Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy

AIM: Clinical surveys on stress fractures (SF) in female military recruits are scarce. The aim of this study was to characterize the scintigraphic findings and classify the distribution and pattern of SF in a group of female recruits of the Israel Defense Forces (IDF). MATERIALS AND METHODS: The bone scans of 146 female recruits (age range, 19-20.6 years) with suspected SF were assessed retrospectively. The SF lesions were classified qualitatively into 4 grades of bone response according to the classification criteria introduced by Zwas et al. SF location and distribution were analyzed, and in several cases, the abnormalities were correlated radiographically. RESULTS: One hundred forty-six female recruits were examined, of which 93 (64%) had bone scan findings of SF with a total of 247 SF. Forty-eight patients (with or without SF) had shin splints, 32 had thigh splints, and 34 had normal scans. Several SF were detected in sites that were not clinically suspected. Thirty-nine percent of the SF were located in the feet (tarsal bones 22.7%, metatarsal 16.2%), 36.8% in tibiae (predominantly in the midthird), 15.7% in femurs, 6.5% in the pubic and sacroiliac regions, and 2% in the fibula. SF in the tibiae and femurs were mainly located in the posterior aspect of the medial cortical region. Forty-nine percent of the patients had bilateral SF. The SF were classified on a 4-grade scale: 41.3% were grade I, 37.2% grade II, 15.8% grade III, and 5.7% grade IV. Thirty-three percent of the patients had one site of SF, 31% had 2 sites, 7.5% had 3 sites, 12% had 4 sites, 7.5% had 5 sites, and 9% had more than 5 sites of SF. Different grades of lesions were often found in the same patient. Sixty-five percent of the patients had SF in the feet, 59% in the tibiae, 26% in the femurs, 14% in the pubic or sacroiliac regions, and 5% in the fibula. Radiography was performed in 15% of the patients. Only one patient had a positive finding on radiography. CONCLUSIONS: This study shows that lower leg SF are not uncommon in female military recruits. We clearly distinguished between SF and shin splints, which have important clinical consequences on treatment. Most of the SF were mild (grade I and II) located in the feet and tibiae. This study supports the experience gained in other studies, and emphasizes the significant number of pubic and sacroiliac SF in female soldiers, which is significantly higher in comparison with previous reports on male soldiers.     

Reliability of bone scintigraphy for suspected scaphoid fractures

PURPOSE: To examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images. METHODS: One hundred bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter- and intraobserver variation. Three nuclear medicine physicians independently evaluated all bone scans at 2 different points in time with a 3-month interval. The observers filled out a blinded scoring sheet for each patient. They scored if a scaphoid fracture was present or not. In addition, they scored the presence or absence of another fracture. The inter- and intraobserver variation was analyzed using the kappa statistic. RESULTS: The interobserver variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. The intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture. CONCLUSIONS: In the present study, early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter- and intraobserver variation. In addition, expertise does not seem to have a negative influence on the results. This enhances the possibility of using bone scintigraphy in daily practice.     

Pitfalls of bone scintigraphy in suspected hip fractures

In a review of 2617 patients who were admitted with a suspected fractured neck of femur over a period of five years, 213 had normal or equivocal plain radiographs, and were subsequently investigated by bone scintigraphy. Normal scans were obtained in 127 (60%) cases. Of the remaining 86 cases, 82 (38%) were reported to show fractures of the proximal femur, three showed pubic ramus fractures, and one acetabular fracture was demonstrated. Review and follow-up has revealed eight false positive and two false negative scans. The various factors accounting for these errors are considered, and the clinical implications discussed. Careful analysis of accompanying plain radiographs is stressed when interpreting scintigrams.     

Prospective study of biomechanical risk factors for second and third metatarsal stress fractures in military recruits

Objectives

This prospective study investigated anatomical and biomechanical risk factors for second and third metatarsal stress fractures in military recruits during training.

Clinical value of grading the scintigraphic appearances of tibial stress fractures in military recruits.

PURPOSE: This study evaluated the relation between the scintigraphic appearances of tibial stress fracture in military recruits and the likelihood that they would complete basic military training. MATERIALS AND METHODS: The authors retrospectively reviewed 58 Tc-99m MDP scans of recruits referred for possible tibial stress fracture and graded them according to the criteria of Zwas et al. (1987). Stress fracture appearances were correlated with clinical information such as the duration of rehabilitation and final outcome with regard to completion of the initial basic military training program. RESULTS: Thirty-seven of the 58 patients (64%) had tibial stress fractures, all of which were located in the tibial diaphysis, with most occurring in the middle and lower thirds. Most (23 of 37) patients had stress fractures of grade I or II, and the others had grade III or IV stress fractures. There was no statistical difference in the proportion of patients with bilateral fractures between grades I-II and III-IV. There was no significant difference in the duration of rehabilitation for recruits successfully recovering from grade III-IV fractures compared with grade I-II fracture. There was a greater proportion of patients with lower grade fractures than higher grade fractures (P = 0.0006) who, despite rehabilitation, could not continue training because of unremitting or recurring pain at the fracture site and were medically discharged from military service. CONCLUSIONS: Contrary to expectation, recruits with higher-grade stress fractures were not less likely to complete basic military training compared with recruits with lower grade stress fractures.     

Acetabular stress fractures in military endurance athletes and recruits: incidence and MRI and scintigraphic findings

OBJECTIVE: To evaluate the incidence and the MRI and scintigraphic appearance of acetabular stress (fatigue) fractures in military endurance athletes and recruits. DESIGN AND PATIENTS: One hundred and seventy-eight active duty military endurance trainees with a history of activity-related hip pain were evaluated by both MRI and bone scan over a 2-year period. Patients in the study ranged in age from 17 to 45 years. They had hip pain related to activity and had plain radiographs of the hip and pelvis that were interpreted as normal or equivocal. The study was originally designed to evaluate the MRI and scintigraphic appearance of femoral neck stress fractures. Patients had scintigraphy and a limited MRI examination (coronal imaging only) within 48 h of the bone scan. Twelve patients demonstrated imaging findings compatible with acetabular stress fractures. RESULTS: Stress fractures are common in endurance athletes and in military populations; however, stress fracture of the acetabulum is uncommon. Twelve of 178 patients (6.7%) in our study had imaging findings consistent with acetabular stress fractures. Two patterns were identified. Seven of the 12 (58%) patients had acetabular roof stress fractures. In this group, two cases of bilateral acetabular roof stress fractures were identified, one with a synchronous tensile sided femoral neck stress fracture. The remaining five of 12 (42%) patients had anterior column stress fractures, rarely occurring in isolation, and almost always occurring with inferior pubic ramus stress fracture (4 of 5, or 80%). One case of bilateral anterior column stress fractures was identified without additional sites of injury. CONCLUSIONS: Stress fractures are commonplace in military populations, especially endurance trainees. Acetabular stress fractures are rare and therefore unrecognized, but do occur and may be a cause for activity-related hip pain in a small percentage of military endurance athletes and recruits.     

Sonographic findings in stress fractures of the lower limb: preliminary findings

Stress fractures are common injuries frequently overlooked on first radiographs, especially in the early course. The gold standard for accurate diagnosis is MRI and scintigraphy. We report six cases of stress fractures of the lower limb diagnosed with sonography and describe typical sonographic features.     

Photopenia in skeletal scintigraphy of suspected bone and joint infection

The results of skeletal scintigraphy with Tc-99m-medronate of five children, in whom bone or joint infection was suspected, are presented. They illustrate that the demonstration of areas of diminished radionuclide accumulation may be of considerable assistance in establishing a diagnosis.     

Quantification of disease activity in patients undergoing leucocyte scintigraphy for suspected inflammatory bowel disease

Purpose Whole-body gamma camera counting is an alternative to faecal ¹¹¹In collection for quantifying disease activity in inflammatory bowel disease (IBD) but requires administration of imaging activities of ¹¹¹In. The aim of this study was to explore a dedicated whole-body counter which requires 20-fold less activity than gamma camera counting.Methods Thirty patients with known or suspected IBD received ^99mTc-granulocytes (200 MBq) and ¹¹¹In-granulocytes (0.5 MBq). The ^99mTc-cells were injected 45 min after the ¹¹¹In-cells and immediately after a baseline ¹¹¹In whole-body count. The decay-corrected count at 120 h was expressed as a fraction of baseline to give whole-body ¹¹¹In retention (WBR). One patient was excluded as the injected cells were non-viable.Results Median 45-min intravascular ¹¹¹In recovery was 35% in patients compared with 43% in six normal volunteers (p<0.05). WBR in normals ranged from 91% to 93% and in 11 patients with negative ^99mTc imaging from 87% to 96%. Only one of 11 patients with negative imaging had WBR <90% while 11/12 patients with WBR <90% had abnormal imaging. Ten of 13 patients with Crohns disease (CD) had abnormal imaging. The lowest WBR in these ten was 77% and six had values of >90%. There was a significant association between WBR and ^99mTc image grade (R_s=0.73, p<0.002) in 16 patients without CD, but not in 13 patients with CD (R_s=0.54, p>0.05).Conclusion Dedicated whole-body counting is able to quantify disease activity in IBD but may give normal values in active CD.     

Prevention of pelvic stress fractures in female army recruits.

In 1991-1992, a pelvic stress fracture incidence of 11.2% was recorded in a cohort of 143 female Australian Army recruits. An incidence of 0.1% was recorded in a cohort of male recruits trained in the 1992-1993 year using a nearly identical program. A number of preventive strategies were instituted in an attempt to reduce the high incidence of injury in female recruits. Route march speed was reduced from 7.5 to 5 km/h, running occurred on softer surfaces, individual step length was promoted instead of marching in step, march and run formations were more widely spaced, and interval-running training replaced traditional middle-distance runs. Pelvic stress fracture incidence decreased significantly to 0.6% in an immediately subsequent cohort of 161 female recruits (chi 2 = 15.12 for 1 df; p < 0.001). It is likely that the preventive strategies reduced bone strain by reducing the frequency and forces of impact during the training period.     

Magnetic resonance imaging: a cost-effective alternative to bone scintigraphy in the evaluation of patients with suspected hip fractures

Objective. To evaluate the cost-effectiveness of magnetic resonance imaging (MRI) compared with radionuclide bone scan in the evaluation of patients with clinically suspected hip fractures. Design. The medical records of all patients who had been seen in the emergency room over a 4-year period with a clinically suspected hip fracture, negative or equivocal plain films, and either a subsequent bone scan or MRI examination were retrospectively reviewed. The time to diagnosis, admission rate, and time to surgery were determined. A two-sample t-test was used to assess the statistical significance of the results. A theoretical cost analysis was performed using current charges to estimate all expenses. Patients. Forty patients (11 male, 29 female; age 28–99 years) satisfied our inclusion criteria. Results and conclusions. Twenty-one patients had bone scans (six with fractures), and 19 had MRI (four with fractures). The time to diagnosis was 2.24±1.30 days for bone scanning and 0.368±0.597 days for MRI (P<0.0001). Twenty patients in the bone scan group were admitted compared with 13 in the MRI group. The time to surgery was at least 1 day longer in patients undergoing bone scanning. Bone scanning resulted in higher patient costs compared with MRI because of the delay in diagnosis. In the evaluation of patients with suspected hip fractures, early MRI is more cost-effective than delayed bone scanning. Further prospective studies comparing the cost-effectiveness of early MRI with early bone scanning are needed.     

Scintigraphic uptake of 99mTc at non-painful sites in athletes with stress fractures. The concept of bone strain

Stress fractures are commonly found in athletes attending sports medicine clinics for diagnosis of lower limb pain. Plain radiographs are less reliable than the 99mTc bone scan for diagnosing stress fractures because of their low sensitivity. While the heightened sensitivity of the bone scan is advantageous as a diagnostic aid, the uptake of 99mTc at non-painful sites occurs frequently in the athlete. Although the clinical significance has not been determined, asymptomatic uptake may indicate bone remodelling as part of a continuum of adaptation to physical stress. It is not known whether athletes who have uptake of 99mTc in asymptomatic areas represent a separate population from those who do not. This study retrospectively reviewed the medical charts and bone scan reports of 320 athletes diagnosed as having stress fractures, to determine the frequency of asymptomatic focal uptake at sites other than the site of pain. This group was compared with the group who had no asymptomatic uptake on a number of demographic variables and physical findings. Asymptomatic focal uptake was found in 37.5% of athletes with the average number of sites being 1.8 per person. No significant differences between groups with focal asymptomatic uptake and groups with no asymptomatic uptake were found when compared for age, height, weight, mileage in runners, times to diagnosis and recovery, frequency of tenderness, swelling, trauma history, varus alignment, and x-ray abnormalities. It is concluded that asymptomatic uptake of 99mTc occurs frequently in athletes with stress fractures and there are no significant clinical differences between the group with asymptomatic uptake and the group without. It is suggested that symptomatic uptake of 99mTc represents the remodelling response of bone to physical stress.     

应用损害控制策略治疗下肢严重开放性多发性骨折

报告1例严重下肢开放性多发性骨折伴大血管损伤患者运用损害控制技术成功治疗.