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CURRENT CONCEPTS
ISAKOS Clinical Update on Stress Fractures:
Classification and Management
Not only do fractures at high risk anatomical sites have a predilection to progress to complete fracture, delayed union, or nonunion, have a re-fracture, or have significant long term consequences should they progress to a complete fracture, but they also often have worsening prognosis if they have a delay in diagnosis. A delay in treatment may prolong the patient’s period of complete rest of the fracture site and potentially alter the treatment strategy to include surgical fixation with or without bone grafting. Due to their location on the tension side of the respective bones, these fractures possess common biomechanical properties regarding propagation of the fracture line. In comparison to low-risk stress fractures, high-risk stress fractures do not have an overall favorable natural history. With delay in diagnosis or with less aggressive treatment, high-risk stress fractures tend to progress to nonunion or complete fracture, require operative management, and recur in the same location.
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Rib and Upper Extremity Stress Fractures
Though over 90% of stress fractures occur in the lower extremities as a result of impact loading, athletes who perform repetitive tasks with the shoulder and upper extremity may also develop stress injuries of bone. Rib and shoulder girdle stress fractures are most commonly reported in rowers and throwing athletes along with those requiring repetitive rotation of the torso. The most common mechanisms for these injuries involve repetitive bony torsion, weight bearing, and muscle contraction overload. Any athlete complaining of the non-traumatic onset of pain in the ribs or upper extremity that occurs during or shortly after the repetitive activity should raise concern for a possible stress fracture.
In recent years, there has been increased attention focused on upper extremity stress fractures, and case reports of these injuries have increased in athletes such as baseball players who train continuously for one sport. Incidence has also paralleled the increase in popularity of cross-fit sports. In 2012 Miller et al. reviewed 70 cases of stress fractures of the ribs and upper extremity, the largest series in the literature. The authors noted that individuals performing weight- bearing activities of the upper extremity (e.g. gymnastics, cheerleading) developed nearly all of their stress fractures at or distal to the elbow, indicating that with such activities significant bony overload occurs in the distal upper extremity as opposed to the proximal portion.
The great majority of rib and upper extremity stress injuries are considered low-risk and usually require only activity modification to heal. One of the few exceptions to this that may require surgical intervention is the olecranon stress fracture in a competitive thrower (Fig. 5). Though this injury has the potential to heal with conservative management, when a fracture line (Grade 3 injury) is discovered in a throwing athlete’s olecranon process, internal fixation is the ideal treatment.
General Treatment Principles
Treatment principles for stress fractures include re-establishing the normal balance between the creation and repair of microcracks in bone. In order to decrease the creation of microcracks one must evaluate the patient’s training regimen, biomechanics, and equipment. In order to maximize the patient’s biologic capacity to repair microcracks, one must evaluate the general health of the patient, including nutritional status, hormonal status and medication use. The clinician should be aware of the female athletic triad and its potential detrimental effect on healing potential.
26 ISAKOS NEWSLETTER 2015: Volume I
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