Stress Fracture

A stress fracture is a small crack in a bone. These fractures most often result from overuse and can occur with an increase in activity. Stress fractures most commonly occur in the weightbearing bones of the legs. When a bone is subjected to a new stress, such as a new exercise routine, it may not be prepared for the increased workload, and as a result, may develop a stress fracture.

Symptoms

The symptoms of stress fractures vary widely. The most common complaint is pain. The pain may develop gradually and often is relieved by rest. Pain usually becomes more intense with physical activity and can be associated with swelling. It is rare to see bruising or discoloration.

Causes

Overuse is the most common cause of a stress fracture. An increase in exercise, athletics, job duties, or even a change in shoes can cause a stress fracture. Other risk factors include repetitive and high-impact activities, such as running, gymnastics, and dance. Osteoporosis also may increase the risk of a stress fracture. Weaker bones may be more susceptible to changes in activity. Any bone of the foot can develop a stress fracture.

Diagnosis

After learning your medical history, your foot and ankle orthopedic surgeon will examine your foot for areas of tenderness and take X-rays. A stress fracture typically is painful directly over the affected bone. If the X-rays are normal, but there is still a high suspicion for a stress fracture based on your history and exam, your surgeon may order additional imaging such as a CT scan, bone scan, or MRI.

Treatments

Since stress fractures most often occur as a result of overuse, initial treatment includes stopping the activity that brought on the fracture. A period of rest typically is needed. If a low impact type of exercise such as biking does not recreate the pain, it may be permitted.

If pain continues with rest from activity, your surgeon may recommend additional treatment. This can include wearing a stiff-soled shoe, a rigid insert/orthotic, or a walking boot. In some cases, your doctor may recommend limited weightbearing with crutches, or even a cast. Calcium and vitamin D supplements may be prescribed to supplement bone health.

Most stress fractures will heal with conservative treatment. If the bone fails to heal, surgery may be necessary. Surgery often involves placing metal plates and screws to secure the bone. Alternatively, your surgeon may inject a bone substitute through a small incision.

Risks and Complications

The most common complication that occurs with a stress fracture involves the bone not healing, called a nonunion. Other complications include malunion, in which the bone heals but in an abnormal position, or recurrent fractures. Recurrent fractures occur more often if the patient has osteoporosis. Patients with osteoporosis should speak with their doctor regarding treatment options.

FAQs

How can I prevent stress fractures?

There are precautions you can take to reduce your risk of stress fractures:

• Start slowly when beginning an exercise program. You should walk and stretch to warm up before progressing to running.
• Make sure your shoes fit properly and have adequate cushioning.
• Make sure you take the time to cool down properly after exercise.
• If you notice discomfort, avoid higher-impact exercise and activity.

Bone Grafts

A bone graft takes bone from one area of the body and puts it in another area to provide support and/or fill in areas where bone is missing. Bone grafts are either taken from the patient (autograft) or taken from a bone donor (allograft). The best bone graft provides enough bone and healing with minimal problems for the patient.

Proximal tibial bone graft (PTBG) is a type of autograft. The proximal tibia is the upper portion of the leg or shin bone that is just below the knee joint. Getting bone from this body part usually is less painful than from other areas like the pelvis.

Diagnosis

PTBG is done when there is not enough bone to allow healing or when your foot and ankle orthopedic surgeon is trying to improve the chances of your bones healing. This typically includes certain fractures or fractures that have not healed and any fusions (forcing two or more separate bones to grow together) of foot/ankle joints.

The main reason to not have a PTBG is if you have hardware in the upper leg. Such devices include knee replacements, plates, and screws and rods. Other reasons to avoid a PTBG include skin problems or infection at the upper leg. Also, some orthopedic procedures require a specifically shaped graft that the proximal tibia cannot provide. This kind of graft may need to be taken from the pelvis.

Treatment

The graft usually is taken from the leg above the foot/ankle being operated on. Your surgeon will make an incision over an area of the upper leg. The incision may be small or large depending on how much graft is needed for your foot/ankle.

Two types of bone can be taken from the proximal tibia. The first is a harder, outer shell of bone that can be removed as a strip. The second is the spongier bone within the proximal tibia. Tools such as drills, chisels, and scoops are used for a PTBG. At times, the surgeon may leave a drain in the leg at the bone for a short time to prevent excessive blood collection. The skin incision typically is closed with sutures or skin staples.

Recovery

Recovery from a PTBG is related to healing of the wound. This usually takes a couple of weeks. You may bear weight on the leg from which the bone was taken if the foot/ankle surgeries done at the same time allow for it. Bending the knee is usually allowed immediately after a PTBG.

Risks and Complications

Potential problems after a PTBG include infection, fracture of the proximal tibia, and pain related to the procedure.

FAQs

If proximal tibial bone graft is taken from my knee, will this prevent me from being able to have other procedures in this area, such as knee replacement?

No. Most surgeries to treat knee problems can be done safely in the future.

Does harvesting tibial bone grafting damage the knee joint?

No. The graft is taken just below the actual joint with great care taken to protect the knee at all times.

Platelet-rich Plasma (PRP)

Platelets are small cells in the blood that help form clots to stop bleeding. Platelet-rich plasma (PRP) is a patient’s own concentrated platelets. PRP contains a large number of growth factors, which are thought to stimulate healing.

When PRP is injected, it can aid the body’s natural healing of injuries. The goal is not only to relieve symptoms but also to create actual healing. In some cases, PRP injections may reduce the need for medication and/or surgery.

PRP injections have been used to treat tendon, ligament, cartilage and bone injuries, as well as arthritis. Around the foot and ankle, PRP is used for treatment of tendon and ligament injuries such as plantar fasciitis and Achilles tendinitis.

PRP injections are not recommended for the treatment of infections or cancer.

Treatment

A small amount of a patient’s blood is drawn and then spun at high speed. The platelets are concentrated to contain 3-5 times the concentration of growth factors compared to normal human blood. Your foot and ankle orthopedic surgeon will then inject this liquid around or near the area being treated. They may use ultrasound or an X-ray as a guide for placing the injection.

Your surgeon may recommend a single injection or a series of injections based on the injury being treated and your initial response to the therapy.

Recovery

You may experience mild pain and irritation of the area for several days following the injection. Some doctors may ask patients to limit motion or weightbearing activity immediately following the injection. The use of a brace, boot, or cast may be recommended during the early post-injection course.

Three to seven days after the injection, you may gradually return to normal physical activities. The return to full activity is determined based on your response to the therapy and the recommendation of your surgeon.

Risks and Complications

As PRP is obtained from your own blood, the risk of reaction is low. As with any injection, there is a small risk of injury to any structures in the area as well as a very small risk of infection.

FAQs

How many PRP injections can I have?

A treatment may require a series of injections, perhaps 3-5. However, multiple injections often are not recommended if there is no improvement in symptoms following the first or second treatment.

Plantar Fibroma

A plantar fibroma is a benign (non-cancerous) nodule that grows in the arch of the foot and usually appears between ages 20 and 60. It usually is slow-growing and often less than one inch in size. Some can grow faster and are considered plantar fibromatosis. A plantar fibroma or fibromatosis is a disease of the fibrous tissue that grows between the skin and the underlying fascia.

Symptoms

The main symptom is a mass on the bottom of the foot, roughly in the middle of the arch or instep, between the heel pad and the forefoot (front of the foot) pad. The mass will cause a soft curve in the contour of the bottom of the foot that may be painful with pressure or shoe wear.

Causes

The cause is unknown but thought to have a genetic component. Plantar fibromas are commonly seen in people of white, Anglo-Saxon, Protestant backgrounds. Trauma to the foot does not seem to be a factor. Alcohol consumption may be a factor.

Plantar fibromas reside in the deep fascia of the foot between the skin and the first layers of muscle. The more aggressive condition of plantar fibromatosis may involve the skin and the muscle layers and may also wrap around the local digital nerves and arteries.

Diagnosis

Your foot and ankle orthopedic surgeon will conduct a physical exam. If a plantar fibroma exists, they will find a mass in the plantar fascia in the arch. The mass has no swelling, increased warmth, or redness. It is firm and does not move. There are no skin changes. Advanced imaging is usually not needed but MRI will show the fibroma in the plantar fascia layer.

There are a few conditions that can cause soft-tissue masses in the foot, including cysts, swollen tendons or tendon ruptures, nerve tumors (neurilemomas), or fat tumors. Foreign body reactions from previous penetrating trauma also can cause a mass in the bottom of the foot, as can an infection. A more serious synovial cell sarcoma, a malignancy, usually will show calcification on X-ray and a more worrisome appearance on MRI. Clinical exam, X-ray, and sometimes an MRI may be needed for diagnosis. Biopsy usually is not needed.

Pilon Fracture

The tibia (shin bone) and the fibula are the bones of the lower leg. Pilon fractures are injuries that occur at the lower end of the tibia and involve the weightbearing surface of the ankle joint. The fibula also may be broken. These injuries were first described more than 100 years ago and remain one of the most challenging problems for orthopedic surgeons to treat.

The word “pilon” comes from the French and means pestle. A pestle is a tool used for crushing or pounding things. This crushing describes what happens to the tibia and fibula bones at the ankle joint due to the high-energy impact of the injury.

Symptoms

Pilon fractures are very painful and debilitating injuries. Symptoms include pain and inability to bear weight on the leg. They often result in an obvious deformity of the ankle joint. Swelling occurs quickly and can be followed by bruising.

Causes

Pilon fractures occur when the talus (ankle bone) is driven into the leg with such force that the leg bones break at the ankle joint. Common causes of pilon fractures are falls from heights and car accidents.

Diagnosis

Your foot and ankle orthopedic surgeon will take your medical history and perform a physical examination of your leg and ankle. The results of this exam will help the surgeon to determine how best to treat the pilon fracture. Your surgeon will be watchful for other injuries that may be present.

In addition, your surgeon will take X-rays of your leg and ankle to see how badly the tibia and fibula are broken. The bones may be broken in multiple places. The surgeon also may get a CT scan of your ankle to view all of the broken areas of the tibia and fibula.

Treatment

Some pilon fractures do not need surgical treatment. These are typically lower-energy injuries to the tibia and fibula at the ankle joint. The bones are broken but simply shifted out of place and these injuries tend to be less severe. These lower-energy pilon fractures can be treated with a leg cast.

Most pilon fractures have multiple breaks. There often are large separations between fractured fragments and instability in the tibia and fibula at the ankle joint. These fractured bones often benefit from surgery.

The goals of pilon fracture surgery are to restore alignment and stability and allow healing of the tibia and fibula at the ankle joint. Once the fractures are healed, the goals are to restore your ankle’s movement and strength.

Specific Technique

Pilon fracture surgery usually is done in two steps to protect the skin and soft tissue. Orthopedic surgeons do not routinely perform incisions through areas of damaged skin because doing so may result in wound healing problems. Surgeons often must wait until a patient’s soft tissue improves before incisions can be made. A notable exception would be an open fracture where the bone has penetrated through the skin during the initial bone break.

Stage One

In many cases the first stage in treating pilon fractures is by surgically applying an external fixator to the patient’s leg. This fixator is a frame applied outside of the leg that holds the leg and ankle in proper position. This allows both the patient and surgeon to regularly inspect the soft tissue of the leg and ankle without frequent splint changes. The fibula fracture may be treated at the same time the external fixator is placed. This part of the procedure is known as open reduction and internal fixation of the fibula (ORIF).

It may take several weeks after the first surgery before the patient’s soft tissues improve and the leg is ready for the second stage of surgical treatment. This delay can be frustrating for the patient, but it may be necessary to minimize the risk of a wound healing problem. The wait does not affect overall results. In some cases the external fixator is used as the final treatment and is kept in place for many weeks to months. Patients often are asked to elevate their leg to quickly reduce their swelling to prepare for the second stage.

Stage Two

The second stage of surgical treatment is to remove the external fixator and fix the tibia fracture using plates and screws. The fibula may also receive an ORIF if it was not fixed in the first stage.

When an external fixator is applied surgically to the patient’s leg, steel pins are placed in the tibia far above the fracture and also in the heel (calcaneus) and foot (metatarsals) bones far below the fracture. The pins are placed through small incisions that minimize damage to the soft tissues. They attach to metal bars outside the skin. The external fixator helps to hold the leg and ankle in proper position while the patient’s soft tissues improve.

The fibula may be fixed at the same time if the skin is not damaged. ORIF of the broken fibula involves an open incision over the bone. The broken fragments are put back together and held in place with a metal plate and screws. Special care is taken to restore the length of the fibula. The incision is then sewn together in layers. Deep tissue over the bone is closed with sutures and the skin is closed with sutures or staples.

This next step is an ORIF of the tibia bone. This step may be delayed several days or even weeks after the initial surgery. The incisions typically are at the front or the inner side of the ankle. Other incisions may be made depending on the injury. The broken fragments are put back together and held in place with metal plates and screws. Special care is taken to restore the shape and stability of the ankle joint. The fibula may be fixed with an ORIF if it was not previously treated. The incisions are then sewn together. The external fixator is typically removed and the leg is placed in a splint. This involves slabs of plaster that are applied to the rear and sides of the leg, ankle and foot. Special care is taken to cushion the leg with appropriate padding.

Recovery

It often takes 3-6 months for the breaks in the tibia and fibula bones to heal. Until the bones fully heal, the patient’s leg and ankle cannot be stressed or worked too hard. Advancing activity too soon before the tibia and fibula bones are healed can jeopardize the repair and ultimately bone healing.

The surgeon also must schedule regular visits to monitor healing of the fracture and advance the patient’s activity accordingly. Many surgeons have a specific schedule for patients to see them in the office for post-surgical follow-up until the pilon fracture is fully healed.

The patient’s first post-surgical visit is usually about two weeks after surgery. The splint is removed and the patient’s leg is examined. The sutures/staples are removed if the incisions are healing well. If there is more severe leg swelling, the surgeon may wait longer before removing the sutures/staples. X-rays of the leg and ankle are performed to confirm that the tibia and fibula fractures are still in place. The leg in then placed in either a cast or a removable boot.

Patients usually received monthly follow-up with their surgeon. At each of these regular visits, the surgeon checks on the patient’s leg’s soft tissue, bones and ankle joint. The soft tissue is checked for swelling and wound problems, while the bones are checked on X-rays for the progression of healing. The ankle joint is checked for movement, strength, and stability.

Patients are restricted from full weight bearing on their operated leg until there is complete healing of the tibia and fibula bones. Patients are not allowed to bear weight on their leg in their post-surgical splint. Patients are not allowed to bear any weight on their operated leg until there is evidence of bone healing. This period of non-weight bearing is with the leg in either a cast or boot. It usually takes 6-12 weeks to see initial bone healing on X-rays.

So long as the patient’s tibia and fibula are healing with each subsequent visit, weight bearing activity gradually can be increased in the protective boot. Patients ultimately can remove the boot and gradually resume activities in normal shoes.

The time to achieve full bone healing of a pilon fracture typically occurs 3-6 months after surgery, but it often takes patients 12 months or more to fully recover from the injury. These are serious ankle injuries. Most patients do not return to the same function that they had before getting hurt. It is common for patients to have residual aches, swelling, stiffness, and weakness even after the tibia and fibula bones are healed. Some patients may need physical therapy to help in their recovery.

Risks and Complications

Early potential complications are problems that can occur within the first few weeks after surgery. Many of these are wound-related, whether these are healing problems or infection. Some of these are superficial problems or infections that can improve with wound care and oral antibiotics. Deeper wound problems or infections can occur and are more severe. These problems often need further surgery or stronger antibiotics to eliminate the infection.

Other potential complications can occur within several months after surgery. Many of these involve difficulties with bone healing at the fractured areas. Some patients experience “delayed unions” in which the bones ultimately heal but take longer than six months to do so. Many delayed unions can improve by immobilizing the leg and limiting full activities for the longer amount of time it needs to heal. Some surgeons may recommend that the patient use a bone stimulator. This is a removable device that is worn on the patient’s leg that uses ultrasound or electrical impulses to help stimulate bone healing.

Another potential problem is a nonunion. This is when the bones do not fully heal. Some nonunions develop when the blood supply to the bones has been damaged from the injury. Other nonunions occur if there is too much movement between fractured pieces of bone. Some of these can be treated in the same way as delayed unions. Other nonunions may need surgery. The surgery to treat the nonunion depends on an individual’s situation. It may involve procedures like adding healthy bone from other parts of the body or chemicals to help stimulate bone healing.

Long-term complications can occur many years after the patient’s pilon fracture is healed. The most common is ankle arthritis. Restoring tibia and fibula bone and ankle joint alignment lessens the chances of patients developing ankle arthritis. However, the cartilage at the tibia that helps to cushion the ankle joint can be irreversibly damaged during the initial injury. Arthritis can result in pain, swelling, stiffness, and weakness at the leg and ankle.

FAQs

If my ankle is at risk for developing arthritis from the pilon fracture itself, why should I have surgery?

It is true that your ankle is at risk for developing arthritis after sustaining a pilon fracture, but the chances of developing ankle arthritis generally are lower with surgery compared to non-surgical treatment. Surgery offers the advantage of putting the broken pieces of the tibia and fibula back together. The chances of developing arthritis are reduced if the shape of the joint is restored than if the joint heals in an abnormal shape without surgery.

Do the implants that have fixed my pilon fracture ever need to be removed?

There are very few reasons to remove any internal plates or screws from the tibia and fibula bones. One reason would be if they are painful after the fracture is healed. This involves surgery on your leg to get them out. Another reason for implant removal would be if they became infected. This can happen while your fracture is healing or after it has already healed. The treatment for infection can be very complex and depends on your specific situation.

Is there anything I can do to improve bone healing?

What helps your tibia and fibula bones heal best after your pilon fracture surgery is to follow your surgeon’s post-surgical instructions. Advancing activity too soon after surgery can jeopardize the implants fixing the bones and ultimately bone healing. The surgeon must restrict the patient in certain ways after surgery for the bones to heal properly.

There are things that you can do to improve the chances of the ankle joint and bones healing properly. A diet that is too low in protein can result in decreased bone and wound healing. Increasing your calcium and vitamin D intake may help with bone healing. Taking the recommended daily allowance of both (1,000 to 1,200 mg of calcium and 600 to 800 IU of vitamin D) may help your body to heal. Up to 2,000 mg of calcium per day may help broken bones to heal.

Drinking alcoholic beverages should be limited to no more than two drinks a day. Cigarette and cigar smoking should be stopped completely as they can be harmful to bone and wound healing.