Interpretation and classification of bone scintigraphic findings in stress fractures

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.