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Sports fractures of the distal radius — epidemiology and outcome
hjury Vol. 26, No. 1, pp. 33-36, 1995 Copyright (6 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 0020.1383/95 $lO.OO+ 0.00
UTTERWORTH EINEMANN
Sports fractures and outcome G. M. Lawson,
C. Hajducka
of the distal
radius
- epidemiology
and M. M. McQueen
Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
Of 2774 consecutive, prospectively documented fractures of the distal radius, 225 (8 per cent) occurred as sporfs injuries, mainly in young men. Soccer produced the greafest number of wrist fractures with I 12 cases (SO per cent). Skiing, dancing and rugby caused 12 per cent, 9 per cent and 7 per cenf of all sporting wrist fractures respectively. Skiing, horseriding and dancing consistently resulted in more complex fractures. In soccer, synthetic pitches increased the likelihood of a fracture following a fall by a factor of jive. Twelve per cent of fracfures required further treatment because of instability leading to redisplacement. The complication rate was 14 per cent with the majority being casesof malunion (12 per cent). Of the 131 patients who refurned a questionnaire, 72.5 per cent had returned to their original sport. This was influenced mainly by the patient’s age and pre-injury standard of compefifion.
Injury, 1995, Vol. 26,33-36,
January
Introduction Over the last 20 years, the number of people participating in recreational or sporting activities has escalated, due to a combination of increased leisure time, greater public awareness of sport and health, and the financial commitment of the sport and leisure industry. Consequently the numbers of participants injured in sporting pursuits have increased. Coupled with greater patient expectations and demands on the health-care services, this has resulted in the current high profile of sports injuries and their management. Between 4 and 9 per cent of Accident and Emergency department attendances are a result of sports-related injuriesl,‘. Of these, between 4 per cent and 8 per cent are wrist injuries3. Little, however, has been published concerning sport-related fractures of the distal radius with regard to epidemiology, management, outcome and their effect on sporting activitie?. This study prospectively documented all the sports related distal radius fractures presenting to the Edinburgh Orthopaedic Trauma Unit over a 5 year period.
Materials
and methods
Between April 1988 and May 1993,2774 patients presented to the Edinburgh Orthopaedic Trauma Unit with fractures of the distal radius. Of these, 221 patients (8 per
cent) sustained 225 fractures of the distal radius as a result of a sporting pursuit or recreational activity. Clinical details of each patient were recorded at their first attendance and radiological examination was performed in initial presentation, after reduction (if appropriate), at I week and at 6 weeks after fracture. Radiological measurements included dorsal or volar angulation, radial shift” and radial shortening6. The average review time was 27 months (range 7-61 months). All 221 patients were sent a questionnaire to assesstheir return to their original standard of sport. Of the 221 questionnaires distributed, 131 were completed. Fracture instability was defined as loss of position in a cast after a satisfactory initial reduction. Malunion was defined as a dorsal angle of greater than 12”, a volar tilt of more than 15” or radial shortening of more than 3 mm when compared to the contralateral radius. In bilateral injuries, it was assumed that the radius was originally the same length as the ipsilateral ulna.
Results Epidemiology There were 154 males and 67 females with a mean age of 31 years (range 15-70 years). The mean age of the males was 27 years (range 16-54 years) and the mean age of the women was 40 years (range 15-70). The unimodal age distribution of males with sporting wrist fractures is illustrated in Figure I. Figure 2 illustrates the age distribution of sporting wrist fractures compared to that of the total population of wrist fractures attending the Edinburgh Orthopaedic Trauma Unit over the same period. Of the 225 fractures, 126 (56 per cent) were either undisplaced or minimally displaced and required protection for a few weeks in a forearm cast. Ninety-five fractures (42 per cent) required manipulation under either regional or general anaesthesia prior to application of a forearm cast. Four fractures underwent primary open reduction and internal fixation with buttress plates because of primary volar displacement and instability. Twenty-seven fractures (12 per cent) were identified at I week as being unstable. Sixteen of these underwent closed external fixation, seven underwent open reduction, bone grafting and K-wire fixation, two underwent open reduction and internal fixation with a buttress plate and two were remanipulated.
34
Injury: International Journal of the Care of the Injured (1995) Vol. 26/No. 1
80 70 40 50 40 30 20 10 0
20-29
30-39
Figure 1. Age and sex distribution
l&19
20-29
30-39
Figure 2. Age distribution
40-49 Age groups
SW59
60-69
70-79
of sporting wrist fractures. 0 male; n female.
40-49 5W59 60-69 Age groups
of frachres: sporting
Figure 3 illustrates the proportion of different sporting and leisure activities which caused distal radial fractures. It can be seen that football is the largest group comprising 49.8 per cent of the total number of injuries. Skiing comprises 12 per cent - mainly because of the presence of an artificial ski slope in Edinburgh. Wrist fractures in football were caused by either the ball forcibly striking the hand (21 per cent) or as a result of a fall (79 per cent). Of the latter, 54 per cent occurred on synthetic grass pitches, 28 per cent on grass and 18 per cent on asphalt, wood or cinders. Of skiing injuries, 68 per cent occurred on artificial surfaces, of which two-thirds occurred in novices having their first or second lesson on a dry slope. All fractures were classified using the A0 classification’ (Figure 4). Analysis of fractures related to each sport showed consistently higher A0 classes with both highenergy sports such as skiing or horseriding (Figtire 4) and recreation undertaken by an older population including curling and dancing. Football and rugby resulted in a
7&79
versus total population.
80-89
90-99
n sports; 0 total.
greater proportion of more benign, extra-articular fractures
(TableI). Only one of the 225 fractures was open and this was a Gustilo Type 18. Complications Complications occurred in 31 patients (14 per cent) with malunion predominating (28 patients). There were two cases of reflex sympathetic dystrophy and one case with an extensor pollicis longus rupture. There were no cases of carpal tunnel syndrome. Return to sport Of patients who responded to the questionnaire, 72.5 per cent returned to their original sport and previous level of competition. Fear of re-injury and its consequences was the commonest reason for not returning to the original sport. Novices or occasional participants seldom return to the sport in question irrespective of fracture severity or subsequent management. A few patients did not return to
Lawson
et al.: Sports
fractures
35
of the distal radius
football (49.8%)
skiing (12.0%) Figure
3. Distribution
of sports causing distal radial fractures.
30T
Al Figure
A2
A3
4. Fracture distribution
Bl
by A0
B2 B3 A-O Types type. cl total population;
their original sport as they had reached the upper age limit for it. Of the 112 fractures resulting from football, questionnaires were returned in 65 cases. These showed that 53 had made a full return to their sport. Nineteen of 27 questionnaires were completed relating to skiing injuries. None of the nine novices have returned to skiing for fear of re-injury. The remaining 10 skiers (six intermediate and four advanced) have all returned to their previous standard. Thirteen of the 17 questionnaires relating to rugby were returned. All have returned to the original level of club rugby. Nine of the 14 patients who had sustained their fracture on the ice returned their questionnaires. All patients were either middle-aged curlers or novice skaters. None have returned to the sport.
Discussion The epidemiology of fractures of the distal radius caused by sport reflects the epidemiology of other sporting
Cl
n Skiing
C2
C3
/equestrian.
injuries, with a majority of men and a significantly higher mean age among females 2,9P10. The distribution of sports recorded in this study is influenced largely by cultural and geographical factors as well as local facilities available. In central Scotland, football is the largest cause of sports injuries l,ll. It is not surprising, therefore, that half the fractures of the distal radius in this study were sustained whilst playing football. To determine which sports are intrinsically more hazardous, however, an estimate of each participant’s exposure to that sport must be made. Yde and Neilson” calculated 5.6 injuries for every thousand ‘player-hours’ in soccer compared to 3.0 injuries in basketball. Skiing, skating and equestrian events have previously been identified as causing more severe and complex injuries2,9.‘o. This is confirmed by the distribution of skiing and equestrian fractures which show a larger proportion of intra-articular fractures than the overall group (Figure 4). The high incidence of skiing injuries in this study is explained by the presence in Edinburgh of one of Europe’s
36
Table I. Sporting
Injury:
International
Journal
fractures of the distal radius - causative sports and A0 classification A
sport
of the Care of the Injured
Al
Football Skiing Dancing Rugby Curling/skating Badminton Equestrian Basketball/volleyball Climbing/hill-walking Mountain-biking Martial arts Cricket Golf Skateboarding Gymnastics Athletics Parachuting Table tennis Frisbee
: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total
0
B
B7
82
83
Cf
34 6 3
17 6 7
17 ii
: 1 0 0 0 0 0 0 1 1 1 0 0 1 0
0 0 0 0 0 0 0 1 1 0 0 0
1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
1 0 :,
ii 2 0 2 2 1 0 0 0 1 0 0”
24 3 0 6 2 :
0 0 1 0 0 0 0 1 0 0 0 0 1 0 0
40
2
5
38
largest artificial ski slopes. Indeed, the contribution of the playing surface in the severity of sporting wrist fractures is significant. At one extreme, the unforgiving nature of ice may explain the severity of the fractures sustained during curling and skating. Of the footballing fractures caused by falls, 54 per cent were sustained by falling on synthetic turf, 28 per cent on grass and I8 per cent on other surfaces. In the Edinburgh area, there are four full-size and three five-a-side synthetic grass pitches compared with 168 natural grass pitches. It is reported that the synthetic turf pitches in Edinburgh are used on average 10 h per day and the grass pitches 1 h per day. It can be calculated that there is a fivefold increase in the risk of sustaining a wrist fracture falling on synthetic turf than grass. A recent study of injuries in American football has also suggested that falls on synthetic turf resulted in a greater degree of injury than falls on grass13. The complication rate in this study is low compared to other reports. Cooney14 reported a major complication rate of 31 per cent in a mixed population of patients. Fifty per cent of a series of wrist fractures treated with external fixation in Edinburgh had complications of either the fracture or the fixationX5. In conclusion, this study has shown that the epidemiology of sporting wrist fractures accurately reflects the epidemiology of sports injuries as a whole. High-energy sports and increasing participant age both result in more severe and complex fractures. The risk of wrist fracture is increased significantly when playing on synthetic turf compared to natural grass. Our complication rate was low, but despite this, only 72 per cent returned to their original sport. This was influenced largely by pre-injury standard of competition and commitment and not fracture severity.
3
4 5
6 7
8
9
10
11
1 iii 1 0 0 0 2 0 0 0 i 0 0 0 27
C2
c3
N
0 1
9 3 3 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0
112 27 20 17 14 8 5 3 3 2 2 2 2 2 2 1 1 1 1
35
17
i 6 1 4 2 1 1 1 1 0 1 b 0 0”
225
injuries in a total population. Int J Sports Med 1990; II: 66. Matthewson M. Wrist injuries. Sports Med Soft Tissue Trauma 1992; 4: 10. Marder RA, Chapman MW. Principles of management of fractures in sports. Clin Sporfs Med 1990; 9: I. Van der Linden W, Ericson R. Colles’ fracture. How should its displacement be measured and how should it be immobilised?] Bone Joint Surg /Am] 1981; 63A: 1285. Melone CP. Open treatment for displaced articular fractures of the distal radius. C/in Orthop 1986; 202: 103. Muller ME, Nazarian S, Koch P, et al. The Comprehensive Ckussification of Fractures of Long Bones. Berlin: Springer Verlag, 1990. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis. f Bone Joint Surg [Am] 1976; 58A: 453. Sandelin J, Santavirta S, Lattilla R, et al. Sports injuries in a large urban population: occurrence and epidemiological aspects. Inf ] Sports Med 1987; 8: 61. Schmidt B, and Hollwarth ME. Sport accidents in childhood. Z Kinderchir 1989; 44: 357. Watters D, Brooks S, Elton R, et al. Sports injuries in an accident and emergency department. Arch Emerg Med 1985; 2: 105.
1.2 Yde J, Neilson AB. Sports injuries in adolescents’ ball games: soccer, handball and basketball. Br] Sports Med 1990; 24: 51. 13 McCarthy P. Ar&zial turf: does it cause more injuries? Physician Sports Med 1989; 17: 158. 14 Cooney WP III, Dobyns JH, Linscheid RL. Complications of Colles’ fractures. ] Bone Joint Surg [Am] 1980; 62A: 613. 1.~ McQueen MM, Michie M, Court-Brown CM. Hand and wrist function after external fixation of unstable distal radius fractures. C/in Orfhop 1992; 285: 200.
Paper accepted 8 August 1994.
References I Pickard MA, Tullett WM, Pate1 AR. Sports injuries seen at an accident and emergency department. Scott Med J 1988; 33: 296. 2 de Loes M. Medical treatment and costs of sports related
I
c
A3
61
Vol. 26/~o.
of fractures
AZ
0 0
(1995)
Requests for reprints should be addressed to: G. M. Lawson FRCS (ED), Orthopaedic Registrar, Orthopaedic Trauma Unit Royal Infirmary of Edinburgh, 1 Lauriston Place, Edinburgh EH3 9YW, Scotland, UK.
UTTERWORTH EINEMANN
Sports fractures and outcome G. M. Lawson,
C. Hajducka
of the distal
radius
- epidemiology
and M. M. McQueen
Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
Of 2774 consecutive, prospectively documented fractures of the distal radius, 225 (8 per cent) occurred as sporfs injuries, mainly in young men. Soccer produced the greafest number of wrist fractures with I 12 cases (SO per cent). Skiing, dancing and rugby caused 12 per cent, 9 per cent and 7 per cenf of all sporting wrist fractures respectively. Skiing, horseriding and dancing consistently resulted in more complex fractures. In soccer, synthetic pitches increased the likelihood of a fracture following a fall by a factor of jive. Twelve per cent of fracfures required further treatment because of instability leading to redisplacement. The complication rate was 14 per cent with the majority being casesof malunion (12 per cent). Of the 131 patients who refurned a questionnaire, 72.5 per cent had returned to their original sport. This was influenced mainly by the patient’s age and pre-injury standard of compefifion.
Injury, 1995, Vol. 26,33-36,
January
Introduction Over the last 20 years, the number of people participating in recreational or sporting activities has escalated, due to a combination of increased leisure time, greater public awareness of sport and health, and the financial commitment of the sport and leisure industry. Consequently the numbers of participants injured in sporting pursuits have increased. Coupled with greater patient expectations and demands on the health-care services, this has resulted in the current high profile of sports injuries and their management. Between 4 and 9 per cent of Accident and Emergency department attendances are a result of sports-related injuriesl,‘. Of these, between 4 per cent and 8 per cent are wrist injuries3. Little, however, has been published concerning sport-related fractures of the distal radius with regard to epidemiology, management, outcome and their effect on sporting activitie?. This study prospectively documented all the sports related distal radius fractures presenting to the Edinburgh Orthopaedic Trauma Unit over a 5 year period.
Materials
and methods
Between April 1988 and May 1993,2774 patients presented to the Edinburgh Orthopaedic Trauma Unit with fractures of the distal radius. Of these, 221 patients (8 per
cent) sustained 225 fractures of the distal radius as a result of a sporting pursuit or recreational activity. Clinical details of each patient were recorded at their first attendance and radiological examination was performed in initial presentation, after reduction (if appropriate), at I week and at 6 weeks after fracture. Radiological measurements included dorsal or volar angulation, radial shift” and radial shortening6. The average review time was 27 months (range 7-61 months). All 221 patients were sent a questionnaire to assesstheir return to their original standard of sport. Of the 221 questionnaires distributed, 131 were completed. Fracture instability was defined as loss of position in a cast after a satisfactory initial reduction. Malunion was defined as a dorsal angle of greater than 12”, a volar tilt of more than 15” or radial shortening of more than 3 mm when compared to the contralateral radius. In bilateral injuries, it was assumed that the radius was originally the same length as the ipsilateral ulna.
Results Epidemiology There were 154 males and 67 females with a mean age of 31 years (range 15-70 years). The mean age of the males was 27 years (range 16-54 years) and the mean age of the women was 40 years (range 15-70). The unimodal age distribution of males with sporting wrist fractures is illustrated in Figure I. Figure 2 illustrates the age distribution of sporting wrist fractures compared to that of the total population of wrist fractures attending the Edinburgh Orthopaedic Trauma Unit over the same period. Of the 225 fractures, 126 (56 per cent) were either undisplaced or minimally displaced and required protection for a few weeks in a forearm cast. Ninety-five fractures (42 per cent) required manipulation under either regional or general anaesthesia prior to application of a forearm cast. Four fractures underwent primary open reduction and internal fixation with buttress plates because of primary volar displacement and instability. Twenty-seven fractures (12 per cent) were identified at I week as being unstable. Sixteen of these underwent closed external fixation, seven underwent open reduction, bone grafting and K-wire fixation, two underwent open reduction and internal fixation with a buttress plate and two were remanipulated.
34
Injury: International Journal of the Care of the Injured (1995) Vol. 26/No. 1
80 70 40 50 40 30 20 10 0
20-29
30-39
Figure 1. Age and sex distribution
l&19
20-29
30-39
Figure 2. Age distribution
40-49 Age groups
SW59
60-69
70-79
of sporting wrist fractures. 0 male; n female.
40-49 5W59 60-69 Age groups
of frachres: sporting
Figure 3 illustrates the proportion of different sporting and leisure activities which caused distal radial fractures. It can be seen that football is the largest group comprising 49.8 per cent of the total number of injuries. Skiing comprises 12 per cent - mainly because of the presence of an artificial ski slope in Edinburgh. Wrist fractures in football were caused by either the ball forcibly striking the hand (21 per cent) or as a result of a fall (79 per cent). Of the latter, 54 per cent occurred on synthetic grass pitches, 28 per cent on grass and 18 per cent on asphalt, wood or cinders. Of skiing injuries, 68 per cent occurred on artificial surfaces, of which two-thirds occurred in novices having their first or second lesson on a dry slope. All fractures were classified using the A0 classification’ (Figure 4). Analysis of fractures related to each sport showed consistently higher A0 classes with both highenergy sports such as skiing or horseriding (Figtire 4) and recreation undertaken by an older population including curling and dancing. Football and rugby resulted in a
7&79
versus total population.
80-89
90-99
n sports; 0 total.
greater proportion of more benign, extra-articular fractures
(TableI). Only one of the 225 fractures was open and this was a Gustilo Type 18. Complications Complications occurred in 31 patients (14 per cent) with malunion predominating (28 patients). There were two cases of reflex sympathetic dystrophy and one case with an extensor pollicis longus rupture. There were no cases of carpal tunnel syndrome. Return to sport Of patients who responded to the questionnaire, 72.5 per cent returned to their original sport and previous level of competition. Fear of re-injury and its consequences was the commonest reason for not returning to the original sport. Novices or occasional participants seldom return to the sport in question irrespective of fracture severity or subsequent management. A few patients did not return to
Lawson
et al.: Sports
fractures
35
of the distal radius
football (49.8%)
skiing (12.0%) Figure
3. Distribution
of sports causing distal radial fractures.
30T
Al Figure
A2
A3
4. Fracture distribution
Bl
by A0
B2 B3 A-O Types type. cl total population;
their original sport as they had reached the upper age limit for it. Of the 112 fractures resulting from football, questionnaires were returned in 65 cases. These showed that 53 had made a full return to their sport. Nineteen of 27 questionnaires were completed relating to skiing injuries. None of the nine novices have returned to skiing for fear of re-injury. The remaining 10 skiers (six intermediate and four advanced) have all returned to their previous standard. Thirteen of the 17 questionnaires relating to rugby were returned. All have returned to the original level of club rugby. Nine of the 14 patients who had sustained their fracture on the ice returned their questionnaires. All patients were either middle-aged curlers or novice skaters. None have returned to the sport.
Discussion The epidemiology of fractures of the distal radius caused by sport reflects the epidemiology of other sporting
Cl
n Skiing
C2
C3
/equestrian.
injuries, with a majority of men and a significantly higher mean age among females 2,9P10. The distribution of sports recorded in this study is influenced largely by cultural and geographical factors as well as local facilities available. In central Scotland, football is the largest cause of sports injuries l,ll. It is not surprising, therefore, that half the fractures of the distal radius in this study were sustained whilst playing football. To determine which sports are intrinsically more hazardous, however, an estimate of each participant’s exposure to that sport must be made. Yde and Neilson” calculated 5.6 injuries for every thousand ‘player-hours’ in soccer compared to 3.0 injuries in basketball. Skiing, skating and equestrian events have previously been identified as causing more severe and complex injuries2,9.‘o. This is confirmed by the distribution of skiing and equestrian fractures which show a larger proportion of intra-articular fractures than the overall group (Figure 4). The high incidence of skiing injuries in this study is explained by the presence in Edinburgh of one of Europe’s
36
Table I. Sporting
Injury:
International
Journal
fractures of the distal radius - causative sports and A0 classification A
sport
of the Care of the Injured
Al
Football Skiing Dancing Rugby Curling/skating Badminton Equestrian Basketball/volleyball Climbing/hill-walking Mountain-biking Martial arts Cricket Golf Skateboarding Gymnastics Athletics Parachuting Table tennis Frisbee
: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Total
0
B
B7
82
83
Cf
34 6 3
17 6 7
17 ii
: 1 0 0 0 0 0 0 1 1 1 0 0 1 0
0 0 0 0 0 0 0 1 1 0 0 0
1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
1 0 :,
ii 2 0 2 2 1 0 0 0 1 0 0”
24 3 0 6 2 :
0 0 1 0 0 0 0 1 0 0 0 0 1 0 0
40
2
5
38
largest artificial ski slopes. Indeed, the contribution of the playing surface in the severity of sporting wrist fractures is significant. At one extreme, the unforgiving nature of ice may explain the severity of the fractures sustained during curling and skating. Of the footballing fractures caused by falls, 54 per cent were sustained by falling on synthetic turf, 28 per cent on grass and I8 per cent on other surfaces. In the Edinburgh area, there are four full-size and three five-a-side synthetic grass pitches compared with 168 natural grass pitches. It is reported that the synthetic turf pitches in Edinburgh are used on average 10 h per day and the grass pitches 1 h per day. It can be calculated that there is a fivefold increase in the risk of sustaining a wrist fracture falling on synthetic turf than grass. A recent study of injuries in American football has also suggested that falls on synthetic turf resulted in a greater degree of injury than falls on grass13. The complication rate in this study is low compared to other reports. Cooney14 reported a major complication rate of 31 per cent in a mixed population of patients. Fifty per cent of a series of wrist fractures treated with external fixation in Edinburgh had complications of either the fracture or the fixationX5. In conclusion, this study has shown that the epidemiology of sporting wrist fractures accurately reflects the epidemiology of sports injuries as a whole. High-energy sports and increasing participant age both result in more severe and complex fractures. The risk of wrist fracture is increased significantly when playing on synthetic turf compared to natural grass. Our complication rate was low, but despite this, only 72 per cent returned to their original sport. This was influenced largely by pre-injury standard of competition and commitment and not fracture severity.
3
4 5
6 7
8
9
10
11
1 iii 1 0 0 0 2 0 0 0 i 0 0 0 27
C2
c3
N
0 1
9 3 3 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0
112 27 20 17 14 8 5 3 3 2 2 2 2 2 2 1 1 1 1
35
17
i 6 1 4 2 1 1 1 1 0 1 b 0 0”
225
injuries in a total population. Int J Sports Med 1990; II: 66. Matthewson M. Wrist injuries. Sports Med Soft Tissue Trauma 1992; 4: 10. Marder RA, Chapman MW. Principles of management of fractures in sports. Clin Sporfs Med 1990; 9: I. Van der Linden W, Ericson R. Colles’ fracture. How should its displacement be measured and how should it be immobilised?] Bone Joint Surg /Am] 1981; 63A: 1285. Melone CP. Open treatment for displaced articular fractures of the distal radius. C/in Orthop 1986; 202: 103. Muller ME, Nazarian S, Koch P, et al. The Comprehensive Ckussification of Fractures of Long Bones. Berlin: Springer Verlag, 1990. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis. f Bone Joint Surg [Am] 1976; 58A: 453. Sandelin J, Santavirta S, Lattilla R, et al. Sports injuries in a large urban population: occurrence and epidemiological aspects. Inf ] Sports Med 1987; 8: 61. Schmidt B, and Hollwarth ME. Sport accidents in childhood. Z Kinderchir 1989; 44: 357. Watters D, Brooks S, Elton R, et al. Sports injuries in an accident and emergency department. Arch Emerg Med 1985; 2: 105.
1.2 Yde J, Neilson AB. Sports injuries in adolescents’ ball games: soccer, handball and basketball. Br] Sports Med 1990; 24: 51. 13 McCarthy P. Ar&zial turf: does it cause more injuries? Physician Sports Med 1989; 17: 158. 14 Cooney WP III, Dobyns JH, Linscheid RL. Complications of Colles’ fractures. ] Bone Joint Surg [Am] 1980; 62A: 613. 1.~ McQueen MM, Michie M, Court-Brown CM. Hand and wrist function after external fixation of unstable distal radius fractures. C/in Orfhop 1992; 285: 200.
Paper accepted 8 August 1994.
References I Pickard MA, Tullett WM, Pate1 AR. Sports injuries seen at an accident and emergency department. Scott Med J 1988; 33: 296. 2 de Loes M. Medical treatment and costs of sports related
I
c
A3
61
Vol. 26/~o.
of fractures
AZ
0 0
(1995)
Requests for reprints should be addressed to: G. M. Lawson FRCS (ED), Orthopaedic Registrar, Orthopaedic Trauma Unit Royal Infirmary of Edinburgh, 1 Lauriston Place, Edinburgh EH3 9YW, Scotland, UK.