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Nondisplaced
Football Commentary: P h a l a n g e a l F r a c t u res — Displaced/Nondisplaced
In addition to fracture pattern, the management of phalangeal fractures in professional football players is in large dictated by nonbiologically related factors such as the remaining games in the season, player position, and hand dominance. The treatment of an unstable, displaced transverse proximal phalanx fracture in the nondominant hand of a lineman may vary considerably from the identical fracture in the throwing hand of a quarterback. Unique considerations for management of these common fractures in high-level football players are briefly reviewed. The decision for operative versus nonoperative fracture management is typically determined by the stability of the fracture, as outlined in the above article. There are instances, however, when exceptions to this rule may be made. For instance, some nondisplaced fractures at risk for displacement, such as a condylar fracture, may be selected for percutaneous screw fixation to allow more rapid rehabilitation and return to play. Similarly, a long nondisplaced spiral fracture in the throwing hand of a quarterback may be selected for percutaneous screw fixation to allow for more rapid return to sport. Risks and benefits of arguably unnecessary surgery must be clearly explained and documented. These decisions are usually the product of a “team approach” of discussion amongst the player, treating physician, trainer, coach, and, at times, the player’s agent. Also, the timing of surgery may vary depending on the point in the season. For example, the same fracture presenting during preseason, midseason, and with 1 week re-
maining in the season may likely be treated immediately, prior to the next bye week, or at the completion of the season, respectively, if a playing cast can be worn in the interim. However, most fractures that require surgery are treated as soon as possible to allow the earliest institution of rehabilitation. Perhaps the most challenging aspect of caring for professional athletes is the doctor’s note for clearing a participant for return to sport. One must balance the risks of premature return to play and reinjury versus delayed return to play and professional and financial retributions incurred by the player and team. In a recent survey of team physicians for professional sports teams, roughly one-third of physicians allowed immediate return to protected play for nondisplaced hand fractures and another 50% allowed return to protected play in 3 to 4 weeks. Similarly, after rigid internal fixation, roughly one-third allowed immediate return to protected play and another 50% allowed return to protected play at 3 to 4 weeks postoperatively. Most allowed unprotected return to play at the 6to 8-week mark for hand fractures. Phalangeal fractures specifically were not addressed, but my practice parallels the earlier-listed results. Protected play is typically allowed immediately for stable fractures and roughly 1 to 2 weeks after surgery. Unprotected play is allowed usually 6 to 8 weeks after injury or surgery. Range of motion is initiated within 2 to 3 days after surgery. Noncontact workouts are allowed as soon as initial postsurgical swelling calms.
Hand Clin 28 (2012) 407–408 doi:10.1016/j.hcl.2012.05.035 0749-0712/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
hand.theclinics.com
R. Glenn Gaston, MD
408
Phalangeal Fractures Commentary Contact drills with protection are allowed between 1 and 3 weeks depending on the specific fracture. Player position and hand dominance also affect return to play. Players who can play with larger forms of immobilization (linemen) can return more quickly than those in whom little to no immobilization is tolerated (wide receivers and dominant hand of quarterbacks). Hand dominance is mainly an issue with quarterbacks and centers and less so with all other players. College and high school athletes represent the next tier of elite athletes. It is hard to consider all high school and college athletes as a single entity when making generalized treatment recommendations. In reality, there are top-level high school athletes with college scholarships in the balance who we choose to manage aggressively, virtually identical to the recommendations in this article on professional athletes. Other high school athletes do not have aspirations of a career in sports and are managed less aggressively, more in line with the population at large. Similarly, some college athletes are among the elite with National Football League (NFL) careers in the near future who we manage identically to our NFL athletes. One unique aspect of college athletics is the ability to medically redshirt. Athletes, especially in their freshmen and sophomore year, who sustain a potentially season-ending injury can apply for a medical redshirt based on the amount of playing time they have had during that season. If successful, no eligibility is lost for an additional future year. This decision is made in conjunction with the team, school, and player.
NATIONAL ASSOCIATION FOR STOCK CAR AUTO RACING Despite being the most watched sport in the United States, National Association for Stock Car Auto Racing (NASCAR) positions are almost completely unknown except to the most avid of fans. Most Americans know the positions on a football, basketball, and baseball team whether or not they have ever played the sport. Most physicians understand the forces placed on the hands and wrists of each position on a football, basketball, and baseball team, allowing decisions for return to play to be made accurately. NASCAR teams are composed of a driver and pit crew (and technically also crew chiefs and spotters, who can be thought of as coaches). Most can understand generally the forces experienced by the drivers; however, there are subtle differences
in the grip on the wheel that can be important, particularly with phalangeal injuries. The pit crew is composed of the following 7 positions: front and rear changers, front and rear carriers, jack man, fuel man, and utility man. These 7 members can refuel the car and change 4 tires in 12 to 15 seconds and commonly sustain injuries to the hand and wrist. Changers remove and replace the lug nuts on the tires. Carriers bring new tires over the wall and align them on the studs of the car. Carriers also make adjustment to the track bars and wedges. The jack man, as the name suggests, carries a jack to raise the sides of the car during tire changes. The gas man carries the fuel on his shoulder to refill the car. The seventh utility man performs odd jobs such as windshield cleaning. NASCAR has a very long season lasting from mid-February to the end of November; therefore treatment is usually immediate with the rare exception of off-weeks in the near future and the final few weeks of the season in which treatment may be temporarily deferred. The positions can be correlated fairly well with certain positions on a football team. Drivers, such as quarterbacks, are the high-profile members of the team and can tolerate immobilization minimally. When immobilization is required for drivers, it is helpful to have the driver bring the wheel into the office and “mold” splints or casts to match his grip on the wheel. We have used this technique effectively to allow drivers to race with “protected play”. Many drivers, however, rely heavily on the ability to “feel the car” and do not tolerate immobilization of any sort on the hand. Changers are very similar to wide receivers in terms of their hand use and the forces encountered. Carriers are similar to linebackers in terms of strength required but place tremendous loads on the fingers for gripping the heavy tires (similar to a running back’s hands for gripping the ball). The jack man and fuel man can be treated similar to linemen for the most part. Return to play for the aforementioned positions parallel those described in the earlier-mentioned football commentary. Protective splinting is almost identical to those referenced in the article and figures in the article. Hand dominance is relevant for drivers in terms of which fingers rest within the spokes of the steering wheel in terms of splint design. Hand dominance is also relevant for changers, specifically for the “trigger finger” on the gun. R. Glenn Gaston, MD
In addition to fracture pattern, the management of phalangeal fractures in professional football players is in large dictated by nonbiologically related factors such as the remaining games in the season, player position, and hand dominance. The treatment of an unstable, displaced transverse proximal phalanx fracture in the nondominant hand of a lineman may vary considerably from the identical fracture in the throwing hand of a quarterback. Unique considerations for management of these common fractures in high-level football players are briefly reviewed. The decision for operative versus nonoperative fracture management is typically determined by the stability of the fracture, as outlined in the above article. There are instances, however, when exceptions to this rule may be made. For instance, some nondisplaced fractures at risk for displacement, such as a condylar fracture, may be selected for percutaneous screw fixation to allow more rapid rehabilitation and return to play. Similarly, a long nondisplaced spiral fracture in the throwing hand of a quarterback may be selected for percutaneous screw fixation to allow for more rapid return to sport. Risks and benefits of arguably unnecessary surgery must be clearly explained and documented. These decisions are usually the product of a “team approach” of discussion amongst the player, treating physician, trainer, coach, and, at times, the player’s agent. Also, the timing of surgery may vary depending on the point in the season. For example, the same fracture presenting during preseason, midseason, and with 1 week re-
maining in the season may likely be treated immediately, prior to the next bye week, or at the completion of the season, respectively, if a playing cast can be worn in the interim. However, most fractures that require surgery are treated as soon as possible to allow the earliest institution of rehabilitation. Perhaps the most challenging aspect of caring for professional athletes is the doctor’s note for clearing a participant for return to sport. One must balance the risks of premature return to play and reinjury versus delayed return to play and professional and financial retributions incurred by the player and team. In a recent survey of team physicians for professional sports teams, roughly one-third of physicians allowed immediate return to protected play for nondisplaced hand fractures and another 50% allowed return to protected play in 3 to 4 weeks. Similarly, after rigid internal fixation, roughly one-third allowed immediate return to protected play and another 50% allowed return to protected play at 3 to 4 weeks postoperatively. Most allowed unprotected return to play at the 6to 8-week mark for hand fractures. Phalangeal fractures specifically were not addressed, but my practice parallels the earlier-listed results. Protected play is typically allowed immediately for stable fractures and roughly 1 to 2 weeks after surgery. Unprotected play is allowed usually 6 to 8 weeks after injury or surgery. Range of motion is initiated within 2 to 3 days after surgery. Noncontact workouts are allowed as soon as initial postsurgical swelling calms.
Hand Clin 28 (2012) 407–408 doi:10.1016/j.hcl.2012.05.035 0749-0712/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.
hand.theclinics.com
R. Glenn Gaston, MD
408
Phalangeal Fractures Commentary Contact drills with protection are allowed between 1 and 3 weeks depending on the specific fracture. Player position and hand dominance also affect return to play. Players who can play with larger forms of immobilization (linemen) can return more quickly than those in whom little to no immobilization is tolerated (wide receivers and dominant hand of quarterbacks). Hand dominance is mainly an issue with quarterbacks and centers and less so with all other players. College and high school athletes represent the next tier of elite athletes. It is hard to consider all high school and college athletes as a single entity when making generalized treatment recommendations. In reality, there are top-level high school athletes with college scholarships in the balance who we choose to manage aggressively, virtually identical to the recommendations in this article on professional athletes. Other high school athletes do not have aspirations of a career in sports and are managed less aggressively, more in line with the population at large. Similarly, some college athletes are among the elite with National Football League (NFL) careers in the near future who we manage identically to our NFL athletes. One unique aspect of college athletics is the ability to medically redshirt. Athletes, especially in their freshmen and sophomore year, who sustain a potentially season-ending injury can apply for a medical redshirt based on the amount of playing time they have had during that season. If successful, no eligibility is lost for an additional future year. This decision is made in conjunction with the team, school, and player.
NATIONAL ASSOCIATION FOR STOCK CAR AUTO RACING Despite being the most watched sport in the United States, National Association for Stock Car Auto Racing (NASCAR) positions are almost completely unknown except to the most avid of fans. Most Americans know the positions on a football, basketball, and baseball team whether or not they have ever played the sport. Most physicians understand the forces placed on the hands and wrists of each position on a football, basketball, and baseball team, allowing decisions for return to play to be made accurately. NASCAR teams are composed of a driver and pit crew (and technically also crew chiefs and spotters, who can be thought of as coaches). Most can understand generally the forces experienced by the drivers; however, there are subtle differences
in the grip on the wheel that can be important, particularly with phalangeal injuries. The pit crew is composed of the following 7 positions: front and rear changers, front and rear carriers, jack man, fuel man, and utility man. These 7 members can refuel the car and change 4 tires in 12 to 15 seconds and commonly sustain injuries to the hand and wrist. Changers remove and replace the lug nuts on the tires. Carriers bring new tires over the wall and align them on the studs of the car. Carriers also make adjustment to the track bars and wedges. The jack man, as the name suggests, carries a jack to raise the sides of the car during tire changes. The gas man carries the fuel on his shoulder to refill the car. The seventh utility man performs odd jobs such as windshield cleaning. NASCAR has a very long season lasting from mid-February to the end of November; therefore treatment is usually immediate with the rare exception of off-weeks in the near future and the final few weeks of the season in which treatment may be temporarily deferred. The positions can be correlated fairly well with certain positions on a football team. Drivers, such as quarterbacks, are the high-profile members of the team and can tolerate immobilization minimally. When immobilization is required for drivers, it is helpful to have the driver bring the wheel into the office and “mold” splints or casts to match his grip on the wheel. We have used this technique effectively to allow drivers to race with “protected play”. Many drivers, however, rely heavily on the ability to “feel the car” and do not tolerate immobilization of any sort on the hand. Changers are very similar to wide receivers in terms of their hand use and the forces encountered. Carriers are similar to linebackers in terms of strength required but place tremendous loads on the fingers for gripping the heavy tires (similar to a running back’s hands for gripping the ball). The jack man and fuel man can be treated similar to linemen for the most part. Return to play for the aforementioned positions parallel those described in the earlier-mentioned football commentary. Protective splinting is almost identical to those referenced in the article and figures in the article. Hand dominance is relevant for drivers in terms of which fingers rest within the spokes of the steering wheel in terms of splint design. Hand dominance is also relevant for changers, specifically for the “trigger finger” on the gun. R. Glenn Gaston, MD