Delayed unions and nonunions of stress

Transcription

1 Delayed unions and nonunions of stress fractures in athletes S. ORAVA,* MD, AND A. HULKKO, MD From the *Department of Sports Medicine, Deaconess Institute and University of Oulu, Oulu, Finland, and the Department of Surgery, Keski-Pohjanmaa Central Hospital and Sports Injury Clinic Medirex, Kokkola, Finland ABSTRACT From 1971 to 1985, 369 athletes presented to us with stress fractures. Of these patients, 10% (37) were treated for development of delayed unions or nonunions. Twenty-seven of the patients were male and 10 were female. Their mean age was 23.1 years (range, 17 to 39). About half of the athletes were involved in endurance sports. The diagnostic criteria for a delayed union or nonunion were clinical and radiological evidence. There was a diagnostic delay of about 3.5 months in the series. Plain radiographs, tomography, and isotope scans were used in the diagnosis. Special radiographic views were also used. In 15 cases (10 hallux sesamoid bone fractures, 1 midtibial shaft fracture, 1 metatarsal V base fracture, 1 tarsal navicular fracture, 1 olecranon fracture, and 1 proximal tibial shaft fracture) nonoperative treatment was used. Operative treatment was used 22 times (5 sesamoid fractures, 5 midtibial fractures, 5 metatarsal V base fractures, 3 tarsal navicular fractures, 3 olecranon fractures, and 1 proximal tibial shaft fracture). Results were good or excellent in 32 cases (86.5%), moderate in 4 cases, and poor in 1 case. Stress fractures in athletes usually heal well, if the causative factor, excessive loading, is eliminated.3,16 Avulsion stress fractures involving bones such as the olecranon, metatarsal V and patella, however, need a long period of nonweightbearing or nonuse. Some stress fractures develop delayed or nonunion tendencies because athletes are too active. Such fractures have been described in the midtibia,1,6,17,24 tarsal navicular, 10,21 sesamoid bones of the great toe,9, 23 base of the fifth metatarsal,2,8, 11,20 olecranon,,, 12,15,22 and humerus.19 In * Address correspondence and repnnt requests to: S. Orava, MD, Deaconess Institute, Albertinkatu 18, Oulu, Finland. 378 treating these fractures, long training pauses, cast or brace immobilization, and operative procedures are needed. The purpose of this report is to present our experience in the diagnosis and treatment of these often problematic cases. MATERIALS AND METHODS Of a series of 369 cases of stress fractures in athletes during the 14 year period 1971 to 1985, 37 cases (10%) of delayed and nonunion stress fractures were seen (Table 1). These involved 27 males (73%) and 10 females (27%), with a mean age of 23.1 years (range, 17 to 39). All of the patients were competitive athletes or joggers. The distribution of the fractures among various sports is given in Table 2. About half of the patients were endurance athletes. The distribution of the 37 cases by injury site is given in Table 3, and the distribution by site of delayed unions versus nonunions is given in Table 4. The criteria for a delayed union or nonunion was that the fracture had not healed clinically or radiologically during a 3 month follow-up period, a delayed union then being distinguished from a nonunion by radiological findings. Diagnosis All patients had a history of local pain during exercise, and in most cases a clinical examination revealed local tenderness and swelling. In several patients the symptoms and signs were produced only by a hard training session. Radiographs were diagnostic in all cases at the late stage of the condition, whereas the primary radiologic findings were often minimal or absent (approximately 60%), which led to diagnostic delay. Tomography was used 12 times and bone scanning 11 times, each with positive results. In about half of the cases special radiographic views, such as an oblique AP view of the tibia and tarsal navicular, and tangential and side views of the sesamoid bones and olecranon, were used (Fig. 1).

2 379 TABLE 1 Stress fractures seen from 1971 to 1985 Other causes of diagnostic delay were late consultations of a physician and misdiagnosis in cases where the symptoms more closely resembled &dquo;benign&dquo; overuse injuries. The mean diagnostic delay was 3.5 months (range, 1 to 12 months). Treatment The treatment was nonoperative in 15 cases (40%) and operative in 22 cases (60%). Table 5 shows the treatment used at various sites. The treatment was chosen based on the type, symptoms, length of training pause, and by the experience of the authors. Nonoperative (conservative) treatment. Treatment of the sesamoid fractures consisted of avoidance of the training that had caused the symptoms, use of shoes with thicker and stiffer soles, and the use of inner shoe supports. The patients with stress fractures of the midtibia avoided running or jumping for 6 months, performed exercises of rising intensity and low frequency during that time, and then gradually began running. TABLE 2 Distribution of sports in athletes with delayed unions and nonunions TABLE 3 Fracture site distribution of delayed unions and nonunions Figure 1. Tangential view of lateral sesamoid stress fracture of the first metatarsophalangeal joint (crushed appearance) in a 24-year-old male middle-distance runner; great toe maximally dorsiflexed. TABLE 4 Delayed unions versus nonunions TABLE 5 Treatment of delayed unions and nonunions

3 380 The patients with stress fracture of the tarsal navicular avoided jumping and running until the fracture was radiologically healed, which took about 5 months. The patient whose stress fracture of the olecranon was treated conservatively was not able to throw a javelin for 1 year. His fracture consolidated while he was waiting for operation several months without training. The patient with a stress fracture of the proximal tibial shaft was treated by plaster cast and partial weightbearing for 1 month. After that he avoided all athletic activities for 5 months, but was allowed to move about freely. Operative treatment. The operative procedures performed are shown in Table 6. The histologic findings confirmed the diagnosis in all cases in which biopsies were taken (Fig. 2). The operations were performed by three surgeons (20, 1, and 1, respectively). A plaster cast without weightbearing was used postoperatively in four cases (one midtibia, one proximal tibia, two tarsal naviculars) and a functional brace with partial weightbearing was used in one midtibial fracture. Other patients were allowed to bear weight and walk normally. Patients who underwent excision of the sesamoid bone were allowed TABLE 6 Operative procedures used in treatment of delayed unions and nonunions to walk as soon as they were able. Four weeks after surgery of the tarsal navicular, the patients were allowed partial weightbearing (Fig. 3). The osteosynthesis material was removed from all patients 2 to 12 months after operation. RESULTS In one case a reoperation was needed because of a refracture. An oblique stress fracture of the olecranon in a female javelin thrower recurred 1 year after the first operation (2 K-wires and cerclage), and an AO compression screw and two bone pegs were inserted across the fracture line at the reoperation. After that the healing was uneventful (Fig. 4). The interval from the operation to full athletic activity varied from 3 to 6 months. The patients who underwent sesamoid bone excision were able to run maximally about 3 months after operation. All of the other patients had to wait longer, but in spite of the osteosynthesis material the training was close to a maximal level half a year after the surgery. The patient with the proximal tibial shaft fracture was able to practice sports 14 months after the onset of the symptoms. One of the patients with a tarsal navicular nonunion was unable to continue training because of the pronounced osteoarthrosis on both sides of the navicular bone. The follow-up period was from 2 to 5 years. The results were graded excellent or good if the patients were able to perform maximally without symptoms. Results were graded moderate if maximal training incurred mild symptoms. Results were considered poor if the patients were unable to continue sports participation. Table 7 shows the results. DISCUSSION Figure 2. Histological features of nonunion in a chronic stress fracture of the midtibial shaft of a 30-year-old male soccer player. Displacement has been described as a potential complication of stress fractures of the femoral neck and shaft in both military recruits and athletes.3,14, IS Delayed unions and nonunions are rare in recruits, but have been increasingly reported in athletes. Highly motivated athletes continue to train and compete in spite of pain, while recruits are more easily sent to rest. Athletes also tend to curtail the recommended rest period, as was often proved by the patients in the present study. A high motivation in training was also the reason for the midtibial stress fractures in ballet dancers described by Burrows and Devas. 3 The hallux sesamoids were the most common site of delayed unions and nonunions in this series. The diagnosis of a sesamoid bone stress fracture requires careful examination, radiographs with tangential view of the bones, bone scan, and followup.9~23 The interruption in training often tends to become inappropriately long when conservative treatment is prescribed; therefore, the surgical excision of the affected crushed bone is sometimes indicated. Distraction stress fractures of the midtibia constitute only a small percent of all tibial stress fractures.16 The diagnosis of this type of stress fracture is not easy because the normal radiographic AP and side views may only show thickening

4 381 Figure 3. A, plain radiograph of a stress fracture that separated across the tarsal navicular in an 18-year-old male during 110 meter hurdle competition; B, same case after compression screw fixation; C, healed stress fracture 6 months after surgery. of the anterior cortex. Therefore, oblique views and tomography are often required to show the fracture line inside the cortex.1,6,17,24 Bone grafting is recommended in cases of complete or nearly complete fractures. We have treated patients with a stable diaphysis and chronic symptoms with transversal drilling. Several 2 to 3 mm drill holes are made 4 to 5 cm proximally and distally to the fracture gap.l Compression stress fracture of the tibia seldom leads to delayed union, but if the fracture traverses the bone and new bone formation is seen on both sides of it, delayed healing ought to be suspected and the fracture should be treated with a cast or brace immobilization. An &dquo;acute&dquo; stress fracture of the base of the fifth metatarsal will heal well if it is primarily treated with immobilization and nonweightbearing.2 In delayed union and nonunion cases, operative treatment should be used if the athlete is not prepared for a very long training pause.2,8,20 An autogenous inlay graft, 21 screw fixation,ll and tension band fixation all have been used with success. Tension band fixation seems to be very effective in allowing bony union, especially since the cast is not necessary and weightbearing can be allowed in 3 to 4 weeks. According to the reports of Torg et al.,21 Graff and Krahl,5 and Matheson et a1.,13 stress fracture of the tarsal navicular is more frequent than previously realized. We have seen and treated several cases since the collection of this series. The tarsal navicular stress fracture is usually related to hard jumping and running. Displacement and nonunion are complications that indicate operative therapy. The only poor result in our series occurred in a young middle-distance runner, and was due to the osteoarthrosis caused by the inveterate nonunion of the navicular bone. One of the least known causes of elbow pain in javelin throwers is the stress fracture of the olecranon. This type of fracture may be located at the tip or more distally., 12,15 It is possible to treat a tip fracture conservatively, but our opinion is that the tip fragment should be excised if the symptoms last several months and prevent throwing. The healing process of the midolecranon stress fracture is slow, and the risk of nonunion is high. Therefore, we also regard a distal stress fracture in a javelin thrower as an indication for operative treatment. Although delayed unions and nonunions of stress fractures are relatively rare in athletes, they seem to be on the increase, perhaps because of a gradual intensification of training programs at all ages. In many cases, diagnosis is difficult and repeated clinical, radiological, and isotope examinations are necessary. Stress fractures at risk sites must be kept under careful observation in order to ensure adequate primary healing. Established nonunions and some delayed unions, especially in professional and other top level athletes, require operative treatment.

5 382 TABLE 7 Results of nonoperative and operative treatment a Stress fractures (crush fracture) of hallux sesamoids with symptoms present only during hard training. b Stress fracture of proximal tibia. Exploration case of tarsal navicular (osteoarthrosis). Figure 4. A, tomography (AP view, elbow in extension) of recurrent oblique stress fracture of the olecranon in a 28- year-old female javelin thrower, 2 months after onset of symptoms. This fracture was seen only vaguely in plain radiographs. B, isotope scan (technetium-99) shows clearly increased uptake of the tracer at the fracture site; C, after treatment with one compression screw and two bone pegs (AP view). REFERENCES 1. Burrows HJ: Fatigue infraction of the middle of the tibia in ballet dancers. J Bone Joint Surg 38B: 83-94, DeLee JC, Evans JP, Julian J. Stress fracture of the fifth metatarsal. Am J Sports Med 11: , Devas MB. Stress Fractures. Edinburgh, Churchhill Livingstone, Devas MB: Stress fractures in athletes. Proc R Soc Med 62: , Graff K-H, Krahl H: Uberlastungsschaden im Fussbereich beim Leichtathleten Leichtathletik 24: 81-87, Green NE, Rogers RA, Lipscomb AB: Nonunions of stress fractures of the tibia. Am J Sports Med 13: , Hulkko A, Orava S, Nikula P. Stress fractures of the olecranon in javelin throwers. Int J Sports Med, in press, Hulkko A, Orava S, Nikula P: Stress fracture of the fifth metatarsal in athletes. Ann Chir Gynaecol 9. Hulkko A, Orava S, Pellinen P, et al: Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes. Arch Orthop Traum Surg 104: , Hulkko A, Orava S, Peltokallio P, et al: Stress fracture of the navicular bone. Nine cases in athletes Acta Orthop Scand 56: , Kavanaugh JH, Brower TD, Mann RV: The Jones fracture revisited. J Bone Joint Surg 60A: , Kvidera DJ, Pedegana LR: Stress fracture of the olecranon. Orthop Rev 12(7): , Matheson GO, McKenzie DC, Clement DB, et al: Characteristics of tarsal stress fractures in athletes (Congr abstract). Med Sci Sports Exerc 17: 224, Meurman KOA: Stress fractures in soldiers. An analysis of 986 consecutive cases. (Thesis.) Acta Univ Oulu D: 78, Miller JE: Javelin thrower s elbow. J Bone Joint Surg 42B: , Orava S: Stress fractures. Br J Sports Med 14: 40-44, Orava S, Hulkko A: Stress fracture of the mid-tibial shaft. Acta Orthop Scand 55: 35-37, Orava S, Puranen J, Ala-Ketola L: Stress fractures caused by physical exercise. Acta Orthop Scand 49: 19-27, Rettig AC, Beltz HF: Stress fracture in the humerus in an adolescent tennis tournament player. Am J Sports Med 13: 55-58, Torg JS, Balduini FC, Zelko RR, et al: Fractures of the base of the fifth metatarsal distal to tuberosity Classification and guidelines for non-surgical and surgical treatment. J Bone Joint Surg 66A: , Torg JS, Pavlov H, Cooley LH, et al: Stress fractures of the tarsal navicular. A retrospective study of twenty-one cases. J Bone Joint Surg 64A: , Tullos HS, Erwin WD, Woods W, et al: Unusual lesions of the pitching arm Clin Orthop 88: , Van Hal ME, Keene JS, Lange TA, et al: Stress fractures of the great toe sesamoids. Am J Sports Med 10: , Zweymuller K, Frank W. Ermudungsbruche der tibia im kindesalter. Z Orthop 112: , 1974