Working Diagnosis:
Grade 3 proximal radius bone stress injury extending from the radial head into the proximal radial diaphysis.

Treatment:
The athlete was instructed to avoid loading the left upper extremity for 6 weeks. Treatment focused on relative rest, activity modification, and gradual progressive loading. Nonsteroidal anti-inflammatory medications were avoided to minimize potential effects on bone healing. A gradual return to sport progression was initiated once the athlete was pain free with activities of daily living.

Outcome:
At 7 weeks following diagnosis, the athlete was pain free and began progressive return to fencing. By 11 weeks, she returned to fencing 4 times weekly without symptoms. Two and a half years later she developed recurrent symptoms, and repeat magnetic resonance imaging confirmed recurrence of a grade 3 proximal radius bone stress injury. Case Photo #4 , Case Photo #5 Subsequent metabolic and bone health evaluation, including complete blood count, comprehensive metabolic panel, thyroid stimulating hormone, vitamin D, and dual energy x-ray absorptiometry scan, was unremarkable. Following another period of relative rest and subsequent progressive loading, she again returned to full fencing participation without symptom recurrence.

Author's Comments:
Bone stress injuries result from repetitive submaximal loading that exceeds the bone’s capacity for repair. Although most commonly seen in the lower extremities, upper extremity bone stress injuries are increasingly recognized in repetitive limb loading sports. Proximal radius bone stress injuries are rare and have primarily been described in skeletally immature gymnasts, likely due to the lower mechanical tolerance of growing bone.

This case demonstrates that repetitive high velocity wrist extension and forearm pronation in fencing can precipitate proximal radius bone stress injury in a skeletally mature athlete. To our knowledge, this is the first reported radial head stress fracture in a skeletally mature athlete. This case also suggests proximal radius bone stress injuries may be underrecognized in athletes with lateral forearm pain, particularly when symptoms overlap with radial nerve entrapment syndromes.

Editor's Comments:
Bone stress injuries are rare causes of upper extremity injuries, but should be considered in athletes who experience repetitive loading through the arms. Classically, repetitive axial loading should raise suspicion, but as in this case, torsional loading is also relevant to the radius and ulna. While bone stress injury treatment protocols are less defined than those of the lower extremity, the same principles can be relied upon to guide treatment (relative rest, activity modification, gradual bone loading, and return to play). Evaluation of form and technique maybe especially useful in minimizing the risk of recurrence.

References:
1.Santelli J, McCambridge TM, Valasek AE, Standiford K. Proximal radial head fractures in young gymnasts: a case series of newly described overuse injuries. Clin J Sport Med. 2019;29(1):e1-e3. doi:10.1097/JSM.0000000000000498.
2. Sinha AK, Kaeding CC, Wadley GM. Upper extremity stress fractures in athletes: clinical features of 44 cases. Clin J Sport Med. 1999;9(4):199-202. doi:10.1097/00042752-199910000-00003.
3. Miller TL, Harris JD, Kaeding CC. Stress fractures of the ribs and upper extremities: causation, evaluation, and management. Sports Med. 2013;43(8):665-674. doi:10.1007/s40279-013-0048-7.
4. McBride AP, Brais G, Wood T, Ek ET, Hoy G. Stress reactions and fractures around the elbow in athletes. J Sci Med Sport. 2021;24(5):425-429. doi:10.1016/j.jsams.2020.10.010.
5. Wilson PL, Wyatt CW, Searls WC, et al. Elbow overuse injuries in pediatric female gymnastic athletes: comparative findings and outcomes in radial head stress fractures and capitellar osteochondritis dissecans. J Bone Joint Surg Am. 2021;103(18):1675-1684. doi:10.2106/JBJS.20.01863.
6. Brooks AA. Stress fractures of the upper extremity. Clin Sports Med. 2001;20(3):613-620. doi:10.1016/S0278-5919(05)70272-6.
7. Brukner P. Stress fractures of the upper limb. Sports Med. 1998;26(6):415-424. doi:10.2165/00007256-199826060-00004.

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