Stress fractures: classification and management.

Stress fractures occur as a result of microdamage secondary to repetitive strains. A mechanism for the development of stress fractures involves the accumulation of microdamage, which occurs with multiple subultimate failure loads applied to the bone. Stress fractures may be classified as high or low risk, depending on the grade of the injury. The most common site of injury is the lower extremity. In this article, we review the pathophysiology, etiology, diagnosis, and management of stress fractures, and present treatment guidelines for return to play.

Issues for the Traveling Team Physician.

This article outlines the value of having the team physician traveling with athletes to away venues for competitions or training sessions. At present, this travel presents several issues for the team physician who crosses state lines for taking care of the athletes. In this article, these issues and their possible remedies are discussed. A concern for the travelling team physician is practicing medicine while caring for the team in a state where the physician is not licensed. Another issue can be the transportation of controlled substances in the course of providing optimal care for the team athletes. These two issues are regulatory and legislative issues at both the state and federal levels. On the practical side of being a team physician, the issues of emergency action plans, supplies, and when to transport injured or ill patients are also reviewed.

In vivo degradation characteristics of bioabsorbable cross-pins in anterior cruciate ligament reconstruction.

BACKGROUND: We evaluated degradation of bioabsorbable femoral cross-pins following anterior cruciate ligament (ACL) reconstruction. METHODS: Four patients underwent ACL reconstruction using hamstring autograft with femoral fixation provided by a polylactic acid/polyglycolic acid copolymer (LactoSorb L15) cross-pin. Serial computed tomography (CT) scans were performed of the reconstructed knees at approximately 6 weeks, 4 months, 1 year and 2 years, postoperatively. A radiologist evaluated the scans for density of pins and surrounding bone and pin morphology. RESULTS: The cross-pins demonstrated a relative reduction in density of 7.7%, 49.1%, and 75.0% at 4 months, 1 year and 2 years, respectively. Bone density values adjacent to the pin decreased by an mean of 8.6% between 6 weeks and 4 months. At one year an additional 14.2% reduction in bone density was seen but at 2 years the relative reduction in bone density had decreased to 7.4%. Evaluation of pin morphology revealed that minimal change had occurred after 6 weeks. At 4 months all of the pins were showing some morphologic changes on the surface, but none had fractured. After 1 year, two of the pins had fractured. By 2 years all of the pins had fractured. None of the pins had completely reabsorbed at 2 years postoperatively. CONCLUSIONS: LactoSorb L15 cross-pins for femoral fixation in ACL reconstruction remain largely unchanged 4 months postoperatively, suggesting that this device maintains the necessary structural integrity to allow early integration of soft tissue grafts within bone tunnels. LEVEL OF EVIDENCE: IV, case series.

Classification and return-to-play considerations for stress fractures.

Stress fractures are common injuries, particularly in endurance athletes. Stress fracture management should take into consideration the injury site (low risk versus high risk), the grade (extent of microdamage accumulation), and the individual's competitive situation. The authors briefly discuss the pathophysiology and diagnostic process of stress fractures and expand on the classification of stress fractures and its impact on return-to-play decision making based on the relative risk of the fracture.

Management and return to play of stress fractures.

OBJECTIVE: The purpose of this article is to provide the clinician an evidence/experience-based algorithm for the management of stress fractures. DATA SOURCES: Medline search of peer reviewed publications regarding stress fracture etiology, classification, treatment, and natural history. DATA SYNTHESIS/METHODS: The algorithm was developed from a review of retrospective case series, a few evidence-based papers, and the clinical experience of 4 sports medicine team physicians with a combined experience of over 40 years in the care of athletes at the college and professional level. The literature is almost entirely case series without control groups; therefore, clinical consensus is included as the next best guide to treatment. RESULTS: The emphasis of this article is to provide a clear and simple approach to the management of these fractures by classifying them as either high-risk or low-risk. This separation into 2 groups is based on the biomechanical environment and natural history of the fracture. High-risk stress fractures occur in the superolateral femoral neck, anterior tibial shaft, tarsal navicular, proximal fifth metatarsal, and talar neck. Low-risk stress fractures occur in the lateral malleolus, calcaneus, 2nd through 4th metatarsals, and the femoral shaft. CONCLUSIONS: The undertreatment of high-risk stress fractures can lead to catastrophic bone failure and/or prolonged loss of playing time. Overtreatment of low-risk stress fractures can result in unnecessary deconditioning and unneeded loss of playing time. We propose that the use of the simple and clinically relevant algorithm will help guide appropriate management and return to play decision-making as well as encourage future prospective research.