Comminuted fracture with butterfly fragment of the humerus ...

Comminuted fracture of the humerus during arm wrestlingThis article must be cited as:Hyun-Soo Kim, Young Ho Shin, Youn Wha Kim. Comminuted fracture with butterfly fragment of the humerus sustainedduring arm wrestling. Biomed Res- India; 2013; 24 (3): 320-323.DiscussionIntense muscular contractions can be a mechanism of injuryin various sports and can affect various bones. Thehumeral shaft fracture during arm wrestling occurs whenmoments of torsional forces induced by intense muscularcontractions are transmitted onto it. The moments of theseforces are resultant of forces acting in the direction ofinternal rotation by the pectoralis major, latissimus dorsi,teres major and subscapularis, and resultant of externalrotational forces applied by the opponent and transmittedby the long forearm lever through the elbow. In both casesthe results of opposite directional forces occur thanksto the work of the internal rotator shoulder muscles.When the dominant competitor exerts force, the internalrotator muscles of the opponent undergo rapid stress fromtheir maximum concentric contraction to eccentric passivecompensatory relaxation, causing an increase in the humeralrotational force. This results in the transmission ofthe stress through the distal part of the arm and elbow,causing a shifting of the maximum force to the humerusand its fracture. Nyska et al. [15] note that the fracture isusually in the distal third of the humerus, and suggest thatthe forces acting on the humerus are bending, axial compressionand torsional forces, while the flexor muscles ofthe forearm are forcefully contracted.In our case, we could easily consider the possibility ofhumeral fracture with the patients’ clinical presentations,so we performed imaging studies without any hesitations.Some fractures, however, which are not related to director indirect contact forces, can be missed if they do notcause severe symptoms. Intense muscular contractionsrelatedfractures of protruded bone, such as those of theolecranon, anterior superior ischial spine of the pelvis andfifth metatarsal base of the foot, are good examples. Wetherefore suggest that a diagnosis of fracture should beconsidered in cases of intense muscular contractions. Acareful history taking and radiologic examination willenable to prevent misdiagnosis and mismanagement.Every long bone fractures do not require computed tomographyscanning routinely, but in our case, we performedit due to the presence of a large butterfly fragment. Withthe understanding of three-dimensional morphology offracture site as well as its location, we could decide properoperative methods. Also, fracture of the distal one thirdof humerus is deeply associated with the occurrence ofradial nerve palsy. Of the few complications with humerusfracture sustained during arm wrestling that have beenreported, the most common is radial nerve palsy, whichusually manifests as wrist drop. It can be caused by direct322damage due to the butterfly fragment, so it is very importantto understand the morphology of the fracture site.For the treatment of such injury, conservative managementwas mainly recommended at past. However, becauseof developed instruments and increased patients’ requirements,operative treatments have been recently performedby many orthopedic surgeons.In summary, the present case illustrates that the extremelyhigh indirect forces generated by sudden intense muscularcontractions during arm wrestling can cause a comminutedfracture of the humerus. Severe pain in arm wrestlersshould not be attributed solely to musculoskeletal sprainsand ruptures. All patients who present with histories ofsudden arm pain after arm wrestling should receive appropriateradiologic studies and a careful neurologic examinationto exclude fracture and prevent misdiagnosisand mismanagement. This type of fracture may occur inanyone of any age engaging in this type of sport. Especially,amateurs are injury-prone because they use badwrestling techniques. Because of the possibility of participantssustaining such an injury, arm wrestling shouldnot be considered a totally benign injury.AcknowledgementsThe views and opinions expressed in this article are thoseof the author and do not reflect the official policy or positionof the Republic of Korea Air Force or Republic ofKorea Ministry of National Defense. The author thanksmedical librarian Ja Ok Kim (Aerospace Medical Library,Aerospace Medical Center, Republic of Korea Air Force)for her assistance in searching for literature.References1. Brinker MR, O'Conner DP. The incidence of fracturesand dislocations referred for orthopaedic services in acapitated population. J Bone Joint Surg Am 2004; 86:290-297.2. Fenyo G. On fractures of the shaft of the humerus: areview covering a 12-year period with special considerationof the surgically treated cases. Acta Chir Scand1971; 137: 221-226.3. Baker DM. Fractures of the humeral shaft associatedwith ipsilateral fracture dislocation of the shoulder: reportof a case. J Trauma 1971; 11: 532-534.4. Chao SL, Miller M, Teng SW. A mechanism of spiralfracture of the humerus: a report of 129 cases followingthe throwing of hand grenades. J Trauma 1971; 11:602-605.5. Reed WJ, Mueller RW. Spiral fracture of the humerusin a ball thrower. Am J Emerg Med 1998; 16: 306-308.Biomed Res- India 2013 Volume 24 Issue 3