Olecranon Fracture Sustained in Arm Wrestling
MAJ Paul F. Pasquina, MC, USA; LTC Francis G. O'Connor, MC, USA
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 4 - APRIL 1999
In Brief: This case report describes an arm-wrestling injury in which a violent triceps contraction was determined to have caused an olecranon fracture. Such a fracture has not been reported in arm wrestling; more typical are fractures of the humeral shaft or medial epicondyle. The authors suggest awareness of this potential and recommend appropriate radiographic studies for injuries involving intense muscle contraction. The patient was treated conservatively. After rehabilitation, he was able to return to his job, which involved lifting, but did not resume arm wrestling.
Arm wrestling is a popular activity enjoyed by men and women of all ages. Although arm-wrestling injuries are not common, several have been reported in the medical literature. These have included fractures of the humeral shaft (1,2), fracture-separation of the medial humeral epicondyle in teenagers (3), and rupture of the subscapularis tendon (4). In a thorough review of the literature, however, no previous reports of olecranon fractures as a result of arm wrestling could be found.
This case of an arm wrestler who sustained an olecranon fracture illustrates the potential effect of violent muscle contraction in arm wrestling and emphasizes the importance of radiographic evaluation.
A 31-year-old, right-handed US National Guardsman presented at the troop medical clinic with elbow pain.
The patient reported finishing his annual 2 weeks of military training without difficulty, trauma, or elbow pain until the last night, when he and another soldier were arm wrestling.
He and his opponent had stood across a kitchen table with their right thumbs and wrists interlocked, the opposite hand of each cradling the opponent's elbow. Approximately 10 to 15 seconds into the match the patient, needing to drive his opponent's arm another 3 to 4 in. downward to win, exerted a burst of energy. During the struggle he felt a "pop" and immediate diffuse elbow pain. Swelling was minimal to nonexistent. He denied striking his elbow on the table.
At the clinic the next morning, the patient described persistent pain, primarily with elbow movement. He denied presence of any numbness or paresthesias.
Physical exam. Examination of the patient's painful elbow revealed no obvious deformity, erythema, ecchymosis, or swelling. He was tender to palpation along the medial collateral ligament, antecubital fossa, and olecranon. He lacked 30° of full active and passive extension because of pain. In addition, he had pain with active resisted pronation, supination, and extension. His distal neurovascular examination was normal.
X-rays. Anteroposterior (AP), lateral, and radial head x-rays of the patient's elbow were obtained (figure 1). Cortical disruption was evident on all views as was a nondisplaced, circular-appearing fracture of the olecranon, which did not appear to be intra-articular.
Treatment and follow-up. The patient was referred to an orthopedic surgeon who elected to treat him by immobilization in a long arm cast with the elbow in approximately 90° of flexion. Weekly x-rays showed good fracture healing and no displacement.
The cast was subsequently removed at 4 weeks and replaced with a removable elbow orthosis set at 90° of flexion, which the patient wore for an additional 3 weeks. The orthosis was removed several times a day for bathing and to perform range-of-motion exercises at home and in supervised physical therapy.
In the last stages of treatment, the patient took part in several trials of deep heat therapy in order to gain greater range of motion. This treatment involved ultrasound and active assisted stretching. Despite this therapy, he continues to lack 10° to 15° of terminal extension due to residual contracture.
He subsequently returned to work as a beverage deliverer, lifting moderately heavy loads without significant problems. He has not resumed arm wrestling.
Violent muscle contraction can be a mechanism of injury in various sports and can affect various bones, but it rarely causes olecranon fracture. The olecranon process is a large, curved eminence that makes up the proximal posterior portion of the ulna and is the attachment site of the triceps muscle (figure 2). Because of its immediately subcutaneous position, the olecranon is especially vulnerable to direct trauma, which is the mechanism of injury for most olecranon fractures (5). Olecranon fractures are also not uncommon secondary to indirect loading of the joint, such as happens with a fall on the upper extremity. We could find, however, no reported cases of olecranon fractures occurring as a result of violent muscle contraction.
In arm wrestling, violent muscle contractions are a common fracture mechanism in other bones such as the humerus in adults and the medial epicondyle in teenagers. Many humeral shaft fractures have been described in arm wrestlers (1-4) as well as in javelin throwers (6), baseball players (7), and grenade throwers (8). These fractures have been attributed to a strong internal rotation force at the shoulder created by the subscapularis, pectoralis, and latissimus dorsi muscles and resisted by the external rotation force of an opponent or other counterforce. This results in transmission of stress through the distal arm and elbow sufficient to cause a fracture of the humerus (9). Unlike adult arm wrestlers, the skeletally immature are more likely to sustain a fracture of the medial epicondyle. These fractures occur because of traction at the origin of the common flexor tendon as a result of a strong contraction of the wrist flexors (3).
A violent triceps contraction may well have created enough force to cause our patient's olecranon fracture, in a mechanism similar to that in the humeral shaft or medial epicondyle fractures described above. In support of this hypothesis, the patient's own account describes forceful extension of the elbow against the counterforce of the opponent as he attempted to press for the last few inches to win the match.
Diagnostic imaging. Although this patient did not sustain direct trauma to his elbow, standard AP and lateral x-rays as well as a radial head view were obtained because he presented with significant bony tenderness and lacked full range of motion. One should always consider radiographic examination in cases of violent muscle contraction. When ordering x-rays in skeletally immature patients, comparison views of the contralateral side should also be considered because of the propensity for growth-plate injuries. Computed tomography and magnetic resonance imaging studies are typically reserved for complex or intra-articular fractures.
Treatment. It is generally accepted that nondisplaced olecranon fractures can be managed nonoperatively with a long arm cast in 45° to 90° of elbow flexion for 2 to 4 weeks. Casting in full extension has historically been shown to create a stiff elbow, resulting in a significant loss of elbow flexion. The arm may alternatively be immobilized in a posterior splint (10). After immobilization in a cast or splint for 2 to 4 weeks, a removable splint should be used and the patient should begin range-of-motion exercises. Nondisplaced intra-articular fractures can often be treated in a similar fashion.
It is imperative that all nondisplaced olecranon fractures, including those that are intra-articular, be followed closely with weekly x-rays to look for any signs of fracture displacement. A displaced fracture should be managed by open reduction and internal fixation.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the US Army, US Department of Defense, or US Government.
Dr Pasquina, a major in the US Army, is director of the ambulatory care clinic in the department of physical medicine and rehabilitation at the Walter Reed Army Medical Center in Washington, DC. Dr O'Connor, a lieutenant colonel in the US Army, is director of the primary care sports medicine fellowship at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Address correspondence to MAJ Paul F. Pasquina, MC, USA, Dept of Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, 6825 Georgia Ave, Washington, DC 20307-5001.