”

“…[3] However, predisposing factors under normal stress include genetic factors, hormonal imbalances, metabolic bone disorders (i.e., osteoporosis, osteomalacia), liver and kidney failure, systemic diseases, rheumatic diseases, nutritional deficiencies, heavy smoking, and the use of medications which may cause osteoporosis. [3][4][5] Herein, we report a repetitive spontaneous distal tibial insufficiency fracture in the right and left distal tibia and discuss predisposing factors, diagnosis, and treatment in the light of the current literature.…”