■ sports medicine update

Acute Traumatic Fracture in a Female College Hockey Player

Brian Culp; Jason G. Hurbanek, MD; Jennifer Novak, MS, ATC; Kendra L. McCamey, MD; David C. Flanigan, MD

lower forces. Other conditions and the rugby player made a Despite the lower forces to the chest incurred during a in the differential of chest pain full recovery. sports injury compared to a motor vehicle accident, it is in an athlete are more likely, This article describes a rare prudent to perform the standard of care chest radiographs and include stress fractures, fracture to the distal one-third and electrocardiogram to rule out any potentially severe dislocations, soft tissue inju- of the sternum sustained by a complications. ries, and nonmusculoskeletal- female hockey player after a related issues.10,13 Because the checking collision. physis of the sternum or medi- rauma literature contains The pathomechanics of al clavicle do not completely CASE REPORT Tdocumentation of ster- sternal fractures in an athlete ossify before age 18, physeal An 18-year-old female college nal fractures, and the man- differ signifi cantly from the injury must be suspected with hockey player sustained a chest- agement principles continue classic steering wheel syn- chest pain in a young athlete. to-chest check from another play- to evolve.1-4 However, little drome and the more recently Traumatic sternal fractures er during a game. She was able to has been reported about ster- described safety-belt syn- often have other associated skate off the ice but reported im- nal fractures in athletes. The drome. The large forces as- injuries, the most frequent of mediate chest pain. The patient sports literature is limited to sociated with a motor vehicle which are fractures (22% was transported to the local emer- case reports of sternal stress accident can cause a number to 32% when an associated gency department. Her history re- fractures in sports such as of injuries presenting as has occurred).12,14 The vealed no pertinent medical issues. baseball, diving, golf, gym- pain, including pathology of injury pattern describing She was found to be medically nastics, weight lifting, and the , , vasculature, stress fractures of the sternum stable, with negative radiographs wrestling,5-10 as well as 1 re- and .12 These are rarely consistent with repetitive mi- and a normal electrocardiogram port of a nondisplaced sternal associated with sporting in- crotrauma has far fewer co- (EKG), and was discharged. fracture of a rugby player.11 juries due to the dramatically morbidities than some of the Follow-up 2 days later re- mentioned etiologies. vealed persistent anterior chest Mr Culp is from the College of Medicine, Ms Novak and Dr Flanigan To our knowledge, there has pain worsened with breathing. are from the Sports Medicine Center, Department of Orthopedics, and Dr been only 1 previous report of The patient had normal vitals, and McCamey is from the Department of Family Medicine, The Ohio State Uni- a sports-related, isolated ster- a review of systems was otherwise versity, Columbus, Ohio; and Dr Hurbanek is from Hinsdale Orthopaedic Associates, Hindsdale, Illinois. nal fracture, which occurred in negative. Physical examination Mr Culp, Drs Hurbanek and McCamey, and Ms Novak have no relevant a rugby match.11 That player’s demonstrated pain on palpation of fi nancial relationships to disclose. Dr Flanigan is on the speaker’s bureau injury was missed on routine the inferior third of the sternum, for Genzyme. radiographs, but was eventu- but no or obvious defect Correspondence should be addressed to: David C. Flanigan, MD, OSU Sports Medicine Center, 2050 Kenny Rd, Ste 3100, Columbus, OH 43221- ally diagnosed by scan. was noted. The follow-up radio- 3502 (david.fl [email protected]). Upper body training and activ- graph showed a fracture within the doi: 10.3928/01477447-20100722-17 ity was restricted for 6 weeks, distal body of the sternum, with

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one should have a high index of suspicion of sternal pathol- ogy when an athlete presents with symptoms of chest pain and examination fi ndings of tenderness over the midline of the anterior chest. We believe that a thorough physical examination is key to a good diagnosis, proper eval- uation, and outcome. The key elements of the initial onsite physical examination include assessing for stability of the 1 2 patient, palpation of the chest wall and surrounding struc- Figure 1: Lateral at 2-day follow-up revealing a minimally displaced sternal fracture within the distal body of the sternum. Figure 2: Lateral chest radiograph at 12-week follow-up revealing stable radiographic healing. tures, and auscultation of the heart and lungs. Regardless, any chest pain that is persis- posterior displacement of 3 to 4 ity spectrum between a motor (3.1%).12 Authors have rec- tent in an athletic environment mm (Figure 1). Cardiothoracic vehicle accident-type sternal ommended that after normal usually requires removal of surgery was consulted, and it was fracture with several comor- advanced trauma life support the athlete from competition decided that the fracture was not bidities that must be ruled out, protocol, a negative EKG and evaluation. For a stable displaced enough to merit surgical and a sternal stress fracture that suffi ciently rules out any in- patient, an EKG and chest intervention. Furthermore, since it lacks a single inciting event or jury to myocardium.2-4,12,14-16 radiograph should be done to was Ͼ48 hours postinjury and the associated sequelae. The ap- Therefore, patients do not re- evaluate for cardiac, pulmo- patient had previously had a nor- propriate management for the quire serial cardiac enzyme nary, and sternal pathology. mal EKG, no further monitoring team physician can be gleaned levels, continuous telemetry, Sternal radiographs may also was needed. from the trauma literature. or echocardiography as was be needed if the chest radio- The patient was instructed to Historically, sternal frac- the previous standard of care. graph does not show a fracture refrain from all sports and training tures were described as occur- Similarly, if routine chest ra- and there is suspicion for a until she could breathe pain free ring with blunt impact on an diographs indicate that there is sternal fracture. With a stable without analgesia. By 6 weeks, automobile steering wheel, but no severe displacement of the patient, these can be done on the patient was able to train and now the described mechanism fractured sternum, no poten- an outpatient basis when re- only had pain with extreme exer- involves fl exion forces over tial for , sources are immediately avail- tion. Physical examination was the strap of a seat and no additional fractures, able. With an unstable patient normal at 12-week follow-up, and belt, which acts as a fulcrum. then no operative intervention or if outpatient resources are 3-month follow-up radiographs This change in mechanism of is indicated. Patients can then not available, emergency de- revealed a stable and healing ster- injury has decreased severity be given appropriate analgesia partment consultation is often nal fracture (Figure 2). The patient of injury and led numerous and discharged without a hos- needed to evaluate the cause of was cleared to return to sports authors to recommend a less pital admission. chest pain and rule out poten- with no restrictions, and she had aggressive management plan The incidence of sport- tial life-threatening injuries. no residual pain or issues. to rule out associated pathol- ing-related sternal injuries is The notably lower energy ogy.2-4,12,14-16 approximately 5%, with no of forces in a sports injury con- DISCUSSION Associated injuries with reported serious complica- trasts with that seen in a motor This article presents a case motor vehicle accident-re- tions or deaths.15 Sternal stress vehicle accident; however, rul- of an isolated traumatic sternal lated sternal fractures include fractures are more common in ing out cardiac injury and ob- fracture in a college hockey concomitant fracture (53.5%) the athletic population than taining chest and sternal radio- player. This type of injury and pulmonary (24.4%), head traumatic fractures. After a graphs should be the standard lies somewhere on the sever- (14.2%), and cardiac injuries traumatic injury to the chest, of care for sports trauma as it

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is in motor vehicle accidents. agreed on and healing for each algorithm for management. Am 11. Douglas RJ. Sternal fracture in J Emerg Med. 1997; 15(3):252- an Australian Rules footballer. These types of pathology patient is unique, clinical reso- 255. Med J Aust. 2008; 188(8):493- 494. should always be considered lution of symptoms and radio- 5. Barbaix EJ. Stress fracture of when a blow to the chest has graphic stability remain the the sternum in a golf player. Int 12. Athanassiadi K, Gerazounis occurred, even if no obvious guiding principles for return to J Sports Med. 1996; 17(4):303- M, Moustardas M, Metaxas E. 304. Sternal fractures: retrospective bony changes are seen, as they play.7 While we acknowledge analysis of 100 cases. World J 6. Hill PF, Chatterji S, DeMello Surg. 2002; 26(10):1243-1246. can be associated with severe that not every patient will need WF, Gibbons JR. Stress frac- conditions if missed. If diag- a full 12 weeks to recover, our ture of the sternum: an unusual 13. Perron AD. Chest pain in ath- injury? Injury. 1997; 28(5- letes. Clin Sports Med. 2003; nosis is not made with conven- patient took that course due to 6):359-361. 22(1):37-50. tional radiology, yet the patient a surgery for an unrelated 7. Jones GL. Upper extrem- 14. Gouldman JW, Miller RS. Ster- remains clinically symptom- shoulder injury that occurred ity stress fractures. Clin Sports nal fracture: a benign entity? atic, the patient should be as- after the fracture. Med. 2006; 25(1):159-174. Am Surg. 1997; 63(1):17-19. sessed with computed tomog- 8. Keating TM. Stress fracture of 15. Hills MW, Delprado AM, Deane the sternum in a wrestler. Am J SA. Sternal fractures: associ- raphy to confi rm diagnosis and REFERENCES Sports Med. 1987; 15(1):92-93. ated injuries and management. J Trauma. 1993; 35(1):55-60. to assess adjacent structures 1. Velissaris T, Tang AT, Patel A, 9. McCurdie I, Etherington J, Bu- for injury.13 It may also be use- Khallifa K, Weeden DF. Trau- chanan N. Sternal fracture in a 16. Johnson I, Branfoot T. Ster- matic sternal fracture: outcome ful to obtain an ultrasound or female army offi cer cadet. Br J nal fracture—a modern re- following admission to a Tho- Sports Med. 1997; 31(2):164. view. Arch Emerg Med. 1993; bone scan to rule out an occult racic Surgical Unit. Injury. 10(1):24-28. 5-7,10,11 2003; 34(12):924-927. 10. Gregory PL, Biswas AC, Batt fracture. ME. Musculoskeletal problems When considering return to 2. Roy-Shapira A, Levi I, Khoda of the chest wall in athletes. J. Sternal fractures: a red fl ag or play guidelines for the athlete, Sports Med. 2002; 32(4):235- a red herring? J Trauma. 1994; 250. the approach can be similar to 37(1):59-61. that taken for stress fractures. 3. Peek GJ, Firmin RK. Isolated sternal fracture: an audit of 10 Time frames for return to play years’ experience. Injury. 1995; have varied from a minimum 26(6):385-388. Coming next issue... of 6 weeks11 to Ͼ6 months.6 4. Chiu WC, D’Amelio LF, Ham- Although time frames are not mond JS. Sternal fractures in trauma update blunt chest trauma: a practical

Section Editor: Darren L. Johnson, MD

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