Sports Injuries Barton Fracture in a Soccer Player Psoas Avulsion Fracture in a Baseball Player Avulsion Fracture in a Skier Osteochondral Fracture in a Baseball Player

September 1, 2006

While playing soccer, a 24-year-old man fell on his outstretched hand, felt a "pop," and immediately noticed a deformity of his wrist. He was in severe pain when he presented to the emergency department.

While playing soccer, a 24-year-old man fell on his outstretched hand, felt a "pop," and immediately noticed a deformity of his wrist. He was in severe pain when he presented to the emergency department.

Anteroposterior and lateral radiographs of the wrist showed a distal radius fracture with dorsal dislocation of the radiocarpal joint.

One of the most common fracture dislocations of the wrist, the Barton fracture usually extends into the wrist joint. The fracture can involve either the dorsal or volar portion of the distal radius but, by definition, has an associated dislocation of the carpus, with proximal and either dorsal or volar displacement. Often, a radial styloid fracture is also present.

A Barton fracture differs from a Smith or Colles fracture because of the associated proximal carpal row dislocation. In a Barton fracture, the radial fracture fragment is generally smaller than the fracture fragments seen in Smith and Colles fractures.

Most Barton fractures are managed nonoperatively with manipulative reduction, followed by immobilization for 6 weeks. For unstable fractures, reduction with pin insertion or application of an external fixator may be necessary.

In this patient, the alignment and stability of the wrist after manipulative reduction was adequate, and a cast was placed on the wrist in extension. After 6 weeks, the cast was removed. He then underwent 6 weeks of physical rehabilitation and returned to playing soccer within 3 months. *

(Case and photographs courtesy of Douglas Beall, MD, of Edmond, Okla, and John Whyte, MD, of Silver Spring, Md.)

During a baseball game, a 29-year-old man had taken a lead off first base. He then did a half pivot to rapidly plant his foot back on the base before he ran and slid into second base. Immediately after sliding into the base, he felt pain in the right groin and required assistance to walk.

He had no previous injury to the groin area. Seven years earlier, he had sustained a traumatic fracture of the ankle. He had no family history of metabolic bone or connective-tissue disorders.

The patient's right leg was warm, with normal reflexes and sensation, good pulses, and soft compartments.The skin was intact. Active range of motion was preserved in the knee and ankle of the right leg but was limited in the right hip, secondary to pain. He complained of pain with hip flexion and of discomfort with adduction and rotation of the right hip.

A radiograph of the pelvis showed avulsion of the lesser trochanter.

In avulsion fractures of the pelvis, the involved muscle may be identified by the location of the fracture and, when the patient can tolerate a muscular strength evaluation, certain resistance testing clues:

Pain with hip flexion and rotation: iliopsoas muscle has pulled off part of the lesser trochanter, as in this patient.

Worsening pain with hip flexion and abduction: sartorius muscle has pulled off part of the anterior superior iliac spine.

Worsening pain with hip flexion: rectus femoris muscle has pulled off part of the anterior inferior iliac spine.

Worsening pain with hip extension: hamstring muscle has pulled off part of the ischial tuberosity.

Pain with abduction and external rotation: piriformis muscle has pulled off part of the greater trochanter.

Pain with adduction: hip abductor has pulled off part of the ischiopubic ramus.

Avulsion fractures of the pelvis are most common in patients between the ages of 11 and 15 years. The differential diagnosis includes muscle strain and periostitis. Consider osteomyelitis or tumor in patients with groin pain who have asymmetric radiographic findings and no history of trauma.

Treatment consists of rest and the use of crutches, with toe-touch weight bearing, for up to 2 months in most patients. A gradual return to stretching and activity is determined by the patient's symptoms; consultation with an orthopedist is recommended. Injuries with either large fragments or more than 15 mm of displacement may require surgical fixation. Complications include nonunion and healing with a bony prominence that can affect future function.

This patient was referred to an orthopedist. He fully recovered in 6 months. *

(Case and photograph courtesy of D. Brady Pregerson, MD, of Los Angeles.)

A 26-year-old woman presented with acute pain at the base of her thumb after her ski pole hit her hand as she jumped over a small mogul.

The patient's thumb was significantly swollen and markedly weak. It was difficult for her to grasp an object, and she had decreased range of motion.

Radiographs of the thumb showed a small avulsion fracture at the ulnar side of the base of the first proximal phalanx. The fracture was only minimally displaced, and the small fragment was successfully pinned in place using a small Kirschner wire. The patient's hand was placed in a cast.

After 6 weeks, the cast and Kirschner wire were removed. Two weeks later, the patient was asymptomatic, and radiographs showed evidence of healing.

Tears of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint of the thumb are common injuries in skiers, when the ski pole forces the thumb to deviate radially.1 A torn UCL that is completely disrupted can become displaced superficial to the adductor pollicis aponeurosis (a finding known as the Stener lesion).2 The pollicis aponeurosis can become interposed between the metacarpophalangeal joint and the UCL and can interfere with healing of the ligament.

Although splinting is appropriate for stable, undisplaced avulsion fractures and for incomplete ligamentous lesions of the UCL, surgery is required when the ligament has ruptured.1 Untreated UCL disruptions may have chronic, disabling sequelae. In addition to instability at the first metacarpophalangeal joint, chronic UCL disruption can cause weakness, stiffness, and severe pain. The surgical repair of a chronically disrupted ligament can be significantly more difficult because of proximal folding or retraction of the ligament.

Ligament displacement is sometimes signaled by the presence of an avulsed bone fragment from the medial portion of the proximal first phalanx. This type of avulsion fracture is often accompanied by complete ligamentous disruption. Although MRI may be used to visualize the UCL disruption, the radiographic and clinical findings that demonstrate instability at the first metacarpophalangeal joint are usually sufficient to make an accurate diagnosis of complete ligamentous disruption. *

1.Fricker R, Hintermann B. Skier's thumb. Treatment, prevention, and recommendations. Sports Med. 1995;19:73-79.

2.Louis DS, Julius J, Hankin FM. Rupture and displacement of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb: preoperative diagnosis. J Bone Joint Surg (Am). 1986;68: 1320-1326.

(Case and photographs courtesy of Douglas Beall, MD, of Edmond, Okla, and John Whyte, MD, of Silver Spring, Md.)

A 12-year-old boy presented with pain in the right shoulder. Six months earlier, he had fallen on his outstretched right hand during baseball practice and had persistent shoulder pain ever since.

The patient had full range of motion, but he complained of pain with abduction of his right arm. Tenderness was noted over the anterior portion of the shoulder joint capsule. There was also generalized muscle weakness in the right arm but no evidence of decreased muscle bulk. The weakness was attributed to decreased effort by the patient as a result of the pain.

MRI of the right shoulder showed a subchondral crescent-shaped area of signal abnormality on the superomedial portion of the humeral head (A, black arrow) along with subchondral edema (B, white arrow). The appearance of the signal abnormality, along with the underlying edema, is consistent with an osteochondral fracture of the humeral head.

Osteochondral fractures, also known as osteochondritis dissecans, frequently occur in children and have no gender predilection. Symptoms include the inability to bear weight and intense pain, which typically decreases within 2 or 3 weeks of the original injury. Osteochondral fractures are primarily caused by either ischemia or trauma, which may be direct or repetitive microtrauma. They are most common in the weight-bearing areas and are often seen in a femoral condyle and the talus. When the fracture occurs in the shoulder joint, it usually involves either the humeral head or the glenoid.

Treatment typically consists of splint application and subsequent immobilization of the joint. Resting of the injured extremity along with NSAIDs can reduce pain severity. Surgery is occasionally necessary to remove the intra-articular loose body. *

(Case and photographs courtesy of Douglas Beall, MD, of Edmond, Okla, and John Whyte, MD, of Silver Spring, Md.)

References:

FOR MORE INFORMATION:

m Pregerson DB.

Quick Essentials: Emergency Medicine.

Carlsbad, Calif: ERpocketbooks.com; 2006.

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