CLINICS IN SPORTS MEDICINE Upper Extremity Stress Fractures

tress fractures occur typically in the lower extremity, caused by impact loading from running, walking, or jumping. In one large series, Matheson and colleagues [1] reported on 320 stress fractures, in which 90% occurred in the lower extremity. However, upper-extremity stress fractures are now being recognized more frequently. These fractures occur either as a result of repetitive loading at the point of muscular attachments to bone or as a result of impact loading, as seen in upper-extremity weight-bearing athletes [2]. In a recent review of 196 stress fractures [3], rib stress fractures were second only to tibia fractures in frequency, and ulnar olecranon fractures were fourth in occurrence. In this study [3], rib fractures were the most common type of stress fracture in rowing athletes, whereas olecranon fractures were most common among baseball players. Sinha and colleagues [4] reported on 44 cases of upper-extremity stress fractures in athletes, including rib fractures but excluding spine and physeal fractures. The authors divided the patients into four categories based on the predominant type of upper-extremity activity required for participation in their sport: (1) weight lifting (eg, football, weight lifting, and wrestling); (2) upperextremity weight bearing (eg, gymnastics, diving, and cheerleading); (3) throwing (eg, pitcher, soccer goalie, and javelin); and (4) swinging (eg, golf and tennis). The authors noted that all fractures in the weight bearers were distal to the elbow, whereas most fractures in the throwers affected the shoulder girdle. In the swingers, lower-rib fractures predominated. The weight lifters, on the other hand, had stress fractures throughout the upper extremity but none in the ribs. Overall, the ulnar shaft stress fracture was the most frequently reported stress fracture in their series and occurred in all four groups. The present article reviews the different types of upper extremity and torso stress fractures seen in athletes, starting with the sternum and extending outward to the fingers. The presentation, diagnosis, mechanism of injury, treatment, prevention, and prognosis for each of these injuries will be discussed.