Robert Gotlin
Bony injuries include various types of fractures, which are discussed in turn. An overview of injuries to ligaments and joints, muscles and tendons, skin injuries, and finally systemic disorders follows. Of all sports injuries, those to muscles, tendons, and ligaments are probably the most common. Naturally, the more physical a sport is and the more contact and high-energy collisions it involves, the greater the risk for injuries. American football and rugby are more likely to cause fractures, for instance, than tennis or basketball, in which ankle sprains tend to be more common.
One of the most common injuries that occurs to bones, particularly the longer bones of the arms and legs is a fracture, or a break in the bone. (A fractured bone and a broken bone are the same thing; one is not worse than the other.) Other common places for fractures are the bones of the wrist, ankle, and kneecap. The many types of fractures include the following:
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Simple or nondisplaced fractures (see figure 3.1) are those in which a break is noted on an X-ray, but the bone is still in perfect position. These fractures are much less likely to require surgical intervention than displaced fractures are.
• Displaced fractures usually occur in the long bones of the body and typically result in severe trauma (see figure 3.2). These fractures involve either a separation or an angulation of the fracture segments. Displaced fractures frequently require surgery and often require metal plates to be inserted to add strength and preserve the length of the bone.
• Comminuted (involving fragmentation or splintering of the bone) or impacted fractures are those in which one part of the broken bone is pushing into the other, shortening the length of the bone (figure 3.3). This type of fracture is serious because loss of bone height can adversely affect the function of the bone. Such breaks are seen in fractures of the wrist. Wrist fractures become impacted when athletes instinctively try to break a fall with their hands. These dangerous injuries always relate to the falling action and are frequently seen in skiing, ice hockey, and in-line skating.
• Compound fractures are complicated. Such fractures include multiple fractures with displacement of bones, comminuted sections, and even bone piercing skin (see figure 3.4). These fractures are usually related to severe trauma (e.g., motorcycle crashes) but can occur in any high-impact sport. Rodeo cowboys and football and rugby players are particularly susceptible to compound fractures.
• Fracture dislocations are injuries that involve a break in a bone as well as damage to ligaments and muscles, causing the broken bone to dislocate at the joint (figure 3.5). These types of injuries are usually caused by the type of trauma seen in auto racing or parachuting.
• Epiphyseal fractures are very serious injuries. The epiphyses, or growth centers, are seen in growing children. These growth centers are located near the ends of the long bones. The growth centers are soft and until they fuse do not have the strength of more mature bones. When fractures penetrate the growth centers (see figure 3.6), they can adversely affect future growth of the long bones. Such breaks must be handled with extreme care.
Classifications of epiphyseal fractures are called Salter type I through Salter type IV, depending on the location and severity of the fracture. The Salter classification relates to how involved the growth centers are in the injury. A mild separation is a type I, and severe breaks through the growth center are categorized as types II, III, or IV, with IV being the most severe. When the fracture is extensive through the growth center, the healing process can dangerously affect the future growth of the bone. Fortunately, epiphyseal fractures in children are rare, but occasionally a child will get hit by a baseball or a bat, for example, and receive a serious injury.
• Stress fractures are the most intriguing of all fractures (see figure 3.7). These injuries can be caused by overuse, poor training habits, and poor environmental or practice facilities. They result from an abnormal stress being placed upon a normal bone. Often, the diagnosis is not made until after healing has taken place and new bone has been laid down. Often no treatment other than rest is necessary. If a weight-bearing bone is affected, weight should not be placed on the bone while it is healing; for a leg bone injury, the athlete must use crutches for a time (three to four weeks for an adolescent, four to six weeks for an older athlete). The amount of rest required depends on the type and degree of stress fracture. Of course no one can predict when rest alone will be sufficient, so a diagnosis and additional treatment if needed is preferable. In some cases of stress fracture, X-rays might not show a break, so a nuclear bone scan, magnetic reasonance imaging (MRI), or computed tomography (CT) scan is needed for diagnosis.
• Avulsion fractures are related primarily to torn ligaments or tendons. As a ligament or tendon tears, it may pull, or avulse, a small piece of bone with the ligaments or tendons as shown in figure 3.8. The soft tissue trauma rather than the fracture is the focus of treatment for these injuries. Avulsion is frequently seen in injuries to fingers. Baseball catchers are notorious for avulsions in the fingers. Fractures are suspected when swelling, pain, or a history of trauma is present and can be confirmed by X-ray, bone scan, CT scan, or MRI. Typically athletes experience pain with fractures for two reasons: the periosteum (the lining of the bone where the nerve endings lie) may be disrupted, or a bone contusion or bruise (not really a fracture) may be present. A bone bruise can be extremely painful and just as disabling as a fracture, and it often takes as long as a fracture to heal. Bruised shins and hip pointers (located near the hip joint) are common in American football. Bone bruises are diagnosed by taking a careful history and possibly an X-ray. In some instances a bone scan or MRI, which may reveal increased activity within the bone, can be helpful.
A fracture must always be ruled out before calling an injury a bone bruise.