Osteopenia

Stress Fractures CT Bone Densitometry in patients

with Multiple Stress Fractures: Preliminary Data

LT Rowland J. Rivero, DO

LCDR Richard G. Schuster, DO

LT Sean Swiatkowski, DO

LT Philip D. Davis, PA-C

LT John J. Kim, DPM

CDR (RET) David Petty, MD

James Kedrow, PA-C

Art Studabaker, DPM

Sports Medicine and Rehabilitation Therapy Clinic

Agenda

•  Stress Fractures –  History –  Types –  Causes –  Diagnoses

•  History •  Physical Exam •  Radiographs

–  Treatment

•  CT Bone Density In Patients with Multiple Stress Fractures

History of Stress Fractures

•  1855 Britehaup, German Military Surgeon – Foot Swelling after marching – “Inflammation of the Tendon Sheath”

•  1897 Stechhow – Classified first stress fracture of a metatarsal

Stress Fracture: AKA •  March Foot •  March Fracture •  Fatigue Fracture •  Spontaneous Fracture •  Crack Fracture •  Pseudofracture •  Deutschländer’s Disease •  Pied Force

Stress Fracture Types

•  Fatigue Fractures – Abnormal Stress on normal bone –  Increased activity – Repeated activity

•  Insufficiency Fractures – Normal Stress on Abnormal Bone – Osteoporosis – Disease States

Causes of Stress Fractures

•  Compressive Forces: Wt Bearing Areas – MTP, Tib Plafond, Fem. Condyles

•  Tensile Forces: Areas under tension on Wt. Bearing – Lateral Femoral Neck – Anterior Tibia – Pubic Ramus

Stress Fracture

Diagnosis

History

•  Pain with Insidious Onset •  3-4 weeks of symptoms •  Resolves with rest •  Progressively longer intervals for pain to

resolve

Physical Exam

•  Point Tenderness at site of fracture •  NO Physical Deformity

– May have redness and swelling at site •  +/- pain with vibratory/percussion initiated

distal to fracture site •  +/- Fulcrum •  +/- Patricks Sign (Figure 4)

Radiographic Studies

•  Plain Film Radiographs – Unicortical Disruption – Periosteal Reaction – Callous Formation

•  Bone Scan – Focal Increased Radioisotope Uptake – Better sensitivity than plain films

Radiographs: Periosteal Reaction

Radiograph: Callous

Radiographs: Sclerosis

Bone Scan

Bone Scan

Bone Scan

Treating Stress Fractures

•  Relative Rest –  Protect –  Prevent Progression

•  Pain Control •  Continue

Cardiovascular Exercise –  Swimming –  Cycling

•  Advance Wt-Bearing as tolerated –  PAIN FREE –  Build Slowly

•  Eventually Return to Full Duty.

•  Duration 4-8 weeks

Sports Medicine and Rehabilitation Therapy NHGL

•  Phase I –  Upper Body Only

•  Phase II –  Add Cycling and

Swimming •  Phase III

–  Add Stair Stepper •  Phase IV

–  Add Treadmill

•  1-2 weeks per phase •  Helps Keep tabs on

progress. •  Weekly Meetings with

Recruit Division Commander –  Overall wellness –  Behavior/Discipline –  Therapy Compliance

Recruit Training Command

•  Keep Recruit with Division –  Increase morale – Motivation – Decreased Attrition

•  Recruit Convalescent Unit – When Division Leaves – Pending Medical Board Results

Preliminary Data CT Bone Densitometry in patients

with Multiple Stress Fractures

LT Rowland J. Rivero, DO

LCDR Richard G. Schuster, DO

LT Sean Swiatkowski, DO

LT Philip D. Davis, PAC

CDR (RET) David Petty, MD

James Kedrow, PAC

LT John J. Kim, DPM

Art Studabaker, DPM

Sports Medicine and Rehabilitation Therapy Clinic

Introduction

•  First described in Military Personnel •  Continue to cause morbidity in Naval

Recruits –  1-3 in 4000 –  60% Separated from the Navy in 2000

“May Day”

•  May 2001 •  20 year old Female Recruit with 6 areas of

uptake on Bone Scan •  Division Officer Decision:

– Bone Density on this Patient

•  Osteoporosis T Score of -2.52 * Patient was evaluated by Bone

Density Dexa scan of the Spine

“May Day”

•  Division Officer Policy Decision: – Bone Density on all Multiple Stress Fractures – Find out how many Osteopenics were being

missed. – Arbitrary Standard: More than 1 stress fracture – Consider Calcium Replacement – Consider Birth Control Pills – Consider alendronate therapy

Division Officer Policy Decision

•  CT Bone Density Evaluation. – Owned by the Hospital (Cheap) – San Francisco Studies by Dr. Cann

•  Established Age Matched Bone Densities

Purpose

•  To determine if a correlation exists between bone density and multiple stress fractures in United States Navy Recruits.

• Review the CT Bone Densitometry Policy of the SMART Clinic.

•  Convince Director of Ancillary Services that these studies do not waste OPTAR $$.

Methods

•  Patient presented to Sports Medicine Clinic. •  Diagnosed with Multiple Stress Fractures

– Physical Exam – Verified with Plain Films or Bone Scan

•  By SMART Team policy: – CT Bone Density

Methods

•  Demographic Information – From Composite Healthcare System (CHCS) –  Information is entered into CHCS upon in-processing to the Recruit Training Command

(RTC)

Stress Fractures by Gender

0

10

20

30

40

50

60

70

Patie

nts

Single

Multiple

Single 29 37

Multiple 10 28

Male Female

26%

74%

57%

43%

104 Total Stress Fractures Jun 2001 - Jan 2002

39

65

Multiple Stress Fractures by Gender

26%

74%

MaleFemale

1028

Multiple Stress Fractures by Race

52%

32%

3%

13%

Asian/Pacific IslanderBlackWhiteOther

20120105

Osteopenia Overall

58%

42%

OsteopeniaNon Osteopenia

2216

Osteopenia in Males

80%

20%


82

Osteopenia in Females

50%50%


1414

Bone Denisty of Recruits with Multiple Stress Fractures

29%

29%

16%

26%

Mild OsteopeniaModerate OsteopeniaNormalAbove Mean

11110610

Multiple Stress Fractures in Asian/Pacific Islanders by Gender

60%

40%FemaleMale

1208

Total Osteopenia in Asian/Pacific Islanders

70%

30%

OsteopeniaNormal

1406

CT Bone Densities in Overall Asian/Pacific Islanders with Multiple Stress Fractures

25%

45%

10%

20%

Mild OsteopeniaModerate OsteopeniaAbove MeanNormal

5924

Osteopenia of Female Asian/Pacific Islanders

58%

42%

OsteopeniaNormal

75

Bone Densities of Female Asian/Pacific Islanders

17%

42%8%

33%


2514

Bone Densities of Female Asian/Pacific Islanders

17%

42%8%

33%


2514

Osteopenia of Male Asian/Pacific Islanders

87%

13%

OsteopeniaNormal

71

Bone Densities of Male Asian/Pacific Islanders

38%

49%

13% 0%


3410

Osteopenia in Blacks Overall

33%

67%

OsteopeniaNormal

48

Bone Densities in Black Patients with Multiple Stress Fractures

33%

0%

17%

50%

Mild OsteopeniaModerate OsteopeniaNormalAbove Mean

*Only one Black Male in Study (Above mean)

4025

Osteopenia in Other/Non Specified Races

60%

40%

OsteopeniaNormal

32

Bone Densities in Other/Non Specified Races

40%

20%

40%

0%


2120

Results Recap •  Osteopenia in 58% of patients with Multiple

Stress Fractures. •  52% of patients with Multiple Stress

Fractures were Asian/Pacific Islander. •  Asian/Pacific Islanders had “worse” bone

densities. •  Males with multiple stress fractures may

have a higher osteopenia rate than females. •  Blacks had Increased Bone densities.

Conclusions:

•  CT Bone Densitometry MAY be a useful Study.

•  May be a component of Insufficiency that has been overlooked in Military Recruits with Stress Fracture.

Fatigue Stress Fractures Insufficiency Stress Fractures

Fatigue Stress Fractures Insufficiency Stress Fractures

Questions Still to be Answered

•  Risk Factors: – Tobacco Use – Alcohol Use – Sex – Age – Anatomic Risk Factors – Diet and Activities Before Boot Camp

Questions Still To Be Answered

•  Role of Calcium Loss and Supplementation •  Role of alendronate in this child-bearing

population •  Is there an outcome difference in patients

with multiple stress fractures with low bone density vice patients with normal bone density?

Questions? R. J. Rivero, LT, MC, USNR

[email protected]

Health & Medicine

Osteopenia