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Stress fracture of the scaphoid in an elite junior tennis player: a case report and review of the literature
© Kohyama et al. 2016
Received: 10 March 2015
Accepted: 4 December 2015
Published: 18 January 2016
The carpal scaphoid is the most commonly fractured carpal bone in young adults after a fall on an outstretched arm that results in acute dorsal flexion of the wrist. However, stress fractures of the scaphoid are relatively rare. To the best of our knowledge, we describe the first case in the literature of carpal scaphoid stress fracture in a tennis player.
An 18-year-old Japanese man who was an elite junior tennis player was referred to our hospital after radiography and computed tomography revealed a carpal scaphoid fracture. The patient presented with pain in the wrist joint and tenderness over the anatomical snuff-box with diffuse swelling and reduced active dorsal flexion and flexion of the right wrist. The patient was treated conservatively and resumed participation in competitive events 5 months after his initial presentation.
In this case, the scaphoid stress fracture had resulted from repetitive practicing of the attacking backhand high volley, which involved excessive dorsal flexion of the wrist. Although rare, scaphoid stress fractures must be considered in tennis players with chronic wrist pain.
Stress fracture of the scaphoid has been attributed to repeated dorsal flexion of the wrist . Carpal scaphoid stress fractures have been reported in individuals engaging in gymnastics, shot put, diving, badminton, and cricket [1–10]. To the best of our knowledge, we report the first case in the literature of carpal scaphoid stress fracture in an elite junior tennis player. In our patient, the scaphoid stress fracture was a result of repetitive practice of the backhand high volley, which required excessive dorsal flexion of the wrist.
An 18-year-old man who was an elite junior tennis player developed severe pain over the dorsal aspect of his right wrist when he hit a backhand volley in a tournament match. There was no major trauma, but he could not continue playing in the match and therefore visited a local clinic. On the basis of radiography and computed tomography (CT) findings, he was diagnosed with a carpal scaphoid fracture and was referred to our facility.
The patient is a right-handed player and mainly hits one-handed forehand and one-handed backhand shots. For 4 months before presentation, he had been repeatedly practicing his backhand volley, especially the attacking backhand high volley. He began to experience gradual pain in the right wrist, which worsened with wrist dorsal flexion. However, he had not visited any medical facility and had continued practicing tennis.
His physical examination revealed tenderness over the anatomical snuff-box, with diffuse swelling. The active dorsal flexion and volar flexion of the right wrist was 10 degrees less than in the left wrist, and forced passive dorsal flexion and volar flexion of the right wrist caused increased pain over the wrist joint. Pronation and supination of the forearm and digital motion were within normal limits.
Previously reported stress fractures of the carpal scaphoid
Patient age (yr), sex
Period required to return to sports
Manzione and Pizzutillo, 1981 
Hanks et al., 1989 
Shot put (n = 1),
Gymnastics (n = 3)
Engel and Feldner-Busztin, 1991 
Inagaki and Inoue, 1997 
Matzkin and Singer, 2000 
Hosey et al., 2006 
Rethnam et al., 2006 
Yamagiwa et al., 2009 
Conservative, internal fixation
Nakamoto et al., 2011 
Pidemunt et al., 2012 
In a biomechanical study, Majima et al.  reported that loading patterns at the wrist are different in the dorsally flexed position than in the neutral position. When the wrist is placed in the dorsally flexed position, force transmission shifts radially and concentrates at the scaphoid . Extreme dorsal flexion compresses the radioscaphoid articulation and drives the scaphoid to the volar side. The volar radioscapholunate and radiocapitate ligaments resist the volar force from the proximal scaphoid. Distal to these are less restrictive radiocollateral ligaments, which make the scaphoid just distal to the proximal volar ligaments biomechanically the weakest point . This is where the fracture line was observed in our patient: the waist of the scaphoid.
Modern tennis players require a wide range of wrist movements for the various strokes and volleys. In backhand strokes and backhand volleys, the wrist is in neutral to 2–5 degrees of radial deviation and requires dorsal flexion of the wrist upon impact, especially in advanced players . Chow et al. reported that muscle activation of the extensor carpi radialis in the backhand volley was greater than for the forehand volley in both the pre- and postimpact phases . This suggests that dorsal flexion plays an important role in the backhand volley.
We concluded that the initial cause of the stress fracture in our patient was excessive and repetitive practice of the attacking backhand high volley. This exertion resulted in the carpal scaphoid receiving repetitive shearing and torsional forces, causing a stress fracture at the scaphoid waist. To prevent injury recurrence, the patient was advised to change the form of the backhand volley and not to dorsally flex the wrist excessively. Because the attacking backhand high volley is a relatively less necessary shot in tennis, the patient was advised not to overpractice the shot.
To the best of our knowledge, this is the first reported case in the literature of carpal scaphoid stress fracture in a tennis player. Repetitive practice of the backhand volley, which requires excessive dorsal flexion of the wrist, led to a stress fracture of the carpal scaphoid. A sound bony union was obtained with conservative therapy, and the patient resumed participating in competitive tennis within 5 months of initial presentation. Although scaphoid stress fracture is comparatively rare, we suggest that it must be considered in the differential diagnosis when tennis players present with chronic wrist pain.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We thank Thomas Mayers for English-language revision of the manuscript.
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