Rev. bras. ortop. vol.52 número5

rev bras ortop.2017;52(5):608–611

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Case

Report

Metacarpal

stress

fracture

in

amateur

tennis

player

–

an

uncommon

fracture

夽

Márcio

Luís

Duarte

,

Renan

Rocha

da

Nóbrega

,

José

Luiz

Masson

de

Almeida

Prado

,

Luiz

Carlos

Donoso

Scoppetta

a_{WebImagem,SãoPaulo,SP,Brazil}

b_{HospitalSãoCamilo,Servic¸odeRadiologia,SãoPaulo,SP,Brazil}

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f

o

Articlehistory: Received1June2016 Accepted4August2016 Availableonline30July2017

Keywords: Fractures,stress Racquetsports

Magneticresonanceimaging

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b

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a

c

t

Moststressfracturesoccurinthelowerlimbsandarerarelyobservedintheupperlimbs.The secondmetacarpalisthelongestofallthemetacarpalsandhasthelargestbase,articulating withthetrapezium,trapezoid,capitate,andthirdmetacarpal.Inathletes,stressfractures innon-weightbearingjointsareuncommon.Therefore,theshaftofthesecondmetacarpal boneundergoesahigherload–themaximumtensionatthebaseofthesecondmetacarpal isamplifiedwhenthehandgraspsatoolsuchasatennisracquet.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura

por

estresse

do

metacarpo

em

tenista

amador

–

uma

fratura

incomum

Palavras-chave: Fraturasdeestresse Esportescomraquete Ressonânciamagnética

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e

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o

Amaioriadasfraturasporestresseocorrenosmembrosinferiores,raramentenos superio-res.Osegundometacarpoéomaislongoecomabasemaislarga,articula-secomotrapézio, trapezoide,capitatoeterceirometacarpo.Asfraturasporestresseematletassãoincomuns nasarticulac¸õessemcarga.Portanto,adiáfisedosegundometacarposofrecargaelevada– atensãomáximanabasedosegundometacarpoéamplificadaquandoamãoagarrauma ferramentatalcomoumaraquete.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

夽

WorkdevelopedatHospitalSãoCamilo,SãoPaulo,SP,Brazil. ∗ _{Correspondingauthor.}

E-mail:[email protected](M.L.Duarte).

http://dx.doi.org/10.1016/j.rboe.2017.07.006

rev bras ortop.2017;52(5):608–611

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Introduction

Moststressfracturesoccurinthelowerlimbs,andarerarely observed in the upper limbs.1–5 _{The second metacarpal is}

thelongest, withawider base,articulateswiththe trapez-ium, trapezoid, capitate, and third metacarpal.1,2 _Stress

fracturesinathletes are uncommoninnon-weightbearing joints.4

Therefore,thesecondmetacarpalshaftreceivesahigher load–maximumtensiononthebaseofthesecondmetacarpal isamplifiedwhenthehandgripsatoolsuchasaracquet.2

Knudsonetal.6_{demonstratedthatthemechanicforceonthe}

baseoftheindexfingerincreasestheimpactofaforehandof tennis.

Wedemonstratedacaseofstressfracture ofthesecond metacarpalinatennisplayercausedbytheEasterngrip,a sit-uationthatwasreportedonlyonce,accordingtoBaliusetal.2

Case

report

A27-year-oldpatienthadpainontherighthandforamonth. Hereportedthathehad playedtennisonehouraweekfor threeweeks,isright-handed,madebackhandwithbothhands and Eastern grip (Fig. 1), with a 43/8 racquet handle. He reportedhavingpainwhenserving,andmainlyinthe fore-handmovement.

On physical examination pain was present at palpa-tion.Hedeniedhavingundergoneprevioussurgery,trauma and pain duringcrossfit exercises. Righthand radiographs showednochanges(Fig.2).Magneticresonanceimaging(MRI) showed light bone edema in the second metacarpal shaft withperiostealreactionandtwolinesofhyposignalsuggested stressfracture(Figs.3–5).

Thepatientunderwenttreatmentwithcastimmobilization foramonth,withoutphysicaltherapy,hereturnedtotennis practiceafteratwo-monthtreatment,withnewgrip.

Discussion

The second metacarpal has an increased risk of injury whenundergoingexcessuse,wrongtechniqueorinadequate

Fig.1–Easterngripusedbythepatient.

Fig.2–Righthandanteroposteriorradiographofthe normalpatient.

equipment.Waningeretal.5_{informedthatthechangeinthe}

griptechniquefromWesterntoEasternwasbeneficialtothe symptomaticpatients who wouldlike togoback totennis playing.1,5_{ToBaliusetal.}2_{theincreaseintrainingintensity,}

mainlyoftheforehand,isfundamentalintheproductionof thistypeofinjury,thetypeofgripisanimportantfactor,but itisnotindispensable.2,5

The tennis player’swrist and hand,through which the forceistransmittedtotheracket,aretherecipientsofagreat amountofstrength.Therepeatedmovementoftheendofthe racquetagainstthe palmofthehandcanactuallybequite traumatic,fracturingoneofthecarpalbones.Handinjuries intennisplayersoftenoccurduetoinadequategriporpoor forehand technique;theyare advisedtoseek thehelpofa teacher.3

Generally, radiographs and bone scintigraphy combined with the clinical examination allow the diagnosis of stress fractures.1 _{From the radiological findings, it is}

610

Fig.3–T1-weightedMRIinsagittalsectiondemonstrates twolinesofhyposignalinthesecondmetacarpalshaft (grayarrow),consistentwithstressfracture.

osteosarcoma.1,2 _{Bone scintigraphy is also not a decisive}

exam for stress fractures, since the increase in isotope activity is often observed in several other pathological conditions.1

Computedtomographyismoreaccuratethanconventional radiographsindetectingcorticalthickeningattheendosteal andperiostealsites,causedbynewbonedeposition,andmay revealthefracture.UmansandKaye7_{demonstratedthatMRI}

was excellent indemonstratingfracture lines, callus, bone marrowandsofttissueabnormalitiesassociatedwithstress fractures.

Theinitialtherapystrategyisbasedonrestfromthesport, withgradualreturn.Previousreportsreportnopainbetween 6and12weeks.2

Fig.4–MRIinSPAIRinaxialsectiondemonstratesthe swellingandboneedemaonthesecondmetacarpalshaft withperiostealreaction(whitearrow).

Fig.5–T2-weigthedMRISTIRinaxialsection

demonstratesswellingandboneedemaonthesecond metacarpalwithperiostealreaction(whitearrow).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.BaliusR,PedretC,EstruchA,HernándezG,Ruiz-CotorroA, MotaJ.Stressfracturesofthemetacarpalbonesinadolescent tennisplayers:acaseseries.AmJSportsMed.

2010;38(6):1215–20.

3.MurakamiY.Stressfractureofthemetacarpalinaadolescent tennisplayer.AmJSportsMed.1988;16(4):419–20.

4.MuramatsuK,KuriyamaR.Stressfractureatthebaseof secondmetacarpalinasofttennisplayer.ClinJSportMed. 2005;15(4):279–80.

5.WaningerKN,LombardoJA.Stressfractureofindex metacarpalinanadolescenttennisplayer.ClinJSportMed. 1995;5(1):63–6.

6.KnudsonDV.Factorsaffectingforceloadingonthehandinthe tennisforehand.JSportsMedPhysFitness.1991;31:

527–31.