Fractal analysis of bone texture: a screening tool for stress fracture risk?

The aim of this study was to identify specific bone characteristics of stress fracture (SF) cases in sportswomen. To date, no tool is able to distinguish individuals who are at risk, limiting preventive measures.

We investigated the skeletal system of sportswomen who did sustain SF in the past (n = 19) and compared it with that of female controls (C) with a similar sporting history but without any fracture history (n = 20). Bone mass and body composition were measured using dual-energy X-ray absorptiometry. Bone micro-architecture was investigated by calcaneal ultrasound and fractal analysis of calcaneus radiographic images. Oestradiol levels were measured by E.I.A, and IGF-1 by R.I.A. Menstrual characteristics, nutrient intake, and training were assessed using questionnaires.

The result of the fractal analysis, expressed by the Hmean parameter, was significantly lower in the SF group, reflecting a more complex structure of the trabecular micro-architectural organization (P < 0.005). Body mass index (BMI) at birth was also found to be lower in the SF cases as compared with their C (P < 0.03). Multivariate analysis revealed that the fractal parameter Hmean, bone mineral content (BMC) at Ward's triangle and the BMI at birth correctly assigned 84.85% of the female athletes into their respective SF or C groups (P = 0.001).

These results suggest that the fractal parameter and the BMI at birth may be able to identify female athletes most at risk for this overuse bone injury, as their low indexes might reflect a greater skeletal sensitivity.