A Scoping Review of the Epidemiology, Management, and Outcomes of Golf-Related Fractures.

ABSTRACT: Golf is a popular sport; however, there is a paucity of data in relation to golf-associated fractures, and the rate and timing of returning to golf. The aim of this review is to describe golf-associated fractures, including epidemiology, management, and timing of returning to golf following treatment. A literature search was performed using MEDLINE/PubMed, Embase, and Web of Science. Data were extracted and summarized in a narrative synthesis. A total of 436 articles were identified with an initial search of which 58 met the inclusion criteria. Twelve anatomical sites of golf swing-related fractures were identified, of which 10 sites were specific for stress fractures. The most common sites of golf swing-related stress fractures were the ribs followed by the hook of hamate. There was a common theme of delay to diagnosis, being initially assigned to a soft tissue injury. Most golfers with swing-related stress fractures were able to return to golf with the exception of osteoporotic associated vertebral stress fractures. Timing of returning to golf was between 4 and 12 months for most of the golfers with stress fractures following conservative management. Operative intervention was an option of hook of hamate nonunion, following a stress fracture, and tibial shaft stress fractures. Golf equipment-related fractures were not rare and were associated with major trauma and in some cases associated with significant persistent morbidity. Golf-related stress fractures commonly involve the ribs and hook of hamate; knowledge of this may aid in early diagnosis and appropriate treatment when symptomatic golfers are encountered. Although golf is a noncontact sport, fractures associated with golf equipment can be life changing, and safety training guidelines should be established.

An assessment of the diagnosis, treatment, and outcomes of lower extremity stress fractures in pediatric and adolescent populations.

OBJECTIVES: To present one of the first descriptive case series of pediatric and adolescent lower extremity stress injuries, their management, and outcomes in athletes and non-athletes. METHODS: The IRB-approved retrospective study included patients under 18 years at a tertiary children's hospital who were diagnosed with a lower extremity stress fracture/reaction. Demographic data, mechanism of injury, physical exam, radiographic findings, treatment, & outcomes were collected. Descriptive statistical analysis was conducted. RESULTS: Ninety-seven patients with stress injuries on clinical exams and on radiographs or MRI were included. The average age when diagnosed was 11.7 years (range 1.1-18 years) and the most common injuries were to the tibia (n = 33, 28.4%) and the least common involved were the cuneiforms (n = 4, 3.4%). Patients under the age of 14 were more likely to experience cuboid and calcaneal stress injuries (mean age 5.5 and 8.3 years respectively). Nineteen patients (19.6%) had high-risk stress fractures, with the average age of 14.9 years versus 11.6 for those with low risk (p-value = 0.01) and return to activity time being 15 weeks compared to 10.5 (p-value = 0.027). The most common forms of treatment were controlled ankle motion (CAM), walker boots (58.6%), and physical therapy (PT) (38.1%). The mean Lower Extremity Function Score of the patient population was 73.8, indicating no clinically important difference from full functionality. CONCLUSION: Lower extremity stress injuries in this cohort were most seen in the tibia, although patients younger than 14 had a high number of cuboid and calcaneal stress injuries. Those with high-risk stress fractures were older and took longer to recover from when compared to low-risk injuries. Treatment is commonly conservative, with CAM boots and PT being the most frequently utilized interventions and serving as a successful approach to treatment, with patients returning to activity at an average of 11.4 weeks, which is comparable to similar studies.

Exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies.

The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.

The effect of concentrated bone marrow aspirate in operative treatment of fifth metatarsal stress fractures; a double-blind randomized controlled trial.

BACKGROUND: Fifth metatarsal (MT-V) stress fractures often exhibit delayed union and are high-risk fractures for non-union. Surgical treatment, currently considered as the gold standard, does not give optimal results, with a mean time to fracture union of 12-18 weeks. In recent studies, the use of bone marrow cells has been introduced to accelerate healing of fractures with union problems. The aim of this randomized trial is to determine if operative treatment of MT-V stress fractures with use of concentrated blood and bone marrow aspirate (cB + cBMA) is more effective than surgery alone. We hypothesize that using cB + cBMA in the operative treatment of MT-V stress fractures will lead to an earlier fracture union. METHODS/DESIGN: A prospective, double-blind, randomized controlled trial (RCT) will be conducted in an academic medical center in the Netherlands. Ethics approval is received. 50 patients will be randomized to either operative treatment with cB + cBMA, harvested from the iliac crest, or operative treatment without cB + cBMA but with a sham-treatment of the iliac crest. The fracture fixation is the same in both groups, as is the post-operative care.. Follow up will be one year. The primary outcome measure is time to union in weeks on X-ray. Secondary outcome measures are time to resumption of work and sports, functional outcomes (SF-36, FAOS, FAAM), complication rate, composition of osteoprogenitors in cB + cBMA and cost-effectiveness. Furthermore, a bone biopsy is taken from every stress fracture and analysed histologically to determine the stage of the stress fracture. The difference in primary endpoint between the two groups is analysed using student's t-test or equivalent. DISCUSSION: This trial will likely provide level-I evidence on the effectiveness of cB + cBMA in the operative treatment of MT-V stress fractures. TRIAL REGISTRATION: Netherlands Trial Register (reg.nr NTR4377 ).

[Stress reactions in bones of the foot in sport: diagnosis, assessment and therapy]. / Knöcherne Stressreaktionen des Fusses im Sport: Diagnose, Beurteilung und Therapie.

Stress reactions and stress fractures are defined as structural damage to bone caused by repetitive stress or stereotypical loading. The balance between loading and unloading of bone is disrupted in stress reactions and stress fractures through the sport-specific demands and by the exogenous or endogenous risk factors present. In sports orthopedics the localization of stress reactions and stress fractures are subdivided into high risk fractures and low risk fractures. Conventional diagnostic radiology can initially be inconclusive. With symptoms persisting over 2 weeks further diagnostics using magnetic resonance imaging (MRI) should be performed. In the area of the foot stress reactions and stress fractures can often occur bilaterally or multifocally and most commonly affect the second metatarsals followed by the third metatarsals. Fractures of the fifth metatarsal, second metatarsal base, medial malleolus as well as navicular and sesamoid fractures are high risk fractures requiring special clinical and radiological monitoring. Basically, conservative treatment using the 2-phase model is the treatment of choice. In delayed union or severe pain surgical treatment is indicated.

Les ultrasons pulsés de faible intensité dans le traitement des fractures / Pulsed ultrasound of low intensity in the treatment of fractures

La présente note informative est une revue de la littérature sur l'efficacité, l'innocuité et le coût de l'utilisation des ultrasons pulsés de faible intensité pour traiter les fractures de stress ou celles dues à un traumatisme, qu'elles soient fraîches ou qu'elles présentent un retard ou même un échec de consolidation. Elle traite également des indications et des politiques de couverture en vigueur dans d'autres pays. Elle représente donc une mise à jour de la note technique publiée en 2004 par l'Agence d'évaluation des technologies et des modes d'intervention en santé (AETMIS) et répond à une demande du ministère de la Santé et des Services sociaux (MSSS). Les plus récentes données probantes confirment que l'utilisation des ultrasons pulsés de faible intensité dans le traitement des fractures n'est pas la source de préoccupations majeures au regard de l'innocuité. Cependant, l'incertitude demeure quant à l'efficacité relative et au rapport coût/efficacité de cette option thérapeutique. En effet, tandis que certains auteurs rapportent des résultats positifs, la majorité des quelques études qui portent sur les fractures fraîches montrent que les ultrasons pulsés de faible intensité ne sont pas associés à une réduction significative du temps de guérison des fractures, observable par radiographie, ou à une amélioration de la fonctionnalité. Pour ce qui est des fractures qui présentent un retard ou un échec de consolidation, les rares études qui ont examiné l'effet du traitement sur le temps de guérison ne sont pas concluantes; aucune étude n'a abordé l'effet sur la fonctionnalité. Les deux seules études sur les fractures de stress ne montrent aucun avantage des ultrasons. De surcroît, la preuve est affaiblie par l'hétérogénéité des études, les lacunes méthodologiques qu'elles comportent (elles reposent notamment sur des populations de petite taille) et l'absence de lien entre la guérison observable par radiographie et les résultats cliniques. Les rares évaluations économiques, basées sur des modélisations, montrent des résultats contradictoires relativement aux fractures fraîches et la plupart sont muettes en ce qui concerne les autres types de fracture. De plus, l'utilisation des ultrasons pulsés de faible intensité dans le traitement des fractures ne fait pas consensus parmi les organismes d'évaluation qui se sont penchés sur la question. Alors que le National Institute for Health and Clinical Excellence (NICE), au Royaume-Uni, a émis un avis positif sur l'efficacité et l'innocuité de cet appareil (bien qu'il appartienne à chaque autorité régionale du National Health Service (NHS) de l'inclure dans les services assurés), la Haute Autorité de Santé (HAS), en France, l'exclut de sa liste des produits couverts. Par ailleurs, aux États-Unis, les assureurs publics et privés couvrent habituellement, à certaines conditions, l'utilisation des ultrasons pulsés de faible intensité dans le traitement de fractures non consolidées de tout autre os que le crâne ou les vertèbres. En revanche, ces assureurs ne couvrent pas l'appareil à ultrasons pour le traitement des fractures dont la guérison est retardée et la politique de couverture varie ou n'est pas précisée relativement au traitement des fractures fraîches et des fractures de stress. En définitive, bien que les ultrasons pulsés de faible intensité aient un effet thérapeutique sur certains types de fracture, l'incertitude persiste quant à leur efficacité relative et à leur rapport coût/efficacité. Les données sur l'efficacité réelle, dans un contexte clinique courant, ne sont pas disponibles et aucune étude n'a abordé de façon adéquate les répercussions sur la qualité de vie. En conséquence, l'INESSS conclut que la preuve est insuffisante pour justifier l'introduction de cette technologie dans les services offerts par le régime public d'assurance maladie. Puisque la recherche se poursuit, certains des essais cliniques randomisés étant d'ailleurs réalisés au Canada, l'INESSS assurera une veille des résultats qui en découleront.(AU)

This information brief is a literature review of the efficacy, safety and cost of using low-intensity pulsed ultrasound to treat stress and trauma fractures, whether fresh or exhibiting delayed union or even non-union. This brief also looks at the current indications and coverage policies in other countries. It therefore constitutes an update of the technology brief published in 2004 by the Agence d'évaluation des technologies et des modes d'intervention en santé (AETMIS) and is in response to a request from the ministère de la Santé et des Services sociaux (MSSS). The latest evidence confirms that the use of low-intensity pulsed ultrasound to treat fractures is not a source of major safety concerns. However, uncertainty remains with regard to the relative efficacy and the cost-effectiveness of this treatment option. Indeed, although a few authors report positive results, most of the studies and there are only a few of them involving fresh fractures show that low-intensity pulsed ultrasound is not associated with a significant reduction in radiographic fracture healing time or in improved functional outcomes. As for fractures exhibiting delayed union or non-union, the rare studies that have examined the effect of this treatment on healing time are not conclusive, and no study has examined its effect on functional outcomes. The only two studies involving stress fractures do not show ultrasound to confer any benefit. Furthermore, the evidence is weakened by the studies' heterogeneity, their methodological weaknesses (in particular, these studies are based on small populations) and the absence of a link between radiographic healing and clinical outcomes. The rare economic evaluations, which are based on models, show contradictory results for fresh fractures, and most are silent with regard to the other types of fractures. Furthermore, the use of low-intensity pulsed ultrasound to treat fractures has not gained consensus among the assessment agencies that have examined this matter. While the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom has issued a favourable opinion regarding the use of this device (even though it is up to each regional authority of the National Health Service (NHS) to include it among the insured services), France's Haute Autorité de Santé (HAS) has excluded it from its list of covered services. In the United States, public and private insurers usually cover, subject to certain conditions, the use of low-intensity pulsed ultrasound for the treatment of non-union fractures of all bones except the skull and vertebrae. However, these insurers do not cover the ultrasound device for the treatment of fractures with delayed healing, and the coverage policy varies or is not specified for the treatment of fresh fractures and stress fractures. In short, although the use of low-intensity pulsed ultrasound may have a therapeutic effect on certain types of fractures, uncertainty persists over its relative efficacy and its cost-effectiveness. Evidence on clinical effectiveness is not available and no study has adequately addressed impact on quality of life. Consequently, INESSS concludes that the evidence is insufficient to justify including this technology among the services offered by the public health insurance plan. Since research is ongoing, with, incidentally, some of the randomized clinical trials being carried out in Canada, INESSS will be monitoring their results.(AU)

The use of MR imaging in the assessment and clinical management of stress reactions of bone in high-performance athletes.

Based on experience, the authors believe that MR imaging is a useful tool in the assessment and management of stress fractures and stress phenomenum of bone. The use of standard, graded MR evaluation aides the assessment of a repetitive stress injury to bone by allowing a more accurate diagnosis of bone injury. This more accurate assessment has predictive value in estimating the duration of disability. The use of a standard, graded MR evaluation aides the management of repetitive stress injuries to bone by defining a low grade of stress fracture (i.e., grade 1 and 2) injuries and a high grade of stress fracture (i.e., grade 3 and 4). This grading system has implications in the management of stress fractures, allowing more individualized treatment for the elite athlete.