Risk and grade of foot and ankle stress fractures guide treatment

LAS VEGAS — Diagnosing foot and ankle stress fractures rapidly and accurately provides athletes with the best chance for quick and safe return to play, according to an orthopedist from the Hospital for Special Surgery in New York.

During the American Orthopaedic Society for Sports Medicine 2009 Specialty Day Meeting, held here, Russell F. Warren, MD, team physician for the New York Giants football team, described an algorithm he has found helpful for determining whether his patients need to discontinue their activities or if they require surgery.

“Think about these fractures as being either high-risk or low-risk,” Warren told the sports medicine orthopedists specializing in foot and ankle care. High-risk stress fractures tend to be caused by tension and occur in the anterior tibia, which he referred to as the “black line,” as well as the malleolus, tibia, navicular and fifth metatarsal. In contrast, low-risk fractures are usually compression fractures, he said.

Using grades 1 to 4 to classify stress fractures in combination with their high- or low-risk status helps surgeons manage them, Warren noted. Grades 1 and 2 correspond to fractures with normal radiographs, while grades 3 and 4 describe partial and complete fractures, respectively.

Warren reviewed a few approaches to managing foot and ankle stress fractures, some of which have variable scientific validity or are new. They included modifying foot wear, recommending orthotics, addressing the patient’s bone quality, using electrical bone stimulation and prescribing bisphosphonates to boost fracture healing in high-risk cases.

In terms of surgical treatment, “The standard for any of these patients is going in and putting a rod down,” Warren said. He cited a colleague’s good results using anterior tension band plating in a small series of high-risk cases, saying, “It gets away from the disadvantages of rods, particularly in an athlete where [they are] around the knee. This is a method you can consider.”

Warren receives royalties from Biomet, royalties and research support from Smith & Nephew, research support from Orteq, has stock/stock options with Zimmer, and is a consultant to KFX.

Reference:
Warren RF. How do we get these patient back on the field the quickest? Presented at the American Orthopaedic Society for Sports Medicine 2009 Specialty Day Meeting. Feb. 28, 2009. Las Vegas.