James C. Sterling

Stress Fractures in the Athlete Diagnosis and Management

SummaryStress fractures can be a troublesome injury for the sports medicine clinician. The first description was in military personnel, but recently there is an increasing awareness and diagnosis of stress fractures in the athletic population. Stress fractures have been described in all extremities. Some fractures appear to have a degree of sports specificity. Bone is a dynamic tissue which strengthens and remodels in response to stress. Maladaptation to stress causes osteoclastic activity to supersede osteoblastic activity, thereby allowing weakening of the bone. These areas of weakening may fracture and create prodromal symptoms and clinical findings. Localised pains of insidious onset which are activity related are the hallmarks in the clinical history. The physical examination can exhibit localised tenderness, redness and swelling. Radiographs can be negative for up to 4 months. The gold standard for diagnosis is the triple phase 99mtechnetium bone scan. The treatment of a stress fracture is usually conservative. Very few cases require surgical man-agement. The algorithm of conservative management includes: rest, appropriate education for treatment and preventive care, analgesics, serial radiographs, icing and physical therapy modalities, appropriate exercise to prevent detraining, rehabilitation and a regimented return to participation and competition.

Allograft Failure in Cruciate Ligament Reconstruction Follow-up Evaluation of Eighteen Patients

Previous authors have reported the efficacy of cruciate ligament allograft reconstruction of the knee suggesting that allograft strength is not significantly different than that of autografts. The purpose of this study was to elicit the cause of a higher-than-expected failure rate in cru ciate ligament allograft reconstructions. After clinical di agnoses, 12 male and 6 female patients with cruciate ligament instability underwent intraarticular allograft re construction followed by an aggressive rehabilitation program. Deep-frozen, freeze-dried, ethylene oxide- sterilized, bone-patellar tendon-bone allografts were re hydrated, prestressed, and implanted by an open or ar throscopically assisted technique. Results revealed 6 of 18 failures. Knee instability, postoperative complica tions, and roentgenographic changes were evident. Evaluation of procurement technique showed that graft failure was significantly correlated with time to implan tation. A significant difference in mean time from pro curement and deep freezing to freeze-drying and ster ilization between failed-versus-successful grafts was 265.5 ± 61.9 versus 66.8 ± 43.8 days, respectively. Total mean time of failed grafts from procurement to implantation was significantly greater (528.3 ± 75.1 ver sus 207.3 ± 53.1 days) than for successful grafts. All graft failures came from the same batch number. These findings indicate that cruciate ligament allograft recon struction can be successful; however, longer shelf life negatively affects graft integrity.

Injuries in intercollegiate rodeo athletes

Collegiate rodeo athletes (N = 156) in the National Intercollegiate Rodeo Association (NIRA) Southern Re gion, were examined for injuries during a 7 month (10 rodeo) season from 1987 to 1988. Sixty-two athletes sustained a total of 138 acute injuries resulting from 3292 exposures. One hundred twenty-seven injuries (92% of total injuries) occurred in the roughstock and steer wrestling events, and 11 injuries (8%) occurred in the roping and female events. When calculating oppor tunity for injury, rodeo athletes face an 89% potential for injury per season. Ninety-one of the injuries incurred were upper body injuries; 47 were lower body injuries. A 6:1 exposure to injury ratio among roughstock events exemplifies the magnitude of injury potential in this sport, affecting 25% of roughstock competitors. Con tusions, strains, and concussions comprised 42%, 16%, and 11 % of the total injuries, respectively, whereas fractures and dislocations comprised only 5% of the total. Twenty-three percent of the injuries oc curred during the completion of an athletes ride, with 21 % of injuries attributed to equipment mishaps. Fre quency of injury by performance, relation of seasonal participation and exposure to injury, orthotic care, use of conditioning programs, medication history, and need for enhanced sports medicine education in this sport are discussed.

False negative bone scan in a female runner

Stress fractures are more prevalent in todays fitness cognizant society. Stress fractures of the femoral neck are common and present with specific symptoms and findings. The diagnosis is based on clinical history, physical exam, radiography, bone scintigraphy, and computed tomography (C.T.) scans. The triple-phase bone scan is the most sensitive test for the diagnosis of stress fractures and is considered the gold standard for the diagnosis of the occult stress fracture. This case presents a 42-yr-old female marathon runner who presented with hip pain and clinical symptoms indicating a stress fracture of the femoral neck. Initial radiographs and a triple-phase bone scan were negative. When symptoms persisted, a repeat x-ray revealed a femoral neck fracture of the superior surface. In spite of a false negative bone scan, clinical suspicion allowed appropriate treatment of this femoral neck stress fracture. Nondiagnosed stress fractures of the femoral neck may lead to severe disability, including avascular necrosis of the femoral head. Therefore, clinical index of suspicion is very important even if ancillary tests are nondiagnostic.

Os acromiale in a baseball catcher

Throwing injuries of the shoulder can result from an acute traumatic event or chronic overuse. Shoulder impingement has multiple etiologies; the most common being rotator cuff weakness/overuse and resultant glenohumeral instability. However, an uncommon cause of shoulder impingement syndrome is that of a nonfused os acromiale. There are three centers of ossification in the acromion which are usually completely fused by 18 yr of age. The most common site of nonunion is between the meso-acromion and meta-acromion. Os acromiale is reported at a rate of 14/1000 (1.4%) and is bilateral in approximately 62% of cases. The classic diagnosis is radiographically defined with both AP and axillary lateral views, and a contralateral comparison view may be helpful. Computerized axial tomography also aids in the diagnosis. Most os acromiale are asymptomatic. However, if recalcitrant impingement syndrome and/or rotator cuff tears are found in association with os acromiale, then surgical fusion or resection of the ossicle is recommended.

AN UNUSUAL STRESS FRACTURE IN A MULTIPLE SPORT ATHLETE

Most overuse injuries are a direct result of repetitive stresses which may create a condition of maltraining. Young athletes are no exception to this rule. Swimming and baseball both create stresses to the humerus which may result in injuries to the shoulder and upper extremity. Stress fractures (fatigue fractures) are usually limited to the lower extremity (i.e., tibia or metatarsal). Upper extremity stress fractures, especially of the humerus, are very uncommon. Precipitating factors include repetitive stresses, low grade external forces, rapid application of muscular force to the bone, or an underlying disease or pathologic weakness of the bone. The majority of these fractures are primarily due to abnormal and repetitive stresses to bones. This case study examines the mechanism of injury, clinical presentation, and treatment of a clinically apparent stress fracture which ultimately converted to an overt humerus fracture in a 14-yr-old cross-trained athlete.

Exercise performance of collegiate rodeo athletes.

In this study we examined the physical, hematologic, and exercise response of 20 male and 10 female ath letes of the National Intercollegiate Rodeo Association, Central Rocky Mountain Region. Male subjects were grouped by roughstock, steer wrestling, and roping events. Female athletes were grouped separately. Max imal aerobic capacity, pulmonary ventilation, respiratory exchange ratio, energy expenditure, maximal heart rate, blood pressure, treadmill time, pre- and postex ercise lactate, percent body fat, lean body mass, blood chemistry, serum lipids, and reaction/movement time were analyzed by event. No significant differences (P > 0.05) were found in any of these categories between male events. Mean resting blood chemistry parameters of rodeo athletes were within normal ranges. Steer wrestling athletes possessed greater body size and lean body mass than other groups. When analyzing body composition, blood pressure, and total choles terol:high-density lipoprotein (HDL) cholesterol ratios, results indicate average to low risk for coronary heart disease. When compared to other intermittent-activity sport athletes, college rodeo athletes appear to have similar aerobic capacities, but possess lower lean body mass and greater percent body fat.

Radiographic findings of the upper extremity in collegiate rodeo athletes.

INTRODUCTION AND PURPOSE Upper-extremity trauma has been extensively studied in traditional sports to reduce predisposition to injury. Limited attention has been directed toward nontraditional, high-collision sports such as rodeo. Therefore, the purpose of this study was to quantify radiographic changes of the upper extremity in collegiate rodeo athletes after seasonal competition. METHODS After written informed consent, 25 male roughstock athletes (age = 21.0 +/- 1.4 yr; height = 174.5 +/- 5.7 cm; weight = 73.0 +/- 5.9 kg) competing in the College National Finals Rodeo reported for standard anteroposterior and lateral x-rays of both arms (hand/wrist, forearm, and elbow). RESULTS Radiographs revealed 82 total abnormalities involving both left and right extremities of all athletes. Hand/wrist findings included 24 fractures (19 healed, 5 nonunion) involving scaphoid, styloid, interphalangeal, phalanx, and various metacarpals. Fourteen cases of degenerative joint disease (scaphoid/radius, scapholunate, triangulofibrocartilage, and carpometacarpal), joint calcification, dorsal instability, and scapholunate dissociation were observed. Forearm findings included ulnar cortical thickening, healed stress fractures, and plates/screws. Elbow findings revealed ulnar/humeral degeneration, calcification, posterior olecranon tip fracture, traction spurs, and joint space narrowing with loose bodies. CONCLUSION Findings indicate a significant amount of radiographic evidence of repetitive trauma to the upper extremity in this sport. Development and mandatory use of effective external bracing beyond existing techniques at the collegiate level of competition should be encouraged.

Delayed treatment of a malreduced distal femoral epiphyseal plate fracture.

Fractures of the epiphyseal plate are considered rare when compared with the more prevalent injuries found in competitive sports, but the complications associated with this type of trauma are a major concern. The factors affecting the success or failure of healing include the severity of injury, patient age, and the type and expedience of treatment. This case study examines the clinical presentation and treatment of a 15-yr-old high school football player who sustained a displaced, distal femoral epiphyseal Salter II fracture. Primary treatment consisted of nonmanipulative, nonweight bearing knee immobilization. The treatment resulted in malunion, pain, decreased range of motion and physical deformity; therefore, the patient sought a second opinion. On physical exam, the displacement and rotational deformity of the fracture site were unacceptable. The fracture was treated 20 days post-injury via open reduction with internal fixation. On follow-up, the athlete demonstrated radiographic healing, normal physical exam, and no significant leg length discrepancy or deformity. The athlete successfully returned to full competitive sport activity.

Managing Plica Syndrome of the Knee

In brief Plica syndrome of the knee-a potentially disabling condition-is caused when plicae (bands or pleats of synovial tissue) are aggravated by overuse or trauma. Symptoms include popping, clicking, effusion, swelling, pain, and Interference with normal excursion. Analysis of questionnaires from 66 patients revealed that both surgical and nonsurgical management relieved the symptoms. Plica syndrome should be included in the differential diagnosis of knee problems.