Proximal ulna stress fracture and stress reaction of the proximal radius associated with the use of crutches: a case report and literature review
© Springer-Verlag 2009
Received: 13 January 2009
Accepted: 7 July 2009
Published: 26 August 2009
We report a case of complete stress fracture of the ulna and stress reaction of the radius resulting from the use of crutches in an overweight patient with severe lower extremity arthritis. Plain radiograph showed an undisplaced complete fracture of the proximal metaphysis of the ulna. Magnetic resonance imaging (MRI) was performed to exclude a pathological cause in view of the unusual fracture site, which confirmed the plain radiographic findings and additionally demonstrated a stress reaction in the proximal radius. There are three cases of stress fracture of the ulnar diaphysis resulting from the use of crutches reported previously in the English literature and a further case of bilaterally symmetrical ulnar diaphysial fracture reported in the Danish literature. We report the first case of ulnar metaphysis stress fracture with concomitant stress reaction of the radius.
Stress fractures of the ulna and radius are rare. The middle third of the ulna is the commonest site as this region has the thinnest cortex and smallest cross-sectional area morphologically compared to the proximal or the distal third, and is vulnerable to stress from torsional forces . Stress fractures of the ulna have been reported to be associated with certain sports such as tennis. We present a case of a spontaneous complete fracture of the ulna metaphysis with concomitant stress reaction of the proximal radius occurring in a patient who had been dependent on below elbow crutches for 15 months. The case acts as a reminder that spontaneous complete fractures may be the end result of abnormal stress, and that stress fractures of the ulna may be related to the use of crutches.
Stress fracture of the ulna due to the use of crutches is rare. Previously published case reports describe stress fracture/reaction of the ulna diaphysis [2–5], of which two patients had complete fractures. We report a case of a complete stress fracture of the ulnar metaphysis resulting from the use of crutches. The association of concomitant stress reaction of the radius has not been reported previously.
Troell et al.  first described stress fracture of the ulna in 1941. Since this initial observation, ulnar stress fractures have been described in a variety of sporting activities including tennis , weight lifting , baseball , polo  and Japanese fencing .
Stress fractures occurring in the non-weight bearing bones can cause diagnostic confusion with pathological fractures if the clinical history is not clear or when such fractures occur in the setting of an underlying primary malignancy elsewhere.
The first report of a stress fracture of the ulna resulting from the use of crutches was described by McGoldrick and O’Brien , in a patient who was non-weight bearing following treatment for osteochondritis dissecans of the knee. They described bilateral complete stress fractures involving the mid-diaphysis of the ulna occurring at identical sites, and postulated direct contact of the ulna with the upper crutch ring in combination with a forward bending force as the likely cause. A similar case of a bilaterally symmetrical complete stress fracture of the ulnar diaphysis, which resulted from the use of walking aid for a year, was reported in a 95-year-old patient . Garcia Suarez et al.  reported a further case of an incomplete crutch-related stress fracture of the ulna occurring at the junction of the middle and distal third in a patient treated for osteochondritis of the knee. They postulated that cyclical weight bearing on crutches, with the wrist in a position of flexion, ulnar deviation and pronation, increased the axial load through the ulna, leading to fracture. More recently, Amin et al.  reported a case of ulnar stress reaction from crutch use in a patient who had undergone above-knee amputation for recurrent osteosarcoma of the tibia. None of the reported cases showed concomitant stress reaction of the ipsilateral radius.
In our case, it was thought that the likely mechanism of injury was due to a combination of tractional and torsional force, together with direct pressure on the proximal forearm bones from the upper crutch ring as postulated in the previous case reports [2–4]. Furthermore, MRI and CT showed no evidence of an underlying lesion to suggest a pathological fracture in our case, and the fracture progressed to union without complication.
In conclusion, both clinicians and radiologists involved in the management of such patients should be aware of stress fracture/reaction of the forearm bones that can occur from the use of crutches, which may help in early detection and treatment, preventing further disability in these patients.
Conflict of interest statement
The authors declare that they have no conflict of interest related to the publication of this manuscript.
- Jones GL (2006) Upper extremity stress fracture. Clin Sports Med 25:159–174PubMedView ArticleGoogle Scholar
- Amin A, Singh V, Saifuddin A, Briggs TWR (2004) Ulnar stress reaction from crutch use following amputation for tibial osteosarcoma. Skeletal Radiol 33:541–544PubMedView ArticleGoogle Scholar
- McGoldrick F, O’Brien TM (1988) Bilateral stress fractures of the ulna. Injury 19:360–361PubMedView ArticleGoogle Scholar
- Gracia Suarez G, Garcia Garcia J, Perez Carro L (2001) Stress fracture of the ulna associated with crutch use. J Orthop Trauma 15:524–525View ArticleGoogle Scholar
- Sorensen L (1992) Bilateral symmetrical stress fracture of the ulna (in Danish). Ugeskr Laeger 154:1850–1851PubMedGoogle Scholar
- Troell A, Lauritzen G, Moller A (1941) Fractures of apparently healthy bone without unquestionably true element of accident. Acta Chir Scand 84:226Google Scholar
- Rettig AC (1983) Stress fracture of the ulna in an adolescent tournament tennis player. Am J Sports Med 11:103–106PubMedView ArticleGoogle Scholar
- Hamilton HK (1984) Stress fracture of the diaphysis of the ulna in a body builder. Am J Sports Med 12:405–406PubMedView ArticleGoogle Scholar
- Hamilton BH, Colsen E, Brukner P (1999) Stress fracture of the ulna in a baseball pitcher. Clin J Sport Med 9:231–232PubMedView ArticleGoogle Scholar
- Clark RJ, Sizer PS Jr, Slauterbeck J (2002) Stress Fracture of the ulna in a male competitive polo player. Am J Sports Med 30:130–132PubMedGoogle Scholar
- Sujino T, Ohe T, Shinozuka M (1998) Bilateral stress fractures of the ulnae in a Kendo (Japanese fencing) player. Br J Sports Med 32:340–342PubMed CentralPubMedView ArticleGoogle Scholar
- Craig JG, Widman D, van Holsbeeck M (2003) Longitudinal stress fracture: patterns of edema and the importance of the nutrient foramen. Skeletal Radiol 32:22–27PubMedView ArticleGoogle Scholar