Tibial stress fractures

　　1. Etiology

　　This disease is caused by overuse injuries in sports and military training.

　　2. Pathogenesis

　　Tibial stress fractures were first proposed by Alemen in 1929; in 1956, Burrous reported 5 cases of 'tibial fatigue fractures' in ballet dancers. In 1958, Devas reported 17 cases of tibial stress fractures in athletes, of which 11 had fractures visible on X-rays and 6 only showed periosteal reactions. In 1975, Clement proposed that excessive stress first causes fatigue of the lower leg muscles, causing them to lose the function of absorbing stress. After that, the stress acts directly on the tibia, leading to tibial periostitis and even fractures. After the tibia is subjected to stress injuries, it can gradually adapt to the changes in stress through the reconstruction of its internal structure, and in most cases does not lead to fractures. Therefore, clinically, injuries that only show subperiosteal bone hyperplasia without obvious fracture lines are also called stress periostitis. In addition to the bone stress response, stress periostitis may also be related to the traction of muscles and interosseous membranes, which is actually also a type of stress fracture.

　　The following complications can occur:

　　1. Fascial Compartment Syndrome:When fractures or soft tissue injuries such as muscles occur in the lower leg, and when hematomas and reactive edema occur, increasing the pressure in the fascial compartment can cause circulatory disorders and lead to fascial compartment syndrome. Among them, the incidence of anterior compartment syndrome is the highest.

　　The anterior compartment is located on the anterior and lateral side of the lower leg, where the anterior tibial muscle, long extensor muscle, extensor digitorum longus muscle, third peroneal muscle, common peroneal nerve, and anterior tibial artery and vein are located. When the anterior compartment syndrome occurs, the anterior and lateral side of the lower leg becomes hard and there is marked tenderness. The pain is exacerbated when the toes are passively extended and flexed. The pain is related to the degree of compression of the peroneal nerve, and in the early stage, there may be a decrease in sensation between the first and second toe webs, followed by paralysis of the extensor digitorum longus muscle, extensor digitorum longus muscle, and anterior tibial muscle. Since the peroneal artery has communicating branches with the anterior tibial artery, the dorsalis pedis artery can be palpated in the early stage.

　　2. In addition to the anterior fascial compartment, the three compartments at the posterior tibia can also develop this syndrome.Among them, the incidence of posterior deep compartment syndrome is higher than that of posterior superficial compartment and lateral compartment. The characteristics are posterior compartment pain, numbness of the sole, weakened toe flexion strength, increased pain when the toes are passively extended, increased tension of the medial fascia at the distal end of the gastrocnemius muscle, and marked tenderness. If the symptoms continue to develop without timely treatment, intracompartmental muscle group ischemic contracture can occur, leading to claw-shaped feet. A medial and posterior incision of the lower leg can be made, starting from the origin of the tibialis posterior muscle, longitudinally incising the deep fascia, and if necessary, the epimysium can also be incised to achieve the purpose of decompression.

　　The anterior compartment syndrome is formed by the continuous increase in intracompartmental pressure, vasospasm, increased tissue osmotic pressure, and tissue ischemia and hypoxia. Especially in cases of closed tibiofibular fractures with obvious soft tissue contusions, there is a possibility of developing fascial compartment syndrome, so the fracture should be reduced as soon as possible, and 20% mannitol should be administered intravenously to improve microcirculation and reduce edema, and a close observation should be made.

　　In addition to the fascial compartment syndrome, the lower mouth of the anterior tibial space near the ankle joint, the anterior tibial muscle, the long extensor muscle, and the digital long extensor tendon are closely attached to the tibia. After the fracture heals and the callus forms, the tendons may be worn, causing symptoms, and in some cases, it is necessary to perform surgical fasciotomy to decompress.

　　Patients have a history of excessive use injuries such as long-distance running, race walking, and marching, with initial symptoms being concealed, only local pain in the lower limbs when bearing weight, and the pain gradually increasing later, which cannot be completely relieved even at rest. There may be gradually increasing local swelling and tenderness, and in most cases, the activity of the limbs is not limited.

　　Stress fractures are mainly focused on prevention. In recent years, there have been many research reports on the prevention of stress fractures in sports and training from China and abroad, which can be roughly divided into the following aspects.

　　1. Select venues and improve equipment:Absorb vibration through the selection of sports venues and improvement of equipment to reduce stress injuries. For example, Greaney (1983) chose grass, Mepoil (1991) used soft-padded shoes, and Milgrom (1992) used shock-absorbing shoes. The selection of venues should avoid hard surfaces such as decks and concrete roads, and flat soil or sandy stone venues are preferred.

　　2. Scientifically arrange training:Control the training intensity to benefit the balance of stress-induced bone destruction and bone repair. For new recruits and young athletes, it should be emphasized to increase the amount of exercise gradually. According to the pathogenesis of stress fractures, Scully (1982) proposed periodic training, advocating that upper limb or other adaptive training be arranged in the third week of training to avoid the peak period of stress fractures in the lower limbs. Zhang Liansheng's bone balance training method (1992) and Huang Changlin's intensive cyclic training method (1994) have achieved significant preventive effects.

　　3. Improve training skills and stress distribution:Prevent stress fractures by continuously changing the stress concentration area of the bone during training. Liu Daxiong et al. (1996) alternated the use of flat shoes and slope shoes every other day during the soldier's load-bearing marching training, significantly reducing the incidence of tibial stress fractures. In the training of middle and long-distance running, it is possible to consciously choose different slopes of the site to make the stress concentration area of the tibia change continuously when bearing weight, thereby reducing the destructive changes of local bones. It is advocated to alternate the arrangement of load-bearing marching and running training, which can reduce the occurrence of stress injuries and not affect the requirements and overall effect of the lower limb training program.

　　4. Pre-training preparation:Prepare for the pre-training activities and post-training relaxation exercises to avoid exercise and training under psychological tension and physical fatigue. Zhang Li (1995) applied psychological intervention to keep the trainees in good psychological condition, significantly reducing the incidence of training injuries. Li Zuguozhu (1994) analyzed the risk factors of stress fractures in basic training of new recruits, emphasizing the harmfulness of training with injuries and under fatigue. In addition, attention should be paid to the medical supervision of sports and training, frequently asking the trainees about their own feelings, and regularly checking the prone areas of stress fractures to achieve early detection of early injuries and timely prevention of stress fractures.

　　At the time of diagnosis, in addition to relying on its clinical manifestations, it also needs to rely on auxiliary examinations. There are no positive findings in the early stage of X-ray films for this disease, but for those who persist in training for a long time, stress fractures can be shown on X-ray films. This should attract the high attention of clinical doctors and patients.

　　Firstly, what foods are good for tibial stress fractures?

　　1. Eat more vegetables rich in fiber, and eat bananas, honey, and other foods that promote gastrointestinal digestion and defecation.

　　2. In the early stage, eat some foods that promote blood circulation, remove blood stasis, and dissipate Qi, such as vegetables, soy products, fish soup, and eggs.

　　3. In the middle stage, eat some foods that help relieve pain, remove blood stasis, regenerate new tissue, and continue bones and tendons, such as bone soup, Cordyceps chicken soup, and animal liver.

　　4. In the later stage, eat more foods that benefit the liver and kidney, invigorate the Qi and nourish the blood, and relax the tendons and meridians, which can help the formation of callus, such as chicken soup with old hen, pork bone soup, and sheep bone soup.

　　Secondly, what foods should be avoided for tibial stress fractures?

　　1. Avoid blind supplementation of calcium.

　　2. Avoid indigestible foods.

　　3. Avoid eating too much meat and drinking bone soup.

　　(The above information is for reference only; for details, please consult a doctor.)

　　1. Reduction:Recover the displaced fracture segment to a normal or nearly normal anatomical relationship, and reconstruct the skeletal support function. This is the first step in the treatment of fractures and the basis for fracture fixation and functional exercise. Early and correct reduction is a necessary condition for the smooth progress of the fracture healing process.

　　2. Fixation:Maintaining the fracture in the position after reduction, so that it reaches a firm union under good alignment, is the key to fracture healing.

　　3. Functional Exercise:Restore the activity of the affected limb as soon as possible without affecting the fixation. Early and reasonable functional exercise can promote blood circulation in the affected limb, reduce swelling, reduce muscle atrophy, maintain muscle strength, prevent osteoporosis and joint stiffness, promote fracture healing, and is an important guarantee for the recovery of the function of the affected limb.