Humeral Fracture in a Female Arm Wrestler: A Patient-Centered Focused Review

Abstract

Humeral fractures in arm wrestling are rarely reported entities in the orthopedic literature and can present with significant pain and debilitation. These injuries are even more uncommon in female practitioners of the sport. Rotational forces applied to the humerus during competition can result in the transmission of stress into the distal part of the humerus, thereby causing a spiral fracture. Common complications that can arise from such an injury can include radial nerve palsy and butterfly fragments of the humerus. These can occur in arm wrestling and can present with prominent pain, weakness, and functional impairment. Treatment often varies according to the presenting case and are often operative in cases with displaced fractures, and non-operative in those of nondisplaced fractures. Prognostic outcomes are often favorable and uneventful. In this article, we explore a distal humeral fracture in a female arm wrestler and discuss the mechanism, presentation, and management of such an injury, based on a thorough yet concise review of literature.

Arm wrestling is a popular sport around the world, mainly depicted as a nontraumatic method to showcase strength and power.¹ Nevertheless, debilitating injuries and ailments can occur due to the implementation of poor techniques and the biomechanical vulnerabilities that arise to the upper limb during engagement.^1,2 The humerus, specifically, can be subjected to high amounts of stress and pressure during arm wrestling competitions, and as a result, the risk of its fracture increases significantly.² Reports exploring humeral fractures in arm wrestling have been limited in the literature, with only a few studies reporting on patient presentation and management.^1-16 In addition, the vast majority of these studies often involve male participants, and we found only three reports on humeral fractures in female arm wrestlers.^2,10,14 Exploring additional cases in light of recent medical and surgical advancements can help guide surgeons to the appropriate management guidelines for future patients. Accordingly, we present the rare case of a woman, aged 22 years, who sustained a distal humeral fracture while arm wrestling at an amateur level. We discuss the characteristics of this case, explore the mechanism behind this injury, and examine appropriate management, while conducting a concise yet thorough review of the relevant literature using the PubMed/Medline database.

Case Presentation

The patient was a healthy female, age 22 years, who presented with a fracture in her right distal humeral shaft following an amateur arm wrestling match. She was around 160 cm tall and weighed around 55 kgs. Video footage of the match was available for analysis. She was in the losing phase in the competition, having had sustained an angle of approximately 150 degrees between her forearm and the table for around 17 seconds before hearing a snapping sound and fracturing her humerus (Figure 1). Radiograph imaging revealed a spiral fracture at the distal third of the humerus, with no butterfly fragments (Figure 2). The patient did not exhibit any neurological symptoms in her upper extremity following the incident. She was otherwise healthy, with no previous rheumatologic, endocrinologic, or musculoskeletal pathologies, and was taking no medications.

Figure 1.

Snapshots of video footage showing the mechanism of injury in the presented patient. The patient held a losing arm-wrestling position at around 150 degrees for 17 seconds before sustaining a humeral fracture.

Figure 2.

Radiograph imaging showing a spiral fracture at the distal end of the humeral shaft. There is no medial butterfly fragment.

Open reduction and internal plate fixation of the right humeral shaft was decided upon for the management plan. The patient was placed in the lateral decubitus position, and a posterior paratricipital approach was used to expose the fracture. Careful consideration was given to the radial and ulnar nerves, which were visualized and secured throughout the procedure (Figure 3). Two lag screws were placed to secure the fixation, and a 10-hole Synthes 3.5 dynamic compression plate was placed along the humeral shaft. Six screws were then drilled into the plate and appropriate fixation was achieved. Radiograph imaging at 10 days post-surgery revealed appropriate fixation, bone mineralization, and healing (Figure 4). At 6 months post-surgery, the patient was able to resume full regular activity. She had full upper extremity range of motion, and was fully satisfied with her outcomes.

Figure 3.

Radial and ulnar nerves were visualized and secured throughout the surgical procedure.

Figure 4.

Postoperative radiograph showing appropriate fixation of the distal humeral fracture.

Discussion

Humeral fractures in arm wrestling are an uncommon yet debilitating finding, and reports on these fractures in the literature have been limited. To our knowledge, and through exploring the PubMed/Medline database, we were able to extract 16 studies that reported on such fractures (Table 1).^1-16 This literature search was conducted using the terms “arm wrestling” and “fractures”, combined by the Boolean Operator AND (July 2022). Only observational studies, trials, and case reports written in the English language were included, along with relevant articles extracted from reference lists of retrieved publications. The retrieved studies involved 180 patients (N=180) (without including our patient), and out of which, 161 were males (89%), 5 were females (3%), and 14 (8%) were unspecified (Table 1). Given the relative sparsity of existing literature on humeral fractures in arm wrestlers in general, and in female arm wrestlers specifically, providing additional insight on similar cases is essential. In the last 10 years, only two studies described three humeral shaft fractures that occurred in female arm wrestlers. As such, our report provides a notable updated addition to the existing literature, as it discusses the different treatment strategies that can be employed in female arm wrestlers whose anatomic biology, surgical expectations, and cosmetic concerns may differ from those of their male counterparts.

Table 1.

Findings of available literature on humeral shaft fractures in arm wrestlers

Authors	Number of Patients	Fracture Location	Fracture Type	Nerve Injury	Medial Butterfly Fragment	Stance during injury	Treatment and Outcome
Whitaker (1977)3	5 Males	All between middle and distal third of humerus	Spiral	Radial nerve palsy was present in one patient	Present in 5 patients	3 patients were losing 2 patients were in a draw	All opted for nonoperative treatment using collar and cuff sling with a protective U slab. Two presented with refracture. Three recovered uneventfully.
Peace PK (1977)4	2 Males	All at distal humerus	Spiral	None	Present in one patient	Not specified	Both patients opted for conservative treatment with a hanging cast and successful union of the fracture occurred in both cases
Heilbronner et al. (1980)5	7 (Gender not specified)	All at distal humerus	Spiral	None	Not specified	Not specified	Four patients opted for nonoperative treatment Three patients were treated using open reduction and internal fixation All fractures united
Moon et al (1980)6	7 (Gender not specified)	At the junction of middle and distal humerus in 2 patients At the medial epicondyle in 5 patients	Not specified	Not specified	Present in 2 patients	Not specified	Not specified
Helm & Stuart (1986)7	1 Male	At distal humerus	Spiral	None	None	Not specified	Patient was treated with a collar and cuff sling with a protective U slab Fracture union was achieved after 10 weeks
De Barros & Oliviera (1995)8	2 Males	At the junction between middle and upper part of the humerus in one patient At the middle part of the humerus in one patient	Spiral	None	Present in one patient	One was losing One was not specified	Both patients opted for conservative treatment One was treated with a sugar tong splint for 6 weeks. The other was treated with a splint for 4 weeks followed by a hanging cast Both fractures showed satisfactory union
Ogawa & Ui (1996)9	10 Males	All at medial epicondyle of the humerus	Not specified	Ulnar nerve palsy was present in one patient	None	3 patients were winning 3 patients were losing 3 patients were in a draw 1 unknown	Two cases opted for conservative treatment Eight underwent open reduction and internal fixation All cases witnessed bony union and return to sport
Ogawa & Ui (1997)10	28 Males 2 Females	All at junction between middle and distal parts of humerus	Spiral	Radial nerve palsy was present in 7 patients	Present in 7 patients	5 patients were winning 9 patients were losing 16 patients were in a draw	13 patients opted for conservative treatment 17 treated patients opted for surgical treatment using plating or screwing
Khashaba (2000)11	1 Male	At distal humerus	Spiral	None	None	Losing	Opted for nonoperative treatment using collar and a cuff in a net bondage Patient recovered satisfactorily
Napp et al. (2011)12	1 Male	At distal humerus	Spiral	Radial nerve palsy was present in the patient	None	Not specified	Patient was treated with open reduction and internal fixation. Patient exhibited a full recovery
Kruczynski et al (2012)2	8 Males 1 Female	All at distal humerus	Spiral	Radial nerve palsy was present in 3 patients	Present in 5 patients	Not specified	All patients were treated with surgical fixation All achieved favorable outcomes
Bumbasirevic et al (2014)13	6 Males	All at junction between middle and distal parts of humerus	Spiral	None	Present in one patient	Not specified	Three patients were treated operatively Three underwent closed reduction followed by a hanging arm cast All patients witnessed fracture union
Mayfield & Egol (2018)14	7 Males 2 Females	All at distal humerus	Spiral	Radial nerve palsy present in one patient	Not specified	Not specified	All patients opted for nonoperative treatment All achieved radiographic union
Pande et al. (2021)15	6 Males	All at distal humerus	Spiral	None	Present in one patient	One patient was winning Four patients were losing One patient was in a draw	Three patients opted for nonoperative management Surgical treatment using open reduction and internal fixation was used in three. All patients showed satisfactory healing
Kim et al (2021)16	65 Males	Not specified	Spiral	Radial nerve palsy was present in 17 patients	Not specified	Not specified	All patients opted for open reduction and internal fixation
Karadeniz et al (2022)1	19 Males	All at distal humerus	Spiral	Radial nerve palsy present in 5 patients	Present in 11 patients	Not specified	12 opted for nonoperative treatment 7 opted for surgical treatment All patients had favorable outcome and full recoveries

The majority of studies that have reported on this fracture type have indicated it as a spiral fracture, mainly due to the biomechanical properties of the injury, which involve rapid stress in the internal rotator muscles of the losing competitor when faced by the pressure of the more dominant competitor.² This rapid stress causes an increase in the humeral rotational force, which allows the transmission of stress to the distal part of the humerus, resulting in a spiral fracture.² This also explains why the distal third of the humerus was the most commonly impacted part of the humerus in such fractures, given it was involved in 98 patients (54%) of those reported in the literature.^1-7,10-15 The medial epicondyle of the humerus, on the other hand, was involved in 15 patients (8%), and this injury was often found in children, where the epiphyseal plate is yet to close, and the area is more vulnerable to injury.^{6, 9} Our review also showed that the injury can occur in any phase of competition, as arm wrestlers were winning in 9 cases (5%), losing in 21 cases (12%), and in a draw in 22 cases (12%) (Table 1). The phase of competition was not specified in 128 cases (71%).

Complications arising from humeral fractures in the setting of arm wrestling mainly include the comminution of a medial butterfly fragment in the humerus and concomitant nerve palsies.^1,10 A medial butterfly fragment is a common finding in the setting of arm wrestling humeral fractures. While not present in our patient, 34 patients (19%) of the 180 reported were found to have radiographic evidence of a medial butterfly fragment of the humerus as a result of the arm wrestling injury (Table 1).^{1-4,6,8,10,13,15} This injury was not present in 65 patients (36%), and its presence was not specified in 81 patients (45%) (Table 1). This relatively common finding is said to arise due to axial loading while bending, and not due to the torsional force of the upper arm muscles alone.³ Moreover, while our patient did not exhibit any neurological symptoms, careful consideration should be given to any suspected nerve palsies. As a matter of fact, and as reported in the literature, radial nerve palsy were found in 35 arm wrestling patients with humeral fractures (19%) (Table 1).^{1-3,10,12,14,16} The injury to the radial nerve is mainly associated with the location of the fracture and the anatomic distribution and route of the radial nerve.¹⁷ Similarly, we found one report of an ulnar nerve palsy in the literature, which occurred following a medial epicondylar avulsion in an arm wrestling adolescent.⁹ Our findings fall in accordance with Correia et al,¹⁸ who identified an age-dependent pattern, whereby adolescents arm wrestlers are more likely to suffer a medial epicondylar injury with a possible ulnar nerve palsy, and fully grown adults are more likely to sustain a distal humeral fracture with a possible radial nerve palsy. Nevertheless, considerable attention should be given to both neural structures during inspection, examination, and surgical planning of the patient. In our case, we were careful on securing both nerves during exploration and fixation to avoid any injuries or deficits.

Treatment options catering to these injuries are dependent on the presentation of the patient and can include conservative or operative options. In a rather stable nondisplaced fracture, immobilization using casts or splints can achieve appropriate union and favorable outcomes.^1,14,15 Of the cases extracted from the literature, 48 (27%) underwent conservative therapy, and all reported favorable outcomes except for 2 cases that presented with refracture (Table 1).^{1,3-5,7-11,13,15} Similarly, 43 (24%) patients were reported to opt for surgical management, and outcomes reported were all favorable (Table 1).^{1,2,5,9,10,12,13,15} In our case, open reduction and internal plate fixation of the fracture was the treatment of choice. The paratricipital approach was used to avoid violating the triceps muscle. This provided improved elbow range of motion and decreased chances of postoperative contractures.¹⁹ Appropriate fixation of the fracture was achieved at the end of the operation, and the patient made a full recovery, as was the case with the vast majority of the existing cases, where outcomes were generally favorable. To note, it is important during these competitions to take into account the weight and performance levels of the competitors to avoid such injuries. While the risk for injury is inherently present in arm wrestling due to the nature of the sport, ensuring that the competitors involved are of equivalent size and skill may help prevent similar injuries in future events.

Conclusion

Humeral fractures can occur in arm wrestling and can present with prominent pain, weakness, and functional impairment. These fractures often arise due to increased humeral rotational forces during competition, causing the transmission of stress to the distal part of the humerus. As such, the most common vignette includes an adult arm wrestler with a spiral fracture in the distal third of the humerus. Arising complications in this setting include radial nerve palsies and the comminution of a medial butterfly fragment. Treatment options include operative and non-operative measures, depending on the characteristics of the injury itself, and prognostic outcomes are often favorable and uneventful.