Specific Anatomic Sites

Stress fractures have been reported to occur at multiple sites in the upper extremity. Although numerous athletic activities have been associated with these injuries, the two most common are gymnastics and throwing sports, such as baseball and softball. See Table 1 for a list of stress fracture sites in the upper extremity and the sports associated with injuries at each site. A more detailed discussion of specific injuries follows.

Clavicle, Scapula, and First Rib

The clavicle and scapula connect the upper extremity to the axial skeleton. Although fractures of these bones are most commonly secondary to acute, major

Table 1

Upper extremity stress fractures: sites and associated activities

Clavicle Scapula

First rib

Humerus

Proximal physis Shaft

Medial epicondyle Ulna Olecranon tip Posteromedial olecranon Mid-olecranon Ulnar shaft

Distal radius Wrist Scaphoid Hamate Triquetrum Metacarpals

Gymnastics, rowing, diving, javelin Golf, trap shooting, cricket, jogging with hand weights Pitching, weightlifting, volleyball, basketball

Baseball

Baseball, softball, javelin, shot put, arm wrestling, weightlifting Baseball

Javelin Baseball

Baseball, weightlifting, javelin Softball, tennis, volleyball, bowling, table tennis, polo, baton twirling Gymnastics

Gymnastics, shot put Tennis

Breakdancing Tennis, softball trauma, stress fractures have been reported to involve both. Although they are not part of the upper extremity proper, stress fractures of the first rib are discussed as well, because these are often secondary to activities involving the upper extremities.

Clavicle

The clavicle is anchored to the shoulder by the acromioclavicular joint and to the axial skeleton by the sternoclavicular joint. The pectoralis major and deltoid muscles tend to pull the clavicle downward, whereas the sternocleidomas-toid and trapezius pull upward. Depending on the activity, these opposing forces can result in bending, torsional, and shear forces affecting the clavicle, especially when there are muscular imbalances [25]. Clavicular stress fractures have been reported in athletes participating in gymnastics, diving, rowing, and javelin throwing [25,26]. Osteolysis of the distal clavicle is another stress-related process, often seen in weightlifters (Fig. 1) [27].

Scapula

Like those affecting the clavicle, scapular stress fractures are rare, but they have been reported in a golfer (acromion), a trapshooter (coracoid process), a cricket player (inferolateral border), and a jogger running with hand weights (superior margin) (Fig. 2) [28-31].

First rib

Stress fractures of the first rib have been described in athletes involved in a number of sports, including baseball pitching, basketball, volleyball, weight-lifting, and even soccer (related to ''heading'' the ball) [32]. These injuries are related to the shear forces that develop when the scalene muscles pull the rib

Osteolysis The Distal Clavicle

Fig. 1. Distal clavicular osteolysis. (A) Anteroposterior radiograph reveals ill-defined, stress-related osteolysis of the distal clavicle (arrow). (B) Coronal fat-saturated T2-weighted image of the shoulder in a different patient (a young firefighter who also lifted weights) demonstrates increased signal intensity in the distal clavicle (short arrow) compatible with stress-related changes. CL, clavicle; CO, coracoid process.

Fig. 1. Distal clavicular osteolysis. (A) Anteroposterior radiograph reveals ill-defined, stress-related osteolysis of the distal clavicle (arrow). (B) Coronal fat-saturated T2-weighted image of the shoulder in a different patient (a young firefighter who also lifted weights) demonstrates increased signal intensity in the distal clavicle (short arrow) compatible with stress-related changes. CL, clavicle; CO, coracoid process.

Coracoid Apophysis

Fig. 2. Stress fracture at base of coracoid process. (A) Axial gradient echo image through the shoulder demonstrates a nondisplaced stress fracture at the base of the coracoid process in this trapshooter (open arrow). (B) Sagittal fat-saturated T2-weighted image displays the fracture (small arrow), as well as associated edema in the coracoid process and adjacent soft tissues. (Courtesy of T. Sanders, MD, Charlottesville, VA.)

Fig. 2. Stress fracture at base of coracoid process. (A) Axial gradient echo image through the shoulder demonstrates a nondisplaced stress fracture at the base of the coracoid process in this trapshooter (open arrow). (B) Sagittal fat-saturated T2-weighted image displays the fracture (small arrow), as well as associated edema in the coracoid process and adjacent soft tissues. (Courtesy of T. Sanders, MD, Charlottesville, VA.)

upward while the serratus anterior muscle pulls the rib caudally. The resulting stress fracture occurs at the level of the groove for the subclavian artery—the site of maximum shear forces (Fig. 3). Notably, in throwers, these fractures tend to involve the first rib on the side of the nondominant arm [33].

Golf Rib Stress Fracture
Fig. 3. Bilateral first rib stress fractures. (A) Anteroposterior radiograph reveals bilateral stress fractures of the first ribs in this weightlifter (arrows). (B,C) The fractures are well demonstrated on oblique radiographs.

Humerus

Epiphysiolysis

Also known as ''Little Leaguer's shoulder,'' this is a stress reaction of the un-fused proximal humeral physis that is usually seen in young, skeletally immature throwers. This injury is most likely related to the shear stresses that develop during the cocking phase of throwing, which may also lead to humeral retrotorsion [34]. Radiographic findings include widening of the proximal humeral physis relative to the unaffected side. MRI may reveal changes of marrow edema adjacent to the injured physis (Fig. 4) [35].

Shaft fractures

Stress fractures of the humeral shaft have been described in athletes participating in numerous sports, primarily those involving throwing (baseball, softball, javelin, shotput), but also arm wrestling and weightlifting [12,36,37]. Regardless of the sport, these injuries most commonly result in a spiral fracture involving the mid- to distal shaft, often with a large butterfly fragment [13,36].

During the throwing motion, tremendous torsional stresses are applied to the humerus, most notably at the point between the late cocking and early acceleration phases when the external rotators (deltoid, supraspinatus, infraspinatus, and teres minor) are still contracting and the powerful internal rotators

Humeral Epiphysiolysis Mri

Fig. 4. Proximal humerus epiphysiolysis. (A,B) Axillary radiographs of the shoulders in a young baseball pitcher who presented with right shoulder pain demonstrate widening of the proximal humeral physis on the right (arrows) compatible with epiphysiolysis. (C) The same finding is present on this oblique coronal gradient echo image (open arrow). (D) Note the associated marrow edema on this fat-saturated T2-weighted image (dashed circle).

Fig. 4. Proximal humerus epiphysiolysis. (A,B) Axillary radiographs of the shoulders in a young baseball pitcher who presented with right shoulder pain demonstrate widening of the proximal humeral physis on the right (arrows) compatible with epiphysiolysis. (C) The same finding is present on this oblique coronal gradient echo image (open arrow). (D) Note the associated marrow edema on this fat-saturated T2-weighted image (dashed circle).

(pectoralis major, latissimus dorsi, subscapularis) begin to contract in the opposite direction [13]. The forces generated are of such a magnitude that the humerus may fracture as a result of a single throw [38,39].

In arm wrestling, torsional, bending, and axial compressive forces are all exerted on the humerus and may result in a similar fracture [36]. Humeral shaft fractures have also been reported in weightlifters, again most likely resulting from the opposing muscular forces involved in maneuvers such as the bench press [39].

These spiral, often mildly comminuted fractures are evident on radiographs at the junction of the mid- and distal thirds of the humerus (Fig. 5). Earlier diagnosis of a humeral stress fracture has been accomplished using radionuclide imaging [40]; theoretically, MRI should be able to display the changes of early humeral stress reactions as well.

Elbow

Medial epicondyle

Because of the valgus force that occurs at the elbow throughout much of the throwing motion, the medial aspect of the joint experiences significant tensile forces. In the older athlete, the medial (ulnar) collateral ligament is most vulnerable to injury, whereas in the younger thrower, the medial epicondyle apoph-ysis is most often affected. Although the medial epicondyle ossification center may become acutely avulsed, chronic stresses often lead to epiphysiolysis (apo-physitis) at this site [41]. Also known as ''Little Leaguer's elbow,'' this is similar to the process that occurs in the proximal humerus and is manifested on radiographs as widening and poor definition of the growth plate [16]. As with the proximal humerus, comparison views of the opposite elbow are often helpful in making the diagnosis (Fig. 6). The identification of marrow edema within

Humeral Shaft Osteolytic

Fig. 5. Humeral shaft fracture. Lateral radiograph of the humerus demonstrates an angulated fracture of its mid- to distal shaft in this patient who sustained the injury while arm wrestling.

Common Arm Wrestling Injuries

Fig. 6. Medial epicondylar apophysitis. (A,B) Anteroposterior radiographs of both elbows in an adolescent baseball pitcher reveal asymmetric widening of the left medial epicondylar growth plate (arrow) compatible with apophysitis. (C,D) Anteroposterior radiographs in a different adolescent pitcher reveal similar findings in the left medial epicondylar physis, with associated marrow edema (dashed circle) identified on the corresponding fat-saturated axial T2-weighted image obtained at that level (E).

Fig. 6. Medial epicondylar apophysitis. (A,B) Anteroposterior radiographs of both elbows in an adolescent baseball pitcher reveal asymmetric widening of the left medial epicondylar growth plate (arrow) compatible with apophysitis. (C,D) Anteroposterior radiographs in a different adolescent pitcher reveal similar findings in the left medial epicondylar physis, with associated marrow edema (dashed circle) identified on the corresponding fat-saturated axial T2-weighted image obtained at that level (E).

the apophysis on MRI may allow for earlier diagnosis, before the appearance of radiographic findings.

Olecranon

A stress fracture of the olecranon may occur at one of three sites, resulting from a different mechanism of injury at each.

Proximal tip. A stress fracture of the extreme proximal tip of the olecranon has been reported in javelin throwers and is thought to be due to impingement of the tip against the olecranon fossa at terminal extension of the elbow [42]. This ''door-stop'' mechanism typically results in a small, triangular-shaped fracture fragment that may be evident on a lateral radiograph (Fig. 7).

Proximal, posteromedial olecranon. MRI in a small group of professional baseball players presenting with posterior elbow pain revealed focal marrow edema at the posteromedial margin of the proximal olecranon (Fig. 8) [43]. Of interest, this edema was seen at the site where other throwing athletes develop poster-omedial osteophytes, usually in the setting of medial instability due to ulnar collateral ligament insufficiency. All of the patients in this study demonstrated intact ulnar collateral ligaments, and the authors postulated that this presumed stress reaction resulted from tensile failure of the trabeculae at this site, related to the steady valgus overload produced with throwing. The posteromedial os-teophytes seen in patients who have torn or insufficient ulnar collateral ligaments most likely develop from shear forces related to the ulnar subluxation that occurs in those patients.

Mid-olecranon. A transverse or oblique stress fracture through the mid-olecra-non has been reported in baseball players, javelin throwers, and weightlifters and is thought to result from repeated, forceful contraction of the triceps musculature (Fig. 9) [15].

Ulnar Shaft

Midshaft fractures of the ulna have been reported in athletes competing in a variety of sports, including softball, tennis, volleyball, bowling, polo, and table tennis, as well as in a baton twirler and in a patient who was using crutches as part of her treatment for osteochondritis dissecans of the opposite knee [44-46]. These diaphyseal fractures are of two different types.

Torsional

This type of mid-diaphyseal fracture is observed in athletes who undergo repetitive alternation between extremes of pronation and supination (eg, the ''windmill'' pitching mechanism in softball, the two-handed backhand in tennis). The

Olecranon Osteophyte Tennis Elbow
Fig. 7. Fracture at tip of olecranon. Lateral radiograph of the elbow demonstrates a small curvilinear fracture through the extreme tip of the olecranon in this javelin thrower (arrow).
Olecranon MriRotator Cuff Mri Images

Fig. 8. Focal edema of the posteromedial olecranon (MRI). (A) Axial, (B) coronal (at the level of the olecranon), and (C) coronal (at the level of the ulnar collateral ligament [short arrow]) fat-saturated T2-weighted images reveal focal edema in the posterior medial aspect of the olecranon of this 13-year-old baseball pitcher (arrows). Note also the marrow edema in the medial epicondylar apophysis (/arge arrow) and coronoid process (open arrow).

torsional shear stresses associated with these movements are concentrated in the midshaft of the ulna, presumably because of three factors: this segment is where the cross-sectional area of the bone is smallest, where its cortex is thinnest, and where it assumes a more triangular (rather than circular) shape [44,45].

Bending ("lifting")

Repetitive flexion of the elbow with loading of the forearm but without excessive pronation or supination (eg, in weightlifting, underhand volleyball setting) results in significant bending forces in the forearm [44,45]. The stresses of this type of loading are most concentrated at sites where the bone changes shape rapidly, and this occurs in the proximal and distal thirds of the ulna, where this type of stress fracture is typically found [47].

Distal Radius

Epiphysiolysis

Stress injuries involving the distal radial physis have been described almost exclusively in young gymnasts [14]. This predominance is probably due to a number of factors. Gymnastics is an unusual sport in that the upper extremity is commonly used for weight bearing, which results in compressive forces [5].

Fig. 9. Mid-olecranon stress fracture (MRI). Sagittal fat-saturated T2-weighted image of the elbow shows a nondisplaced, incomplete stress fracture in the mid-olecranon (arrow). (Courtesy of T. Sanders, MD, Charlottesville, Virginia.)

In many events, rotational forces are also involved, leading to additional torsional shear stresses. As with epiphysiolysis at other sites, this injury is manifested as a widening of the distal radial physis on radiographs; because of the nature of the sport, it may be present bilaterally (Fig. 10).

Distal shaft

A case of stress fractures involving the distal radial shafts bilaterally has been reported in a gymnast, although this is an unusual site for a stress injury [48].

Wrist

Scaphoid

Several reports exist of midscaphoid stress fractures in gymnasts, with a similar injury reported in a shot putter as well [49-52]. The mechanism of this injury is

Hamate Fracture
Fig. 10. Distal radial epiphysiolysis. (A,B) Anteroposterior radiographs of the wrists reveal widening and poor definition of the distal radial physes. This is more pronounced on the right (larger arrows) than on the left (smaller arrow).
Pics Torn Rotator Cuff Mri
Fig. 11. Hook of hamate fracture (MRI). (A) Axial and (B) sagittal fat-saturated images of the wrist reveal diffuse marrow edema in the hamate as well as a nondisplaced fracture (arrows). H, hook; MC, proximal metacarpal. (Courtesy of T. Sanders, MD, Charlottesville, VA.)

most likely weight bearing (or weightlifting in the case of the shot putter) on a severely dorsiflexed wrist. In this position, the compressive forces attempt to push the scaphoid into palmar flexion, while at the same time the volar extrinsic ligaments of the wrist act to keep the proximal portion of the bone in a more extended position [50,52]. The forces are then concentrated just distal to these ligaments at the level of the midscaphoid, which is where the fractures were observed in these patients.

Other carpal bones

Stress injuries in the other carpal bones are exceedingly rare. A fracture of the hook of the hamate is usually the result of an acute injury, such as the

Fig. 12. Second metacarpal stress fracture. (A) Anteroposterior radiograph of the hand shows no evidence of osseous injury in this 19-year-old tennis player who presented with right hand pain. (B) A follow-up radionuclide bone scan reveals focal abnormal uptake in the proximal aspect of the second metacarpal (arrow).

Phase Bone Scan Results

Fig. 12. Second metacarpal stress fracture. (A) Anteroposterior radiograph of the hand shows no evidence of osseous injury in this 19-year-old tennis player who presented with right hand pain. (B) A follow-up radionuclide bone scan reveals focal abnormal uptake in the proximal aspect of the second metacarpal (arrow).

impaction of the hook against a golf club or tennis racquet. However, there has been one reported case of a stress fracture at this site in a tennis player who had recently changed his serving technique (Fig. 11) [53]. A triquetral stress reaction was also reported in a breakdancer, engaged in an activity that places similar stresses on the wrist to those of gymnastics [54].

Metacarpals

Stress fractures of the metacarpals are also extremely uncommon, with only a few case reports in the literature. Two reports exist of second metacarpal stress fractures, both in tennis players (Fig. 12) [55]. Possible factors include the length of this, the longest of the metacarpals, and its restricted range of motion at the second carpometacarpal joint, where it is essentially limited to flexion and extension. A stress fracture involving the proximal aspect of the fifth metacarpal in a softball pitcher was thought to have resulted from strong adduction forces at that site related to gripping the ball [56].

SUMMARY

Although it is much less common than injuries in the lower extremities, an upper extremity stress injury can have a significant impact on an athlete, especially when it is not recognized until it has progressed to a displaced fracture. If an accurate and timely diagnosis is to be made, the clinician must have a high index of suspicion of a stress fracture in any athlete who is involved in a throwing, weightlifting, or upper extremity weight-bearing sport and presents with chronic pain in the upper extremity. Imaging should play an integral role in the work-up of these patients; if initial radiographs are unrevealing, further cross-sectional imaging should be strongly considered. Although a three-phase bone scan is highly sensitive in this regard, MRI has become the study of choice at most centers.

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