12y.o. first met stress #

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Hello all, I'm hoping for some helpful advice. 12 year old young lady who is an avid gymnast has suffered a stress # to her mid portion first met shaft, confirmed on MRI with mid portion marrow oedema and mild periostial oedema. Pain began 9 days ago following gym. Soft tissue oedema, and very sensitive to touch.
Does anyone have some great ideas on treatment options? My thoughts were - obviously rest, elevation, GP gave her some Ibuprofen. Considering post op shoe or short cam walker, but wondering if soft cast would be beneficial.
Thanks in advance for your thoughts.
Matt

 

1) She has no real option but to rest --> progressive load as get better
2) Check nutrition/eating disorder related issues -- ie female athlete triad common in gymnasts

 

Yup, what Craig says.

Don't forget she is also in the prime age for freibergs which can also precipitated by an injury or repetitive stress. So while it is showing mid shaft oedema, just keep that in the back of your mind. Either way, rest is the order of the day.

 

Matt:

A few points are in order. First metatarsal stress fractures are relatively uncommon stress fractures of the forefoot being at least 6-7 times less common, in one study, than 2nd metatarsal fractures.

http://www.ajronline.org/doi/pdf/10.2214/ajr.130.4.679

In addition, soft tissue edema, and marrow edema on MRI may indicate a first metatarsal stress reaction or bone contusion, and not a true stress fracture. The fracture line needs to be visible on some imaging study to constitute a stress fracture. Bone marrow edema can exist in microfractures that are not true stress fractures. Think of a stress reaction as a "pre-stress fracture". Medial tibial stress fracture is a stress reaction and is commonly associated with bone edema without stress fracture.

From your description, I wouldn't be so sure your patient will ever develop the bone callous remodeling that would normally occur after a stress fracture. My guess is that she actually has a first metatarsal stress reaction, not a stress fracture.

Next, on the subject of the female athlete triad that Craig mentioned, in order for this to be present, the female athlete would need to have started her menstrual cycle already or be past the normal age of onset of the menstrual cycle to have this diagnosis. Since the average starting age for menstrual cycle is 12-13 years, many 12 year old girls will not have yet started to menstruate. In all my female athlete patients, this is a question that is always asked of the parent of the child, especially before one starts assuming that a 12 year old girl has developed an injury because of the female athlete triad.

As far as treatment is concerned, if it were my patient, she would be placed in a boot-brace walker and not a short one, but one that comes to just below the knee to better reduce the internal forces through the first metatarsal. She would also be radiographed at 2 weeks and 4 weeks after being placed in the brace to check for bone changes post injury.

I would tell the parent that she must wear the brace for a full four weeks before considering gradually allowing her to do any running or jumping in school or in her gymnastics activities. A "soft cast", post-op shoe or short brace will be inadequate to off-load a first metatarsal, in my opinion. In addition, if you don't feel you can trust the patient to stay in the brace, then put her in a below knee weightbearing fiberglass cast for four weeks.

One more thing, acetaminophen is a better choice than ibuprofen for relieving the pain of healing fractures (see attached article). However, she probably won't need any oral pain medications once she starts wearing the brace to stand and walk in.

Hope this helps.:drinks

 

I just re-read my last post in this thread and would like to make a correction to it:

The sentence:

should read as:

Sorry for any confusion.

 

Thank you very much for this helpful advice.
Regards,
Matt

 

Despite a High Prevalence of Menstrual Disorders, Bone Health Is Improved at a Weight-Bearing Bone Site in World-Class Female Rhythmic Gymnasts.
Maïmoun L, Coste O, Georgopoulos NA, Roupas ND, Mahadea KK, Tsouka A, Mura T, Philibert P, Gaspari L, Mariano-Goulart D, Leglise M, Sultan C.
J Clin Endocrinol Metab. 2013 Oct 8.