Joe A Shaw PA-C - 3/13/2008

Question
History: I was in an auto accident in 2004. I sustained a tib/fib fx. They placed a rod and three screws to fix the fracture. The hardware has been removed, and now I'm having problems with my knee. When my orthopedic surgeon went in and did the surgery, he commented to my parents that it was the worse knee contusion he has ever seen in his 10 years of practice without there being any actual bone or joint damage. He later stated that I could have problems with this knee in the future.

I started running and started having serious knee pain. To the point where I couldn't walk on the right leg, same leg that I injured in 04'. I went back to the orthopedic surgeon to see what was going on. He ordered an MRI and the results were a proximal tibia stress fracture. Same location as the screws were. It has been 12 weeks since the diagnosis of a stress fracture, and it is not healing. I have done a little treadmill walking, but after about two days I'm back to where I started pain wise, and can't walk again.

Today, at the orthopedic doctors, he said something was going on with me knee he just didn't yet know what it was. The MRI showed everything to be structurally okay. He drew blood today to check my Vitamin D levels, and ordered a CT scan and bone density test. I'm only 24 year's old and he said the possibility of osteoporosis is small, but still a possibility. The doctor is thinking more along the lines that the bone has not filled in from when the screws were in place like it should have. He said if that was the case he wanted to do a bone graph to promote healing.

My questions: I know what a bone graph is, but is it major surgery? Where do they take the bone that they're going to graph; my hip or cadaver? How long is the recovery and will I be placed in a cast?

I know you can't diagnose me, but based on what I've listed, do you think my doctor is following the right course of action, or is he jumping to surgery too soon?

Thank you so much and sorry for the long email!


Answer
Kati,
I think your ortho is looking at everything and that is good. You do want to make sure its not a bad case of runners knee..which is really common in runners due to their gait etc while jogging.See if you can get this link http://www.medpagetoday.com/Surgery/Orthopedics/tb/5530

I found a good article from emedicine which is a very reliable source and it talks about the diff. stages of treatment..yours may be a little unique if he thinks the screw holes are where the stress fx is..but the treatment options would be about the same.

Tibial stress fracture

The tibial shaft is the most common site of stress fractures. Unfortunately, shin pain is a frequent complaint among athletes and can result from a variety of causes, including tibial periostitis (ie, shin splints) and exertional compartment syndromes (a potentially serious condition). A careful history is helpful in distinguishing these entities. Pain that occurs early in the exercise program and then improves with ongoing activity suggests periostitis. Pain precipitated by exercise that worsens progressively with continued activity may herald a stress fracture.

Physical examination typically reveals localized tenderness over the medial aspect of the tibia. Tibial stress fractures may be more common among athletes with rigid cavus feet. Excessive subtalar pronation can also predispose an athlete to tibial stress fractures. The clinical diagnosis can be confirmed by conventional radiography, although one study suggests that this imaging modality shows evidence of stress fracture or periosteal reaction in only 10% of cases. Scintigraphy and/or MRI may be useful for confirming the suspected clinical diagnosis.

Treatment consists of activity restriction to minimize symptoms (ie, a period of non weight bearing may be necessary) before engaging in a program of increasingly demanding strengthening and conditioning exercise, leading to an eventual return to play in 8-12 weeks. Interestingly, 3 studies have demonstrated that use of a pneumatic leg brace allowed athletes to recover more quickly than athletes treated with activity restriction alone (Anderson, 2000; Swenson, 1997; Whitelaw, 1991). It may be that compression of the leg's soft tissues helps to unload the tibia during weight-bearing activities, thereby minimizing further microdamage and facilitating bony repair.

Cortical stress fractures of the anterior tibial midshaft should be treated with care because they tend to heal more slowly (average of 6 mo) and are prone to delayed union or nonunion. In such cases, electromagnetic stimulation may potentially be helpful in promoting healing. Some authors recommend immobilization as initial therapy. Failure of nonoperative care warrants consideration of surgical intervention. Options include reamed intramedullary nailing and internal fixation with bone grafting. Postoperative recovery time averages 6 months.