Ymi Ton, MD, MS
Resident Physician
NewYork-Presbyterian
New York, California, United States
Parker Nguyen, MD
Resident Physician
NewYork-Presbyterian
New York, New York, United States
Jack Haberl, MD, MBA
Resident Physician
NewYork-Presbyterian
New York, New York, United States
Kristian von Rickenbach, MD, MSc
Attending Physician
Columbia University Irving Medical Center
New York, New York, United States
Non-healed second metatarsal stress fracture, anterior femoral neck stress reaction, third proximal phalangeal stress reaction.
Case Description:
39-year-old female with hypermobility (Beighton score 4/9) and left second metatarsal stress fracture (SF) one year prior presented with one month of recurrent left foot pain after re-initiation of running. She also reported two months of anterior right hip pain and one year of left dorsal hand pain, both previously uninjured. X-rays of her right hip and left hand were benign, and x-ray of her left foot showed a thickened cortex of the second metatarsal suggestive of chronic stress injury. Exam revealed increased range of motion in all left ankle planes with positive hop test, left third metacarpophalangeal joint tenderness, and anterior right hip tenderness with positive Faber’s test.
Discussions:
MRIs revealed cortical thickening of the left second metatarsal with endosteal bone marrow edema, endosteal edema along the anterior right femoral neck, and left hand third proximal phalangeal shaft bone marrow signal, suggestive of concurrent stress reactions. She was recommended for non-weight bearing status to the bilateral lower extremities and left hand, use of a CAM boot and hand splint, and initiation of physical and hand therapy. Subsequent bone density scan demonstrated above average bone density. She received a clinical genetics evaluation and tested negative for connective tissue disorder and bone fragility conditions. She had gradual symptom improvement with conservative management and was started on a bisphosphonate per endocrinology.
Conclusions:
Patients with previous SF are at high risk of developing another. This patient developed metatarsal and femoral neck SFs, both common lower extremity SF sites. Uniquely, she developed a phalangeal SF, an uncommon site for upper extremity SFs. In addition to addressing biomechanical stressors with bracing and therapy, it is important to investigate other etiologies including endocrinological and genetic disorders that may predispose patients to repeat SF.
