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Bone contusions - are they really fractures?

Bone contusions

With the advent of MRI, we now have a new category of bone injury called a bone contusion (also called bone swelling).  Is a bone contusion really a fracture?  I think so, but thus far, we don’t really have the vocabulary in the literature to call a bone contusion a fracture.  Let me explain…

A contusion is a term usually applied to soft tissue injuries that involve numerous structures.  A contusion may involve nerve, subcutaneous tissue, tendon, etc.  When we use the term contusion and refer to a bone injury, we’re describing a crush injury to the bone.  Bone is usually made of a hard, outer surface with a softer, spongy inner surface.  That softer, spongy surface acts as a shock absorber, absorbing load.  But with a contusion, the hard, outer bone and the softer inner bone is crushed.

This is a hard injury for the bone to heal.  And often, a hard choice for surgeons to try to rebuild.  We drill it, graft it.  But in most cases, the idea is to restore the bone to its’ normal load bearing structure.

So is a bone contusion really a fracture?  I think so.  Any thoughts?

Jeff

Dr. Jeffrey Oster

Jeffrey A. Oster, DPM
Medical Director
Myfootshop.com

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7/2/2014 3:41 PM
I have a history of surgeries to my left foot (sesamoidectomy/bunionectomy/hammertoe fusion), and have grappled with foot issues for nearly 2 years (major surgery was a year ago). In the fall of 2013, I noticed I was having more pain in the ball of my foot, directly my very bone first metatarsal head, basically where the medial sesamoid was removed. I don't have much padding in my foot anymore, due to the months of injury, surgery recovery, and NUMEROUS cortisone shots before and after surgery... I had an MRI back in April, which only should mild bone marrow edema--in the first met head, the lateral sesamoid, and then some thickening in my abductor hallucis (probably scar tissue). My ortho said I could go into supportive sneakers OR a CAM boot for 6-8 weeks, plus doe intensive PT, which I've been doing for about 11 weeks now. I was also in the boot full-time (when walking) for about 8 weeks before attempting to slowly wean out. At first, I felt decent when walking in sneakers, but I keep having issues... I have a new physical therapist now, who says we really need to focus on the mobility of my foot and the fact that my hammertoes are curling even more tightly, and all of the tendons on the top of my foot are taut (totally noticeable, too). She feels the fat pad will not be restored, but I need to start working on regaining balance, strength, etc. She wants me to be in sneakers or comfortable, supportive sandals (NO Danskos), and also barefoot when I can (SLOWLY) to work on strength. I'm a little nervous, but honestly, my orthopedic doc barely gave me any direction re: the process. I have been doing it on my own with advice from my PTs. I feel like he thinks this is not a big deal, but given my history, I clearly got this contusion due to mechanical stress--probably wearing too hard of shoes after the surgery. It's not as though I was doing anything high-impact that would cause a bone contusion. Just curious if it's indeed fine for me to start wearing sneakers (I know my ortho will say "fine") and working on bare footed exercises (controlled!). I fear doing more damage, but honestly, after being in the boot for 2 months straight, and in and out for another 3 weeks, I don't notice much difference when I'm in a sneaker. I assume "mild bone marrow edema" is not quite the same as extensive marrow edema... The bottom of my foot does not even swell--I can just feel the painful, sort of bony spot where the sesamoid once was and what is now my rather unprotected first met head... Unfortunately, I also have nerve pain from this situation... I know this is a strange case, but any thoughts?
7/2/2014 3:55 PM
Tiffany, In your case it sounds as if the bone edema might be related to the absence of the sesamoid or even just the trauma of the surgery. Have you tried a Dancer's pad? Check out the reusable dancer's pads on our site. The reason I mention them is that you'd be able to wear them while barefoot in the transition you've described as instructed by your PT. Jeff
7/23/2014 11:11 AM
Thank you so much for responding, Dr. Jeff! I have tried just about everything one could imagine re: dancer's pads, K-tape, rocker-sole shoes, etc... I'm still struggling. It's very up and down. PT has been helpful in MANY ways, but as I try to challenge myself a bit more (with some yoga, Pilates, and some light "hiking" on uneven ground), I am finding it to be painful. I have pain daily, most of the day--that's the norm, whether I am more active or less active. I find that soft-bed Birkenstocks aren't too bad, but I'm just having a tough time bending my foot normally at "push-off" when I walk... Standing is less difficult, but the motion of walking normally, without pronating and pushing off of the painful first met head, is hard. I'm meeting with an orthotics & prosthetics specialist this Friday to get new orthotics--this will be my fourth set! Also, meeting with my ortho doc again next week after about 5 months... I'd like a new MRI, but I wonder if that is a waste of time. I'm just so discouraged. I'm only 39 and feel like this foot is beyond frustrating and dysfunctional some days. I really regret having all that surgery done, but I truly did not understand what the outcome might be at that point in time. Do you know of anyone who has had a sesamoidectomy, bunionectomy, and second toe fusion done simultaneously? No one I know has seen this--not my doctor, PTs, nor anyone, it seems. What little I have found online is pretty discouraging. Thank you for you time!!
7/23/2014 1:37 PM
The combination of procedures is not really unusual, Tiffany. The combination of the bunionectomy and second toe procedures is common. The sesamoidectomy? Certainly less common but not unheard of. I don't think a follow-up MRI is going to provide all that much new information for you. Be sure to speak with your doctor about it. Let's see what your care providers can do for you locally. Fingers crossed. jeff
7/24/2014 7:22 AM
Thank you, Dr. Jeff! Yes, I concur--the second toe fusion (to allow the plantar plate injury to heal) coupled with the bunionectomy is not at all unusual. However, none of my ortho surgeons or PTs have seen those together with the sesamoidectomy. That is why this is so difficult to rehab... I will see what my surgeon in Boston says next week, and work with the orthotics & prosthetics lab tomorrow to sort out new orthotics. I just need a little hope at some point, and perhaps an extra fat pad! ;)
9/23/2014 5:15 AM
Hi! I actually found out that I have three osseous contusions on my left foot due to a bike riding accident on July 1. It's been a long and painful few months with not much progress and lots of waiting. I finally found a great foot/ankle surgeon that I like but always have more questions after I leave the appts. I do look up things on the Internet but that either just makes me angry or confuses me as to why I haven't been treated a certain way. Ill give you the brief story first and if you answer and need more questions I can help. July 1 I went for a bike ride in flip flops. Dumb I know, hit a curb the tire blew I put my left foot down to prevent falling. Violently twisted my left foot as well as ripping off part of my big toe nail. Immediate swelling and could not bear weight. Got home was in pain when weight bearing but ok while off my foot. Put ice on wrapped it and fell asleep. Woke up at three am in severe pain. Major swelling in foot and toes as well as dark bruising along inner arch of foot and toes. Went to er and had X-rays. Told there was a bone chip but the dr suspected a fracture that wasn't showing on X-ray. Gave me crutches, wrapped, pain meds and told to see orthodo ASAP. I was able to get an appt with a new ortho in my area that morning. At this point in severe pain even while resting went to the dr and explained what had happened and he looked at hospital X-ray. Said there was no fracture just a mid foot sprain. Told me to rice, gave me pain meds and said to stay off it till Saturday then begin to bear weight on it. Was able to get a week off from work and spent the time in bed all week rice, still in a lot of pain for just a sprain no matter how bad. Swelling and bruising peaked at about Saturday and began to slowly go down. Noticed bruising had spread to bottom of foot as well as outside of foot. One week post injury attempted to go to work but had to leave cause I could barely limp around. I went to a foot and ankle surgeon for another opinion and was given a boot for tendinitis, some NSAIDs and a note off from work. Went back to ortho for first follow up since accident. Still a lot of trouble bearing weight with swelling and bruising. He did take an X-ray and said it all looked good. When told about the pain I was in he said it took three months to fully heal and scheduled N appt for one month. The next month I kept the boot on, iced Nd elevated when I was not working and stayed off it as much as possible. My theory was I was being a wimp and while I had broken bones and grade three sprains the pain was worse cause it was my foot. At this time I still couldn't bear full weight on my foot when it was out of boot and had a lot of pain in bending toes. Went back to ortho he took another X-ray and told me to begin pt three times a week and get an orthotic for my shoe. At this point I was fed up it had been six weeks and I couldn't walk on my foot and was still in constant pain. I went to a foot/ankle surgeon that same day. He agreed that it was not normal and suspected a possible tendon tear or rupture. Sent me for an MRI the next day. Went for the MRI and got a phone call from the dr that I needed Nother MRI as well as a cat scan ASAP. Got both and dr called me on phone to come into office. I had a disruption of the lisfranc ligament with minimal subluxation at the lisfranc joint. I also had a small fracture at the superior medial cuneiform and superior middle cuneiform. His treatment was keep using the boot as well as a bone stimulator daily for four weeks in hope it would heal fracture. Went back and not healed yet and still pain in foot. He suggested the bone stim another month, wear boot for another two weeks before starting pt. I'm possibly loosing my insurance by the end of the year and need this to be somewhat resolved by then. I understand his not wanting to rush into surgery and appreciate it. I also am aware after looking up this injury for almost here months that its a serious injury, it's not a common injury, often isn't diagnosed and can lead to a lot of problems. So I guess my question is what is the typical time frame before surgery is required.? What exactly is a disrupted lisfranc ligament.? Does that mean it was a complete tear and is why I have an a upsilon fracture? How does that heal non surgically? I have read that most treatment even non surgiCal is immobilization and non weight earring for six weeks. Is it not healing cause I did not do this? I'm not wanting to rush into surgery but feel time is running out. I've read it's a difficult recovery after surgery. I've had broken bones, ankle surgery for chronic instability of my right ankle and knee surgery and can honestly say this injury as minor as it seems is the most painful, frustrating and the worst one I've had so far.
9/23/2014 1:18 PM
Hi, Sorry about your injury. Funny how life can change in just an instant. Lisfranc's injuries are not only difficult to diagnose but they are equally hard to treat. Think about Lisfranc's joint in this manner; the joint is a series of joints held together by a strong, fibrous network of ligament that create an envelope. In addition to this ligamentous envelope, the second metatarsal is set back within the cuneiform bones creating a key hole notch. The combination of the ligamentous envelope and the key hole notch make Lisfranc's joint able to provide the range of motion necessary to walk and run but strong enough to withstand enormous forces applied to it. That being said, it take an even more powerful injury (force) to either dislocate the joint or create a series of fractures in the joint. In response to your question about surgery, surgery for Lisfranc's injuries is reserved for dislocation or fracture. Without a dislocation or fracture, surgery is not indicated. In terms of rehab, it sounds as if you're on the right track. Activity to tolerance and weight bearing to tolerance are the best approach for the time being. Ice and NSAID's are also indicated. How long is it going to take to heal? There's so many variables associated with that question. With your MRI you've defined the injury but you also have to factor in the co-morbidities associated with healing. Factors such as age, physical condition, smoker/nonsmoker, diabetes - all weigh into the definition of how long it'll take to heal. What kind of guidance has your foot and ankle doc given you on these questions? Jeff
9/23/2014 2:44 PM
He's brought up surgery when I first got the results of scans, at the time putting it off for conservative treatment seemed better than to rush into surgery. I think he expected more progress with the bone stimulator but there was either very little to none. As for fracture there is one and it is noticeable on the weight bearing X-ray, widening between the first and second metatarsal. He did say it was unusual it was only between these two bones and usual there was displacement in the other bones.