Report of eight cases of humeral fracture following the throwing of hand grenades

Clinical Characteristics, Mechanism, and Outcome of Humeral Shaft Fractures Sustained during Arm Wrestling in Young Men: A Retrospective Study

OBJECTIVE

Humeral fractures are common in arm wrestling and other sports and military activities requiring similar movements; however, the precise mechanism is poorly understood. Here, we present an overview of the characteristics, possible mechanisms, and treatment of humeral shaft fractures sustained during arm wrestling.

METHODS

We reviewed 8 years (January 2013 to January 2021) of medical records and retrospectively analyzed data from 27 patients with humeral shaft fractures sustained during arm wrestling. The clinical data included sex, age, affected arm, alcohol consumption, muscle warm-up, history of competitive participation, opponents' characteristics, wrist position, and post-fracture radial nerve injuries. The fracture configurations were radiographically assessed and analyzed. Surgical management included single or dual plating. Scores on the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) were evaluated preoperatively and postoperatively at the last follow-up visit.

RESULTS

All fractures sustained during arm wrestling were spiral fractures of the distal third of the humerus. Of these, 11 were 12-A1 type and 16 were 12-B2 type with a wedge fragment. The two subtypes differed in the total fracture line length (12-A1: 0.18 ± 0.04; 12-B2: 0.23 ± 0.04; P < 0.001). The radial nerve injury rate was 0/11 (0%) in patients with 12-A1 type fractures and 7/16 (43.8%) in patients with 12-B2 type fractures (P = 0.011). Most patients were young men (mean age, ~25 years) with a history of competitively participating in arm wrestling for >2 years. Cold seasonal temperatures and a lack of warm-ups increased the risk of injury. All patients showed improved DASH scores at the last follow-up (12-A1:77.82 ± 5.14 to 10.25 [5.38]; 12-B2:78.91 ± 7.46 to 8.95 [3.17]; P < 0.001). No significant differences were observed among the different surgical treatments.

CONCLUSIONS

Individuals who participated in arm wrestling were at risk of humeral shaft fractures (type 12-A1 or 12-B2). The 12-B2 type occurs with a wedge fragment and is frequently accompanied by radial nerve injuries. The characteristics of arm-wrestling fractures and the mechanism(s) underlying these fractures can help orthopedic surgeons understand the causes of these fractures and similar fractures sustained in traditional sports. This understanding will help surgeons choose more effective surgical treatments that will result in more desirable functional outcomes and a faster return to work.

Humeral fractures sustained during arm wrestling

PURPOSE

The aim of this study was to present our experience of treating humerus fracture sustained during arm wrestling.

METHODS

Data of patients treated in our clinic with the diagnosis of humeral shaft fracture due to arm wrestling between 2000 and 2020 was retrospectively reviewed. Data collected included age, sex, dominant arm, history of professional or experienced participation, type and laterality of fracture, presence of radial nerve palsy, other surgical complications, management (surgical or conservative), duration of union defined as the time from injury until callus was evident on the radiograph, and the range of motion of the elbow joint at the last follow-up.

RESULTS

Nineteen patients with humeral shaft fracture as a result of the arm wrestling were included. All had right arm fracture and all had right as the dominant side. All of the fractures were spiral at the distal third of the humerus and medial butterfly fragment was present in eleven (57.9%). Seven (36.8%) were treated surgically. Five (26.3%) had radial nerve palsy on admission. At last follow-up, no patient had neural deficit and none had significant loss of range of movement.

CONCLUSION

Arm wrestling is an important cause of humerus shaft fracture. The dominant side is invariably affected. In this series all fractures were spiral type and occurred in the distal third of the humerus. One quarter of patients experienced radial nerve palsy, which can resolve spontaneously. Satisfactory results can be obtained with both conservative and surgical treatment.

LEVEL OF EVIDENCE

IV.

Humeral shaft fracture and radial nerve palsy in Korean soldiers: focus on arm wrestling related injury

INTRODUCTION

Humeral shaft fractures can lead to radial nerve injury and may require surgery and rehabilitation. We determined the causative events of humeral fracture, including arm wrestling, in young Korean soldiers and examined whether humeral fracture is related to demographic characteristics and the presence of radial nerve palsy.

METHODS

We reviewed 7.5 years (July 2012 to June 2019) of medical records covering patients who had experienced a humeral shaft fracture after entering military service and had received surgery for open reduction and internal fixation. Data were obtained on basic demographics, initial event provoking the fracture, presence of radial nerve palsy, initial and follow-up severity of the weakness, and any discharge from military service because of prolonged radial nerve palsy.

RESULTS

Of 123 cases, arm wrestling was the leading cause (52.8%). A high energy injury, such as falling from a height (11.4%), and sports related slips (10.6%) were other causes. All humeral shaft fractures caused by forceful contraction were spiral, while 40% of the fractures caused by external force related events were of a transverse type. The percentage of left-sided fractures was significantly higher for fractures arising from an external force than in those caused by forceful contraction related events. Radial nerve palsy was found in 34 patients (27.6%), and 16 were discharged from the military because of prolonged radial nerve palsy 6 months after the fracture. The causative events and other factors did not affect the presence of radial nerve palsy.

CONCLUSION

Arm wrestling was the leading cause of humeral fracture in young Korean soldiers but the chance of developing comorbid radial nerve palsy did not differ from that of other causes. These epidemiologic findings in this young active group may help in understanding the causes of humeral shaft fracture in soldiers and in the wider young population.

Operative treatment of torsional humeral shaft fractures in throwers leads to an earlier return to sport: a survey of expert shoulder and elbow surgeons

PURPOSE

To determine the management of torsional humeral shaft fractures in a group of expert shoulder and elbow surgeons and analyse the rate of return to sport of these throwing athletes.

METHODS

A survey was sent to all physician members of two prominent sports medicine professional associations: the American Shoulder and Elbow Surgeons and the Herodicus Society. Due to the rare nature of this injury, a historical survey of management and return to play was performed to allow analysis of trends in treatment and return to play after both non-operative and operative management.

RESULTS

The survey was emailed to 858 physician members. Out of the 95 respondents, 35 surgeons indicated they had treated ≥ 1 torsional humeral shaft fractures in throwing athletes (average 1.7 per surgeon). A total of 72 fractures were recorded with an average age of 20.4 years and the majority being male (68/72). Eighty-one percent (58/72) of the fractures were classified as simple spiral. Sixty-one percent (44/72) of the fractures were treated non-operatively, while 35% (25/72) of the fractures were treated by open reduction and internal fixation (ORIF). Patient age, return to sport rate and level, type of fracture, and fracture healing time did not significantly differ based on treatment type. Average time to return to sport was significantly shorter for patients who underwent ORIF compared to non-operative treatment (p = 0.001). Overall, 48 (92.3%) of the 52 athletes returned to sport, with 84% (36/43) returning to the same level of play.

CONCLUSION

Torsional humeral shaft fractures in throwers are most commonly seen in young men and can be treated both operatively and non-operatively with overall similar results for healing time, rate of non-union, and return to sport. The only significant difference in the groups was an earlier return to sports in those fixed surgically, however, operative intervention also yielded a higher complication rate. Regardless of the treatment method, the overall rate of return to play was moderate. These finding are clinically relevant and can assist physicians with decision making for treatment and can help when advising throwers of appropriate expectations for recovery after this injury.

LEVEL OF EVIDENCE

IV.

Humeral stress fracture in a female CrossFit athlete: a case report

Background

Humeral stress fractures are rare injuries usually related to sports practice and joint overload without a direct trauma. A proximal humeral stress fracture has never been reported in a CrossFit athlete.

Case presentation

We report a stress fracture in the humerus of a 22-year-old woman after intense CrossFit training. Patient’s previous medical history included amenorrhea and reduced Vitamin D levels. The patient was treated conservatively and resumed CrossFit training after she was advised not to until follow up imaging.

Conclusions

We present the MRI features of the case and emphasize the difficulties in diagnosis due to multiple possible causes of shoulder pain in a CrossFit athlete and by negative findings on early radiographs. Hormonal variations, Vitamin D insufficiency and the patient’s attitude towards exercise were important factors that contributed for the stress injury after weight-lifting in CrossFit.

Surgical treatment of type III acromioclavicular dislocation: Bosworth technique versus hook plating

OBJECTIVE:

In this study, it was compared the clinical results of the Bosworth technique and hook plating in acromioclavicular (AC) dislocations.

METHODS:

44 patients are retrospectively evaluated in this study whom diagnosed as type III AC dislocations and treated by two different surgical methods in two different clinics. The patients were 30 males and 14 females with a mean age of 44 years (range, 18–80 years). The patients were divided into 2 groups according to the applied surgical technique. Group I comprised 25 patients to whom coracoclavicular fixation was applied by using the Bosworth technique. Group II comprised 19 patients to whom acromioclavicular fixation was applied by using hook plate. All patients are evaulated by The University of California at Los Angeles Shoulder Score (UCLA) and The disabilities of the arm, shoulder and hand (DASH) scoring system.

RESULTS:

The mean follow-up period was 23 months (range, 12–42 months). A statistically significant diffference was determined between the surgical groups in respect of the modified UCLA scale (p=0.012) and Quick DASH score (p=0.008). Hook plating group had better clinical results according to Bosworth group in terms of both UCLA and DASH score. A statistically highly significant negative correlation was determined between the UCLA and DASH scores (r=0.677, p=0.000).

CONCLUSION:

Although hook plating had better clinic outcomes compared to Bosworth technique, there is not seen difference between two groups in terms of the time of return to work. Treatment of the AC dislocation should perform early reconstruction for better reduction, fewer complications and higher levels of patient satisfaction.

Thrower's Fracture of the Humerus: An Investigation of Risk Factors Following an Unlikely Scenario: A Case Report

CASE

A 26-year-old amateur baseball player without prodromal arm pain sustained a thrower's fracture of the humerus on a warm-up throw performed with submaximal effort. The fracture occurred during the first throwing session following a 6-week layoff. The patient was treated nonoperatively and made a full recovery, but he elected to not return to throwing sports.

CONCLUSION

Because of the lack of risk factors in this case, we suggest that time off or irregularity in throwing may play a greater role in a thrower's fracture than previously established. Recreational throwers should undergo appropriate preseason training before returning to throwing.

Thrower's fracture of the humerus

Thrower's fractures are spiral fractures of the humerus caused by forceful throwing of a ball. Although these fractures have been cited in the literature, little research exists regarding the significance of stress fractures and fatigue injuries that may precede these injuries. This article presents 3 cases of middle-aged recreational baseball pitchers who sustained mid to distal third spiral humerus fractures, reviews the biomechanics of a thrower's fracture, and provides a detailed review of the literature to help better understand this condition and guide treatment.

Throwing injuries of the upper extremity

The overhead throwing motion is a complex sequence of maneuvers that requires coordinated muscle activity in the upper and lower extremities. The shoulder and elbow are subject to multidirectional forces and are particularly vulnerable to injury during specific phases of the overhead throwing motion. Ligamentous, tendinous, neural, and osseous pathology that may occur in the shoulder or elbow of an overhead-throwing athlete will be discussed, with an emphasis on the role of MR imaging and MR arthrography.

Case report: Longitudinal stress fracture of the humerus: imaging features and pitfalls

Longitudinal stress fractures are an uncommon injury in which a diaphyseal fracture line occurs parallel to the long axis of a bone in the absence of direct trauma. They have been described in the tibia and less commonly in the femur but apparently not in the upper limb. We report a longitudinal stress fracture occurring in the humerus of a 62-year-old woman who had a history of osteoporosis and had undergone recent surgery of the contralateral wrist. We present the radiographic, MRI, and CT features of the case and emphasize the difficulties in diagnosis caused by negative findings on early radiographs and by nonspecific bone marrow edema pattern on MRI. The risk of a contralateral upper extremity stress fracture from activities of daily living in a patient with osteoporosis whose other upper extremity is immobilized also is highlighted.

Thrower's fracture of the humerus with radial nerve palsy: an unfamiliar softball injury

A fracture of the normal humerus in a healthy young adult most commonly results from significant direct trauma. Throwing sports have become increasingly popular outside of North America and bring with them a novel injury mechanism for clinicians. A 21 year old woman sustained a "thrower's fracture" of the distal humerus and radial nerve palsy while throwing a softball. She was treated by internal fixation. Her fracture united, and radial nerve neurapraxia resolved after 8 weeks. Clinicians should be aware of this entity so that prodromal symptoms can be recognised early and thrower's fractures are not investigated unnecessarily.

Humeral shaft fractures secondary to throwing

Twenty-seven male military recruits with humeral shaft fractures that occurred during throwing of a hand grenade were analyzed to determine the causes and contributing factors of this fracture in recreational pitchers. Average patient age was 22 years (range: 19-27 years). Objective criteria included type and fracture site on radiographs. Subjective data such as throwing style, previous pitching experience, and prodromal arm pain were obtained. The recruits' throwing style was deemed faulty. Analysis of the fracture configurations indicated an external rotation mechanism.

Locked nailing of spiral humeral fractures with or without radial nerve entrapment

The experience of locked nailing of spiral humeral fractures and the perioperative conditions of the radial nerve are reported. The nerve is at risk of entrapment after such a fracture, and severe injury may occur during closed nailing. Among 162 humeral fractures treated by locked nailing, there were 21 spiral fractures: 18 acute fractures, and three delayed unions. The distribution of the fractures was two at the middle and 19 at the distal (1/3). Twelve patients had preoperative radial nerve palsy. All fractures excluding one middle fracture were retrograde nailed, and all patients had radial nerve exploration. Thirteen fractures were locked statically, seven were locked distally and had cerclage wiring, and one was locked distally only. Fisher's exact tests showed that the risk of radial nerve entrapment significantly increased in fractures with varus angulation or resulting from high-energy trauma. All the patients achieved fracture union and regained satisfactory joint functions. The author suggests that in external rotational spiral humeral fractures, radial nerve exploration should be done if nerve entrapment is highly suspected, irrespective of the fracture location or nerve palsy. Locked nailing with transfixing screws or cerclage wire could be a reliable treatment method for these fractures.