Greg A. J. Robertson

The epidemiology of sports-related fractures in adolescents.

OBJECTIVE To examine the epidemiology of sports-related fractures in adolescents aged 10-19 years. METHODS All fractures in adolescents presenting to the Royal Hospital for Sick Children and the Royal Infirmary of Edinburgh in a one-year period were prospectively documented and all sports-related fractures retrospectively examined. These two hospitals have a defined population facilitating epidemiological studies. RESULTS There were 408 adolescent sports-related fractures giving an overall incidence of 5.63/1000/year. The gender ratio was 87/13% male/female and 84% were upper limb fractures. Thirty sports produced 22 different fracture types. Football, rugby and skiing accounted for 66.2% of the fractures. The commonest fractures were in the finger phalanges (28.7%), distal radius and ulna (23.0%) and metacarpus (12.7%). CONCLUSIONS Sport-related fractures are common in adolescents, particularly in males. They tend to be low-energy injuries affecting the upper limb in particular. Few require operative treatment although their frequency means that they impose significant demands on orthopaedic surgeons and health systems.

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.

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.

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.

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.

Freezing and non-freezing cold weather injuries: a systematic review

INTRODUCTION The debilitating impact of cold weather on the human body is one of the worlds oldest recorded injuries. The severe and life-changing damage which can be caused is now more commonly seen recreationally in extreme outdoor sports rather than in occupational settings such as the military. The diagnosis and treatment of these injuries need to be completed carefully but quickly to reduce the risk of loss of limb and possibly life. Therefore, we have conducted a systematic review of the literature surrounding cold weather injuries (CWIs) to ascertain the epidemiology and current management strategies. SOURCES OF DATA Medline (PubMED), EMBASE, CINHAL, Cochrane Collaboration Database, Web of Science, Scopus and Google Scholar. AREAS OF AGREEMENT IMMEDIATE FIELD TREATMENT The risk of freeze thaw freeze injuries. Delayed surgical intervention when possible. Different epidemiology of freezing and non-freezing injuries. AREAS OF CONTROVERSY Prophylatic use of antibiotics; the use of vasodilators surgical and medical. GROWING POINTS The use of ilioprost and PFG2a for the treatment of deep frostbite. AREAS TIMELY FOR DEVELOPING RESEARCH The treatment of non-freezing CWIs with their long-term follow-up.

Fractures in sport: Optimising their management and outcome

Fractures in sport are a specialised cohort of fracture injuries, occurring in a high functioning population, in which the goals are rapid restoration of function and return to play with the minimal symptom profile possible. While the general principles of fracture management, namely accurate fracture reduction, appropriate immobilisation and timely rehabilitation, guide the treatment of these injuries, management of fractures in athletic populations can differ significantly from those in the general population, due to the need to facilitate a rapid return to high demand activities. However, despite fractures comprising up to 10% of all of sporting injuries, dedicated research into the management and outcome of sport-related fractures is limited. In order to assess the optimal methods of treating such injuries, and so allow optimisation of their outcome, the evidence for the management of each specific sport-related fracture type requires assessment and analysis. We present and review the current evidence directing management of fractures in athletes with an aim to promote valid innovative methods and optimise the outcome of such injuries. From this, key recommendations are provided for the management of the common fracture types seen in the athlete. Six case reports are also presented to illustrate the management planning and application of sport-focussed fracture management in the clinical setting.

Epidemiology of open fractures in sport: One centre’s 15-year retrospective study

AIM To describe the epidemiology of sport-related open fractures from one centre’s adult patient population over a 15-year period. METHODS A retrospective review of a prospectively-collected database was performed: The database contained information all sport-related open fractures, sustained from 1995 to 2009 in the Edinburgh, Mid and East Lothian Populations. RESULTS Over the 15-year period, there were 85 fractures recorded in 84 patients. The annual incidence of open sport-related fractures was 0.01 per 1000 population. The mean age at injury was 29.2 years (range 15-67). There were 70 (83%) males and 14 females (17%). The 6 most common sports were soccer (n = 19, 22%), rugby (n = 9, 11%), cycling (n = 8, 9%), hockey (n = 8, 9%); horse riding (n = 6, 7%) and skiing (n = 6, 7%). The five most common anatomical locations were finger phalanges (n = 30, 35%); tibial diaphysis (n = 19, 23%); forearm (n = 12, 14%); ankle (n = 7, 8%) and metacarpals (n = 5, 6%). The mean injury severity score was 7.02. According to the Gustilo-Anderson classification system, 45 (53%) fractures were grade 1; 28 (33%) fractures were grade 2; 8 (9%) fractures were grade 3a; and 4 (5%) fractures were grade 3b. Out of the total number of fractures, 7 (8%) required plastic surgical intervention as part of management. The types of flaps used were split skin graft (n = 4), fasciocutaneous flaps (n = 2); and adipofascial flap (n = 1). CONCLUSION We analysed the epidemiology of open fractures secondary to sport in one centre over a 15-year period. Soccer and rugby were the most common causative sports while fractures of the finger phalanx and of the tibial diaphysis were the most common sites. Open fractures are uncommon in sport; however, when they are sustained they usually occur on muddy sport fields or forest tracks and therefore must be treated appropriately. It is important that clinicians and sports therapists have knowledge of these injuries, in order to ensure they are managed optimally.

Femoral Neck Stress Fractures in Sport: A Current Concepts Review

Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. The commonest causative sports are marathon and long-distance running. The main types of FNSF are compression-sided, tension-sided and displaced. The most common reported symptom is exercise-related groin pain. Radiographs form the first line of investigation, with MRI the second-line investigation. The management of FNSFs is guided by the location and displacement of the fracture. Delay in diagnosis is common and increases the likelihood of fracture displacement. Sporting outcomes are considerably worse for displaced fractures. Education programmes and treatment protocols can reduce the rates of displaced FNSFs. This article aims to provide a current concepts review on the topic of FNSFs in sport, assess the current evidence on the epidemiology and pathophysiology of these injuries, detail the current recommendations for their imaging and management, and review the recorded sporting outcomes for FNSFs in the existing literature. From this study, we conclude that although FNSFs are a rare injury, they should be considered in all athletes presenting with exercise-related hip pain, because delay in diagnosis and subsequent fracture displacement can significantly impair future return to sport. However, when detected early, FNSFs show promising results in terms of return-to-sport rates and times.