Alonso-Bartolomé P, Martínez-Taboada V M, Blanco R, Rodriguez-Valverde V
Division of Radiology, Hospital Universitario Marques de Valdecilla, Facultad de Medicina, Universidad de Cantabria, Santander, Spain.
Semin Arthritis Rheum. 1999 Jun;28(6):413-20. doi: 10.1016/s0049-0172(99)80007-9.
Insufficiency fractures (IF) occur when normal or physiological muscular activity stresses a bone that is deficient in mineral or elastic resistance. IF of the tibia and fibula are probably less common than IF of the ribs, vertebrae, hip, pelvis, and distal ulna, and therefore they are frequently underrecognized and mistaken for other conditions. Our aim was to analyze the main features and outcome of IF of the tibia and fibula in patients attending our Rheumatology Service.
IF was considered when occurring spontaneously or with minimal trauma. Between January 1984 and July 1997, 25 patients were diagnosed as having IF of the tibia and fibula. The main predisposing factors, clinical features, therapy, and outcome were retrospectively reviewed.
All the patients except four were women (mean age, 66+/-12 years). Three cases were diagnosed between 1984 and 1990 (0.42 cases/year) and 22 between 1991 and 1997 (three cases/year). Eighteen patients had an underlying condition: rheumatoid arthritis (RA, 13 cases), psoriatic arthritis (2), systemic lupus erythematosus (SLE) (1), kidney transplant (1), and Crohn's disease (1). Eleven patients had osteoporotic fractures in other locations. Risk factors for osteoporosis were corticosteroids (13 cases), prolonged immobilization (10), early menopause (2), and methotrexate therapy (10). All patients had pain on weight bearing and marked functional impairment, 16 had local inflammatory signs, and 10 had deformity. In only five patients the diagnosis of IF was considered at the first examination. The diagnostic delay was 76+/-117 days (median, 21). The initial radiograph was diagnostic in 20 patients, and in the remaining the diagnosis was made by computed tomography (CT) scan (three cases), magnetic resonance imaging (MRI) (1), and bone scan (1). IF were located as follows: tibia (10 cases), fibula (seven), tibia and fibula (eight). Nineteen patients were treated with conservative management, four received no specific treatment, and two required surgery. Sixteen patients were hospitalized for a mean period of 12+/-8 days. Most patients had complete recovery. The high frequency of IF seen in RA patients is probably due to the severe disease in patients treated by our Service and that such patients have a higher risk for osteoporosis and its complications.
IF of the tibia and fibula are probably more common than previously thought. They usually occur in patients with underlying rheumatic diseases, mainly RA, and are frequently mistaken for other joint and bone conditions. Despite a frequent delay in diagnosis, they have a good prognosis with conservative management. Nonetheless, a higher index of suspicion may avoid unnecessary investigations and treatments.
当正常或生理性肌肉活动对矿物质或弹性阻力不足的骨骼施加压力时，就会发生应力性骨折（IF）。胫腓骨的应力性骨折可能比肋骨、椎骨、髋部、骨盆和尺骨远端的应力性骨折少见，因此它们常常未被充分认识，而被误诊为其他病症。我们的目的是分析在我们风湿病科就诊的患者中胫腓骨应力性骨折的主要特征和结局。
如果应力性骨折是自发发生或在受到极小创伤时发生，则予以考虑。在1984年1月至1997年7月期间，25例患者被诊断为胫腓骨应力性骨折。对主要的诱发因素、临床特征、治疗方法和结局进行了回顾性分析。
除4例患者外，其余均为女性（平均年龄66±12岁）。1984年至1990年期间诊断出3例（每年0.42例），1991年至1997年期间诊断出22例（每年3例）。18例患者有基础疾病：类风湿关节炎（RA，13例）、银屑病关节炎（2例）、系统性红斑狼疮（SLE）（1例）、肾移植（1例）和克罗恩病（1例）。11例患者在其他部位发生过骨质疏松性骨折。骨质疏松的危险因素包括皮质类固醇（13例）、长期制动（10例）、过早绝经（2例）和甲氨蝶呤治疗（10例）。所有患者负重时均有疼痛且功能严重受损，16例有局部炎症体征，10例有畸形。初诊时仅5例患者被考虑为应力性骨折。诊断延迟时间为76±117天（中位数为21天）。20例患者的初始X线片具有诊断价值，其余患者通过计算机断层扫描（CT）（3例）、磁共振成像（MRI）（1例）和骨扫描（1例）确诊。应力性骨折的部位如下：胫骨（10例）、腓骨（7例）、胫腓骨（8例）。19例患者接受了保守治疗，4例未接受特殊治疗，2例需要手术治疗。16例患者住院，平均住院时间为12±8天。大多数患者完全康复。RA患者中应力性骨折的高发生率可能是由于我们科室治疗的患者病情严重，且此类患者发生骨质疏松及其并发症的风险较高。
胫腓骨应力性骨折可能比以前认为的更为常见。它们通常发生在患有基础风湿性疾病的患者中，主要是RA，并且常常被误诊为其他关节和骨骼疾病。尽管诊断常常延迟，但保守治疗预后良好。尽管如此，提高怀疑指数可以避免不必要的检查和治疗。
