Thrower’s Fracture of the Humerus: A Case Report

CASE REPORT:


A 35-year-old, right-handed male presented to the emergency department with complaint of right upper arm pain. He was a member of an amateur baseball team; just prior to arrival he threw a ball and immediately felt a pop and sharp pain in his right upper arm. Since that time, he had been unable to move his arm due to pain. He reported no prior injury to the arm but did state that over the last several weeks he had been having an ache in that arm. He was otherwise healthy, took no medications, denied weakness, numbness and tingling in his right arm. He was a non-smoker and an occasional drinker. He used no drugs.

Physical exam was non-focal except for the right upper extremity. His right upper arm was swollen and tender to the touch. He had decreased range of motion in his elbow and his shoulder secondary to the pain. He had an obvious deformity of the right bicep region. Distally the patient was neurovascularly intact with normal range of motion and light touch sensation intact in the wrist and hand. He had a 2+ radial pulse and capillary refill was less than 3 seconds.

The patient was given pain medication and sent for an x-ray of his right humerus. The x-ray demonstrated a displaced spiral fracture of the humerus (fig 1). The patient was placed in a coaptation splint and prior to discharge, reexamination revealed no evidence of radial nerve palsy or radial artery injury. The patient followed up with the orthopedic doctor on-call and underwent open reduction and internal fixation of his injury within 1 week (fig 2).

Figure 1. AP and oblique radiographs of the right humerus demonstrating a spiral fracture

Figure 1. AP and oblique radiographs of the right humerus demonstrating a spiral fracture

Figure 2: Right Humerus status post open reduction and internal fixation

Figure 2: Right Humerus status post open reduction and internal fixation

DISCUSSION:

This patient's presentation is consistent with a well described, but rarely observed phenomenon known as a 'Thrower's Fracture.' First reported in 1930 [1], cases have been reportedly related to everything from a baseball [2, 3], to a cricket ball [4], to a dodge ball [5], and hand grenades [6]. As with our patient, many patients who present with this injury are amateur athletes who have likely not developed adequate cortical strength of their bones as compared to professional athletes [7]. The injury is often preceded by several weeks to months of aching in the region of the humerus, which is thought to represent a stress fracture [2, 4, 8]. The complexity of the throwing motion and related transfer of forces, results in significant torque being applied to the humeral shaft, leading to a fracture, most commonly in the mid to distal third of the diaphysis.

These patients can have similar complications to any mid-shaft, spiral humeral fracture including damage to the radial artery and radial nerve [9, 10]. In these cases, given the active nature of these athletes, and if underlying complications have occurred, surgeons may elect to repair this injury surgically [2, 4, 10], though this is not always necessary given the fracture morphology.

Faculty Reviewer: Dr. Kristy McAteer

REFERENCES:

  1. Wilmoth, C., Recurrent fracture of the humerus due to sudden extreme muscular action. Journal of Bone and Joint Surgery, 1930. 12: p. 168-169.

  2. Miller, A., C.C. Dodson, and A.M. Ilyas, Thrower's fracture of the humerus. Orthop Clin North Am, 2014. 45(4): p. 565-9.

  3. Perez, A.Z., C.; Atia, H., Thrower's fracture of the humerus: An otherwise healthy 29-year-old man presented for evaluation of acute onset of severe right arm pain. Emergency Medicine, 2016. 48(5): p. 221-222.

  4. Evans, P.A., et al., Thrower's fracture: a comparison of two presentations of a rare fracture. J Accid Emerg Med, 1995. 12(3): p. 222-4.

  5. Colapinto, M.N., E.H. Schemitsch, and L. Wu, Ball-thrower's fracture of the humerus. CMAJ, 2006. 175(1): p. 31.

  6. Chao, S.L., M. Miller, and S.W. Teng, A mechanism of spiral fracture of the humerus: a report of 129 cases following the throwing of hand grenades. J Trauma, 1971. 11(7): p. 602-5.

  7. Ogawa, K. and A. Yoshida, Throwing fracture of the humeral shaft. An analysis of 90 patients. Am J Sports Med, 1998. 26(2): p. 242-6.

  8. Reed, W.J. and R.W. Mueller, Spiral fracture of the humerus in a ball thrower. Am J Emerg Med, 1998. 16(3): p. 306-8.

  9. Curtin, P., C. Taylor, and J. Rice, Thrower's fracture of the humerus with radial nerve palsy: an unfamiliar softball injury. Br J Sports Med, 2005. 39(11): p. e40.

  10. Bontempo, E. and S.L. Trager, Ball thrower's fracture of the humerus associated with radial nerve palsy. Orthopedics, 1996. 19(6): p. 537-40.

AEM Early Access 21: Long-term Mortality in Pediatric Firearm Assault Survivors

Welcome to the twenty-first episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (CLICK ON LINK FOR FULL TEXT, OPEN ACCESS THROUGH DECEMBER 31):

Long-term mortality in pediatric firearm assault survivors: a multi-center, retrospective, comparative cohort study. Ashkon Shaahinfar, MD, MPH, Irene H. Yen, PhD, MPH, Harrison J. Alter, MD, MS, Ginny Gildengorin, PhD, Sun-Ming J. Pan, James M. Betts, MD and Jahan Fahimi, MD, MPH.

listen now: first author interview with ashkon shaahinfar md mph

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Ashkon Shaahinfar, MD, MPH

Attending Physician and Emergency Ultrasound Director

Division of Emergency Medicine

UCSF Benioff Children’s Hospital Oakland

ABSTRACT

Objectives: The objective was to determine whether children surviving to hospital discharge after firearm assault (FA) and nonfirearm assault (NFA) are at increased risk of mortality relative to survivors of unintentional trauma (UT). Secondarily, the objective was to elucidate the factors associated with long-term mortality after pediatric trauma.

Methods: This was a multicenter, retrospective cohort study of pediatric patients aged 0 to 16 years who presented to the three trauma centers in San Francisco and Alameda counties, California, between January 2000 and December 2009 after 1) FA, 2) NFA, and 3) UT. The Social Security Death Master File and the California Department of Public Health Vital Statistics (2000–2014) were queried through December 31, 2014, to identify those who died after surviving their initial hospitalization and to delineate cause of death. Multivariate Cox proportional hazards regression was performed to determine associations between exposure to assault and long-term mortality.

Results: We analyzed 413 FA, 405 NFA, and 7,062 UT patients who survived their index hospital visit. A total of 75 deaths occurred, including 3.9, 3.2, and 0.7% of each cohort, respectively. Two-thirds of all long-term deaths were due to homicide. After multivariate adjustment, adolescent age, male sex, black race/ethnicity, and public insurance were independent risk factors for long-term mortality. FA (adjusted hazard ratio [AHR] = 1.8, 95% confidence interval [CI] = 0.82–4.0) and NFA (AHR = 1.9, 95% CI = 0.93–3.9) did not convey a statistically significant difference in risk of long-term mortality compared to UT. Being assaulted by any means (with or without a firearm), however, was an independent risk factor for long-term mortality in the full study population (AHR = 1.9, 95% CI = 1.01–3.4) and among adolescents (AHR = 1.9, 95% CI = 1.01–3.6).

Conclusion: Children and adolescents who survive assault, including by firearm, have increased long-term mortality compared to those who survive unintentional, nonviolent trauma.

Money Minutes for Doctors #9 - The Catastrophic Financial Plan

Welcome to the 9th installment of our monthly podcast dedicated to financial education and wellness, Money Minutes for Doctors. This month we sit down with Ms. Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors, to talk about an often neglected topic in financial planning, what to do when encountered with the unspeakable reality of a catastrophe. In the past six months alone, communities on the east and west coasts of the United States have absorbed natural disasters that have left cities and towns in shambles. The human toll is staggering and many families are left to start from scratch following devastating circumstances. While catastrophes come in many forms: disability, loss of a loved one, job loss, loss of home, etc…planning for the worst does not have to be as painful as the topic implies.

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary: 

When it comes to a crisis, there are three main problems that you might encounter sometime during your career:

  1. Disability: you are too sick or injured to work. Fortunately you can insure away this risk with disability insurance.  

  2. Pre-mature death of the breadwinner: your untimely death could leave your loved ones without a needed source of income. This risk can also be insured away with life insurance.

  3. Job Loss: Every other doctor we have who suddenly became unemployed, found another job within 6 weeks because physicians are in such high demand. The key is to have enough funds to last during the transition.

Consequently, we usually recommend every doctor have easily accessed funds equal to three to five months fixed living expenses for an emergency/rainy day fund:

  • Enough to pay mortgages, student loans, food and other fixed expenses.

  • The exact amount is variable and depends on how much you need to be able to sleep comfortably at night.

Structure your savings to cover the short-term emergencies while you are still building wealth for the future. This is a balance between funds designated for the distant future (therefore higher risk to reach higher returns) vs. funds that may be needed in the near future (invested more conservatively with lower potential for loss). 

A five-step approach to protect you and your family from potential loss: 

  • Step One: The emergency fund. This is an account at a bank. It is easily accessed and the money will be there when needed

  • Step Two: The intermediate account (also known as the put and take account). These are funds are in a taxable, “non-qualified” brokerage account that are earmarked for a big purchase in the next one to eight years such as a down payment for the new house, the new car, college for the kids, etc.  The goal is to do better than the bank (avg 3%/yr).  Accounts are mostly bonds and some stocks that can be accessed anytime.   

  • Step Three: The Wealth Accumulation Account (also known as the put and keep account). These funds are also invested in a taxable, “non-qualified” brokerage account and are earmarked for retirement.   They are generally mostly stocks and some bonds, depending on the risk level of the physician.

  • Step Four: The 401-k/403-b, retirement accounts. Most of our doctors can borrow up to 50% of their 401-k or 403-b accounts that they have with their current employer.

  • Step Five: Roth Accounts or IRAs. We only use these if it is absolutely necessary as there is a 10% penalty and ordinary income tax on the gain, if funds are withdrawn before age 59 ½ in most cases. This is the source of last resort due to the tax penalties.

An alternate approach, step 2 + if you will, may be cash value in permanent life insurance policies. This may be preferable to taking funds out of brokerage accounts, particularly if those accounts are at a loss, and frequently the loan provisions are more favorable than borrowing from a bank.