Stress fractures in athletes

During the 14-year period of 1971-1985, 368 stress fractures in 324 athletes were treated. The series contained 268 fractures in males and 100 fractures in females; 32 fractures occurred in children (less than 16 years), 117 in adolescents (16-19 years), and 219 in adults. Forty-six fractures were incurred by athletes at an international level, 274 by athletes at a national or district level and 48 by recreational athletes. Of the total cases, 72% occurred to runners and a further 12% to athletes in other sports after running exercises. The distribution of the stress fractures by site was: tibia 182, metatarsal bones 73, fibula 44, big toe sesamoid bones 15, femoral shaft 14, femoral neck 9, tarsal navicular 9, pelvis 7, olecranon 5 and other bones 10. Of the total fractures, 342 were treated conservatively and 26 fractures required surgical treatment. The operative indication was dislocation in 5 cases and delayed union/nonunion in 21 cases. The sites most often affected by delayed union were: anterior midtibia, sesamoid bones of the big toe, base of the fifth metatarsal, olecranon, and tarsal navicular. The athletes at an international level experienced the greatest risk of multiple separate fractures, protracted healing, or fractures requiring surgery.     

Stress fractures of the femur in athletes

Femoral stress fractures represent an uncommon but important lower-extremity injury in athletes and soldiers. Careful assessment of the involved and contralateral lower extremity and the spine is required to make the diagnosis. Based on a review of the literature, specific treatment is based on individual patient assessment. In most cases, nonoperative management results in an excellent outcome. Certain fractures will require operative intervention to prevent displacement or to reduce a displaced fracture and return stability to the lower extremity. Complications in athletes with femoral stress fractures are rare. Most athletes can expect to return to their preinjury level of competition, if they are compliant with the treatment plan.     

Stress fractures in adolescent competitive athletes with open physis

There have been no studies devoted exclusively to stress fractures in competitive athletes with immature skeletal systems so far. The object of this case series was to describe special features of stress fractures in athletes with immature skeletal systems, with special reference to sport-specific strain, diagnosis and treatment results. The study population was made up of 19 children and adolescents with a total of 21 stress fractures. The average observation period was 4.83 years [standard deviation (SD) 2.69] and the average age at diagnosis, 14.04 years (SD 4.7). The lower extremity was affected in most of our cases. In adolescent athletes, endurance sports appear to lead preferentially to stress fractures in the region of the metatarsal bones, while sports requiring sudden stops at high speed appear to increase the risk of fractures in the region of the tibial diaphysis (P=0.0322). Most (20 of 21) of the fractures in this study were treated conservatively with refraining from athletic activity and reduction of stress/weight-bearing for an average of 6.73 weeks (SD 2.91). In five cases the extremity was in addition immobilized in a plaster cast for 5.32 weeks (SD 2.21). Complete healing was achieved in 14 cases. In seven cases, however, the treatment did not lead to a satisfactory outcome. Most of the patients whose symptoms persisted over a long period had fractures in the tibia and were engaged in sports requiring frequent sudden stops. Our data suggest that stress fractures in athletes, whose skeletal systems are still immature, lead to a clinical picture that does not always culminate in a good outcome of treatment. We therefore recommend a thorough and early diagnostic investigation (including MRI) and consistent treatment whenever a patient's history and clinical picture give any indication that a stress fracture might be present.     

Stress reactions and fractures around the elbow in athletes

Stress fractures of the upper limb affect athletes from a wide range of sports. Athletes involved in throwing sports are particularly susceptible along with athletes from sports involving high repetitive and compressive loads such as gymnastics. Diagnosis can be made from clinical history, examination and radiography in some cases however MRI imaging is often required for definitive diagnosis. The mainstay of management is rest and activity modification however advanced pathology often requires surgical management for successful resolution and return to play. In the elbow, the bones susceptible to excessive stress in sport are the distal humerus, the olecranon process of the ulna, the coronoid process of the ulna, the sublime tubercle and the radial head. In immature patients, medial epicondyle apophysis is the most common location. The article presents a narrative review of the literature.     

Stress fractures in athletes. A study of 320 cases

We analyzed cases of 320 athletes with bone scan-positive stress fractures (M = 145, F = 175) seen over 3.5 years and assessed the results of conservative management. The most common bone injured was the tibia (49.1%), followed by the tarsals (25.3%), metatarsals (8.8%), femur (7.2%), fibula (6.6%), pelvis (1.6%), sesamoids (0.9%), and spine (0.6%). Stress fractures were bilateral in 16.6% of cases. A significant age difference among the sites was found, with femoral and tarsal stress fractures occurring in the oldest, and fibular and tibial stress fractures in the youngest. Running was the most common sport at the time of injury but there was no significant difference in weekly running mileage and affected sites. A history of trauma was significantly more common in the tarsal bones. The average time to diagnosis was 13.4 weeks (range, 1 to 78) and the average time to recovery was 12.8 weeks (range, 2 to 96). Tarsal stress fractures took the longest time to diagnose and recover. Varus alignment was found frequently, but there was no significant difference among the fracture sites, and varus alignment did not affect time to diagnosis or recovery. Radiographs were taken in 43.4% of cases at the time of presentation but were abnormal in only 9.8%. A group of bone scan-positive stress fractures of the tibia, fibula, and metatarsals (N = 206) was compared to a group of clinically diagnosed stress fractures of the same bone groups (N = 180), and no significant differences were found. Patterns of stress fractures in athletes are different from those found in military recruits. Using bone scan for diagnosis indicates that tarsal stress fractures are much more common than previously realized. Time to diagnosis and recovery is site-dependent. Technetium99 bone scan is the single most useful diagnostic aid. Conservative treatment of stress fractures in athletes is satisfactory in the majority of cases.     

Stress fractures and bone health in track and field athletes

The effect of exercise on bone health has received much attention in recent years. The problems of the female athlete triad: disordered eating, amenorrhea and osteoporosis have helped us to better understand and appreciate the important interaction of mechanical, hormonal, nutritional as well as genetic factors on bone health in the young female athlete. The relatively high stress fracture incidence of young track and field athletes can be quite disabling for the athlete's present and future running career. A number of risk factors including low bone mineral density (BMD), menstrual irregularities, dietary factors and prior history of stress fractures have been associated with an increased risk for stress fractures in the female athlete. Few studies have found risk factors for stress fractures in the male athlete. Female gender has been found to be a risk factor for stress fractures in the military population, but this finding is less apparent in athlete studies. Caucasians have been found to have a higher risk for stress fractures than African-American military recruits, but there is very limited data assessing stress fracture risk in athletes of varying ethnicity. Prevention of stress injury to bone involves maximizing peak bone mass in the pediatric and young adult age groups. Maintaining adequate calcium nutrition, caloric intake as well as hormonal and energy balance are important preventive measures, as are ensuring appropriate amounts of weight bearing exercise for optimizing bone health and preventing fractures. More research is needed to determine factors leading to improvements in bone density and fracture reduction in athletes at risk.     

Malleolar fractures in athletes

Ankle injuries occur frequently in the athlete. The incidence of ankle fractures has been estimated to be 250,000 per year in the United States; therefore, it is one of the most common fractures treated by the orthopedic surgeon. The usual mechanism of injury is supination-eversion, making up 42% to 72% of ankle fractures. With displaced fractures, anatomic reduction of the joint and rigid internal fixation are crucial for proper healing and returning to sports activities.     

Carpal fractures in athletes

A review of the literature shows that 3% to 9% of all athletic injuries occur to the hand or wrist. Also, hand and wrist injuries are more common in pubescent and adolescent athletes than adults. Although knee and shoulder injuries are more common athletic injuries, an injury to the hand or wrist significantly can impair the athlete's ability to throw or catch a ball, or swing a bat or racquet. A college football player trains year round for just 11 or 12 hours of playing time. An athletic injury that occurs during the season can have profound consequences for the athlete's career and emotions. When defining a management plan for a particular wrist athletic injury, the time to heal the injury and the time to rehabilitate fully must be considered. The athlete must be informed fully of the length of recovery. The continued advancement of fixation methods and techniques are diminishing fracture morbidity considerably. Small-cannulated compression screws that provide rigid fixation can be inserted with decreased surgical dissection, thus preserving critical vascular supply and promoting accelerated healing and earlier rehabilitation. The arthroscope as a valuable adjunct in the management of wrist fractures was virtually unheard of years ago, but is now common. The ability to arthroscopically guide a cannulated compression screw to stabilize a scaphoid fracture without a formal open volar approach can reduce surgical morbidity significantly and allow the athlete to return to competition more quickly. Mechanisms of injury that cause osseous fractures of the wrist are fairly high energy. A high index of suspicion for associated soft tissue injuries should be kept in mind when fractures of the wrist are identified. The wrist is composed of eight carpal bones tightly interwoven with each other by intrinsic and extrinsic wrist ligaments. The management of carpal fractures depends on prompt diagnosis, stable and anatomic alignment of the involved carpal bone, protective immobilization of the injury, and thorough rehabilitation. Displaced fractures of the hook of the hamate, trapezial ridge fractures, and comminuted pisiform fractures are managed best by early excision to promote uncomplicated recovery and early return to sport. For most athletes, return to competition can be expedited safely with the use of padded gloves and custom playing splints or casts. The sports medicine physician always must put the athlete's safety first when deciding the appropriate time for return to competition.     

Rib fractures in athletes

Rib fractures are the most common serious injury of the chest. They occur most commonly in the middle and lower ribs with blunt trauma, and also with direct force to a small area of the chest wall and violent muscle contractions. Diagnosis is generally not difficult. The athlete should have a chest x-ray to confirm the diagnosis. Differential diagnosis includes severe rib contusion, costochondral separations, muscle strains and pneumothorax. If no internal problems exist, treatment consists of ice, NSAIDs, analgesics and a rib belt or tape. Healing should be well on its way before a return to sports. Fractures of the first 4 ribs or the last 2 ribs, multiple fractures and flail segments are less benign than other fractures, and may result in injury to surrounding structures. First rib and floating rib fractures are uniquely athletic fractures; they are avulsion fractures caused by a sudden vigorous contraction in different directions of pull.     

Stress fractures of the femoral shaft in athletes: a new treatment algorithm

Background

Femoral shaft stress fractures in athletes are not common but pose a great diagnostic challenge to clinicians. Because of few clinical signs, diagnosis and treatment are often delayed. Furthermore, if not treated correctly, these fractures are well known for complications and difficulties.

Objective

To develop a well structured and reproducible treatment algorithm for athletes with femoral shaft stress fractures.

Methods

The proposed algorithm is carried out in four phases, each lasting three weeks, and the move to the next phase is based on the result of the tests carried out at the end of the previous phase. Over nine years, we treated seven top level athletes, aged 17–21. In all athletes, diagnosis was based on physical examination, plain radiographs, and bone scan.

Results

As a result of the treatment method, all the athletes were fully engaged in athletic activity 12–18 weeks after the beginning of treatment. After completion of the treatment, the athletes were followed up for 48–96 months. During the follow up, there was no recurrence of discomfort or pain, and all the athletes eventually returned to competition level.

Conclusion

These results and data available from the literature suggest that the algorithm is the optimal treatment protocol for femoral shaft stress fractures in athletes, avoiding the common complications and difficulties.     

Avulsion fractures in athletes.

34 cases of avulsion fractures are described. Each fracture took place during athletic training or competition. Excepting six sportsmen participating in a general fitness programme, every patient was an active competitive athlete. There were six women and 28 men; their average age was 20.1 years, raised by a few middle-aged "fitness sportsmen". Most avulsion fractures took place in sprinters and hurdlers; next were middle and long distance renner, footballers, fitness joggers, skiers and ice-hockey players. The most usual location of a fracture was the anterior pelvic spines; avulsion fractures were also detected in various parts of lower limbs. There were fewer avulsion fractures in the area of the trunk and upper extremities. Roetgenologically, the diagnosis of an avulsion fracture is generally easy to make. However, the diagnosis is facilitated by knowing the mechanism of the injury, the technique of the athletic event, and some of the training methods. Generally, a fracture heals well, even if it requires both sufficient immobilisation and some delay in resuming physical exertion.     

Complicated elbow fractures in athletes

The elbow is a key link in the function of the upper extremity and therefore, is subject to various stresses and strains. These stresses may be in the form of a single macrotrauma or repetitive microtrauma with each having its effect on the architecture of the elbow. In dealing with athletes with elbow disorders, one is faced with the challenge of maintaining mobility while achieving maximal stability. Therefore, what has been proposed are treatment formulas for some of the more common elbow fractures that affect the athletic population, which the author has found to be quite useful in achieving these goals.     

Cervical spine fractures in athletes

This article presents (1) the on-field assessment of the athlete who has sustained a cervical injury, (2) the diagnostic modalities necessary to make an accurate diagnosis, (3) the specific fractures/dislocations seen in the cervical spine, and (4) the guidelines used to determine if the athlete may return to active competition.     

Femoral shaft stress fractures in athletes

Stress fractures of the femoral shaft in athletes occur most commonly in the proximal third of the femur. They can, however, also be found in the mid- or distal third. Conservative treatment is highly successful in healing these fractures without complications. Athletes can usually return to activity in 8 to 14 weeks. Recognition of the symptoms characteristic of these fractures (vague thigh pain, diffuse tenderness, no trauma) will assist early diagnosis. Early definitive diagnosis can be made by radionuclide scanning or later, by plain radiography, if symptoms have been present for a sufficient period. Diagnosis is not limited to novice runners since runners with significant mileage, or baseball or basketball players, can develop femoral shaft stress fractures.     

Stress fractures of the femoral neck in athletes. The consequence of a delay in diagnosis

Twenty-three patients with stress fractures of the femoral neck were followed up at an average of 6.5 years after the injury. There were 16 recreational athletes and seven elite athletes. Most injuries (N = 15) occurred during running. The diagnosis was confirmed within 3 to 104 weeks (mean, 14 weeks) after the initial onset of symptoms. Sixteen of the patients were treated with internal fixation, the remaining seven were treated conservatively. Seven patients (30%) developed complications requiring major surgery. Five of these patients had Type 3 fractures (displaced) and four had been treated with internal fixation initially. The remaining two patients had Type 1 fractures (endosteal or periosteal callus without an overt fracture line); one was treated operatively and the other conservatively. Three patients developed avascular necrosis and two were treated by hip replacement. The third patient was treated with arthrodesis. Three refractures and one pseudarthrosis were treated by osteotomy. At followup, all elite athletes stated that they had to end their career as a result of the injury. Results were rated by the ability of the athlete to return to sports. There were 9 bad or fair results, 13 good, and 1 excellent result. No difference in activity level or subjective rating was observed between the surgically and conservatively treated group either preinjury or postinjury. The most important factor influencing the complication rate seems to be the type of fracture. The high incidence of displaced fractures (Type 3) could speculatively be caused by undiagnosed tension side stress fractures. If so, the delay in correct diagnosis may be disastrous. However, we could only objectively observe this in one of our cases.     

Hook of the hamate fractures in athletes

Five patients have been treated for six hook of the hamate fractures over the past 8 years by the authors. Of these, four patients were professional baseball players and one patient was an accountant. All fractures occurred while playing baseball; four while swinging a bat, and two secondary to a fall on an outstretched hand. Roentgenographic diagnosis was made by carpal tunnel view alone in two, oblique and carpal tunnel view in one, bone scan and subsequent carpal tunnel view in two, and computerized tomography in one fracture. Five of the fractures were through the base of the hook, while one was toward the tip. All patients ultimately underwent hook resection, four early and two late. The patient who sustained the tip of the hook fracture underwent resection of the fracture only to refracture the same hook at its base 6 months later. All patients returned to their previous level of activity in 6 to 8 weeks after surgery without loss of function. Hence, it is the authors' opinion that the entire hook should be resected to the base of the hamate as the primary form of treatment in hook of the hamate fractures.