•
•
Radiology of Athletic Injuries:
Football 1
Diagnostic Radiology
Jack W. Bowerman, M.D., and Edmond J. McDonnell, M.D. During a 17-year period, 33 injuries produced radiographic abnormalities in 26 members of a professional football team. Sites of injury were correlated with playing position and protective equipment worn at the time of injury. Fractures of multiple transverse processes of the lumbar spine are reported in offensive halfbacks and offensive ends. Two linebackers and one center sustained fractures of the mid-forearm. Several related reports of the morbidity and mortality of football injuries are also discussed. INDEX TERMS: Extremities, wounds and injuries. Face, fractures. Knee • Nose. Pelvis, wounds and injuries. Ribs, fractures. Spine, fractures
Radiology 117:33-36, October 1975
•
• OOTBALL PLAYERS in North America are frequently injured and need constant medical attention. The records of 26 professional football players were studied whose injuries produced abnormal radiographic findings.
F
MATERIAL AND METHODS
The radiographs and clinical histories of 26 players who sustained 33 injuries in a 17-year period were reviewed. (In 2 instances, we had the radiologist's report, but the films themselves were not available.) When possible, the site of injury was correlated with playing position and whether protective equipment had been worn at the time of injury. Arthrograms were not obtained regularly in this series and therefore cartilage and ligament injuries are not included in this report. Table I:
Sites of Injury
Upper Extremity Metacarpal fractures Carpal navicular fracture Distal phalanx fracture Mid-radial shaft fracture Radial head fracture Acromioclavicular joint injury Scapulohumeral joint injury Lower Extremity Myositis ossificans of thigh Knee joint calcification or ossification Achilles tendon rupture Lumbar Spine Multiple transverse process fracture Vertebral body compression fracture Pelvis Ischial apophysis avulsion injury Chest Rib fractures Pneumothorax Face Comminuted nasal fracture Total Injuries
4
2 1
3 1
3 1 1 4 1
Fig. 1. Following a forceful tackle to a flankerback; fractures were demonstrated at the right first, second and third lumbar transverse processes. The lowermost fracture site is comminuted. Fig. 2. This enlargement shows the displacement fracture sites of the third and fourth lumbar transverse processes in a second player, who also played a pass-receiving and halfback position. He was hit hard by an opposing player.
4 2
RESULTS
TABLE I summarizes the injuries studied. The upper extremity was injured in 13 players and the lower in 5. Two players suffered three separate fractures of the upper extremity and hand. Six players had fractures of the transverse processes of the lumbar spine or alteration of the end plate of a lumbar vertebral body (Figs. 1
2 1
2 33
1 From the Johns Hopkins Medical Institutions (J. W. B., Assistant Professor of Radiology; E. J. McD., Associate Professor of Orthopedic Surgery), Baltimore, Md. Accepted for publication in April 1975. shan
33
34
JACK
W.
BOWERMAN AND EDMOND J. McDoNNELL
October1975
Fig. 3. A, Band C. Three fractures of the radius resulting from direct blows to two linebackers and one center. The use of extensive padding for protection of the forearm was not popular during their careers. The injury in Figure 3, C has also produced a disruption of the distal radioulnar joint, as shown by the dorsal displacement of the distal ulna on the lateral view.
and 2). Five athletes had various other injuries, including nasal fractures (2 patients), rib fractures (2 patients) and an avulsion fracture of the pelvis (1 patient). When playing position was considered in relation to injuries sustained, it was noted that two of three fractures of the mid-radius occurred in linebackers (Fig. 3). All 4 players with fractures of the transverse processes of the lumbar spine were offensive halfbacks or offensive ends. Two defensive linemen had minimal compression fractures of a lower lumbar vertebral body. Myositis ossificans developed after two separate injuries in one tight end. One injury produced a subperiosteal hematoma that led to the formation of a promontory of bone on the shaft of the femur, and a second, more recent injury produced two zones of immature ossification in the proximal soft tissues of the thigh (Fig. 4). These injuries were usually uncomplicated but one player with fractured multiple lumbar transverse processes had transient hematuria. Another had a rib fracture associated with pneumothorax (Fig. 5). There were no fatalities in this series. From .the standpoint of protective equipment, we observed that both players with comminuted fractures of the nose had played without a face-guard attachment on the helmet. In addition, the three mid-radius fractures
occurred in players who were not wearing extensive forearm padding. DISCUSSION
Football injuries usually result from blocking and tackling or from undue stress in running and falling. Knee and ankle injuries and ligamentous and musculotendinous injuries account for most mishaps (1, 8, 11, 16). Concern with more common injuries has been overshadowed by occasional reports of death after collisions on the field (5, 9, 13, 14). Such accidents predominantly involve the brain and cervical spine (2, 5, 9, 13, 14). Blyth and Arnold (5), surveying football deaths in the United States since 1931, found a yearly average of 17 deaths due to direct injury. In 1968, 36 players died as a direct result of blocking and tackling: 26 were high school youths and only one was a professional athlete. Gonzales (9) studied 22 deaths in football in the New York City metropolitan area over a 32-year period and found that 4 players had died with intracranial hemorrhage, 3 with spinal cord injury associated with cervical and thoracic fractures and dislocations, and 4 following intra-abdominal injury. Non-fatal injuries sustained in football arid other sports are not commonly recorded as events related to
Vol. 117
RADIOLOGY OF ATHLETIC INJURIES:
athletics in hospital or outpatient record systems. Several university health centers, however, have provided data on injuries in collegiate sports. Thorndike (16) recorded 3,453 injuries in 14,375 Harvard undergraduate athletes between 1932 and 1954. Knee, thigh and ankle injuries predominated. Riggsbee gathered data from 11 colleges and found 253 football injuries in 816 sports accidents (11). Eastwood classified college sports according to their degree of hazard based on the number of accidents per thousand exposures to sporting activity (8). His data showed that football is clearly the most hazardous college sport, causing 87.9 accidents per 1,000 exposures. Two reports from college team physicians dealt with radiological findings in football injuries to specific' body areas. In 1965, Chrisman et al. reported 17 lateral flexion neck injuries in a five-year period at Amherst College and the University of Massachusetts (6). The abnormal radiographic findings were confined to limited range of. movement in lateral flexion views of the cervical spine. All other ranges of cervical spine motion were within normal limits. Blazina and Westover did a radiographic survey of the ankle joints of 44 freshman candidates for the UCLA football and basketball teams (4). Despite an average player age of 18 years, 38 ankles (43 %) in 29 athletes showed radiographic abnormalities: the predominant features were joint margin irregularity and spur formation. Radiographic studies of professional football players are widespread. Laurin (10) presented a study of ankle joint findings in 59 professional players. In comparison to ankle findings in age-matched, control patients, osteophyte and periosteal new bone formation, interosseous ligament calcification and radiographic signs of osteoarthritis were much more frequent in the football group. Of particular interest was the finding that ankle joints in linemen were much more affected than in players of lighter weight. Several examples of fractures to the growing skeleton in nonprofessional players have been reported (3, 12). Rogers reported a 13-year-old boy with an epiphyseal fracture of the proximal humerus and a 17-year-old youth with a distal femoral epiphyseal separation diagnosed by stress views (12). Siffert and Levy described "blocker's node" as an example of myositis ossificans in children following trauma to the brachialis muscle near the deltoid tubercle (15). There are two examples of avulsion injuries in the present study. One of the players fell during a scrimmage and landed with his legs spread apart. The result was an avulsion fracture of the ischial apophysis. A second player had minimal irregularity of the infraglenoid tubercle of the scapula at the origin of the long head of the triceps. This injury resulted from a collision with another player. According to Conwell and Reynolds (7), isolated fractures of the radial shaft are relatively rare. Two of the three radial shaft fractures encountered were unassoci-
35
FOOTBALL
Diagnostic Radiology
Fig. 4. The broad arrow indicates the bony prominence at the site of an old subperiosteal hematoma. The fine arrows indicate sites of immature ossification following more recent injury to the thigh of this tight end.
ated with other forearm injury. One other player had a distal radioulnar joint separation in addition to the midradial fracture. The findings of mid-radius and lumbar spine fractures in the present study add to the considerable list of injury sites that warrant careful examination after injury in football. Nearly all parts of the skeleton can be involved in radiological abnormalities of these athletes. This study included findings in the arm, leg, lumbar spine, pelvis, chest and face. Anticipation of these findings should lead to improved radiographic diagnosis of injuries to the football player. REFERENCES 1. Allen ML: Air Force football injuries. A clinicai and statistical study. JAMA 206:1053-1058,28 Oct 1968 2. Alley RH Jr: Head and neck injuries in high school football. JAMA 188:418-422, 4 May 1964 3. Bavendam FA, Nedelman SH: Some considerations in the roentgenology of fractures and dislocations. Semin Roentgen 1: 407-436, 1966 4. Blazina ME, Westover JL: Ankle joints of freshman college athletes. Clin Orthop 42:73-80, Sep-Oct, 1965 5. Blyth CS, Arnold DC: Deaths related to football. Hospital Tribune, 30 Jun 1969, p 20 6. Chrisman 00, Snook GA, Stanitis JM, et al: Lateral-flexion neck injuries in athletic competition. JAMA 192:613-615, 17 May 1965
36
JACK W. BOWERMAN AND EDMOND J. McDoNNELL
October1975
Fig. 5. A. Chest film made for evaluation of dyspnea following a bruising tackle and chest injury. Extensive pneumothorax and hydrothorax are present. B. Several hours later, the mediastinum shifted to the right indicating tension pneumothorax. The mediastinal shift also uncovered the fracture site in the posterior portion of the left ninth rib. A chest tube was inserted and recovery was uneventful.
7. Conwell HE, Reynolds FC: Key and Conwell's Management of Fractures, Dislocations and Sprains. St. Louis, Mosby, 7th ed, 1961 8. Eastwood FR: Hazards to health. Athletic injuries. New Engl J Med 271:411-413,20 Aug 1964 9. Gonzales TA: Fatal injuries in competitive sports. JAMA 146:1506-1511, 18 Aug 1951 10. Laurin CA: Ankle injuries in relation to the position played. Address presented at the Postgraduate Course on Sports in Medicine, Buffalo, N. Y., Sep 1970, sponsored by the Committee on Sports Medicine, American Academy of Orthopaedic Surgeons 11. Riggsbee JB: Accidents at college. GP 26:88-93, Sep 1962 12. Rogers LF: The radiography of epiphyseal injuries. Radiology 96:289-299, Aug 1970
13. Schneider RC, Reifel E, Crisler HO, et al: Serious and fatal football injuries involving the head and spinal cord. JAMA 177:362367, 12 Aug 1961 14. Schneider RC: Serious and fatal neurosurgical football injuries. Clin Neurosurg 12:226-236, 1964 15. Siffert RS, Levy R: Athletic Injuries in children. Pediat Clin N Am 12:1027-1037, Nov 1965 16. Thorndike AT: Frequency and nature of sports injuries. Am J Surg 98:316-324, Sep 1959
Box #63 Radiology Johns Hopkins Hospital Baltimore, Maryland 21205
•
Radiology of Athletic Injuries:
Football 1
Diagnostic Radiology
Jack W. Bowerman, M.D., and Edmond J. McDonnell, M.D. During a 17-year period, 33 injuries produced radiographic abnormalities in 26 members of a professional football team. Sites of injury were correlated with playing position and protective equipment worn at the time of injury. Fractures of multiple transverse processes of the lumbar spine are reported in offensive halfbacks and offensive ends. Two linebackers and one center sustained fractures of the mid-forearm. Several related reports of the morbidity and mortality of football injuries are also discussed. INDEX TERMS: Extremities, wounds and injuries. Face, fractures. Knee • Nose. Pelvis, wounds and injuries. Ribs, fractures. Spine, fractures
Radiology 117:33-36, October 1975
•
• OOTBALL PLAYERS in North America are frequently injured and need constant medical attention. The records of 26 professional football players were studied whose injuries produced abnormal radiographic findings.
F
MATERIAL AND METHODS
The radiographs and clinical histories of 26 players who sustained 33 injuries in a 17-year period were reviewed. (In 2 instances, we had the radiologist's report, but the films themselves were not available.) When possible, the site of injury was correlated with playing position and whether protective equipment had been worn at the time of injury. Arthrograms were not obtained regularly in this series and therefore cartilage and ligament injuries are not included in this report. Table I:
Sites of Injury
Upper Extremity Metacarpal fractures Carpal navicular fracture Distal phalanx fracture Mid-radial shaft fracture Radial head fracture Acromioclavicular joint injury Scapulohumeral joint injury Lower Extremity Myositis ossificans of thigh Knee joint calcification or ossification Achilles tendon rupture Lumbar Spine Multiple transverse process fracture Vertebral body compression fracture Pelvis Ischial apophysis avulsion injury Chest Rib fractures Pneumothorax Face Comminuted nasal fracture Total Injuries
4
2 1
3 1
3 1 1 4 1
Fig. 1. Following a forceful tackle to a flankerback; fractures were demonstrated at the right first, second and third lumbar transverse processes. The lowermost fracture site is comminuted. Fig. 2. This enlargement shows the displacement fracture sites of the third and fourth lumbar transverse processes in a second player, who also played a pass-receiving and halfback position. He was hit hard by an opposing player.
4 2
RESULTS
TABLE I summarizes the injuries studied. The upper extremity was injured in 13 players and the lower in 5. Two players suffered three separate fractures of the upper extremity and hand. Six players had fractures of the transverse processes of the lumbar spine or alteration of the end plate of a lumbar vertebral body (Figs. 1
2 1
2 33
1 From the Johns Hopkins Medical Institutions (J. W. B., Assistant Professor of Radiology; E. J. McD., Associate Professor of Orthopedic Surgery), Baltimore, Md. Accepted for publication in April 1975. shan
33
34
JACK
W.
BOWERMAN AND EDMOND J. McDoNNELL
October1975
Fig. 3. A, Band C. Three fractures of the radius resulting from direct blows to two linebackers and one center. The use of extensive padding for protection of the forearm was not popular during their careers. The injury in Figure 3, C has also produced a disruption of the distal radioulnar joint, as shown by the dorsal displacement of the distal ulna on the lateral view.
and 2). Five athletes had various other injuries, including nasal fractures (2 patients), rib fractures (2 patients) and an avulsion fracture of the pelvis (1 patient). When playing position was considered in relation to injuries sustained, it was noted that two of three fractures of the mid-radius occurred in linebackers (Fig. 3). All 4 players with fractures of the transverse processes of the lumbar spine were offensive halfbacks or offensive ends. Two defensive linemen had minimal compression fractures of a lower lumbar vertebral body. Myositis ossificans developed after two separate injuries in one tight end. One injury produced a subperiosteal hematoma that led to the formation of a promontory of bone on the shaft of the femur, and a second, more recent injury produced two zones of immature ossification in the proximal soft tissues of the thigh (Fig. 4). These injuries were usually uncomplicated but one player with fractured multiple lumbar transverse processes had transient hematuria. Another had a rib fracture associated with pneumothorax (Fig. 5). There were no fatalities in this series. From .the standpoint of protective equipment, we observed that both players with comminuted fractures of the nose had played without a face-guard attachment on the helmet. In addition, the three mid-radius fractures
occurred in players who were not wearing extensive forearm padding. DISCUSSION
Football injuries usually result from blocking and tackling or from undue stress in running and falling. Knee and ankle injuries and ligamentous and musculotendinous injuries account for most mishaps (1, 8, 11, 16). Concern with more common injuries has been overshadowed by occasional reports of death after collisions on the field (5, 9, 13, 14). Such accidents predominantly involve the brain and cervical spine (2, 5, 9, 13, 14). Blyth and Arnold (5), surveying football deaths in the United States since 1931, found a yearly average of 17 deaths due to direct injury. In 1968, 36 players died as a direct result of blocking and tackling: 26 were high school youths and only one was a professional athlete. Gonzales (9) studied 22 deaths in football in the New York City metropolitan area over a 32-year period and found that 4 players had died with intracranial hemorrhage, 3 with spinal cord injury associated with cervical and thoracic fractures and dislocations, and 4 following intra-abdominal injury. Non-fatal injuries sustained in football arid other sports are not commonly recorded as events related to
Vol. 117
RADIOLOGY OF ATHLETIC INJURIES:
athletics in hospital or outpatient record systems. Several university health centers, however, have provided data on injuries in collegiate sports. Thorndike (16) recorded 3,453 injuries in 14,375 Harvard undergraduate athletes between 1932 and 1954. Knee, thigh and ankle injuries predominated. Riggsbee gathered data from 11 colleges and found 253 football injuries in 816 sports accidents (11). Eastwood classified college sports according to their degree of hazard based on the number of accidents per thousand exposures to sporting activity (8). His data showed that football is clearly the most hazardous college sport, causing 87.9 accidents per 1,000 exposures. Two reports from college team physicians dealt with radiological findings in football injuries to specific' body areas. In 1965, Chrisman et al. reported 17 lateral flexion neck injuries in a five-year period at Amherst College and the University of Massachusetts (6). The abnormal radiographic findings were confined to limited range of. movement in lateral flexion views of the cervical spine. All other ranges of cervical spine motion were within normal limits. Blazina and Westover did a radiographic survey of the ankle joints of 44 freshman candidates for the UCLA football and basketball teams (4). Despite an average player age of 18 years, 38 ankles (43 %) in 29 athletes showed radiographic abnormalities: the predominant features were joint margin irregularity and spur formation. Radiographic studies of professional football players are widespread. Laurin (10) presented a study of ankle joint findings in 59 professional players. In comparison to ankle findings in age-matched, control patients, osteophyte and periosteal new bone formation, interosseous ligament calcification and radiographic signs of osteoarthritis were much more frequent in the football group. Of particular interest was the finding that ankle joints in linemen were much more affected than in players of lighter weight. Several examples of fractures to the growing skeleton in nonprofessional players have been reported (3, 12). Rogers reported a 13-year-old boy with an epiphyseal fracture of the proximal humerus and a 17-year-old youth with a distal femoral epiphyseal separation diagnosed by stress views (12). Siffert and Levy described "blocker's node" as an example of myositis ossificans in children following trauma to the brachialis muscle near the deltoid tubercle (15). There are two examples of avulsion injuries in the present study. One of the players fell during a scrimmage and landed with his legs spread apart. The result was an avulsion fracture of the ischial apophysis. A second player had minimal irregularity of the infraglenoid tubercle of the scapula at the origin of the long head of the triceps. This injury resulted from a collision with another player. According to Conwell and Reynolds (7), isolated fractures of the radial shaft are relatively rare. Two of the three radial shaft fractures encountered were unassoci-
35
FOOTBALL
Diagnostic Radiology
Fig. 4. The broad arrow indicates the bony prominence at the site of an old subperiosteal hematoma. The fine arrows indicate sites of immature ossification following more recent injury to the thigh of this tight end.
ated with other forearm injury. One other player had a distal radioulnar joint separation in addition to the midradial fracture. The findings of mid-radius and lumbar spine fractures in the present study add to the considerable list of injury sites that warrant careful examination after injury in football. Nearly all parts of the skeleton can be involved in radiological abnormalities of these athletes. This study included findings in the arm, leg, lumbar spine, pelvis, chest and face. Anticipation of these findings should lead to improved radiographic diagnosis of injuries to the football player. REFERENCES 1. Allen ML: Air Force football injuries. A clinicai and statistical study. JAMA 206:1053-1058,28 Oct 1968 2. Alley RH Jr: Head and neck injuries in high school football. JAMA 188:418-422, 4 May 1964 3. Bavendam FA, Nedelman SH: Some considerations in the roentgenology of fractures and dislocations. Semin Roentgen 1: 407-436, 1966 4. Blazina ME, Westover JL: Ankle joints of freshman college athletes. Clin Orthop 42:73-80, Sep-Oct, 1965 5. Blyth CS, Arnold DC: Deaths related to football. Hospital Tribune, 30 Jun 1969, p 20 6. Chrisman 00, Snook GA, Stanitis JM, et al: Lateral-flexion neck injuries in athletic competition. JAMA 192:613-615, 17 May 1965
36
JACK W. BOWERMAN AND EDMOND J. McDoNNELL
October1975
Fig. 5. A. Chest film made for evaluation of dyspnea following a bruising tackle and chest injury. Extensive pneumothorax and hydrothorax are present. B. Several hours later, the mediastinum shifted to the right indicating tension pneumothorax. The mediastinal shift also uncovered the fracture site in the posterior portion of the left ninth rib. A chest tube was inserted and recovery was uneventful.
7. Conwell HE, Reynolds FC: Key and Conwell's Management of Fractures, Dislocations and Sprains. St. Louis, Mosby, 7th ed, 1961 8. Eastwood FR: Hazards to health. Athletic injuries. New Engl J Med 271:411-413,20 Aug 1964 9. Gonzales TA: Fatal injuries in competitive sports. JAMA 146:1506-1511, 18 Aug 1951 10. Laurin CA: Ankle injuries in relation to the position played. Address presented at the Postgraduate Course on Sports in Medicine, Buffalo, N. Y., Sep 1970, sponsored by the Committee on Sports Medicine, American Academy of Orthopaedic Surgeons 11. Riggsbee JB: Accidents at college. GP 26:88-93, Sep 1962 12. Rogers LF: The radiography of epiphyseal injuries. Radiology 96:289-299, Aug 1970
13. Schneider RC, Reifel E, Crisler HO, et al: Serious and fatal football injuries involving the head and spinal cord. JAMA 177:362367, 12 Aug 1961 14. Schneider RC: Serious and fatal neurosurgical football injuries. Clin Neurosurg 12:226-236, 1964 15. Siffert RS, Levy R: Athletic Injuries in children. Pediat Clin N Am 12:1027-1037, Nov 1965 16. Thorndike AT: Frequency and nature of sports injuries. Am J Surg 98:316-324, Sep 1959
Box #63 Radiology Johns Hopkins Hospital Baltimore, Maryland 21205
