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Stress fracture of the clavicle in a professional baseball player
Stress fracture of the clavicle baseball player Chung-Da
Wu,
MD,
and
Yu-Ching
Chen,
PT,
Tainan,
\N or Id WI‘d e increased interest in physical fitness has made bony stress reactions more frequent and increasingly recognized and reported. In early reports the second metatarsal was one of the most commonly involved structures.9 Although the second metatarsal still remains a common site for stress fracture, many bones of the foot and other parts of the body have been found to be vulnerable to this injury. Stress fractures commonly occur in the lower extremities 24, 6. 10-12,16, 17, 24 Upper extremity stress fractures are uncommon’, l4 and usually involve the humerus or ulna.5, 15, l*, 23 In the shoulder girdle stress fractures have been reported in the acromion and ribs.*, 13, 20, 25 To our knowledge stress fracture of the clavicle has not been reported in the English literature. The only report is in Polish.19 This report documents radiographic evidence of stress fracture in the clavicle of a professional baseball player. CASE REPORT The patient was a 28-year-old
professional baseball player who usually played third base and occasionally was a catcher. He has been a baseball player since Little League at the age of 10 years. During most of his early career he was a catcher but was shifted to play the third base when he (oined the professional league (March 1990). In spring training in 1993 he noted a dull pain around his right shoulder area. The pain was insidious in onset and gradually became more intense and localized as the season began, getting worse in the second month of the season. At that time the senior author (C.D.W.) was consulted. Physical examination showed mild swelling over the right proximal clavicular region and reFrom the Department of Orthopaedic Provmctal Tainan General Hospital, phants Baseball Club.
Sur cry, Taiwan an J Brother Ele-
Reprint requests’ Chung-Da Wu, MD, Department thopaedic Surgery, Taiwan Provincial Tainan Hospital, 125 Chun-Shun Rd., Tainan, Taiwan. J Shoulder Copyrtght Board
Elbow 0
Surg
1998,7.164-7
by Journal
of Shoulder
of Trustees
1058-2746/98/$5
164
1998
of OrGeneral
00 + 0
32/4/04048
and
Elbow
Surgery
in a professional
TCliWCUl
gional tenderness on percussion. Pain was induced with cross-chest adduction of the right shoulder. Roentgenography did not reveal any bony lesion (Figure 1). A bone scan showed a “hot” spot over the right proximal clavicle. The other two lesser uptakes, one over the sternoclavicular joint and the other over the first rib area, were interpreted by the radiologist as reactive in nature. On clinical evaluation no complications were referable to these two regions (Figure 2). A clear fracture line could be seen on computed tomography scanning (Figure 3). Stress fracture of the right clavicle was diagnosed. The player was put on the disabled list, and complete rest of the shoulder was advised for 6 weeks. After 4 weeks there was no pain at rest, but soreness of the affected region during shoulder motion was still present. After 6 weeks the soreness had almost completely subsided, and rehabilitation of the shoulder (range of motion, stretching, strengthening exercises, and finally, a throwing program) was started. Three months after the index injury the patient was allowed to return to play occasionally as a designated hitter after having a medical checkup. Full return to the baseball league was 5 months after injury. Rehabilitation continued during the off season. The player was allowed to train fully in spring training and to play full time as the season began the next year. Shoulder exercises and icing of both shoulders and of the clavicular fracture site were performed as routine daily care. The patient had no more pain, and physical examination did not reveal any abnormality. Follow-up computed tomography scanning was done at 15 months after injury, which showed healing of the fracture (Figure 4). The patient refused a follow-up bone scan. There was no recurrence of symptoms.
DISCUSSION The common mechanism for stress fracture is excessive repetitive stress applied to a bone.9* 21 Bone is a dynamic tissue, and in response to stress it strengthens and remodels. If the bone does not have the structural strength to withstand stress, or maladaptation to stress causes osteoclastic activity to supersede osteoblastic activity, the bone will eventually fatigue and break.22 It has also been shown that muscle fatigue may increase strain on the bone, thus making the bone susceptible to
Wu and Chen
I Shoulder Elbow Surg Volume 7, Number 2
Figure film
1 No
bony
lesion
was
detected
on thus plain
165
x-ray
mecharapid failure. *7 Overuse was the principal nism of injury in this player. Marked changes in playing position and style, in addition to the lack of capable substitute, forced him to play despite having pain. In baseball, third basemen, shortstops, catchers, and pitchers have high demands on their throwing shoulders. Each time a right-handed batter swings, the right shoulder girdle, especially the clavicle and its two articulating joints, sustains tremendous pressure. It is theoretically possible that structures in this high strain area may fail under excessive repetitive loading. Shoulder muscle fatigue may further increase the strain on the clavicle. With these factors combined, a vicious circle is established and eventually can result in stress fracture of the clavicle. In the early stage of stress fracture the symptoms of pain with relation to activity are vague and of insidious onset.9, ** In this stage carefully performed physical examination may identify a discrete area of tenderness; the other physical findings are fairly nonspecific and not very dramatic.9, ** The diagnosis of stress fracture depends on detailed history taking and careful physical examination. X-ray evaluation in the early stage may not be helpful and can be negative for up to 4 months. 9, ** Triple-phase 99mtechnetium bone scan is the most useful diagnostic modality. A bone scan can be positive as early as 2 days after the onset of symptoms.7, 9, *L 26 The treatment of choice is usually conservative. According to Sterling et al.,22 guidelines for conservative management are rest, analgesics, icing and physical therapy, education in treatment and
Figure 2 Bone scans of right cfavrcle A, Anteroposterior view Increased uptake was seen on rrght proximal clavicular area. There was morn “hot spot” over proximal clavicle (Indicated by arrows] wrth two lesser spots over sternoclavrcular joint and first rib. B, Oblique view. Hottest and largest uptake was over proxrmal clavicle (indicated by big arrows) SC (oint is indicated by small arrows, and first rib is indicated by iong-tall arrows
preventive care (including exercise to prevent detraining), rehabilitation, and a regimented return to participation and competition. Serial radiographs, bone scans, and computed tomography scans are required to monitor the progress of bone healing.** This case reports a stress fracture occurring in
166
Wu and Chen
J Shoulder
Elbow
March/April
Surg
I998
a rather unusual location. However, with the increased popularity in throwing and racket sports, orthopaedic surgeons may observe an increasing number of stress fractures around the shoulder girdle. It is therefore important for physicians to obtain a detailed patient history to reach a correct diagnosis and recommend successful treatment. REFERENCES
Fi ure 3 Computed d.QfI erent cuts showed clavrcle as indicated
tomography scan of clavicle. Two discrete fracture line on rrght proximal by arrows
1
Ahluwalta R, Datz FL, Morton KA, Anderson CM, Whiting JH, Jr. Bilateral fatigue fractures of the radial shaft in a gymnast. Clin Nuclear Med 1994; 19 665-7
2.
Beals RK, Cook RD. Stress fractures of the anterior draphysis Orthopedics 1991; 14:869-75.
tibia1
3.
Beaman DN, Roesser WM, HolmesJR, Saltzman Cubold stress fractures. a report of two cases. Ankle Int 1993; 14:525-8.
CL. Foot
4
Black KP, Ehlert KJ A stress porcess of the talus In a runner. Jornt Surg Am 1994;76A:441-3
5.
Bollen SR, Robrnson DG, Crichton KJ, Cross fractures of the ulna in tennis players usin handed backhand stroke. Am J Sports Me f 751-2.
6.
Clement DB, Ammann W, Taunton JE, Lloyd-Smith R, Jesperson D, Goldnng J, et al. Exercise-induced stress iniuries to the femur. Int J Sports Med 1993; 14:34752.
7.
Geslian detection Radiology
8.
Hall RJ, Calvert PT Stress fracture of the acromion. an unusual mechanism and review of the literature J Bone Joint Surg Br 1995,778: 153-4
9.
Heckman JD. Fractures and dislocations In: Rockwood CA Jr, Green DP, Fractures in adults Phrladelphia: 1991. p 2060-l.
ture
line
Fracture
had
healed
wrth
drsappearance
of frac-
of the lateral report. J Bone MJ. Stress a double 1993;2 1.
GE, Thrall JH, Espinosa JL, Older RA. of stress fracture using99mTC-poly-phosphate 1976; 12 1:683-7
Early
of the foot. Bucholz RW JB Lippincott;
10
Johnson AW, Weiss CB Jr, Wheeler DL. Stress fractures of the femoral shaft in athletes-more common than expected A new clinical test. Am J Sports Med 1994;22:248-56.
11
Khan KM, Brukner CJ, Kiss ZS. Tarsal Sports Med 1994;
12
Krauss fracture
13
tin HC, Chou CS, Hsu TC. Stress in amateur golf players. Chinese 3 3-7
14.
Looslr AR, Leslie M Stress fracture of the distal radius A case report. Am J Sports Med 199 1; 19: 523-4. Maffullr N, Chan D, Aidridge MJ. Overuse iniuries of the olecranon rn young gymnasts. J Bone Joint Surg Br 1992;74B 305-8.
15 4
Figure
fracture A case
MD, Van Orthop
PD, Kearney C, Fuller PJ, Bradshaw navicular stress fracture in athletes. 17:65-76. Meter CD. A longitudrnal Rev 1994;23: 163-6.
tibia1
stress
fractures of the ribs Med J 1994;54,
Wu and Chen
I Shoulder Elbow Surg Volume 7, Number 2
167
16
Miller MD, Marks of the distal fibula Int 1994,15.450-3
PH, Fu FH. Bilateral stress fractures in a 35year-old woman. Foot Ankle
22.
Sterlrng JC, Edelstein DW, Calvo fractures in the athlete. Diagnosis Sports Med 1992; 14.33646
17
Nieiens H, Devogelaer JP, Mal hem], Occurrence of a painful stress fracture o f the femoral neck simultaneously wrth six other asymptomatrc localizations In a runner J Sports Med Phys Fitness 1994; 3491 79-82.
23.
Tanabe S, Nakahira J, Bando E, Yamaguchr Miyamoto H, Yamamoto A. Fatrgue fracture ulna occurrmg In pitchers of fast-pitch softball Sports Med 199 1; 19:3 17-2 1.
24.
18
Nuber GW, Drment MT Olecranon stress fractures in throwers. A report of two cases and a review of the Irterature. Clin Orthop 1992;278:58-61
Tertz CC, Harrrngton RM Sports Med 1992,20:76
25
Ward fracture Sports
26.
Wdcox
27.
Yoshrkawa T, Mod S, Santiesteban AJ, Sun TC, Hafstad E, Chen J,et al The effect of muscle fatigue on bone strain. J Exp Biol 1994; 188:217-33.
19
Pizro Z, Tubek Wradomosci
S. Stress Lekarskre
20
Read golfer
2 1
Santa M, Sartoris DJ, Resnick tarsal and metatarsal stress Rev 1989;18 178-85.
MT. Case Br J Sports
fracture of the clavicle 1992,45.477-9
report-stress fracture Med 1994;28:206-7
of the
[Polish]. rib
in a
D. Diagnostic imaging of fractures (part I) Orthop
Pateliar l-5
RD, Webb R Stress and management.
stress
WG, Bergfeld JA, Carson of the base of the acromral Med 1994;22: 146-7
IR. Moniot Al, Green evaluatibn of exercise-related 1977; 12 3 699-703
fracture. WG Jr process
H, of the Am J AmJ Stress Am J
IP Bone scannina In the stress iniuries Radiology
Wu,
MD,
and
Yu-Ching
Chen,
PT,
Tainan,
\N or Id WI‘d e increased interest in physical fitness has made bony stress reactions more frequent and increasingly recognized and reported. In early reports the second metatarsal was one of the most commonly involved structures.9 Although the second metatarsal still remains a common site for stress fracture, many bones of the foot and other parts of the body have been found to be vulnerable to this injury. Stress fractures commonly occur in the lower extremities 24, 6. 10-12,16, 17, 24 Upper extremity stress fractures are uncommon’, l4 and usually involve the humerus or ulna.5, 15, l*, 23 In the shoulder girdle stress fractures have been reported in the acromion and ribs.*, 13, 20, 25 To our knowledge stress fracture of the clavicle has not been reported in the English literature. The only report is in Polish.19 This report documents radiographic evidence of stress fracture in the clavicle of a professional baseball player. CASE REPORT The patient was a 28-year-old
professional baseball player who usually played third base and occasionally was a catcher. He has been a baseball player since Little League at the age of 10 years. During most of his early career he was a catcher but was shifted to play the third base when he (oined the professional league (March 1990). In spring training in 1993 he noted a dull pain around his right shoulder area. The pain was insidious in onset and gradually became more intense and localized as the season began, getting worse in the second month of the season. At that time the senior author (C.D.W.) was consulted. Physical examination showed mild swelling over the right proximal clavicular region and reFrom the Department of Orthopaedic Provmctal Tainan General Hospital, phants Baseball Club.
Sur cry, Taiwan an J Brother Ele-
Reprint requests’ Chung-Da Wu, MD, Department thopaedic Surgery, Taiwan Provincial Tainan Hospital, 125 Chun-Shun Rd., Tainan, Taiwan. J Shoulder Copyrtght Board
Elbow 0
Surg
1998,7.164-7
by Journal
of Shoulder
of Trustees
1058-2746/98/$5
164
1998
of OrGeneral
00 + 0
32/4/04048
and
Elbow
Surgery
in a professional
TCliWCUl
gional tenderness on percussion. Pain was induced with cross-chest adduction of the right shoulder. Roentgenography did not reveal any bony lesion (Figure 1). A bone scan showed a “hot” spot over the right proximal clavicle. The other two lesser uptakes, one over the sternoclavicular joint and the other over the first rib area, were interpreted by the radiologist as reactive in nature. On clinical evaluation no complications were referable to these two regions (Figure 2). A clear fracture line could be seen on computed tomography scanning (Figure 3). Stress fracture of the right clavicle was diagnosed. The player was put on the disabled list, and complete rest of the shoulder was advised for 6 weeks. After 4 weeks there was no pain at rest, but soreness of the affected region during shoulder motion was still present. After 6 weeks the soreness had almost completely subsided, and rehabilitation of the shoulder (range of motion, stretching, strengthening exercises, and finally, a throwing program) was started. Three months after the index injury the patient was allowed to return to play occasionally as a designated hitter after having a medical checkup. Full return to the baseball league was 5 months after injury. Rehabilitation continued during the off season. The player was allowed to train fully in spring training and to play full time as the season began the next year. Shoulder exercises and icing of both shoulders and of the clavicular fracture site were performed as routine daily care. The patient had no more pain, and physical examination did not reveal any abnormality. Follow-up computed tomography scanning was done at 15 months after injury, which showed healing of the fracture (Figure 4). The patient refused a follow-up bone scan. There was no recurrence of symptoms.
DISCUSSION The common mechanism for stress fracture is excessive repetitive stress applied to a bone.9* 21 Bone is a dynamic tissue, and in response to stress it strengthens and remodels. If the bone does not have the structural strength to withstand stress, or maladaptation to stress causes osteoclastic activity to supersede osteoblastic activity, the bone will eventually fatigue and break.22 It has also been shown that muscle fatigue may increase strain on the bone, thus making the bone susceptible to
Wu and Chen
I Shoulder Elbow Surg Volume 7, Number 2
Figure film
1 No
bony
lesion
was
detected
on thus plain
165
x-ray
mecharapid failure. *7 Overuse was the principal nism of injury in this player. Marked changes in playing position and style, in addition to the lack of capable substitute, forced him to play despite having pain. In baseball, third basemen, shortstops, catchers, and pitchers have high demands on their throwing shoulders. Each time a right-handed batter swings, the right shoulder girdle, especially the clavicle and its two articulating joints, sustains tremendous pressure. It is theoretically possible that structures in this high strain area may fail under excessive repetitive loading. Shoulder muscle fatigue may further increase the strain on the clavicle. With these factors combined, a vicious circle is established and eventually can result in stress fracture of the clavicle. In the early stage of stress fracture the symptoms of pain with relation to activity are vague and of insidious onset.9, ** In this stage carefully performed physical examination may identify a discrete area of tenderness; the other physical findings are fairly nonspecific and not very dramatic.9, ** The diagnosis of stress fracture depends on detailed history taking and careful physical examination. X-ray evaluation in the early stage may not be helpful and can be negative for up to 4 months. 9, ** Triple-phase 99mtechnetium bone scan is the most useful diagnostic modality. A bone scan can be positive as early as 2 days after the onset of symptoms.7, 9, *L 26 The treatment of choice is usually conservative. According to Sterling et al.,22 guidelines for conservative management are rest, analgesics, icing and physical therapy, education in treatment and
Figure 2 Bone scans of right cfavrcle A, Anteroposterior view Increased uptake was seen on rrght proximal clavicular area. There was morn “hot spot” over proximal clavicle (Indicated by arrows] wrth two lesser spots over sternoclavrcular joint and first rib. B, Oblique view. Hottest and largest uptake was over proxrmal clavicle (indicated by big arrows) SC (oint is indicated by small arrows, and first rib is indicated by iong-tall arrows
preventive care (including exercise to prevent detraining), rehabilitation, and a regimented return to participation and competition. Serial radiographs, bone scans, and computed tomography scans are required to monitor the progress of bone healing.** This case reports a stress fracture occurring in
166
Wu and Chen
J Shoulder
Elbow
March/April
Surg
I998
a rather unusual location. However, with the increased popularity in throwing and racket sports, orthopaedic surgeons may observe an increasing number of stress fractures around the shoulder girdle. It is therefore important for physicians to obtain a detailed patient history to reach a correct diagnosis and recommend successful treatment. REFERENCES
Fi ure 3 Computed d.QfI erent cuts showed clavrcle as indicated
tomography scan of clavicle. Two discrete fracture line on rrght proximal by arrows
1
Ahluwalta R, Datz FL, Morton KA, Anderson CM, Whiting JH, Jr. Bilateral fatigue fractures of the radial shaft in a gymnast. Clin Nuclear Med 1994; 19 665-7
2.
Beals RK, Cook RD. Stress fractures of the anterior draphysis Orthopedics 1991; 14:869-75.
tibia1
3.
Beaman DN, Roesser WM, HolmesJR, Saltzman Cubold stress fractures. a report of two cases. Ankle Int 1993; 14:525-8.
CL. Foot
4
Black KP, Ehlert KJ A stress porcess of the talus In a runner. Jornt Surg Am 1994;76A:441-3
5.
Bollen SR, Robrnson DG, Crichton KJ, Cross fractures of the ulna in tennis players usin handed backhand stroke. Am J Sports Me f 751-2.
6.
Clement DB, Ammann W, Taunton JE, Lloyd-Smith R, Jesperson D, Goldnng J, et al. Exercise-induced stress iniuries to the femur. Int J Sports Med 1993; 14:34752.
7.
Geslian detection Radiology
8.
Hall RJ, Calvert PT Stress fracture of the acromion. an unusual mechanism and review of the literature J Bone Joint Surg Br 1995,778: 153-4
9.
Heckman JD. Fractures and dislocations In: Rockwood CA Jr, Green DP, Fractures in adults Phrladelphia: 1991. p 2060-l.
ture
line
Fracture
had
healed
wrth
drsappearance
of frac-
of the lateral report. J Bone MJ. Stress a double 1993;2 1.
GE, Thrall JH, Espinosa JL, Older RA. of stress fracture using99mTC-poly-phosphate 1976; 12 1:683-7
Early
of the foot. Bucholz RW JB Lippincott;
10
Johnson AW, Weiss CB Jr, Wheeler DL. Stress fractures of the femoral shaft in athletes-more common than expected A new clinical test. Am J Sports Med 1994;22:248-56.
11
Khan KM, Brukner CJ, Kiss ZS. Tarsal Sports Med 1994;
12
Krauss fracture
13
tin HC, Chou CS, Hsu TC. Stress in amateur golf players. Chinese 3 3-7
14.
Looslr AR, Leslie M Stress fracture of the distal radius A case report. Am J Sports Med 199 1; 19: 523-4. Maffullr N, Chan D, Aidridge MJ. Overuse iniuries of the olecranon rn young gymnasts. J Bone Joint Surg Br 1992;74B 305-8.
15 4
Figure
fracture A case
MD, Van Orthop
PD, Kearney C, Fuller PJ, Bradshaw navicular stress fracture in athletes. 17:65-76. Meter CD. A longitudrnal Rev 1994;23: 163-6.
tibia1
stress
fractures of the ribs Med J 1994;54,
Wu and Chen
I Shoulder Elbow Surg Volume 7, Number 2
167
16
Miller MD, Marks of the distal fibula Int 1994,15.450-3
PH, Fu FH. Bilateral stress fractures in a 35year-old woman. Foot Ankle
22.
Sterlrng JC, Edelstein DW, Calvo fractures in the athlete. Diagnosis Sports Med 1992; 14.33646
17
Nieiens H, Devogelaer JP, Mal hem], Occurrence of a painful stress fracture o f the femoral neck simultaneously wrth six other asymptomatrc localizations In a runner J Sports Med Phys Fitness 1994; 3491 79-82.
23.
Tanabe S, Nakahira J, Bando E, Yamaguchr Miyamoto H, Yamamoto A. Fatrgue fracture ulna occurrmg In pitchers of fast-pitch softball Sports Med 199 1; 19:3 17-2 1.
24.
18
Nuber GW, Drment MT Olecranon stress fractures in throwers. A report of two cases and a review of the Irterature. Clin Orthop 1992;278:58-61
Tertz CC, Harrrngton RM Sports Med 1992,20:76
25
Ward fracture Sports
26.
Wdcox
27.
Yoshrkawa T, Mod S, Santiesteban AJ, Sun TC, Hafstad E, Chen J,et al The effect of muscle fatigue on bone strain. J Exp Biol 1994; 188:217-33.
19
Pizro Z, Tubek Wradomosci
S. Stress Lekarskre
20
Read golfer
2 1
Santa M, Sartoris DJ, Resnick tarsal and metatarsal stress Rev 1989;18 178-85.
MT. Case Br J Sports
fracture of the clavicle 1992,45.477-9
report-stress fracture Med 1994;28:206-7
of the
[Polish]. rib
in a
D. Diagnostic imaging of fractures (part I) Orthop
Pateliar l-5
RD, Webb R Stress and management.
stress
WG, Bergfeld JA, Carson of the base of the acromral Med 1994;22: 146-7
IR. Moniot Al, Green evaluatibn of exercise-related 1977; 12 3 699-703
fracture. WG Jr process
H, of the Am J AmJ Stress Am J
IP Bone scannina In the stress iniuries Radiology