technetium-tc-99m-medronate and Tibial-Fractures

We show a patient who presented leg pain triggered by intense exercise. The most likely diagnosis was a possible tibial stress fracture or a "shin splint" syndrome (soleus enthesopathy). We performed a bone scintigraphy including SPECT/CT that revealed the presence of the two concomitant pathologies. SPECT/CT identified the hot spot superimposed with bone lesion in the tibial stress fracture and only remodeling activity without evidence of cortical lesions in the enthesopathy processes.

Topics: Fractures, Stress; Humans; Male; Medial Tibial Stress Syndrome; Technetium Tc 99m Medronate; Tibia; Tibial Fractures; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed; Young Adult

To develop a quantitative method of interpreting tibial scintigrams of Thoroughbred racehorses with tibial stress fractures that may facilitate diagnosis of fractures and to provide prognostic information regarding future performance of affected horses.. 35 Thoroughbred racehorses.. Static bone-phase scintigrams of tibial stress fractures were quantitatively analyzed by use of ratios of the mean radionuclide counts per pixel in a region of interest (ROI) drawn around the area of increased uptake of radiopharmaceutical to mean counts per pixel in a second ROI drawn around an apparently normal area of the tibial diaphysis. In horses with unilateral fractures, ratios for the contralateral tibia were determined by use of 2 ROIs drawn at the same positions as the ROIs in the fractured tibia. Ratios were compared between fractured versus apparently normal tibias, between horses that returned to racing versus those that did not, and among horses with various grades of lameness. The association between ratios for fractured tibias and intervals between diagnosis and return to racing was also assessed.. Mean ratio of ROIs in apparently normal tibias was 1.35 (95% confidence interval [CI], 1.21 to 1.50); that in tibias with stress fractures was 3.55 (95% CI, 2.50 to 4.60). These ratios were significantly different. None of the associations between ratios for fractured tibias and grades of lameness or performance outcomes were significant.. Tibial stress fracture scintigrams can be quantitatively analyzed. A prospective study with a controlled rehabilitation period is necessary to evaluate the possible applications of this method.

Topics: Animals; Female; Fractures, Stress; Horses; Male; Radionuclide Imaging; Radiopharmaceuticals; Statistics, Nonparametric; Technetium Tc 99m Medronate; Tibial Fractures

To test the hypothesis that the improved resolution afforded by 16-detector computed tomography (CT) would translate to better stress fracture detection when compared with skeletal scintigraphy.. Thirty-three cases of suspected stress fractures in 26 patients were investigated using skeletal scintigraphy and 16-detector CT performed on the same day. Planar images of the lower limbs were taken 3h post-injection of 400MBq (99m)Tc-methylene diphosphonate ((99m)Tc-MDP). (99m)Tc-MDP uptake was quantified at suspected fracture sites. CT was performed using a 16-detector multisection machine employing 0.75mm detectors and images reconstructed in 0.5mm increments. Examinations were reported independently and discordant results were compared at follow-up.. At initial reporting scintigraphy identified fractures in 13 of the 33 cases and CT identified four of the 33. In one case, on review of the CT images, a fracture was present in the distal fibula that was not initially identified. This resulted in eight scintigraphic-positive CT-negative discordant cases. The (99m)Tc-MDP uptake was significantly lower in the discordant fracture group compared with the concordant group (p<0.01).. Despite technological advances in CT, scintigraphy appeared to detect more stress fractures. As such, multidetector CT should not be used as a routine initial investigation in stress fracture detection. The potential use of (99m)Tc-MDP quantification at fracture sites is of interest and may be worth further investigation.

Topics: Adolescent; Adult; Aged; Female; Fibula; Fractures, Stress; Humans; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Technetium Tc 99m Medronate; Tibial Fractures; Tomography, Spiral Computed

Tibial stress fractures are an important cause of lameness in the Thoroughbred racehorse. While it is recognised that these injuries can vary in clinical presentation and radiographic or scintigraphic appearance, little has been done to quantify lesion severity. By contrast the scintigraphic grading of tibial stress fractures in human athletes is widely reported and assists in the selection of appropriate management regimes.. To determine the relationship between scintigraphic grade, clinical severity and radiographic appearance of tibial stress fractures.. The current study involved the retrospective analysis of records from 42 Thoroughbreds with abnormal tibial scintigraphic activity.. There was a significant association between lesion site and scintigraphic grade and good correlation of scintigraphic scoring between investigators. No significant association was found between scintigraphic grade and either radiographic grade or degree of lameness.. The study confirmed that radiographic appearance is an unreliable measure of clinical severity or stage of progression of lesions. The scintigraphic grading system used in the study was not of use in defining stress fracture severity in the equine tibia.. Despite this finding, there is clearly a need for prospective investigations to explore the potential for targeted management regimes for tibial injuries based on lesion site or clinical criteria.

Topics: Animals; Female; Fractures, Stress; Horse Diseases; Horses; Lameness, Animal; Male; Radionuclide Imaging; Retrospective Studies; Stress, Mechanical; Technetium Tc 99m Medronate; Tibial Fractures; Trauma Severity Indices

This study evaluated the relation between the scintigraphic appearances of tibial stress fracture in military recruits and the likelihood that they would complete basic military training.. The authors retrospectively reviewed 58 Tc-99m MDP scans of recruits referred for possible tibial stress fracture and graded them according to the criteria of Zwas et al. (1987). Stress fracture appearances were correlated with clinical information such as the duration of rehabilitation and final outcome with regard to completion of the initial basic military training program.. Thirty-seven of the 58 patients (64%) had tibial stress fractures, all of which were located in the tibial diaphysis, with most occurring in the middle and lower thirds. Most (23 of 37) patients had stress fractures of grade I or II, and the others had grade III or IV stress fractures. There was no statistical difference in the proportion of patients with bilateral fractures between grades I-II and III-IV. There was no significant difference in the duration of rehabilitation for recruits successfully recovering from grade III-IV fractures compared with grade I-II fracture. There was a greater proportion of patients with lower grade fractures than higher grade fractures (P = 0.0006) who, despite rehabilitation, could not continue training because of unremitting or recurring pain at the fracture site and were medically discharged from military service.. Contrary to expectation, recruits with higher-grade stress fractures were not less likely to complete basic military training compared with recruits with lower grade stress fractures.

Topics: Fractures, Stress; Humans; Military Personnel; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Technetium Tc 99m Medronate; Tibial Fractures; Treatment Outcome

The author reports three cases of longitudinal tibial fatigue fractures, reviews the literature, and discusses characteristic features that suggest the diagnosis may be made by bone scintigraphy.. Radiographs and two- or three-phase bone scintigraphs with Tc-99m MDP were obtained in three runners who had exercise-related leg pain and whose clinical symptoms suggested either stress fractures or shin splints. The literature was reviewed and previously reported scintigraphic findings were compared with those seen in these three cases.. In contrast to the focal, elliptical, cortex-based abnormal activity usually seen in the upper or middle tibia in patients with tibial stress fractures, all three patients had a long area of abnormal diffusely increased tibial activity that extended from the tibiotalar region proximally. This finding was seen on the 3-hour delayed static images of all three patients and was suggested on the blood-pool (tissue phase) images. The literature also contained reports of these same scan characteristics. Radiographs subsequently disclosed a longitudinal tibial stress fracture in one patient, computed tomography was positive in the second patient, and findings of clinical follow-up and radiographs were consistent with this diagnosis in the third patient.. In the appropriate clinical setting and with normal or nondiagnostic radiographs, the presence of a long area of diffusely increased activity in the distal tibia extending proximally from the tibiotalar junction is indicative of a longitudinal fatigue fracture.

Topics: Adult; Cumulative Trauma Disorders; Female; Fractures, Stress; Humans; Male; Middle Aged; Radionuclide Imaging; Radiopharmaceuticals; Running; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors

Topics: Adult; Fractures, Stress; Humans; Injury Severity Score; Male; Military Personnel; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Technetium Tc 99m Medronate; Tibial Fractures; Tomography, X-Ray Computed

A scintigraphic study of the healing process of type A and B closed tibial shaft fractures was carried out in 40 cases treated non-operatively, comprising 32 men and eight women aged 30.6 yr on average. Scintigraphic scans were obtained with technetium methylenediphosphonate (MDP-Tc99m, 25 mCi) at 6, 12 and 24 weeks after the fracture and an activity index was calculated taking the mean of three consecutive uptake counts for both fractured and normal opposite leg, used for comparison. The results showed that the activity index in general decreased progressively from the first to the third evaluation, with little difference in behaviour between the two types of fractures. However, for B type fractures the activity index remained stable from the first to the second evaluation, followed by a marked decrease at the third evaluation, with a comparable end result for both fracture types. It was concluded that a decrease of the activity index occurs in both types of closed fractures undergoing uneventful healing and that such a decrease can be taken as a parameter for further studies which include delayed union and non-union.

Topics: Adult; Analysis of Variance; Female; Fracture Healing; Fractures, Closed; Humans; Male; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibia; Tibial Fractures

Topics: Adult; Athletic Injuries; Fractures, Stress; Humans; Leg Injuries; Male; Radionuclide Imaging; Radiopharmaceuticals; Running; Sprains and Strains; Technetium Tc 99m Medronate; Tibial Fractures

The tibia is a fairly common site for stress fractures of both the fatigue and insufficiency types. The majority are transverse or, less frequently, oblique. The present report outlines four cases of vertical stress fractures, an orientation that is very uncommon and leads to bone scan findings which can be misleading.

Topics: Aged; Female; Fractures, Stress; Humans; Male; Radiopharmaceuticals; Technetium Tc 99m Medronate; Tibial Fractures; Tomography, X-Ray Computed

Combined bone scanning and immunoscintigraphy (IS) with 99mTc-monoclonal antigranulocyte antibodies were performed in two patients with suspected reactivation of chronic osteomyelitis of the lower extremity. Because bone scanning and IS were strongly positive, both patients underwent surgical intervention.. Macroscopic findings did not show purulent infection and microbiologic results remained negative, but histology revealed unexpected ectopic bone marrow, explaining the strong uptake on IS. One patient exhibited active hematopoietic bone marrow at the former fracture site of the tibial bone. The second patient presented with interspersed bone marrow in the cortical bone of the femoral diaphysis after several intramedullary surgical procedures.. Unexpected ectopic hematopoietic marrow may occur in the appendicular skeleton after trauma and repeated surgical interventions. The bone marrow shows a physiologic uptake with IS and may be misinterpreted as granulocyte accumulation due to infection. This may lead to false-positive diagnosis in cases of suspected osteomyelitis.

Topics: Adult; Aged; Antibodies, Monoclonal; Bone Marrow; Choristoma; Diagnosis, Differential; Female; Femoral Fractures; Femur; Hematopoiesis; Humans; Male; Osteomyelitis; Radioimmunodetection; Radiopharmaceuticals; Technetium Tc 99m Medronate; Tibia; Tibial Fractures

Topics: Adult; Fractures, Stress; Humans; Magnetic Resonance Imaging; Male; Radiopharmaceuticals; Technetium Tc 99m Medronate; Tibial Fractures; Tomography, X-Ray Computed

Topics: Aged; Bone Transplantation; Humans; Ilium; Male; Osteitis Deformans; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibia; Tibial Fractures

Osteonecrosis and osteopenia are widely recognized skeletal complications of therapy in recipients of renal transplants. These conditions are often complicated by fractures, usually in the femora, pelvis or vertebrae. The authors describe two sedentary adult allograft recipients who presented with leg pain and in whom bone scintigraphy, serial radiographs, and clinical progress were suggestive of insufficiency fractures of the tibiae. Although seldom reported, insufficiency fractures should be considered in the differential diagnosis of renal allograft recipients with leg pain.

Topics: Diagnosis, Differential; Female; Fractures, Spontaneous; Humans; Kidney Transplantation; Middle Aged; Radiography; Radionuclide Imaging; Technetium Tc 99m Medronate; Technetium Tc 99m Pentetate; Tibial Fractures

Twelve athletes presenting acute knee injury with normal radiological findings underwent both three-phase radionuclide bone imaging (TPBI) and magnetic resonance imaging (MRI). The association of these highly sensitive diagnostic procedures detected occult fractures in all patients. The areas of signal intensity alterations on MRI corresponded to those of increased radionuclide uptake in blood pool images. However, the same areas seemed to be more extended on delayed TPB images. TPBI yielded early diagnostic information about lesion sites and functional activities, while MRI provided better anatomical definition and specific information about associated soft tissue lesions and served to establish the correct therapeutic approach and follow-up.

Topics: Adolescent; Adult; Athletic Injuries; Female; Femoral Fractures; Humans; Knee Injuries; Magnetic Resonance Imaging; Male; Radionuclide Imaging; Sensitivity and Specificity; Technetium Tc 99m Medronate; Tibial Fractures

The results of combined scintigraphy in which indium-111-labeled leukocytes and technetium-99m methylene diphosphonate were used were compared with the results of cultures of open bone at 102 sites of delayed union or non-union, to determine the effectiveness of this combination as a preoperative indicator of osteomyelitis. There were twenty-five true-positive, fifty-nine true-negative, eleven false-positive, four false-negative, and three indeterminate interpretations, yielding, for the diagnosis of osteomyelitis, a sensitivity of 86 per cent, a specificity of 84 per cent, an accuracy of 82 per cent, a positive predictive value of 69 per cent, and a negative predictive value of 94 per cent. There were few false-negative scans; false-positive results were most likely at a metaphyseal site adjacent to a joint in which there was post-traumatic arthropathy, at the site of a failed arthrodesis, and at the site of an unstable delayed union or non-union.

Topics: Adolescent; Adult; Aged; Child; False Positive Reactions; Female; Femoral Fractures; Fractures, Ununited; Humans; Indium Radioisotopes; Leukocytes; Male; Osteomyelitis; Radionuclide Imaging; Shoulder Fractures; Technetium Tc 99m Medronate; Tibial Fractures

Technetium-99m methylene diphosphonate (99mTc-MDP) bone scintigraphy was performed in 45 patients (42 male and 3 female) with established non-united fractures to predict the healing response to pulsing electromagnetic field stimulation therapy. The bone scans revealed 3 different scintigraphic patterns. The most frequent pattern was an increased uniform uptake of the tracer at the non-union site (group 1). The second pattern was increased activity at the bone ends with a photon-deficient area between the fracture sites (group 2a) or a generalized decrease in the radionuclide concentration in the region of bone fragments (group 2b). When the scintigraphic pattern did not fit either of the two patterns or when the presence of the cold area between the bone fragments could not be judged with certainty, it was called indeterminate (group 3). All patients underwent pulsing electromagnetic field stimulation. The healing rate was 87.5% and 42.8% in group 1 and group 3 patients, respectively. None of the group 2 patients had any evidence of healing, and they all underwent surgical exploration, revealing complicated non-unions. We conclude that 99mTc bone scintigraphy is a useful tool in determining complicated non-unions and selecting the proper therapy mode.

Topics: Adult; Electromagnetic Fields; Electromagnetic Phenomena; Female; Femoral Fractures; Fracture Healing; Fractures, Ununited; Humans; Humeral Fractures; Male; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

Stress fracture of the tibia occurs in individuals who subject their extremities to repeated trauma. They can arise in otherwise healthy bone that is subjected to excessive loads (as in the marathon runner) or in abnormal bone that is subjected to minor loads (as in osteoporosis). These fractures may be anywhere along the tibial shaft and tend to be either transverse or oblique in orientation. We report two cases of stress fracture that ran longitudinally in the distal one third of the tibia. Both patients were healthy and did not describe excessive physical activity prior to fracture. Both describe a repetitive twisting action prior to fracture. Computed tomography was diagnostic in both cases following abnormal bone scans and normal plain radiographs. This unusual pattern of fracture has been reported on only four occasions in five patients in the literature.

Topics: Adult; Female; Fractures, Stress; Humans; Male; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibia; Tibial Fractures; Tomography, X-Ray Computed

Three patients with osteosarcoma of the femur developed abnormal radiopharmaceutical uptake in the bones of the contralateral leg. This uptake was not due to metastases. The histology in one patient, the form of the lesion and the disappearance of the abnormal uptake without treatment in the other two, indicated that the uptake was probably due to stress fractures. Changes in weight bearing and walking in the normal leg as a result of the osteosarcoma in the other leg could have been the cause of the stress fractures. It should be recognized that new abnormal uptake on bone scintigraphy in patients with osteosarcoma of the leg may not necessarily indicate metastasis. It may be caused by a stress fracture and disappears after rest.

Topics: Adult; Bone Neoplasms; Child; Female; Femur; Fibula; Fractures, Stress; Humans; Osteosarcoma; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

Imaging with technetium-99m methylene diphosphonate (99mTc-MDP) is established in the diagnosis of infection, neoplasia and ischaemic necrosis in orthopaedic practice, but its role in fracture healing is less well-defined. Previous studies have shown a relationship between fracture site activity (region A), activity in adjacent normal bone (region C) and time to union. The predictive value of the A/C ratio of the image obtained 300-800 s after injection was assessed in a prospective study of 50 patients with closed tibial fractures managed with plaster casts, external fixators and intramedullary nails. There were significant differences in absolute uptake and A/C ratio between the three groups (P less than 0.05), but this was not related to time to union. Reamed nailing alters the distribution of 99m-Tc-MDP uptake so as to reduce the A/C ratio (1.10 +/- 0.20), but there is a promising role for early phase bone scanning in non-operative (A/C = 1.40 +/- 0.21) or externally fixed (A/C = 1.26 +/- 0.22) fractures in conjunction with other non-invasive methods of monitoring the biomechanical environment.

Topics: Adolescent; Adult; Aged; Female; Humans; Male; Middle Aged; Radionuclide Imaging; Retrospective Studies; Technetium Tc 99m Medronate; Tibial Fractures; Wound Healing

Healing patterns were compared between transverse and 60 degrees oblique osteotomies in canine tibiae stabilized under external fixation. Under similar in vitro testing conditions (osteotomy ends in contact), the axial stiffness of the oblique osteotomy under external fixation was 45% of the paired transverse osteotomy. Under torsion and bending, the two sides exhibited similar fixation rigidity. The animals put significantly less weight on the oblique side than on the transverse side in the early phases of bone healing (p less than 0.05 for static and p = 0.024 for dynamic weight bearing). The osteotomy bending stiffness at 60 days (in vivo) and the torsional stiffness of osteotomy union measured after sacrifice at 90 days were significantly higher on the transverse side (p = 0.013 and p = 0.016, respectively). Intracortical new bone formation was significantly higher on the transverse side (p less than 0.01), indicating a difference in the rate of cortical healing and remodeling. The average pin removal torque was significantly lower on the oblique side (p less than 0.05), a sign of increased pin loosening. In the clinical situation, unstable oblique or spiral fractures should be protected from weight bearing even under stable external fixation due to the delayed recovery of bone union stiffness property as well as increased pin tract problems.

Topics: Animals; Bone and Bones; Bony Callus; Dogs; External Fixators; Osteotomy; Radionuclide Imaging; Technetium Tc 99m Medronate; Tensile Strength; Tibia; Tibial Fractures; Torsion Abnormality; Wound Healing

Topics: Animals; Bone Resorption; Calcification, Physiologic; Radionuclide Imaging; Rats; Technetium Tc 99m Medronate; Tibial Fractures

We have shown that stress fractures can be induced in the tibial diaphysis of an animal model by the repeated application of non-traumatic impulsive loads. The right hind limbs of 31 rabbits were loaded for three to nine weeks and changes in the bone were monitored by radiography and bone scintigraphy. The presence of stress fractures was confirmed histologically in some cases. Most animals sustained a stress fracture within six weeks and there was a positive correspondence between scintigraphic change and radiological evidence. Microscopic damage was evident at the sites of positive bone scans. The progression, location, and time of onset of stress fractures in this animal model were similar to those in clinical reports, making the model a useful one for the study of the aetiology of stress fractures.

Topics: Animals; Bony Callus; Female; Fractures, Stress; Rabbits; Radiography; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

Forty-nine patients with 50 fracture nonunions 4-48 months after injury underwent technetium-99m methylene diphosphonate (99mTc-MDP) scintigraphy on day 1, combined 99mTc-MDP and indium-111 leukocyte (111In-WBC) scintigraphy on day 2, and gallium-67 (67Ga) scintigraphy on day 3. The results were compared to evaluate the relative abilities of these scintigraphic techniques to detect osteomyelitis. Nine patients had clinical evidence of infection at the time of imaging, and 40 patients (41 fractures) did not. Open-biopsy cultures were performed at all fracture sites and were positive at 21 (42%) of the 50 sites. Combined 99mTc-MDP/111In-WBC images were interpreted with the use of two criteria. A positive study by the first criterion required 111In-WBC localization in the region of the nonunion fracture. A positive study by the second criterion required 111In-WBC localization in bone at the fracture site. The first criterion yielded a sensitivity of 84%, specificity of 72%, and accuracy of 74%; the specificity improved to 97% with an accuracy of 88% when the second criterion was used. Ten (25%) of the 40 patients thought not to have osteomyelitis by clinical criteria at the time of imaging had true-positive 99mTc-MDP/111In-WBC studies by biopsy culture results. Gallium-67 studies were interpreted as nondiagnostic if localization of radioisotope at fracture sites was equal to that with 99mTc-MDP, positive if 67Ga localization was greater than that of 99mTc-MDP, and negative if it was less than that of 99mTc-MDP. Twenty-one 67Ga studies were interpreted as nondiagnostic; 11 (52%) of the 21 had culture-positive fracture sites. The accuracy of 67Ga/99mTc-MDP imaging was 39%. Combined 99mTc-MDP/111In-WBC imaging is useful in the detection of osteomyelitis at fracture nonunion sites and improves the specificity of 111In-WBC imaging by differentiating inflammation/infection in adjacent soft tissue from osteomyelitis at the fracture site. Gallium-67 with 99mTc-MDP imaging is not sufficiently reliable in this clinical setting to be useful as an indicator for osteomyelitis.

Topics: Adult; Aged; Female; Femoral Fractures; Fractures, Ununited; Gallium Radioisotopes; Humans; Humeral Fractures; Indium Radioisotopes; Leukocytes; Male; Middle Aged; Osteomyelitis; Prospective Studies; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

Topics: Cumulative Trauma Disorders; Fractures, Closed; Humans; Male; Middle Aged; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibia; Tibial Fractures; Tomography, X-Ray Computed

Fifty unilateral closed adult tibial shaft fractures treated by closed methods were studied prospectively using bone scintigraphy to predict the healing potential of individual fractures. Dynamic and static scintigrams, using 99mtechnetium methylene diphosphonate, were obtained at zero, six, and 12 weeks after fracture. The data were analyzed according to the methods of recent workers in this field. Forty-one fractures united normally at 20 weeks and nine fractures developed delayed union. Analysis of results showed significant differences in uptake ratios, mean net counts, and an osteogenesis index between fractures with normal and delayed union. Of particular value was a ratio of uptake over the fracture site to an adjacent site in the same bone obtained at six weeks. A ratio greater than 2 indicated the potential to heal normally. The findings suggest that a single static scintigram at six weeks is strongly predictive of subsequent healing.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Humans; Middle Aged; Osteogenesis; Predictive Value of Tests; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures; Wound Healing

Differentiation of occult skeletal injuries from early acute osteomyelitis in infants and young children is important clinically. The Tc-99m MDP scintigraphic findings in six patients who had occult femoral or tibial fractures were reviewed. The images obtained early (at 1-4 days from the onset of symptoms) shared the common characteristic finding of a subtle but definite, generalized increased uptake of the tracer along the entire length of the injured bone. This pattern of uptake was similar regardless of the type of fracture. These were different from the focal abnormalities that have been observed in early acute osteomyelitis. In the absence of an extensive cellulitis or a vascular occlusive disease, a bone image showing a mild diffuse uniform increased uptake along the entire length of the tibia or femur in infants and young children with lower extremity pain of less than 1 week's duration should suggest the diagnosis of occult skeletal fractures.

Topics: Acute Disease; Diagnosis, Differential; Female; Femoral Fractures; Humans; Infant; Infant, Newborn; Male; Osteomyelitis; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors

A new system for classification of stress fractures identified by bone scintigraphy was developed and divided into four grades according to lesion dimension, bone extension, and tracer accumulation. The scintigraphic findings were evaluated for severity of lesions by extent of the visualized bone response, ranging from ill-defined cortical lesions with slightly increased activity (I) to well-defined intramedullary transcortical lesions with intensely increased activity (IV). Bone scintigraphies using [99mTc]MDP were obtained in 310 military recruits suspected of having stress fractures. In 235 patients, 391 stress fractures were diagnosed. Forty percent of the lesions were asymptomatic. Most of the lesions were in the tibiae (72%), and 87% of the patients had one or two lesions, while 13% had three to five lesions. Eighty-five percent of the lesions were classified as mild and showed early and more complete resolution on follow-up studies after treatment as compared to the severe grades. Furthermore, specific scintigraphic patterns have been introduced for distinguishing inflammatory shin-splints from stress fractures, allowing for their appropriate early treatment. Thus, early recognition of mild stress fracture scintigraphic patterns representing the beginning of pathologic bone response to stress enabled a prompt and effective treatment to prevent progression of lesions, protracted disability, and complications.

Topics: Adult; Bone Diseases; Diagnosis, Differential; Femoral Fractures; Follow-Up Studies; Fractures, Bone; Humans; Male; Military Personnel; Physical Exertion; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures

The uptake of 99mTc-MDP was studied in 73 patients after a tibial fracture. The image obtained five minutes after injection during a period between one and four weeks after fracture was found to be related to the incidence of non-union after six months. A ratio of 1.3 between the uptake at the fracture site and at normal bone adjacent to it predicted non-union in an individual patient with a sensitivity of about 70% and a specificity of 90%.

Topics: Adolescent; Adult; Fractures, Ununited; Humans; Middle Aged; Predictive Value of Tests; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors; Wound Healing

The clinical significance of nonfocal increased uptake on skeletal scintigraphy in suspected tibial stress fractures is controversial, because it may represent either bone reaction to stress or a stress fracture in evolution. The scintigraphic evolution of areas of abnormal tibial activity, graded according to a 1 to 4 rating system and their corresponding clinical courses, were analyzed in 27 military recruits, as part of a prospective study. Disappearance of pain correlated with scintigraphic healing and increased pain with progression to stress fracture. Decreased or persistent pain had equivocal scintigraphic correlation. Eight of 14 nondiscrete scintigraphic lesions disappeared in spite of continuous training by the recruits; four such lesions, however, progressed to stress fractures. This uncertainty of progression suggests that military recruits and people training for sports who have such scintigraphic activity should have a brief rest period and proper monitoring before resuming training.

Topics: Adolescent; Adult; Fractures, Spontaneous; Humans; Male; Military Personnel; Radionuclide Imaging; Stress, Physiological; Technetium Tc 99m Medronate; Tibial Fractures

Topics: Adolescent; Athletic Injuries; Football; Fractures, Spontaneous; Humans; Male; Radionuclide Imaging; Technetium Tc 99m Medronate; Tibia; Tibial Fractures

Three-phase radionuclide bone (TPB) imaging was performed on 238 patients with sports-related injuries. A wide variety of lesions was encountered, but the most frequent lesions seen were stress fractures of the lower part of the leg at the junction of the middle and distal thirds of the posterior tibial cortex (42 of 79 lesions). There were no differences in the type, location, or distribution of lesions between males and females or between competitive and noncompetitive athletes. In 110 cases, bone stress lesions were often diagnosed when radiographs were normal, whereas subacute or chronic soft-tissue abnormalities had few specific scintigraphic features. TPB imaging provides significant early diagnostic information about bone stress lesions. Normal examination results (53 cases) exclude underlying osseous pathologic conditions.

Topics: Adolescent; Adult; Aged; Athletic Injuries; Back Pain; Bone and Bones; Child; Connective Tissue Diseases; Diphosphonates; Female; Fibula; Follow-Up Studies; Foot Injuries; Fractures, Bone; Hip Fractures; Humans; Leg Injuries; Male; Middle Aged; Radionuclide Imaging; Retrospective Studies; Sports; Technetium; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors

Simultaneous digital acquisition of [67Ga] and [99mTc]MDP images, and subsequent division of the first by the second to produce a parametric ratio image (G/T), is employed to characterize the relative localization of the two radiopharmaceuticals in early rabbit tibia Staphloccocus aureus osteomyelitis and fracture repair. Images obtained during the first 48 hr of each condition show preferential 67Ga accumulation probably reflecting an initial inflammatory response while G/T images at 5-7 days show predominance of the bone-seeking scan agent, which may indicate that the dominant process is osteoblastic repair.

Topics: Animals; Diphosphonates; Gallium Radioisotopes; Osteoblasts; Osteomyelitis; Rabbits; Radionuclide Imaging; Staphylococcal Infections; Technetium; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors; Wound Healing

Incomplete stress fractures of the proximal tibial diaphysis can be diagnosed by bone scintigraphy. The scintigraphic appearance of incomplete rather than complete tibial stress fractures is apparently reported for the first time in this article. With no treatment other than restricted activity, this injury heals rapidly and completely in 4 to 6 weeks. The major threat to the patient's welfare is unfounded suspicion of tumor or infection which may lead to biopsy or inappropriate therapy.

Topics: Adolescent; Adult; Athletic Injuries; Diphosphonates; Humans; Male; Physical Exertion; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Tibial Fractures

When a massive free bone graft has to be incorporated into a large bone defect in the presence of a poor vascular recipient bed, the risks of absorption and failure of the graft to revascularise are high. Experimental studies have confirmed that a bone graft transferred to its recipient site with an intact pedicle of blood supply remains viable, and unites directly with the recipient bone without having to be revascularised and replaced by creeping substitution. It also provides a live bone bridge for reconstruction of a massive bone defect, and is a ready source of vascular osteogenic tissue which sprouts new outgrowths to revascularise avascular recipient bone. A vascularised bone graft can be raised on a pedicle of muscle attachment or a main axial vessel, but the mobility of the vascularised pediculated graft is limited by the length of its pedicle. The vascularised muscle-pedicle graft of the ipsilateral fibular shaft described by Chacha et al has been proved viable both in monkeys and in humans. The shaft is raised on a pedicle of the peroneal vessels and the peroneal and the anterior tibial muscles, and provides an excellent viable bone strut to bridge a large defect in the tibial shaft. Judet's quadratus femoris muscle-pedicle graft from the greater trochanter has proved superior to Phemister's tibial cortical or fibular strut graft for the treatment of non-union of the femoral neck and the silent-phase of avascular necrosis of the femoral head. The tensor fascia lata muscle-pedicle graft of the anterior iliac crest, described by Davies and Taylor, provides a good viable bone strut for anterior hip fusion and for filling defects in the acetabulum and the upper femur. The whole of the greater trochanter attached to a thick pedicle of the gluteal muscles can be used as a live extra-articular graft for hip fusion. A pedicular rib graft raised on its intercostal vessels, as described by Rose et al. and Bradford, is a very useful live bone strut for correction of kyphosis and grafting of infective lesions of the vertebral bodies. The cortical graft of the radius within the radial forearm skin flap for reconstruction of the thumb, the pronator quadratus muscle-pedicle graft of the lower radius for non-union of the scaphoid and avascular necrosis of the lunate, and the erector spinae muscle-pedicle graft of the posterior ilium for intertransverse fusion are new concepts which need to be evaluated for wider clinical application.

Topics: Adult; Angiography; Animals; Bone and Bones; Bone Transplantation; Child; Diphosphonates; Dogs; Female; Fibula; Fluorescent Dyes; Haplorhini; Hip; Humans; Male; Methods; Rabbits; Radius; Ribs; Spine; Surgical Flaps; Technetium; Technetium Tc 99m Medronate; Tibial Fractures

Topics: Adolescent; Adult; Athletic Injuries; Diphosphonates; Female; Fibula; Fractures, Bone; Humans; Male; Middle Aged; Radionuclide Imaging; Running; Stress, Mechanical; Technetium; Technetium Tc 99m Medronate; Tibial Fractures

In a prospective study of stress injuries of the lower extremities of U.S. Marine recruits, we derived a frequency distribution of stress fractures. The most frequently fractured bone was the tibia (73%), while the single most common site was the posterior calcaneal tuberosity (21%). The natural history of stress fractures by scintigraphy and radiography has been outlined, showing the evolutionary changes on either study as a universal progression independent of injury site or type of stress. An identical spectrum of changes should be present within any group undergoing intense new exercise. The frequency distribution of stress fractures should be a function of differing forms and intensities of exercise, therefore, our figures should not be applied to other groups. We used the presence of a scintigraphic abnormality at a symptomatic site as the criterion for diagnosis of stress fracture. Since the distribution of skeletal radiotracer uptake is directly dependent on local metabolic activity, it is expected that a focal alteration in bone metabolism will result in a scintigram approaching 100% sensitivity for the abnormality (9). In the proper clinical setting, the specificity should approximate this figure; however, a focal, nonstress-related bone abnormality which has not manifested any radiographic change, such as early osteomyelitis, could result in a false-positive examination. Specificity cannot, therefore, be accurately determined without an actual determination of the pathologic changes within the bone, necessarily involving biopsy. In summary, we believe that we have established bone scintigraphy as an early and accurate means for the detection of lower extremity stress fractures, even in the absence of radiographic findings (6). We feel that a focally abnormal scintigram, in the proper clinical setting, establishes the diagnosis of stress fracture, with radiography to be performed at the time of initial work-up only to rule out a non-stress injury (such as complete fracture, fibrous dysplasia, osteomyelitis, primary bone tumor).

Topics: Adult; Calcaneus; Diphosphonates; Fractures, Bone; Humans; Male; Metatarsus; Military Medicine; Physical Exertion; Prospective Studies; Radionuclide Imaging; Stress, Mechanical; Technetium; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors

A review of 13 cases of suspected child abuse in which radionuclide (RN) scans, radiographic skeletal surveys, and sufficient follow-up were available showed that the RN scans were insensitive, even though fractures were more than 48 hours old at the time of the scan. Frequently missed lesions included skull and extremity fractures. Furthermore, soft tissue and visceral abnormalities that were identified on radiographic examination went undetected on RN scan. We conclude that, although the RN scan may augment the radiographic examination, it should not be used alone to screen for the battered child.

Topics: Battered Child Syndrome; Child Abuse; Child, Preschool; Diphosphonates; False Negative Reactions; False Positive Reactions; Femoral Fractures; Humans; Infant; Infant, Newborn; Male; Radiography; Radionuclide Imaging; Retrospective Studies; Rib Fractures; Skull Fractures; Technetium; Technetium Tc 99m Medronate; Tibial Fractures

A scintigraphic study of the human tibia in the early stages following fracture of the shaft was carried out to investigate the condition of the blood supply of the main fracture fragments. Using a gamma camera and 99mTc-MDP, scintigraphs were obtained from less than 24 hours to 21 days after injury. A generalized increase in tracer uptake was found in the tibia in all cases. In some cases very early after injury there was an additional local increase at the fracture site. In 10% of cases "cold spots" were observed, which may indicate an impaired blood supply to bone tissue adjacent to the fracture. Neither the presence of a "cold spot" nor any other scintigraphic feature could be correlated with the progress or time to fracture union.

Topics: Adolescent; Adult; Aged; Diphosphonates; Female; Humans; Male; Middle Aged; Radionuclide Imaging; Regional Blood Flow; Technetium; Technetium Tc 99m Medronate; Tibia; Tibial Fractures; Time Factors; Wound Healing

An insufficiency fracture of the tibial plateau may be the cause of knee pain in patients with osteoporosis. The diagnosis is usually not suspected until a bone scan is done, as initial radiographs are often negative or inconclusive and clinical findings are nonspecific and may simulate osteoarthritis or spontaneous. In five of 165 patients referred for bone scans due to nontraumatic knee pain, a characteristic pattern of intense augmented uptake of radionuclide confined to the tibial plateau led to a presumptive diagnosis of insufficiency fracture, later confirmed on radiographs.

Topics: Adult; Aged; Diphosphonates; Female; Humans; Knee Joint; Male; Middle Aged; Osteoporosis; Pain; Radiography; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Tibial Fractures

The effect of thyrocalcitonin on secondary bone healing was studied in 180 Sprague-Dawley-rats. The right tibia of all the rats was osteotomized. Half of the animals was treated with thyrocalcitonin. Until the 60th postoperative day, the increase in 99mTc-methylendiphosphonate activity was measured and significant differences in ratios were noted. Between the postoperative days 10 to 25, there was a significant difference in the impulse quotients between the thyrocalcitonin and untreated rats (P less than 0.05). These results indicate that thyrocalcitonin may aid in secondary bone healing.

Topics: Animals; Calcitonin; Diphosphonates; Fracture Fixation, Internal; Male; Radionuclide Imaging; Rats; Rats, Inbred Strains; Technetium; Technetium Tc 99m Medronate; Tibial Fractures; Wound Healing

In 20 cases routine static bone scans were no value in the detection of delayed fracture healing. Using the 7.5-15 min net uptake of technetium labelled phosphate, disturbed fracture healing was detected in a series, of 37 cases. Normally healing fractures had an increase of 3 per cent per month and delayed unions less than half that amount. Non-unions had no net uptake.

Topics: Bone Transplantation; Diphosphates; Diphosphonates; Fracture Fixation; Fractures, Bone; Fractures, Ununited; Humans; Male; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Technetium Tc 99m Pyrophosphate; Tibial Fractures; Time Factors; Wound Healing

The uptake of the bone-seeking tracer technetium-99m-methylenediphosphonate increases following bone fracture as bone healing occurs. To investigate the pattern of change in normal healing and compare it with delayed union and nonunion, an analysis of automated computer profiles was carried out on serial scan data for 22 patients. The type of fracture (simple, comminuted, etc.) influenced the appearance of the activity profile; however, no significant differences in the patterns of change were noted between normal healing and delayed or non-union.

Topics: Adolescent; Adult; Aged; Computers; Diphosphonates; Female; Humans; Male; Middle Aged; Radionuclide Imaging; Technetium; Technetium Tc 99m Medronate; Tibial Fractures; Time Factors; Wound Healing

Topics: Adolescent; Diagnosis, Differential; Diphosphonates; Humans; Male; Osteomyelitis; Radionuclide Imaging; Stress, Mechanical; Technetium; Technetium Tc 99m Medronate; Tibial Fractures