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Case
:;
:
#{149}

Report

MRI in Stress
Susan A. Stafford,1 Daniel

Fracture
I. Rosenthal,1 Mark
C.

Gebhardt,2

Thomas

J. Brady,1

and James

A. ft1

Stress fractures occur in normal or abnormal bones that have been subjected to repeated traumas, which in themselves would not be sufficient to cause fracture. Stress fracture can be further categorized as fatigue or insufficiency fractures. Fatigue fracture occurs when normal bones are
subjected to increased load, classically described in military

recruits [1 ] and runners [2]. Insufficiency fractures result from loads applied to bone weakened by underlying disorders such as osteoporosis, rheumatoid arthritis, osteomalacia, fibrous dysplasia, Pagets disease, and radiation [3].

a minor muscular injury, and was placed in a knee immobilizer. No radiographs were obtained. Pain persisted and reexamination 2 weeks later revealed decreased range of motion of the left knee. The patient was referred to this hospital because of abnormal radiographs. Plain films of the distal left femur revealed a small focus of metaphyseal cortical resorption with minimal adjacent fluffy periosteal reaction and a fine linear area of circumferential penosteal new bone

extending over a 10-cm length (Fig. 1A). Radionuclide bone scan showed increased activity in the distal femoral metaphysis, and tomograms demonstrated increased bone density but no fracture
line. The possibility of fatigue continuing clinical concern fracture was entertained, but because of over potential malignancy, angiography

Stress fracture is increasingly common in this era of enthusiasm for physical fitness. The initial radiographic appearance of stress fractures may be troublesome, since the new bone
formation sarcoma,
appropriate

was performed.

This suggested

a 2 x 1 cm soft-tissue

mass along

that is seen may be confused and patients with stress fractures

age category for the development

with osteogenic are often in the

of primary

osseous malignancies. Unfortunately, the histologic appearance may also be misleading at this stage, and thus accurate
radiographic diagnosis is essential to insure appropriate treat-

Because of the importance of making a correct diagmultiple imaging techniques will often be employed. We present three cases in which MRI was performed in an effort to differentiate fatigue fracture from tumor. Case
Case 1

ment. nosis,

the posterior surface of the femur (Fig. 1 B). To further investigate the possibility of a soft-tissue mass, MRI was performed using a 0.6-T superconducting Technicare system. Multiplanar spin-echo images of the femurs were obtained in transverse and sagittal planes using a body coil. On Ti -weighted images (SE 500/30), there was decreased signal (suggesting lengthened Ti) involving the bone marrow of the distal metaphysis and diaphysis of the femur, but sparing the epiphyseal center(Fig. i C). An oblique line of even lower signal intensity was demonstrated in the cortex adjacent to the area of marrow abnormality, suggesting a fracture. This

corresponded
coronal
increased

in location
signal

and orientation
images
when intensity

to bone sclerosis

seen on

tomograms.
marrow

T2-weighted

Reports

(SE 2000/i 20) show slightly compared with the unaffected

knee

A 1 0-year-old competitive runner complained of pain in the left after a game of tackle football. He was initially thought to have

side, suggesting lengthened T2 (Fig. 1D). No soft-tissue mass was demonstrated by MRI. At subsequent open biopsy, adequate tissue was obtained to confirm the impression of stress fracture with histologic demonstration of fracture callus, marrow fibrosis, hemorrhage,
and endosteal and penosteal woven bone.

Received November 12, 1985; accepted after revision April 10, 1986. I Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 021 14. Address of Radiology, ACC-415, Massachusetts General Hospital, 15 Parkman St., Boston, MA 02114. 2 Department of Orthopaedks, Massachusetts General Hospital arid Harvard MedaI School, Boston, MA 02114.
AJR

reprint

requests

to D. I. Rosenthal,

Dept.

147:553-556,

September

1986 0361-803X/86/1473-0553

American

Roentgen

Ray Society

554

STAFFORD

ET AL.

AJR:147, September1986

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Fig. 1 -Case 1 . Lateral view of distal left femur (A) shows fine linear periosteal new bone adjacent to anterior femoral cortex (straight arrows). Late arterial phase from an angiogram of same area (B) demonstrates enhancing soft tissue (curved arrow) adjacent to posterior metaphyseal cortex that is suspicious for malignancy. Coronal Ti-weighted image (SE 500/30) (C)and transverse T2-weighted image(SE 2000/120) (D). On Ti-weighted image (C), there is excellent demonstration of extent of marrow abnormality, and a fracture line (white arrows) is faintly visible. Area of uTegular low signal intensity (black arrow) in metephysis ofnormal side represents volume averaging of adjacent posterior femoral cortex in these 1 .5-cmthick slices. On T2-weighted image (D), there is only slight increased marrow signal intensity on affected side (large arrow) as compared with normal. Area of rncreased signal in soft tissues surrounding femur, possibly representing edema (small arrows).

Case 2

boy fractured the left proximal tibia and fibula in a and was treated by closed reduction and cast immobilization for 4 months. Three months after cast removal, he complained of pain in the right calf. Physical examination revealed a warm and mildly tender mass over the right proximal tibia. Plain films demonstrated fine linear periosteal reaction in the right proximal tibial metaphysis with no underlying cortical abnormality (Fig. 2A). Spin-echo MRI images with relative Ti weighting (SE 500/30) demonstrated decreased bone-marrow signal intensity in the right proximal tibia in the area where periosteal new bone was seen on
An 8-year-old

addition, a crescentic area with prolonged Ti and T2 characteristics was demonstrated in the soft tissues surrounding the tibia. This is
most satisfactorily explained stress fracture was confirmed as edema on delayed (Fig. 2C). The diagnosis of plain films obtained 6 weeks healing with resolution of the

motor

vehicle

accident,

after presentation, which demonstrated periosteal response.

Case 3 An 1 8-year-old student took an after-school construction job that required him to break up stone by repeatedly striking it with a mallet. Soon thereafter he complained of pain in the right forearm. Physical

plain films (Fig. 2B). In transverse T2-weighted images (SE 2000/60), bone marrow had minimally increased signal intensity when compared with the opposite leg. There was extensive involvement of the

examination
linear

was unrevealing,
reaction

but a radiograph

showed

an isolated
was

periosteal

of the ulnar diaphysis

(Fig. 3A). There

metaphysis

and proximal

diaphysis

with sparing of the epiphysis.

In

extensive

uptake

of radionuclide

in this area on a bone scan (Fig.

AJR:147,

September1986

MRI

IN STRESS

FRACTURE

555

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Fig. 2.-Case 2. A, Thin layer of per,osteal reaction along medial border of nght proximal libial metaphysis (arrow) with no discernible underlying bone abnormality. B, Coronal MR image(SE 500/ 30) demonstrates extensive low-signalintensity bone marrow (white arrows) in right proximal tibial metaphysis corresponding to region of plain film abnormality (A). Healed left tibial fracture (black arrow) is also demonstrated. C, Transverse images in this case, done with Ti weighting (SE 500/30), again show low intensity in marrow (long arrow). Bright signal is not present in surrounding soft tissues on this pulse sequence. Instead, there is very faintly decreased signal around tibia (short arrows).

2B). MRI performed at another institution demonstrated an interruption of the ulnar cortex and a crescentic area of inhomogeneous low
signal intensity on the T2-weighted images (SE 2000/40, SE 2000/

80) (Fig. 3C). The appearance of the MRI was initially interpreted as representing malignancy breaking through the cortex, and this opinion was supported by the extensive area of abnormal increased activity
on

the

bone

scan.

The

patient

was

referred

to this

hospital

for

treatment. Diagnostic uncertainty resulted in an open biopsy that showed cortical widened osteones, active remodeling, and periosteal woven bone without evidence of malignancy or infection consistent with stress fracture.

a 4-month period of ambulation with a cast on the opposite leg. The diagnostic triad of localized penosteal reaction, endosteal thickening, and radiolucent cortical line [4] was not present on the first radiographs, and consequently the diagnosis of primary bone malignancy was entertained. In these three cases, extent of the marrow and cortical abnormalities demonstrated by MR was marked. Because of low-proton density and extremely short T2 relaxation times, cortical bone produces a weak MR signal, and is poorly imaged by MR. However, strong contrast with adjacent marrow and soft tissues usually makes cortical bone readily and
plainly demonstrable. Despite this contrast with adjacent soft

Discussion Cases 1 and 3 represent fatigue fracture secondary fatigue fractures; case 2 is also a to an overuse phenomenon during

tissues, the ability of MRI to detect the fractures in two of the three cases was unexpected. Changes within the bone marrow were more extensive than anticipated. The decreased marrow signal on Ti -weighted

556

STAFFORD

ET

AL.

AJR:147,

September1986

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right forearm shows fine linear penosteal reaction (arrow) along ulnar diaphysis. B, 99m-technetium MDP (methylene diphosphonate) bone scan view offorearms shows an extensive area of marked increased activity in middle right ulna (arrow) corresponding to region of periosteal reaction on plain film. C, Transverse SE 2000/40 images of middle right ulna demonstrate interruption of cortex (arrows) with surrounding crescentic region of mixed, but predominantly increased, signal intensity. This may represent edema at site of fracture.

Fig. 3.-Case view of proximal

3. A, Anteroposterior

images is seen in malignancy, osteonecrosis, and other disorders. Abnormalities seen in the tissues surrounding the bone probably represent edema. Hematoma is less likely, as extracranial hematoma generally has increased signal on both Ti - and T2weighted images [5J. As MR is not used for screening, its sensitivity for the diagnosis of stress fracture is unlikely to be determined. However, like the radionudide bone scan, MR is highly sensitive to the pathophysiologic changes accompanying stress fracture. In attempting to use MRI to differentiate between stress fracture and primary osseous malignancy, it is important to realize that bone marrow abnormalities demonstrated by MRI may extend well beyond the area of cortical failure in
similar changes may be

MR images and increased relatively nonspecific as

signal

on T2-weighted

cases of simple stress intepreted as suggesting

fracture. This malignancy.

finding

should

not

be

REFERENCES RS, Johnson HA. Stress fractures in military recruits. A review of 12 years experience. Military Med 1966;i3i :716-72i 2. Daffner RH, Salutano M, Gehweiler JA. Stress fractures in runi . Gilbert
ners.

JAMA

1982;247(7):

i 039-i

04i

G. Diagnosis of bone and joint disorders. Philadelphia: Saunders, 1981:2245-2249 4. Sweet DE, Allman RM. RPC of the month from AFIP. Radiology
1971;99:687-693 5. Unger EC, Glazer HS, Lee JK, Ling D. MRI of extracranial AJR 1986;i46:403-407

3. Resnick

D, Niwayama

hematomas:

preliminary

observations.