Bony Stress Injuries of the Pelvis and Hip · 2018. 5. 22. · the pelvis, in abnormal bone •Bony...
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Bony Stress Injuries of the Pelvis and Hip Kenneth G. Swan, Jr., M.D. Clinical Assistant Professor Rutgers Medical School May 23, 2018
Transcript of Bony Stress Injuries of the Pelvis and Hip · 2018. 5. 22. · the pelvis, in abnormal bone •Bony...
Bony Stress Injuries of the Pelvis and HipKennethG.Swan,Jr.,M.D.ClinicalAssistantProfessor
RutgersMedicalSchool
May23,2018
• Nodisclosurestoreport
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STRESS FRACTURE SEMANTICS
• ”astressfractureisafatiguefractureofbonecausedbysubmaximalstress….”
• Maybedifferentthanastressreaction,whichisboneinflammation,seenonbonescanorMRI,showingreaction,oredema,butnocorticaldisruption.
• StressInjury termusedtoincludestressfracture,stressreaction,overuseinjuries,evengrowthenthesiopathies(OsgoodSchlatter’s,Sever’s)andtendonitis
• Bonystressinjury(BSI):newertermtoincludestressfractureandstressreactionspectrum
STRESS FRACTURE SEMANTICS II• FATIGUEFRACTURE(akaStressFracture)
– Abnormalstressonnormal(?)bone• “RuleofToos”
– TooMuch,TooSoon,TooFar,TooOften,TooIntense,Toolittlerest/recovery/sleep
– StressTriad:Somethingnew/different,somethingstrenuous,somethingrepetitive
• StressFracturesdonotonlyoccurinyoungathletes….
• INSUFFICIENCYFRACTURE– Normalstressonabnormalbone– Typicallyelderly,osteoporotic
INSUFFICIENCY FRACTURES• Normaleverydayactivitiescauseafracturein
mechanicallyweakbone– Lowbonequality,massorimpairedbonerepair
• Osteoporosismostcommon,butmanyadditionalcauses– Endocrineabnormalities(Cushing’sdisease,hyperPTH,renal
osteodystrophy)– VitaminDdeficiency– Nutrientmalabsorption(viaceliacdisease,lactose
intolerance,priorGIsurgery)– Medications(anti-seizuremeds,EtOH,chemotherapy,
Bisphosphonates)– RA,Diabetes– Post-radiationtherapy[topelvis]
Stress fracture
• “SandontheBeach”– Dailychurnofoceanandsand=Normalboneturnover– HurricaneSandy=Fracture– Suddenstorm,hightide=bonebruise– Severalstormsoverthewinter=Stress[fatigue]fracture
Stress fracture• Incidence:– Generalpopulation:1%– Runners:20%
– 90%ofstressFxs occurinthelowerextremities• Tibia>Foot>hip/pelvis>femur
– Morecommoninwomen– Morecommoninthepre-season– 21%seasonendinginjury(NCAA)
• Rizzone,JAthl Training2017
Potential Risk Factors for Stress Fracture (LEs)
EXTRINSICFACTORS• TrainingRegimen– Distance– Intensity– Season
• Nutrition– Diet– Supplements
• OralContraceptives• OtherMeds(CTSDs)
INTRINSICFACTORS• Gender• PriorHx stressFx• MenstrualCharacteristics• BMD• Dz
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RISK FACTORS: LE Stress Fracture in Runners
• Wright,BrJrSportsMed,2015• SystematicReview,Meta-analysis
• OnlyConsistentlySignificantRiskFactors:–PreviousHx ofStressFx– Femalegender
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Female Athlete Triad
THEN:
• Osteoporosis
• Amenorrhea
• EatingDisorder
NOW:
• PoorBoneHealth
• MenstrualDysfunction
• DecreasedEnergyAvailability
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Fractures, Menstrual Status and Bone Health
• Ackerman,Medicine&ScienceinSports&Exercise,2015• 175femaleathletesandnon-athletes,ages14-25yrsstudied,Retrospective• DXA,HRpQCT,Fx Hx,MenstrualHx,DietHx
• Findings:– WBathleticactivityincreasedBMD,butnotinthosewithmenstrualdysfunction(whoweresameasnon-athletes)
– WBathleticactivityincreasedFx riskinthosewithmenstrualdysfunction(47%)vsnormalathletes(25%)andnon-athletes(12.5%)
– Ageofmenarche** waslater,andBMIlowerinthosewithmenstrualdysfunction
– 26%ofoligoamenorrheic athleteshadhistoryofdisorderedeating(comparedto6%eumenorrheic and0%non-athletes)
– DespiteVit Dlevelssignificantlyhigherinoligoamenorrheicathletes!
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• FATIGUEFRACTURE(akaStressFracture)– Abnormalstressonnormal(?)bone
– OLIGOAMENORRHEICYOUNGATHLETESLACKBONEHEALTHBENEFITSOFWBEXERCISE
– BONEMICROARCHITECTURALANDSTRENGTHDIFFERENCESAREMOREPRONOUNCEDINAMENORRHEICATHLETESWHOEXPERIENCEDMULTIPLESTRESSFXS
• Ackerman,2015
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• Tenforde,AJSM,2018– “LowBMDinmaleathletesisassociatedwithbonestressinjuriesatanatomicsiteswithgreatertrabecularcomposition”
– LevelIII,Retrospectivereview
– ATHLETICSTRESSFRACTURESMAYNOTBEOCCURRINGABOUTNORMALBONE
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Vitamin D, Calcium Supplementation• Lappe J,JBoneMinerRes2008– RCT– FemaleNavyrecruits– 2000mgCalciumand800IUVit Dvsplacebo– 5201recruitsvolunteered;8weeksoftraining
• 309stressfractures(6%)• 20%fewerstressFxs insupplementgroup• Add’l findings:Amenorrhea,+Tobacco,Poorpre-Fitness,Progesterone-onlyOCPsotherRFs
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Femoral Neck Stress Fractures
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Femoral Neck Stress Fractures
• Seriousinjurythatmustnotbemissed• A“High-Risk”stressfracture• Typicallypresentswithgroinpain• Canpresentwithvagueanteriorthigh,evenisolatedkneepain!
• Completiontodisplacedfemoralneckfracturewillhaveseriousramificationsinayoungpatient
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AVASCULAR NECROSIS (AVN) HIP
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Hip AVN THR
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Femoral Neck Fracture Fixation
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Femoral Neck Stress Fx: Does Side Matter?
• TensionSide
• CompressionSide
• Transcervical
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Femoral Neck Stress Fx: Does Side Matter?
• TensionSide
• CompressionSide
• Transcervical
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Femoral Neck Stress Fx: Diagnosis
• History!!!• Physical– GroinpainwithPROM(Flex/IR)hip– Examinebothsides(b/l common)
• XRAYS– Oftennormal
• MRI– BetterthanbonescanorCT,butthoseareoptionsalso
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Femoral neck stress Fx: Treatment
• Transcervical fractureline:NWB,Wheelchair,ORtoday!
• Tensionsidefractureline:CanconsiderNWB,crutches,butrecommendOperativetreatment
• Compressionsidefractureline:ProtectedWB,closemonitoring
• StressRxn only:ProlongedActivityModificationmaybeenough
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Proposed MRI Grading System
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Rohena-Quinquilla,AJR, 2015
• GradeI • GradeII
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• GradeIII
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MRI Classification System?• Rohena-Quinquilla,AJR,2018• Retrospectivereview• GradesIandII=“LowGrade”• GradesIIIandIV=“HighGrade”– HighGradesignificantlylongerReturntoDutyvsLow
• GradesI,II,andIIItreatedconservatively,nonewentontofracture
• GradeIVtreatedwithscrewfixation– 11.5%ofptsrequiredORfixation
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Stress fractures of the pelvis• Sacrum• Rami• Symphysispubis• Iliacwing
• TypicallyduetobonyInsufficiency,ratherthanFatiguefracture
• Etiologywork-upappropriateasindicated
Risk Factors for Sacral Stress Fxs
INSUFFICIENCYFXs• Avg age>71• Osteoporosis• Hx ofpelvicradiationtx• RA• Long-termCTSDuse
Liong,BJR,2012Yoder, JMMT2015
FATIGUEFXs• Avg age25• Recentincreaseintraining
• Deficientdiet– Lowcaloricintake
• LowBMDseenin43%of“fatiguefxs”
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Stress Fx Sacrum• Lowbackpain,sometimesgroinpain• Tendernessaboutsacrum• +Patrick’stest(FABER)• Usuallynoneuro• Xrays typicallynegative• MRI+edemaorfractureline• SPECTcandetectsubtlestressreactions• Treatment:WBAT,meds,PT– Fatigue:Decreaseoffendingactivity– Insufficiency:Tx underlyingdisease(s)
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Avulsion Injuries Around the Pelvis
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• Apophysis:Secondarycenterofossificationthatcontributestosizeandshapeofabone,butnotlength– Usuallyfuseslaterthanphyses oflongbones– Siteofattachmentororiginofmuscles– Commonsiteofacuteandchronicinjuries(weaklink)
• Acuteinjuriesmayresultindisplacementofapophysisfragment– “…rapid,forcefuleccentriclateralflexionorrotationoftorsocausingexcessivestrainofabdominalmusculature”
– 13Xmorecommoninmalesthanfemales!• Chronicinjuriesassociatedwithongoingreparativeinflammation(apophysitis)
Apophyses - Pelvis• Iliaccrest– Externaland
Internalobliques,Transverseabdominus,Gluteusmuscles,TFL
• ASIS– Sartorius• AIIS– Rectus(direct
head)• Ischium– Hamstrings• Lessertuberosity--
Iliopsoas
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Apophyseal Injuries-- Pelvis• Presentation– Typicallysudden,severepaininadolescentathlete– Non-contactinjury– Mayhear/feela“pop”– Ambulationmaybeverydifficult– [butnotallpresentacutely---canpresentlikestressfracture]
– Exam:focaltenderness;difficultywithAROMaffectedmuscle
– Workupincludesxrays;Mayneedobliqueviewstoseetheinjury(ERfilmsmaybereadasNormal)
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ASIS AIIS
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Iliac Crest Apophyseal Fracture
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Iliac Crest Apophyseal Fracture
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Iliac Crest Stress Fracture
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Apophyseal Avulsion Injuries -- Pelvis
• Treatment– UsuallyNon-operative(foracuteorsubacute/stress)– Rest,PT,slowRTP,typically4-6weekslater– Operativetreatmentrarelyconsideredina)significantlydisplacedfractureavulsionsand/orb)chronicallysymptomaticavulsions
– NostrongEvidenceBasedGuidelines
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Take Home Points
• Insufficiencyfracturescommonlyoccuraroundthepelvis,inabnormalbone
• BonyStressInjuriesareaspectrumofoveruseconditionsinathletes,fromstressreactionstostressfractures.Bonemaybenormalorabnormal
• Femoralneckstressfracturescanbeanorthopaedic emergency
• MRIimagingmodalityofchoice
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ReferencesAckermanK,SokoloffN,Maffazioli G,etal.Fracturesinrelationtomenstural statusandboneparametersinyoungathletesMedicine& ScienceinSports&Exercise;2015:1577-1586
BehrensS,Deren M,MatsonA.Stressfracturesofthepelvisandlegsinathletes:areviewSportsHealth2012;165:165-174
Fernbach S,WilkinsonR. AvulsioninjuriesofthepelvisandproximalfemurAJR 1981;137:581-584
HerbertK,Laor T,EmeryK.MRIappearanceofchronicstressinjuryoftheiliaccrestapophysis inadolescentathletesAJR2008;1487-1492
KongC,InY,KimS,etal.Avulsionfractureoftheiliaccrestapophysis treatedwithopenreductionandinternalfixationJOrthop Trauma2011;25(6):e56-e58
Liong S,WhitehouseR.LowerextremityandpelvicstressfracturesinathletesBritishJournalofRadiology;2012:1148-1156
Rohena-Quinquilla I,Rohena-Quinquilla F,ScullyW,etal.Femoralneckstressinjuries:Analysisof156casesinaUSmilitarypopulationandproposalofanewMRIclassificationsystemAJR 2018;210:601-607
Tenforde A,Parziale A,PoppK,etal.Lowbonemineraldensityinmaleatheltes isassociatedwithbonestressinjuriesatanatomicsiteswithgreatertrabecularcompositionAmJSportsMed2018;46:30-36
YoderK,Bartsokas J,AverellK,etal.Riskfactorsassociatedwithsacralstressfractures:AsystematicreviewJManualandManipulativeTherapy2015;23(2):84-92
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THANK YOU!
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