Michael Reeder

High-risk stress fractures: pathogenesis, evaluation, and treatment.

High-risk stress fractures require precise assessment and treatment because of their propensity for delayed union, nonunion, or complete fracture and their resulting disabling complications. Proper diagnosis necessitates a thorough clinical evaluation, centering on the patients diet and history, particularly the training regimen. For a definitive diagnosis, plain radiography, ultrasound, bone scintigraphy, magnetic resonance imagery (MRI), and computed tomography (CT) are helpful, and each plays a specific role. High-risk stress fractures typically require aggressive treatment such as nonweight-bearing immobilization coupled with therapy and often surgery.

Isolated rupture of the plantaris tendon in a high school track athlete.

P lantaris muscle or tendon injuries, although rare, have been discussed for over a century. The plantaris is a rudimentary muscle located in the superficial posterior compartment of the leg and varies in its size and development. It originates at the inferior aspect of the lateral supracondylar line of the femur and consists of a small fusiform fleshy muscle belly with a long, slender tendon that crosses obliquely between the gastrocnemius and soleus before inserting into the medial posterior calcaneus, sometimes via the Achilles tendon or occasionally fusing with the flexor retinaculum or leg fascia. Reports of isolated ruptures of the plantaris muscle or tendon are rare, but this is probably related more to misdiagnosis as Achilles tendon pathology, and that they heal quickly, than the paucity of the injury. Plantaris tendon ruptures rarely are isolated, often involving the gastrocnemius or the Achilles tendon. The term coup de fouet, or snap of the whip, was coined in 1597 to describe an Achilles tendon rupture; some authors have used the term, inappropriately, to describe plantaris tendon ruptures. Tennis leg was used to describe plantaris tendon and muscle ruptures, causing more confusion and debate. Few cases of isolated plantaris tendon rupture have been reported. These ruptures occurred at the insertion on the calcaneus or at the proximal musculotendinous junction. To our knowledge, no case has been reported regarding the rupture of the mid-plantaris tendon in isolation, making our patient’s case unique. CASE REPORT A 16-year-old male high school track athlete (6’3’’, 158 lbs) presented to the office complaining of pain in the right Achilles tendon region. He was in his mid-season training, performing modest speed work twice weekly coupled with distance running of roughly 30–40 miles weekly; he performed no plyometric training. On the previous day (weather was sunny, approximately 501F), while performing an afternoon speed workout, he was nearing the end of his fourth 200-meter sprint and felt a ‘‘pop’’ in his right posterior lower-leg region, causing him to fall. He was able to walk, stiffly, afterwards, but incurred mild swelling and pain that evening. The patient denied numbness, tingling, weakness, joint pain, and previous injuries and was otherwise in excellent health, with no allergies and no present or recent medication or supplement use. Standing exam revealed normal foot structure. Strong, equal pulses were palpated bilaterally at his distal lower extremities and capillary refill was less than 2 seconds. No motor or sensory deficits were identified, and excellent plantar

Avulsion fracture of the iliac crest apophysis in a collegiate wrestler.

INTRODUCTION Fractures of the pelvic girdle along the iliac crest, although rare, have been documented since the mid-1700s. The pelvic girdle is made up of two coxal bones that are joined anteriorly at the symphysis pubis and posteriorly to the sacrum; the two coxal bones join with the sacrum and coccyx to form the pelvis. The pelvis provides protection for internal organs, attachments for muscles, and stable support of the lower extremities to enable locomotion. Although fractures of the iliac crest are rare, they typically occur in individuals aged 11–25 years because of incomplete ossification of the apophyses in the pelvis, with males having an incidence rate 13 times that of females. The mechanism of injury is commonly a rapid, forceful eccentric lateral flexion and/or rotation of the torso causing excessive strain of the abdominal musculature. The tensile force exceeds the strength of the apophysis of the iliac crest, resulting in an avulsion. Fortunately, because of the numerous muscle attachments of the pelvis, bone displacement is minimal, and surgical intervention is often unnecessary. Avulsion fractures of the iliac crest are rare, making up roughly 2% of all pelvic fractures. To our knowledge, no case has been reported regarding an avulsion fracture from wrestling, making our patient’s case unique.

Navicular stress fractures in identical twin runners: high-risk fractures require structured treatment.

Tarsal navicular fractures require an accurate and timely diagnosis to prevent costly and disabling complications. Diagnosis requires a thorough clinical evaluation that focuses on the patients history, particularly his or her training regimen, and diet—as was the case with these 17-year-old girls. Plain radiography, ultrasound, bone scintigraphy, M RI, and CT help make a definitive diagnosis. Treatment of low-risk fractures involves relative rest and cessation of the precipitating activity. High-risk fractures often require non-weight-bearing immobilization, coupled with therapy, and may require surgery.

Urachal cyst in a collegiate football player.

Urachal disease is rare in the adult population and is typically found in infants and children. Nonetheless, when presented in adulthood, it is potentially serious and possibly life-threatening. The urachus is a tract that forms during fetal growth, elongating and forming an epithelialized tube after 4 months, connecting the allantois and the urinary bladder (Fig. 1). Generally, the urachal lumen diminishes in utero 98% of the time. The remaining structure persists as a fibrous cord termed the umbilical ligament, and very rarely, defects in the cord can manifest, forming cysts or fistulae. The incident rate for urachal disorders is low. In autopsy studies, roughly 1 in 5000 pediatrics and 1 in 8000 adults showed urachal anomalies, with urachal cysts accounting for 30% of the disorders. Congenital urachal anomalies are typically found at birth and result from free drainage of urine through the umbilicus, often coupled with other urogenital malformations (e.g., vesicoureteric reflux, obstructive ureteral lesions). The incidence rate is higher in males than females (a 3:1 ratio), and adults very rarely present congenital urachal problems. Conversely, acquired urachal disorders are solely the domain of adults, typically manifesting between the ages of 20 and 40 years, with males having twice the prevalence rate. With acquired urachal disorders, the urachus closes normally but reopens because of a specific pathologic condition, most commonly infection via hematogenous spread, or in our case, blunt trauma to the abdomen. Urachal disease is of concern to sport medicine professionals because of its variable clinical presentations, and in light of our example, can occur from blunt athletic trauma. To our knowledge, we are presenting the first documented case of adult urachal cyst manifestation as the result of blunt athletic trauma. A review of the pathophysiology, diagnosis, and treatment of urachal disease is included.