Alexander M. Wood

The epidemiology of acute sports-related fractures in adults

OBJECTIVE To determine the incidence and epidemiology of acute sports-related fractures in adults. DESIGN Retrospective analysis of a prospectively collected database containing all in-patient and out-patient fractures in a defined patient population in 2000. SETTING Orthopaedic Trauma Unit. RESULTS There were 5953 fractures in 2000 of which 761 (12.8%) were caused in sporting accidents. The overall incidence was 142/10(5) with 261/10(5) in males and 35/10(5) in females. The mean age was 25.6 years. 41 sports caused the fractures but 10 sports accounted for 86.8% of fractures. In 40 sports the highest prevalence of fractures were in the upper limb and the commonest fractures seen were in the distal radius, metacarpus and finger phalanges although the highest prevalence was in the clavicle. Sports fractures comprised 16.5% of upper limb fractures and 7.5% of lower limb fractures. Our results suggest that there are 80,000-85,000 sports fractures annually in the United Kingdom of which about 18,000 require operative treatment. CONCLUSIONS Sporting activities are the third most common cause of fractures. With increasing affluence it is likely that they will increase. Fractures of the wrist and hand are the most common but in some sports there are a number of higher energy fractures. Our results suggest that, even in sport, there are a number of osteoporotic fractures usually occurring in women.

The epidemiology, morbidity, and outcome of soccer-related fractures in a standard population.

Background: Soccer is the most common cause of sporting fracture, but little is known about patient outcome after such fractures. Purpose: To describe the epidemiological characteristics of soccer-related fractures, their outcomes, and the likelihood of return to soccer after injury in a known United Kingdom population at all skill levels. Study Design: Descriptive epidemiology study. Methods: All soccer fractures during 2007-2008 in the Lothian population were prospectively collected, with the diagnosis confirmed by an orthopaedic surgeon when patients attended the only adult orthopaedic service in Lothian. Patients living outside the region were excluded from the study. Patients were contacted in August 2010 to ascertain their progress in returning to soccer. Results: A total of 367 fractures were recorded over the study period in 357 patients; 312 fractures (85%) in 303 patients (85%) were followed up, with a mean interval of 30 months (range, 24-36 months). The mean time for return to soccer from injury was 15 ± 17 weeks (range, 0-104 weeks). For patients with lower limb injuries, the mean time was 26 ± 22 weeks (range, 4-104 weeks) compared with 9 ± 8 weeks for patients with upper limb injuries (range, 0-64 weeks). Fourteen percent of the whole cohort did not return to soccer; 83% returned to soccer at the same level or higher. Thirty-nine percent had ongoing related problems; however, only 8% had impaired soccer ability because of these problems. Fractures with the highest morbidity in not returning to soccer were to the clavicle (24%), distal radius (21%), and tibial diaphysis (20%). Conclusion: Most patients sustaining a fracture while playing soccer will return to soccer at a similar level. While over one third of them will have persisting symptoms 2 years after injury, for the majority, this will not impair their soccer ability.

Epidemiology, Management, and Outcome of Sport-Related Ankle Fractures in a Standard UK Population

Background: The literature on the outcome of sport-related ankle fractures has focused on operatively managed fractures, despite a large proportion being treated nonoperatively. We describe the epidemiology, management, and outcome of acute sport-related ankle fractures in a UK population. Methods: All sport-related ankle fractures sustained during 2007 to 2008 in the Lothian Population were prospectively collected when patients attended the only adult orthopaedic service in Lothian. Fractures were classified using the Lauge Hansen and the Pott’s Classification. The presence of fracture displacement was also recorded. Patients were contacted in February 2011 to ascertain their progress in return to sport. Results: Ninety-six sport-related ankle fractures were recorded in 96 patients. Eighty-four fractures (88%) were followed up at a mean interval of 36 months (range, 30-42). Most common associated sports were soccer (n = 49), rugby (n = 15), running (n = 5), and ice skating (n = 3). The mean time for return to sport was 26 weeks (range, 4-104), the return rate to sport 94%, and the persisting symptom rate 42%. Fifty-two fractures (all nondisplaced) were managed nonoperatively—43 isolated lateral malleolar (30 Weber B, 13 Weber A), 2 isolated medial malleolar, 7 bimalleolar. Forty-four fractures were managed operatively—42 were displaced (2 isolated lateral malleolar, 3 isolated medial malleolar, 18 bimalleolar equivalent, 9 bimalleolar, 3 trimalleolar equivalent, 7 trimalleolar), 2 were un-displaced (2 trimalleolar). The mean times for return to sport were 20 weeks (range, 4-52) for the nonoperative cohort (NOC) and 35 weeks (range, 8-104) for the operative cohort (OC) (P < .001), the return rates to sport were 100% for NOC and 87% for OC (P < .016), and the persisting symptom rates were 17% for NOC and 71% for OC (P < .001). Conclusions: Nondisplaced ankle fractures in athletes were successfully managed with nonoperative care. They had greater return rates to sport, quicker return times, and lower persisting symptom rates but had less severe injuries. Level of Evidence: Level III, retrospective comparative study.

The epidemiology, morbidity and outcome of fractures in rugby union from a standard population

BACKGROUND Rugby union is the second commonest cause of sporting fracture in the UK, yet little is known about patient outcomes following such fractures. OBJECTIVE To describe the epidemiology of fractures in rugby union, their morbidity and the likelihood of return to rugby post-injury in a known UK population at all skill levels. METHODS All rugby union fractures sustained during 2007-2008 in the Edinburgh, Mid and East Lothian populations were prospectively recorded, when patients attended the only adult orthopaedic service in Lothian. The diagnosis was confirmed by an orthopaedic surgeon. Patients living outside the region were excluded from the study. Patients were contacted by telephone in February 2012 to ascertain their progress in return to rugby. RESULTS A total of 145 fractures were recorded over the study period in 143 patients. The annual incidence of rugby-related fractures was 0.28/1000 of the general population and 29.86/1000 of the adult registered rugby playing population. 120 fractures were of the upper limb and 25 were of the lower limb. 117 fractures (81%) in 115 patients (80%) were followed up at a mean interval of 50 months (range 44-56 months). 87% of the cohort returned to rugby post-injury (87% of upper limb fractures and 86% of lower limb fractures), with 85% returning to rugby at the same level or higher. Of those who returned, 39% did so by 1 month post-injury, 77% by 3 months post-injury and 91% by 6 months post-injury. For those who returned following upper limb fractures, 48% did so by 1 month post-injury, 86% by 3 months post-injury and 94% by 6 months post-injury. In patients who returned following lower limb fractures, 0% did so by 1 month post-injury, 42% by 3 months post-injury and 79% by 6 months post-injury. From the whole cohort, 32% had ongoing fracture related problems, yet only 9% had impaired rugby ability secondary to these problems. CONCLUSIONS Most patients sustaining a fracture playing rugby union will return to rugby at a similar level. While one third of them will have persisting symptoms 4 years post-injury, for the majority this will not impair their rugby ability.

A Review on the Management of Hip and Knee Osteoarthritis

Arthritis is the most common chronic condition affecting patients over the age of 70. The prevalence of osteoarthritis increases with age, and with an aging population, the effect of this disease will represent an ever-increasing burden on health care. The knee is the most common joint affected in osteoarthritis, with up to 41% of limb arthritis being located in the knee, compared to 30% in hands and 19% in hips. We review the current concepts with regard to the disease process and risk factors for developing hip and knee osteoarthritis. We then explore the nonsurgical management of osteoarthritis as well as the operative management of hip and knee arthritis. We discuss the indications for surgical treatment of hip and knee arthritis, looking in particular at the controversies affecting young and obese patients in both hip and knee replacements. Patient and implant related outcomes along with survivorships are addressed as well as the experiences and controversies described in national joint registries.

Return to Sport After Tibial Shaft Fractures A Systematic Review

Context: Acute tibial shaft fractures represent one of the most severe injuries in sports. Return rates and return-to-sport times after these injuries are limited, particularly with regard to the outcomes of different treatment methods. Objective: To determine the current evidence for the treatment of and return to sport after tibial shaft fractures. Data Sources: OVID/MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Collaboration Database, Web of Science, PEDro, SPORTDiscus, Scopus, and Google Scholar were all searched for articles published from 1988 to 2014. Study Selection: Inclusion criteria comprised studies of level 1 to 4 evidence, written in the English language, that reported on the management and outcome of tibial shaft fractures and included data on either return-to-sport rate or time. Studies that failed to report on sporting outcomes, those of level 5 evidence, and those in non–English language were excluded. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: The search used combinations of the terms tibial, tibia, acute, fracture, athletes, sports, nonoperative, conservative, operative, and return to sport. Two authors independently reviewed the selected articles and created separate data sets, which were subsequently combined for final analysis. Results: A total of 16 studies (10 retrospective, 3 prospective, 3 randomized controlled trials) were included (n = 889 patients). Seventy-six percent (672/889) of the patients were men, with a mean age of 27.7 years. Surgical management was assessed in 14 studies, and nonsurgical management was assessed in 8 studies. Return to sport ranged from 12 to 54 weeks after surgical intervention and from 28 to 182 weeks after nonsurgical management (mean difference, 69.5 weeks; 95% CI, –83.36 to −55.64; P < 0.01). Fractures treated surgically had a return-to-sport rate of 92%, whereas those treated nonsurgically had a return rate of 67% (risk ratio, 1.37; 95% CI, 1.20 to 1.57; P < 0.01). Conclusion: The general principles are to undertake surgical management for displaced fractures and to attempt nonsurgical management for undisplaced fractures. Primary surgical intervention of undisplaced fractures, however, may result in higher return rates and shorter return times, though this exposes the patient to the risk of surgical complications, which include surgical site infection and compartment syndrome.

Incidence and Time to Return to Training for Stress Fractures during Military Basic Training

Currently, little is known about the length of time required to rehabilitate patients from stress fractures and their return to preinjury level of physical activity. Previous studies have looked at the return to sport in athletes, in a general population, where rehabilitation is not as controlled as within a captive military population. In this study, a longitudinal prospective epidemiological database was assessed to determine the incidence of stress fractures and the time taken to rehabilitate recruits to preinjury stage of training. Findings demonstrated a background prevalence of 5% stress fractures in Royal Marine training; femoral and tibial stress fractures take 21.1 weeks to return to training with metatarsal stress fractures being the most common injury taking 12.2 weeks. Rehabilitation from stress fractures accounts for 814 weeks of recruit rehabilitation time per annum. Stress fracture incidence is still common in military training; despite this stress fracture recovery times remain constant and represent a significant interruption in training. It takes on average 5 weeks after exercise specific training has restarted to reenter training at a preinjury level, regardless of which bone has a stress fracture. Further research into their prevention, treatment, and rehabilitation is required to help reduce these burdens.

Lower limb stress fractures in sport: Optimising their management and outcome

Stress fractures in sport are becoming increasing more common, comprising up to 10% of all of sporting injuries. Around 90% of such injuries are located in the lower limb. This articles aims to define the optimal management of lower limb stress fractures in the athlete, with a view to maximise return rates and minimise return times to sport. Treatment planning of this condition is specific to the location of the injury. However, there remains a clear division of stress fractures by “high” and “low” risk. “Low risk” stress fractures are those with a low probability of fracture propagation, delayed union, or non-union, and so can be managed reliably with rest and exercise limitation. These include stress fractures of the Postero-Medial Tibial Diaphysis, Metatarsal Shafts, Distal Fibula, Medial Femoral Neck, Femoral Shaft and Calcaneus. “High risk” stress fractures, in contrast, have increased rates of fracture propagation, displacement, delayed and non-union, and so require immediate cessation of activity, with orthopaedic referral, to assess the need for surgical intervention. These include stress fractures of the Anterior Tibial Diaphysis, Fifth Metatarsal Base, Medial Malleolus, Lateral Femoral Neck, Tarsal Navicular and Great Toe Sesamoids. In order to establish the optimal methods for managing these injuries, we present and review the current evidence which guides the treatment of stress fractures in athletes. From this, we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport. Following this, key recommendations are provided for the management of the common stress fracture types seen in the athlete. Five case reports are also presented to illustrate the application of sport-focussed lower limb stress fracture treatment in the clinical setting.

Sports-related fractures in South East Scotland: an analysis of 990 fractures

Purpose. To describe the characteristics of all sports-related fractures in patients aged ≥15 years in South East Scotland in one year. Methods. Medical records of 990 consecutive patients aged ≥15 years who presented to the Orthopaedic Trauma Unit of the Royal Infirmary of Edinburgh with sports-related fractures between 1 July 2007 and 30 June 2008 were reviewed. Acute fractures of the upper limbs, lower limbs, pelvis, and cervical spine were included, but those of the skull, facial bones, and thorax were excluded, as were stress and chronic fractures. Results. The incidence of sports-related fractures was 1.8/1000/year (82% involving men). The median age of patients was 25 (interquartile range, 19–35) years. Sports-related fractures accounted for 24.6% and 5.1% of all fractures in men and women, respectively. Men aged 15 to 19 years were 9 times more likely to have sports-related fractures than women of the same age. The sports-related fractures involved the upper limbs (52.4%), lower limbs (45.4%), and axial skeleton (2.2%). 12 of 49 sports (football, rugby, skiing, snowboarding, 3 cycling disciplines, horse riding, motocross, basketball, martial arts, and ice skating) accounted for 82.8% of all sports-related fractures. Upper limb fractures outnumbered lower limb fractures in all sports, except for horse riding and motocross that the proportions were similar. Conclusion. In South East Scotland, most sports-related fractures involved the upper limbs

Return to sport following tibial plateau fractures: A systematic review

AIM To systemically review all studies reporting return to sport following tibial plateau fracture, in order to provide information on return rates and times to sport, and to assess variations in sporting outcome for different treatment methods. METHODS A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, MEDLINE, PEDro, Scopus, SPORTDiscus and Web of Science was performed in January 2017 using the keywords “tibial”, “plateau”, “fractures”, “knee”, “athletes”, “sports”, “non-operative”, “conservative”, “operative”, “return to sport”. All studies which recorded return rates and times to sport following tibial plateau fractures were included. RESULTS Twenty-seven studies were included: 1 was a randomised controlled trial, 7 were prospective cohort studies, 16 were retrospective cohort studies, 3 were case series. One study reported on the outcome of conservative management (n = 3); 27 reported on the outcome of surgical management (n = 917). Nine studies reported on Open Reduction Internal Fixation (ORIF) (n = 193), 11 on Arthroscopic-Assisted Reduction Internal Fixation (ARIF) (n = 253) and 7 on Frame-Assisted Fixation (FRAME) (n = 262). All studies recorded “return to sport” rates. Only one study recorded a “return to sport” time. The return rate to sport for the total cohort was 70%. For the conservatively-managed fractures, the return rate was 100%. For the surgically-managed fractures, the return rate was 70%. For fractures managed with ORIF, the return rate was 60%. For fractures managed with ARIF, the return rate was 83%. For fractures managed with FRAME was 52%. The return rate for ARIF was found to be significantly greater than that for ORIF (OR 3.22, 95%CI: 2.09-4.97, P < 0.001) and for FRAME (OR 4.33, 95%CI: 2.89-6.50, P < 0.001). No difference was found between the return rates for ORIF and FRAME (OR 1.35, 95%CI: 0.92-1.96, P = 0.122). The recorded return time was 6.9 mo (median), from a study reporting on ORIF. CONCLUSION Return rates to sport for tibial plateau fractures remain limited compared to other fractures. ARIF provides the best return rates. There is limited data regarding return times to sport. Further research is required to determine return times to sport, and to improve return rates to sport, through treatment and rehabilitation optimisation.