Ankle Fracture in Sports Medicine

EpidemiologyFrequencyUnited States

The ankle joint is the most commonly injured joint in sports.[1] Approximately 70% of basketball players have sprained an ankle, and the likelihood of reinjury is as high as 80%.[2] Lateral ankle sprains account for 90% of all ankle injuries, whereas an ankle fracture occurs only approximately 15% of the time.[3, 4, 5]

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center. Also, see eMedicineHealth's patient education articles Broken Ankle (Ankle Fracture) and Ankle Sprain.

NextFunctional Anatomy

The distal tibia, distal fibula, and talus bones make up the ankle joint. These 3 bones are bound together by the joint capsule and surrounding ligaments. The anatomic relationship of the tibial plafond (joint surface of the distal tibia) to the talus is important for ankle stability. Because the anterior portion of the talus is more broadly shaped, dorsiflexion increases bone surface contact, thus improving stability. This relationship causes decreased stability during plantarflexion, accounting for the vulnerability to ligamentous injuries when the foot is plantarflexed. See the image below.

Diagram showing the typical locations for ankle fractures occurring from the 4 major injury mechanisms (SA= supination adduction, SE= supination external rotation, PA= pronation abduction, PE= pronation external rotation). Note that the SE fracture is shown as a dashed line, since it is best seen in the lateral projection. PreviousNextSport-Specific Biomechanics

Forces acting on the ankle lead to typical fracture or ligamentous patterns. Determining the position of the ankle during the injury can assist in assessing for ligament stability. Although simple unidirectional forces can be involved in an ankle injury, multidirectional forces are usually involved, making diagnosis a challenge.

Medial complex injuries typically occur from eversion and abduction forces. The medial complex consists of the medial malleolus, the medial facet of the talus, and the superficial and deep components of the deltoid ligament. Eversion of the ankle causes injury to the superficial deltoid ligaments and, if sufficient, the deep deltoid ligament. Avulsion of the distal medial malleolus tends to occur in young and old patients, because the ligamentous strength may be greater than the strength of the bone in these individuals. With continuation of these forces, impaction of the distal lateral malleolus occurs, resulting either in rupture of the syndesmosis or in transverse fracture of the distal fibula.

Most unstable ankle fractures are the result of excessive external rotation of the talus with respect to the tibia. If the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues. If the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results.

The lateral complex consists of the distal fibula, the lateral facet of the talus, and the lateral collateral ligaments of the ankle and subtalar joints. Lateral malleolus injury (most common type of fracture involving the ankle) typically occurs with supination external rotation forces. The inversion force first strains the lateral ligament complex or avulses (transverse fracture) the lateral malleolus. With continuation of this force, the talus impacts the medial malleolus, causing an oblique fracture of the distal tibia. Inversion ligamentous injuries of the ankle are the most commonly observed soft-tissue trauma in sports.

Posterior malleolus injury typically occurs with a supination-external rotation or a pronation-external rotation injury and represents avulsion of the posterior tibiofibular ligament from the posterior distal tibia.

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Brachial Plexus Injury in Sports Medicine

Background

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports such as football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.[1, 2, 3, 4, 5]

The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.

Recent studies

Bertelli et al reviewed the sensory losses and pain symptoms of 150 patients with brachial plexus lesions that were evaluated and operated on. Sensory losses were believed to be documented on the basis of dermatomal root distribution and pain symptoms were believed to be attributed to lower root avulsion. Prior to surgery, patients underwent clinical evaluation and CT myelo scanning with intradural contrast. Hand and finger sensation were evaluated preoperatively; upper root lesions showed hand sensation was preserved. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. C8 and T1 injuries always were avulsed from the cord. This indicated an overlapping of the dermatomes, which was not as widely reported. Hand sensation was largely preserved in patients with partial injuries particularly on the brachial side.[6]

Sulaiman et al reviewed the clinical outcomes in patients who underwent nerve transfer operations for brachial plexus reconstruction at Louisiana State University over a 10-year period, evaluating recovery of elbow flexion and shoulder abduction. The authors found that nerve transfers for repair of brachial plexus injuries resulted in excellent recovery of both elbow and shoulder functions. They also noted that patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.[7]

Terzis and Barmpitsioti studied the use of wrist fusion in patients with brachial plexus injuries with multiple root avulsions resulting in wrist instability, imbalance, and inability to control the placement of the hand in space. Of 35 patients who underwent wrist fusion and answered questionnaires about their overall perceptions, 97.14% were satisfied with wrist stability and 88.57% reported that the procedure enhanced the overall upper limb function. The Disabilities of the Arm, Shoulder and Hand score was 59.14 +/- 12.9, reflecting moderate ability in daily activities. According to the authors, wrist fusion in patients with brachial plexus palsy is recommended as a complementary procedure, offering a stable, painless carpus, with improvement of overall upper limb function and appearance.7

NextEpidemiologyFrequencyUnited States

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly, and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play.[8] Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries.[9] In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.[10] Traumatic brachial plexus injuries can occur in 0.1% of pediatric patients who have experienced multitrauma.[11]

International

True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.

PreviousNextFunctional Anatomy

Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:

C4 - Trapezius; shoulder; top of shouldersC5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radiusC6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumbC7 - Triceps; elbow extension; index and middle finger tipsC8 - Extension of fingers; distal thumb; fourth and fifth fingersPreviousNextSport Specific Biomechanics

The following 3 mechanisms are common to brachial plexus injury:

Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)PreviousProceed to Clinical Presentation , Brachial Plexus Injury in Sports Medicine

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Cervical Spine Acute Bony Injuries in Sports Medicine

Background

Cervical spine fractures lead to substantial morbidity and mortality. Neck injury in athletes can quickly end or change the future of an athlete. Failure to properly recognize and provide early care in cervical spine fracture cases may lead to devastating complications.[1, 2, 3, 4]

A C3 spinous fracture is depicted in the image below.

Lateral view of a C3 spinous fracture.

For patient education resources, see the Back, Ribs, Neck, and Head Center, as well as Neck Strain, Vertebral Compression Fracture, and Whiplash.

NextEpidemiologyFrequencyUnited States

The incidence of all spinal injuries in the United States has been reported at approximately 10,000 cases per year. Nearly 200,000 people in the United States have a history of spinal injuries. These statistics do not differentiate between injuries with fracture and injuries without fracture.[5, 6, 7]

Sports-related activities represent 10-15% of these injuries, and spinal injuries represent 2-3% of all sports-related injuries. Certain sports (eg, American football, diving, gymnastics, skiing, wrestling, rugby, hang gliding, surfing, equestrian events) are more frequently associated with the risk of spinal trauma.[2, 3, 4, 6, 7, 8, 9, 10, 11, 12]

The most common spinal injuries cited in the literature are injuries secondary to contact sports such as football. Nearly 1.2 million high school athletes and 200,000 college and professional athletes participate in football. The National Football Head and Neck Injury Registry contains data on cervical spine injuries as a result of participation in football. A trend can be seen over time, as equipment and helmets improved. The incidence of cervical spine injuries increased until 1976. In that year, antispearing rules were established to prevent the athlete from using the helmet as driving force in tackles. Direct collision created higher axial loads than the neck could withstand, leading to high injury rates. This rule, along with better coaching of blocking and tackling techniques, has resulted in a significant decrease in the number of spinal injuries.[10]

Diving is often cited as another significant cause of cervical spine injuries. Injuries resulting from diving are often associated with devastating outcomes. Diving rules (eg, depth of starting areas) and proper technique have lowered the probability of injury during supervised athletic events. However, unsupervised swimming and diving into shallow water present significant risks. Public awareness of this problem has led to the development of special awareness programs, but the risk of injury remains high.

PreviousNextFunctional Anatomy

The human spine serves to provide structural support and bony protection of the spinal cord. The cervical spine consists of 7 bony vertebrae separated by flexible intervertebral discs. They are joined together by an intricate network of ligaments, which helps form the normal lordotic curve of the cervical neck.[13]

The spinal column can be divided into 2 separate columns based on function and injury patterns. The anterior column consists of the bodies of the vertebrae, intervertebral discs, and the anterior and posterior longitudinal ligaments. The function of the vertebral body is to support weight. The posterior column contains the spinal canal and consists of the pedicles, laminae, articulating facets, and transverse and spinous processes. These structures form the vertebral arch, which encloses the vertebral foramen and protects the neural tissues.

The arch is formed by bilateral pedicles that are oriented posteriorly and join 2 laminae. The spinous process arises posteriorly from the vertebral arch. The cervical transverse processes and 4 articular processes also arise from the arch. The cervical transverse processes are unique to the vertebral column with an oval foramen transversarium. The vertebral arteries pass through these foramina. The posterior column also includes a group of ligaments including the supraspinous, infraspinous, interspinous, and nuchal ligaments.

The first 2 cervical vertebrae are atypical in form and function. The next 5 vertebrae are all similar in structure and function. The atlas, C1, is a ring-shaped bone that supports the skull. Two concave, superior articular facets articulate with the occipital condyles. The atlas does not have a body or spinous process. The atlas has an anterior and posterior arch, each with a tubercle and lateral mass. The axis, C2, is the strongest cervical vertebrae. The atlas rotates on 2 large articulating surfaces. The odontoid process (dens) projects superiorly from the C2 body and is the bony structure that the atlas rotates on. The odontoid process is held in place by the transverse ligament of the atlas.

PreviousNextSport-Specific Biomechanics

Contact sports, falls, and diving in sports may lead to vertebral stress and fractures. Sports that involving tackling can increase exposure to mechanisms causing fractures.

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