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The epidemiology of sports-related fractures of the hand
Injury, Int. J. Care Injured (2008) 39, 1377—1383
www.elsevier.com/locate/injury
The epidemiology of sports-related fractures of the hand Stuart Aitken *, Charles M. Court-Brown Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SU, UK Accepted 4 April 2008
KEYWORDS Fractures; Sports; Upper limb; Hand; Epidemiology
Summary Objective: To describe the incidence and epidemiology of acute sports-related hand fractures in the adult general population. Design: Retrospective analysis of a prospectively collected database recording all inpatient and outpatient fractures in a well-defined population during 2000. Setting: Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK. Results: During 2000, 1430 hand fractures were recorded, 320 of which (22.4%) were sports injuries. Males were more commonly injured (86%). The overall incidence was 60/105 (104/105 among males and 17/105 among females). The average age was 24 years. There were 39 (12.2%) carpal, 108 (33.8%) metacarpal and 173 (54.1%) phalangeal fractures. Damage to the first and fifth rays was most common. Open fractures were uncommon (n = 7; 2.2%). Eight sports were responsible for 87.8% of fractures, each sport displaying a characteristic pattern of injury within the hand. The majority of fractures (87.2%) were treated on an outpatient basis. Conclusions: Sporting activity accounts for 22.4% of all hand fractures, with relatively few requiring operative intervention. Young males are most commonly affected. Certain sports are associated with distinct fracture patterns, allowing appropriate preventive measures to be taken. # 2008 Elsevier Ltd. All rights reserved.
Introduction Participation in sport and exercise has many positive effects on health. Regular, moderate physical activ* Corresponding author. Tel.: +44 131 242 3497. E-mail addresses: [email protected], [email protected] (S. Aitken).
ity can improve cardiovascular status, psychological well-being and weight control. So what of the morbidity and mortality associated with such pursuits? There is a substantial literature describing injury and fracture incidence in popular sports, affecting both professional and amateur participants. Recent research by Court-Brown et al.2 has shown that, of all fractures due to sport
0020–1383/$ — see front matter # 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.04.012
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in the general population, it is fractures of the upper limb that predominate. The majority of these injuries occur in the hand, yet there is little detailed information available on the epidemiology of this group of fractures. Much of the published literature on sports-related trauma describes ‘fracture’ or ‘injury’ to the ‘upper limb’ or ‘hand’, but lacks further delineation.3,7,11,12 Fractures of the carpals, metacarpals and phalanges can often be managed in a straightforward manner, but are not without complication. Malunion and its associated deformities, non-union and particularly stiffness can all lead to functional deficit and disability. The aim of this study is to describe in more detail the epidemiology of sports-related fractures of the hand.
Patients and methods All inpatient and outpatient fractures presenting acutely to the Royal Infirmary of Edinburgh Orthopaedic Unit were recorded on a database. In 2000, the Royal Infirmary of Edinburgh treated all such patients aged 13 years or older from East Lothian and Midlothian, a total of 534,715. Children aged less than 13 years were treated elsewhere, and their records were consequently unavailable for analysis. We retrospectively identified a subgroup whose fracture affected the carpus, metacarpus and hand phalanges; among these, patients whose injury resulted from participation in sporting activity were included in our study. All those not residing in East Lothian or Midlothian were excluded from analysis. Radiographs of the fractures taken immediately after injury were analysed by an orthopaedic surgeon. Each fracture was given a diagnosis and was classified following the AO/OTA system.13 Open fractures were classified according to Gustilo and Anderson,5 and the Salter—Harris classification was used to describe physeal fractures.14 Stress fractures were excluded from analysis. Epidemiological data and the nature of the sporting activity were recorded for each case. Some similar sporting activities were combined to allow for more straightforward analysis; the various mar-
tial arts disciplines were grouped together as martial arts, football and Gaelic football were combined as football, and road cycling and track cycling were combined as cycling; mountain biking was considered a separate sport.
Results During 2000 the Royal Infirmary of Edinburgh treated 5953 fractures, on both inpatient and outpatient bases. Of these fractures, 1430 (24.0%) occurred in the hand, 320 (22.4%) of which were sporting injuries (Table 1). The incidence in the general adult population of sports-related fractures of the hand was 60.0/105, significantly greater among males (104.3/105) than females (16.6/105). Injuries to the carpus accounted for 39 (12.2%) of the 320 sports-related hand fractures (Table 2). One fracture occurred in conjunction with an ipsilateral phalangeal injury. There were 108 (33.8%) fractures of the metacarpus (Table 3) occurring in 102 cases, 5 of which involved fractures of 2 metacarpals in the same hand; one person had bilateral first metacarpal fractures after a skiing accident. Phalangeal fractures were the most common sports-related fracture seen, accounting for 173 (54.1%) injuries in 168 cases (Table 4). Two individuals had fractures of adjacent phalanges in the same digit, and a further three people had injuries to two digits in the same hand. There were no bilateral phalangeal injuries. When all fractures due to sport were analysed, hand phalanx fractures remained more common than distal radial fractures and than fractures of the clavicle. During 2000, the number of hand phalanx fractures caused by sporting activity was equal to the total number of sports-related fractures affecting the entire lower limb. When analysed in combination, fractures of the metacarpals and their respective phalanges accounted for 281 (39.2%) of all sports-related fractures. The 1st and 5th rays were most commonly damaged, together accounting for 57.3% of ray injuries. Use of the OTA fracture classification system allowed accurate documentation of the anato-
Table 1 Prevalence, average age and gender ratio of all hand fractures presenting in 2000 Fracture Carpus Metacarpus Phalanges Total M, male; F, female.
Total
Sports-related (n)
Sports-related (%)
Average age (years)
M:F (%)
159 697 574
39 108 173
24.5 15.5 30.1
26.1 24.0 24.4
87:13 87:13 80:20
1430
320
22.4
24.5
86:14
Incidence and epidemiology of acute sports-related hand fractures
1379
Table 2 The 11 sports associated with various fractures (n) to the carpus Sport
Fracture
% of all carpal fractures
Scaphoid
Triquetral
Pisiform
Trapezium
Total
Football Rugby Snowboarding Ice skating Skiing Basketball Squash Mountain biking Ice hockey Boxing Skateboarding
16 5 3 2 2 1 2 1 0 1 0
0 0 1 1 0 0 0 0 0 0 1
0 0 0 0 0 1 0 0 0 0 0
1 0 0 0 0 0 0 0 1 0 0
17 5 4 3 2 2 2 1 1 1 1
43.5 12.8 10.2 7.7 5.1 5.1 5.1 2.5 2.5 2.5 2.5
Total
33
3
1
2
39
100.0
The contribution of each activity to the total of sports-related carpal fractures is shown.
mical site of injury within each ray (Fig. 1). Physeal fractures accounted for the 20 (7.1%) ray injuries, with 4 Salter—Harris type II fractures in the metacarpus, 15 Salter—Harris type II fractures in the phalanges and a solitary Salter—Harris type I fracture of the ring finger distal phalanx. Of the ray fractures, 274 (97.5%) were closed injuries. Of the seven open ray fractures, one was a Gustilo and Anderson Grade 1 of the distal fifth metacarpal, five were Grade 1 and one was a Grade 3 fracture of the distal phalanx of the ring and little fingers. A total of 26 different sporting activities were identified; in our series, 8 sports were responsible for 8 or more injuries and accounted for 281 (87.8%) of the total 320 hand fractures. Football, rugby,
skiing, snowboarding, field hockey, basketball, martial arts and cricket accounted for 30 (76.9%) carpal fractures, 97 (89.8%) metacarpal fractures and 154 (89.0%) phalangeal fractures (Table 5). The top eight sports caused distinct fracture patterns within the rays (Table 6), commonly to the fifth ray in football and cricket and to the first ray in rugby and hockey. Skiing and snowboarding showed similar injury patterns, but basketball caused damage to the longer rays. A total of 279 (87.2%) sportsrelated hand fractures were treated on an outpatient basis. The remaining 41 fractures required operative intervention and hospital admission (Table 7), the majority of these occurring among males. Reduction and fixation of the scaphoid was
Table 3 The 16 sports associated with fractures (n) to the metacarpus Sport
Metacarpal 1st 2nd
3rd
4th
5th
Total
% of all metacarpal fractures
Football Rugby Skiing Snowboarding Hockey Martial arts Boxing Cricket Skateboarding Basketball American football Golf Horseriding Ice skating Mountain biking Running
7 12 5 0 5 0 0 0 0 0 1 0 0 1 0 0
4 2 0 0 0 1 2 0 0 0 0 1 0 0 0 0
4 2 6 2 0 1 0 0 1 0 0 0 0 0 0 0
1 2 3 4 0 3 0 0 0 0 0 0 0 0 1 1
20 5 3 1 1 0 1 2 1 1 0 0 1 0 0 0
36 23 17 7 6 5 3 2 2 1 1 1 1 1 1 1
33.3 21.3 15.7 6.5 5.6 4.6 2.8 1.9 1.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9
Total
31
10
16
15
36
108
100.0
The contribution of each sporting activity to the total of sports-related metacarpal fractures is shown.
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S. Aitken, C.M. Court-Brown
Table 4 The 19 sports associated with fractures (n) to the phalanges Sport
Phalanx Middle
Ring
Little
Total
% of all phalangeal fractures
Thumb
Index
Football Rugby Basketball Skiing Snowboarding Hockey Martial arts Cricket Horseriding Running Gymnastics Volleyball American football Canoeing Hurling Motocross Netball Shinty Tenpin bowling
10 8 0 4 6 3 0 1 0 0 1 0 0 0 1 1 0 0 0
10 4 4 1 0 3 1 0 0 0 0 0 0 0 0 0 1 1 0
5 2 4 1 0 1 2 1 1 0 1 0 0 0 0 0 0 0 0
9 8 4 2 3 3 0 0 1 3 0 1 1 0 0 0 0 0 1
28 5 2 5 4 2 4 4 2 1 0 1 0 1 0 0 0 0 0
62 27 14 13 13 12 7 6 4 4 2 2 1 1 1 1 1 1 1
35.8 15.6 8.1 7.5 7.5 6.9 4.0 3.4 2.3 2.3 1.6 1.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6
Total
35
25
18
36
59
173
100.0
The contribution of each sporting activity to the total of sports-related hand phalangeal fractures is shown.
involved in 6 of the operative cases; 13 required accurate reduction of an articular surface; 2 underwent washout and reduction of an open fracture; and in the remaining 20, unstable axial or rotational deformities in extra-articular fractures were corrected and fixed.
Discussion
Figure 1 Ray fractures due to sporting activity, seen in Edinburgh Royal Infirmary during 2000. The number of injuries at each site is shown. The proportional involvement of each ray is expressed as a percentage.
The aim of this study was to describe in detail the epidemiology of sports-related hand fractures. Many of the popular sports played in the UK lead to distinct fracture patterns in the hand. It would seem that the vast majority of these fractures are closed injuries and can be managed on an outpatient basis, with few requiring operative treatment. Sports and other physical activities have existed for thousands of years. Participation in sport from a young age has become part of popular culture. There is a wealth of literature describing the health benefits of exercise, such as improved cardiopulmonary function and glycaemic control,1,9 symptomatic improvement in osteoarthritis16 and improved psychological well-being.8 There is also evidence to suggest that regular physical activity contributes to the attainment of peak bone mass in adolescence and young adulthood, potentially protecting the individual from osteopenia and its consequences in later life.17
Incidence and epidemiology of acute sports-related hand fractures
1381
Table 5 The top eight sports associated with fractures (n) in the hand, showing the contribution of each sporting activity to the total of sports-related hand fractures Fracture
Sport Football
Carpus Metacarpus Phalanges Total Total (%)
Rugby
Skiing
Snowboarding
Hockey
Basketball
17 36 62
5 23 27
2 17 13
4 7 13
0 6 12
2 1 14
0 5 7
0 2 6
115
55
32
24
18
17
12
8
17.2
10.0
35.9
7.5
5.6
5.3
Martial arts
3.8
Cricket
2.5
Table 6 The top eight sports associated with hand fractures, showing injury distribution (%) between rays is shown, as well as the absolute number of ray fractures Ray
Sport Football
Rugby
Skiing
Snowboarding
Hockey
Basketball
Martial arts
Cricket
1st 2nd 3rd 4th 5th
17.3 14.3 9.2 12.2 50.0
40.0 12.0 8.0 20.0 20.0
30.0 3.3 23.3 16.7 26.7
30.0 0.0 10.0 35.0 25.0
44.4 16.7 5.5 16.7 16.7
0.0 26.7 26.7 26.7 19.9
0.0 16.7 25.0 25.0 33.3
12.5 0.0 12.5 0.0 75.0
Total (n)
98
50
30
20
18
15
12
Sporting activity is a frequent cause of fractures in the general population. Court-Brown et al. have shown that sport accounts for 12.8% of all fractures, with simple falls among elderly people (45.3%) and direct blows/assault (14.1%) being the two major causes.2 In sport, upper limb fractures are much more common than lower limb and axial skeleton fractures, accounting for 76.7% of sports fractures seen. Of these sporting upper limb fractures, a large proportion occurs in the hand (54.8%). If hand fractures from all causes are analysed, sporting activity accounts for 22.4% of these injuries, which can often be appropriately and successfully managed on an outpatient basis. This would appear to be so in our series, with only 12.8% of cases requiring admission for operative intervention. Further follow-up of the cases analysed was beyond the scope of this study, but it is important to be aware of the potentially disabling complications that can occur with fractures of the carpus, metacarpus and phalanges of the hand.6
8
It is accepted that the epidemiology of any sports-related injury will vary between countries, and even between regions within the same country. In relation to the remainder of the UK, Edinburgh is an affluent city that has in past years hosted a number of major sporting events such as the Commonwealth Games in 1970. There is a wide variety of sports clubs, schools and associations in the city, and many different sports are represented. Football and rugby remain the most popular, and so the results of our study at Edinburgh Royal Infirmary are thought to be representative of the majority of the UK. It is likely that they will also be applicable in many other countries where the pattern of sports participation is similar to our own. Football was the commonest cause of sportsrelated hand fracture in our study, accounting for 35.9% of the total number. It has been shown already that fractures in this sport often affect the distal radius (19.1%), and this might sensibly be attributed to falling onto the outstretched hand
Table 7 Prevalence, average age and gender ratio of all sports-related hand fractures treated on an inpatient basis in 2000 Fracture
Sports-related (n)
Inpatient (n)
Inpatient (%)
Average age (years)
M:F (%)
Carpus Metacarpus Phalanges
39 108 173
6 18 17
15.4 16.7 9.8
22.7 28.1 25.3
100:00 83:17 100:00
Total
320
41
12.8
26.1
93:70
M, male; F, female.
1382 during play.2 However, carpal, metacarpal and phalangeal fractures are also commonly seen, accounting for 5%, 10.6% and 17.6% of football fractures, respectively. The fifth ray is by far the most frequently injured ray in the hand, being affected in 51.7% of these hand fractures. The hand is seldom used (legally) in football, except to help maintain balance on the ball; there is very little ball carrying or contact between players, and so it is likely that the pattern of hand injury on football also may be attributed to falling. Rugby was responsible for 17.2% of sports fractures seen. It would seem from previous work that, although lower limb injuries are frequent, it is the bones of the hand that are most frequently fractured, accounting for 53.6% of all rugby fractures.2,4 In comparison with football, rugby is a very physical sport, with more ball handling, catching and grappling between players during the course of a game. As a result, the ray of the hand predominantly affected is the first, with a relatively high number of first metacarpal fractures. The third ray seldom suffers bony injury and may be protected by its position within the hand. Skiing accounted for 10.0% of sports-related hand fractures, with snowboarding responsible for 7.5%. Sasaki et al.15 and Matsumoto et al.10 have all shown that injury is three times more likely in snowboarding than in skiing, but our series did not demonstrate such a clear difference between the sports. CourtBrown et al.2 have demonstrated that the prevalence of hand phalanx fractures is very similar in both sports, accounting for approximately 23% and 28% of all skiing and snowboarding fractures, respectively, but that metacarpal fractures are more common in skiing. The mechanism of injury in skiing is likely to be related to falling, but might also be attributed to the use of ski poles, as we have demonstrated that the first ray is involved in 34.6% of skiing hand fractures. Snowboarding showed a relatively even fracture distribution across the rays and was associated with more carpal injuries than skiing, suggesting that falling onto the outstretched hand predominates. Field hockey accounted for only 5.6% of the sports-related hand fractures identified, but for 50% of the open fractures seen in the phalanges. Court-Brown et al. have shown that fracture of the hand phalanges is common in hockey, accounting for 48.0% of hockey fractures in their study.2 This is likely to be due to accidental contact between the hand and either a hockey stick or a hockey ball travelling at speed. The first ray was most commonly injured, in particular the metacarpal; this might be explained by the pattern of grip around the stick.
S. Aitken, C.M. Court-Brown Basketball is less popular in the UK than in many other European and North American countries, but accounted for 5.3% of fractures in our series. Injury almost exclusively involved the index, middle and ring fingers, with only one metacarpal fracture seen and no involvement of the first ray. These longer fingers are most at risk when attempting the catch a ball with the arms and hands outstretched. Basketball was the only activity in this series where the third ray was significantly represented when compared with its neighbours. Martial arts and cricket caused 3.8% and 2.5% of sports-related hand fractures, respectively. Falling is likely to account for the majority of martial arts hand fractures, as the ray distribution of injury displayed similarities to those of football and snowboarding. It is accepted, however, that these numbers are small and accurate analysis may not be possible. Fractures due to cricket predominantly affected the fifth ray, suggesting that the pattern of grip around the cricket bat leaves the ulnar border of the hand more exposed. Unlike hockey, however, this did not seem to be associated with an increased prevalence of open fractures. It is of interest that batsmen are likely to be wearing protective gloves.
Conclusions In sport as elsewhere, the focus must be on prevention of injury. In football, rugby and basketball for example, it is likely that hand fractures will always remain a risk for participants. It is difficult to imagine how protective equipment might be worn without limiting the freedom of hand movement that is so often required in these activities. Perhaps there is room for some improvement in the prevention of open fractures in field hockey, where the use of gloves might afford the wearer some protection from direct blows, similar to the assumed protection offered to batsmen playing cricket. The use of gloves is almost universal in skiing and snowboarding, the purpose of which is heat retention, rather than injury prevention. More robust glove design might protect winter sports enthusiasts from hand fractures, but it is accepted that this may simply shift the focus of injury to a different anatomical location.
Acknowledgements The authors are indebted to Mr. Benjamin Caesar, Specialist Registrar in Trauma and Orthopaedics, for his work in collating the 2000 database of acute fractures.
Incidence and epidemiology of acute sports-related hand fractures
Conflict of interest The authors have no conflicts of interest to declare.
References 1. Braith RW, Stewart KJ. Resistance exercise training: its role in the prevention of cardiovascular disease. Circulation 2006;113:2642—50. 2. Court-Brown CM, Wood AM, Aitken SA. The epidemiology of acute sports-related fractures. Injury 2008;39:1365—72. 3. Eyres KS, Abdel-Salam A, Cleary J. Upper limb fractures in rugby in Huddersfield 1986—1990. Br J Sports Med 1991;25: 139—40. 4. Garraway M, Macleod D. Epidemiology of rugby football injuries. Lancet 1995;345:1485—7. 5. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1035 open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg Am 1976; 58:453—8. 6. Henry MH. Fractures and dislocations of the hand. In: Bucholz RW, Heckman JD, Court-Brown C, editors. 6th ed., Rockwood and Green’s fractures in adults, vol. 1, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. p. 771—855. 7. Hickey GJ, Fricker PA, McDonald WA. Injuries of young elite female basketball players over a six-year period. Clin J Sport Med 1997;7:252—6.
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8. Lawlor DA, Hopker SW. The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001;322:763—7. 9. Linke A, Erbs S, Hambrecht R. Exercise and the coronary circulation–—alterations and adaptations in coronary artery disease. Prog Cardiovasc Dis 2006;48:270—84. 10. Matsumoto K, Miyamoto K, Sumi H, et al. Upper extremity injuries in snowboarding and skiing: a comparative study. Clin J Sport Med 2002;12:354—9. 11. Murtaugh K. Injury patterns among female field hockey players. Med Sci Sports Exerc 2001;33:201—7. 12. O’Rourke KP, Quinn F, Mun S, et al. A comparison of paediatric soccer. Gaelic football and rugby injuries presenting to an emergency department in Ireland. Injury 2007;38: 104—11. 13. Orthopaedic Trauma Association/Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 2006;10(Suppl. 1). 14. Salter R, Harris W. Injuries involving the epiphyseal plate. J Bone Joint Surg 1963;45:587—622. 15. Sasaki K, Takagi M, Ida H, et al. Severity of upper limb injuries in snowboarding. Arch Orthop Trauma Surg 1999;119:292—5. 16. Thomas KS, Muir KR, Docherty M, et al. Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ 2002;325:752. 17. Valimaki MJ, Karkkainen M, Lamberg-Allardt C, et al. Exercise, smoking and calcium intake during adolescence and early adulthood as determinants of peak bone mass. BMJ 1994;309:230—5.
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The epidemiology of sports-related fractures of the hand Stuart Aitken *, Charles M. Court-Brown Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SU, UK Accepted 4 April 2008
KEYWORDS Fractures; Sports; Upper limb; Hand; Epidemiology
Summary Objective: To describe the incidence and epidemiology of acute sports-related hand fractures in the adult general population. Design: Retrospective analysis of a prospectively collected database recording all inpatient and outpatient fractures in a well-defined population during 2000. Setting: Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK. Results: During 2000, 1430 hand fractures were recorded, 320 of which (22.4%) were sports injuries. Males were more commonly injured (86%). The overall incidence was 60/105 (104/105 among males and 17/105 among females). The average age was 24 years. There were 39 (12.2%) carpal, 108 (33.8%) metacarpal and 173 (54.1%) phalangeal fractures. Damage to the first and fifth rays was most common. Open fractures were uncommon (n = 7; 2.2%). Eight sports were responsible for 87.8% of fractures, each sport displaying a characteristic pattern of injury within the hand. The majority of fractures (87.2%) were treated on an outpatient basis. Conclusions: Sporting activity accounts for 22.4% of all hand fractures, with relatively few requiring operative intervention. Young males are most commonly affected. Certain sports are associated with distinct fracture patterns, allowing appropriate preventive measures to be taken. # 2008 Elsevier Ltd. All rights reserved.
Introduction Participation in sport and exercise has many positive effects on health. Regular, moderate physical activ* Corresponding author. Tel.: +44 131 242 3497. E-mail addresses: [email protected], [email protected] (S. Aitken).
ity can improve cardiovascular status, psychological well-being and weight control. So what of the morbidity and mortality associated with such pursuits? There is a substantial literature describing injury and fracture incidence in popular sports, affecting both professional and amateur participants. Recent research by Court-Brown et al.2 has shown that, of all fractures due to sport
0020–1383/$ — see front matter # 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2008.04.012
1378
S. Aitken, C.M. Court-Brown
in the general population, it is fractures of the upper limb that predominate. The majority of these injuries occur in the hand, yet there is little detailed information available on the epidemiology of this group of fractures. Much of the published literature on sports-related trauma describes ‘fracture’ or ‘injury’ to the ‘upper limb’ or ‘hand’, but lacks further delineation.3,7,11,12 Fractures of the carpals, metacarpals and phalanges can often be managed in a straightforward manner, but are not without complication. Malunion and its associated deformities, non-union and particularly stiffness can all lead to functional deficit and disability. The aim of this study is to describe in more detail the epidemiology of sports-related fractures of the hand.
Patients and methods All inpatient and outpatient fractures presenting acutely to the Royal Infirmary of Edinburgh Orthopaedic Unit were recorded on a database. In 2000, the Royal Infirmary of Edinburgh treated all such patients aged 13 years or older from East Lothian and Midlothian, a total of 534,715. Children aged less than 13 years were treated elsewhere, and their records were consequently unavailable for analysis. We retrospectively identified a subgroup whose fracture affected the carpus, metacarpus and hand phalanges; among these, patients whose injury resulted from participation in sporting activity were included in our study. All those not residing in East Lothian or Midlothian were excluded from analysis. Radiographs of the fractures taken immediately after injury were analysed by an orthopaedic surgeon. Each fracture was given a diagnosis and was classified following the AO/OTA system.13 Open fractures were classified according to Gustilo and Anderson,5 and the Salter—Harris classification was used to describe physeal fractures.14 Stress fractures were excluded from analysis. Epidemiological data and the nature of the sporting activity were recorded for each case. Some similar sporting activities were combined to allow for more straightforward analysis; the various mar-
tial arts disciplines were grouped together as martial arts, football and Gaelic football were combined as football, and road cycling and track cycling were combined as cycling; mountain biking was considered a separate sport.
Results During 2000 the Royal Infirmary of Edinburgh treated 5953 fractures, on both inpatient and outpatient bases. Of these fractures, 1430 (24.0%) occurred in the hand, 320 (22.4%) of which were sporting injuries (Table 1). The incidence in the general adult population of sports-related fractures of the hand was 60.0/105, significantly greater among males (104.3/105) than females (16.6/105). Injuries to the carpus accounted for 39 (12.2%) of the 320 sports-related hand fractures (Table 2). One fracture occurred in conjunction with an ipsilateral phalangeal injury. There were 108 (33.8%) fractures of the metacarpus (Table 3) occurring in 102 cases, 5 of which involved fractures of 2 metacarpals in the same hand; one person had bilateral first metacarpal fractures after a skiing accident. Phalangeal fractures were the most common sports-related fracture seen, accounting for 173 (54.1%) injuries in 168 cases (Table 4). Two individuals had fractures of adjacent phalanges in the same digit, and a further three people had injuries to two digits in the same hand. There were no bilateral phalangeal injuries. When all fractures due to sport were analysed, hand phalanx fractures remained more common than distal radial fractures and than fractures of the clavicle. During 2000, the number of hand phalanx fractures caused by sporting activity was equal to the total number of sports-related fractures affecting the entire lower limb. When analysed in combination, fractures of the metacarpals and their respective phalanges accounted for 281 (39.2%) of all sports-related fractures. The 1st and 5th rays were most commonly damaged, together accounting for 57.3% of ray injuries. Use of the OTA fracture classification system allowed accurate documentation of the anato-
Table 1 Prevalence, average age and gender ratio of all hand fractures presenting in 2000 Fracture Carpus Metacarpus Phalanges Total M, male; F, female.
Total
Sports-related (n)
Sports-related (%)
Average age (years)
M:F (%)
159 697 574
39 108 173
24.5 15.5 30.1
26.1 24.0 24.4
87:13 87:13 80:20
1430
320
22.4
24.5
86:14
Incidence and epidemiology of acute sports-related hand fractures
1379
Table 2 The 11 sports associated with various fractures (n) to the carpus Sport
Fracture
% of all carpal fractures
Scaphoid
Triquetral
Pisiform
Trapezium
Total
Football Rugby Snowboarding Ice skating Skiing Basketball Squash Mountain biking Ice hockey Boxing Skateboarding
16 5 3 2 2 1 2 1 0 1 0
0 0 1 1 0 0 0 0 0 0 1
0 0 0 0 0 1 0 0 0 0 0
1 0 0 0 0 0 0 0 1 0 0
17 5 4 3 2 2 2 1 1 1 1
43.5 12.8 10.2 7.7 5.1 5.1 5.1 2.5 2.5 2.5 2.5
Total
33
3
1
2
39
100.0
The contribution of each activity to the total of sports-related carpal fractures is shown.
mical site of injury within each ray (Fig. 1). Physeal fractures accounted for the 20 (7.1%) ray injuries, with 4 Salter—Harris type II fractures in the metacarpus, 15 Salter—Harris type II fractures in the phalanges and a solitary Salter—Harris type I fracture of the ring finger distal phalanx. Of the ray fractures, 274 (97.5%) were closed injuries. Of the seven open ray fractures, one was a Gustilo and Anderson Grade 1 of the distal fifth metacarpal, five were Grade 1 and one was a Grade 3 fracture of the distal phalanx of the ring and little fingers. A total of 26 different sporting activities were identified; in our series, 8 sports were responsible for 8 or more injuries and accounted for 281 (87.8%) of the total 320 hand fractures. Football, rugby,
skiing, snowboarding, field hockey, basketball, martial arts and cricket accounted for 30 (76.9%) carpal fractures, 97 (89.8%) metacarpal fractures and 154 (89.0%) phalangeal fractures (Table 5). The top eight sports caused distinct fracture patterns within the rays (Table 6), commonly to the fifth ray in football and cricket and to the first ray in rugby and hockey. Skiing and snowboarding showed similar injury patterns, but basketball caused damage to the longer rays. A total of 279 (87.2%) sportsrelated hand fractures were treated on an outpatient basis. The remaining 41 fractures required operative intervention and hospital admission (Table 7), the majority of these occurring among males. Reduction and fixation of the scaphoid was
Table 3 The 16 sports associated with fractures (n) to the metacarpus Sport
Metacarpal 1st 2nd
3rd
4th
5th
Total
% of all metacarpal fractures
Football Rugby Skiing Snowboarding Hockey Martial arts Boxing Cricket Skateboarding Basketball American football Golf Horseriding Ice skating Mountain biking Running
7 12 5 0 5 0 0 0 0 0 1 0 0 1 0 0
4 2 0 0 0 1 2 0 0 0 0 1 0 0 0 0
4 2 6 2 0 1 0 0 1 0 0 0 0 0 0 0
1 2 3 4 0 3 0 0 0 0 0 0 0 0 1 1
20 5 3 1 1 0 1 2 1 1 0 0 1 0 0 0
36 23 17 7 6 5 3 2 2 1 1 1 1 1 1 1
33.3 21.3 15.7 6.5 5.6 4.6 2.8 1.9 1.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9
Total
31
10
16
15
36
108
100.0
The contribution of each sporting activity to the total of sports-related metacarpal fractures is shown.
1380
S. Aitken, C.M. Court-Brown
Table 4 The 19 sports associated with fractures (n) to the phalanges Sport
Phalanx Middle
Ring
Little
Total
% of all phalangeal fractures
Thumb
Index
Football Rugby Basketball Skiing Snowboarding Hockey Martial arts Cricket Horseriding Running Gymnastics Volleyball American football Canoeing Hurling Motocross Netball Shinty Tenpin bowling
10 8 0 4 6 3 0 1 0 0 1 0 0 0 1 1 0 0 0
10 4 4 1 0 3 1 0 0 0 0 0 0 0 0 0 1 1 0
5 2 4 1 0 1 2 1 1 0 1 0 0 0 0 0 0 0 0
9 8 4 2 3 3 0 0 1 3 0 1 1 0 0 0 0 0 1
28 5 2 5 4 2 4 4 2 1 0 1 0 1 0 0 0 0 0
62 27 14 13 13 12 7 6 4 4 2 2 1 1 1 1 1 1 1
35.8 15.6 8.1 7.5 7.5 6.9 4.0 3.4 2.3 2.3 1.6 1.6 0.6 0.6 0.6 0.6 0.6 0.6 0.6
Total
35
25
18
36
59
173
100.0
The contribution of each sporting activity to the total of sports-related hand phalangeal fractures is shown.
involved in 6 of the operative cases; 13 required accurate reduction of an articular surface; 2 underwent washout and reduction of an open fracture; and in the remaining 20, unstable axial or rotational deformities in extra-articular fractures were corrected and fixed.
Discussion
Figure 1 Ray fractures due to sporting activity, seen in Edinburgh Royal Infirmary during 2000. The number of injuries at each site is shown. The proportional involvement of each ray is expressed as a percentage.
The aim of this study was to describe in detail the epidemiology of sports-related hand fractures. Many of the popular sports played in the UK lead to distinct fracture patterns in the hand. It would seem that the vast majority of these fractures are closed injuries and can be managed on an outpatient basis, with few requiring operative treatment. Sports and other physical activities have existed for thousands of years. Participation in sport from a young age has become part of popular culture. There is a wealth of literature describing the health benefits of exercise, such as improved cardiopulmonary function and glycaemic control,1,9 symptomatic improvement in osteoarthritis16 and improved psychological well-being.8 There is also evidence to suggest that regular physical activity contributes to the attainment of peak bone mass in adolescence and young adulthood, potentially protecting the individual from osteopenia and its consequences in later life.17
Incidence and epidemiology of acute sports-related hand fractures
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Table 5 The top eight sports associated with fractures (n) in the hand, showing the contribution of each sporting activity to the total of sports-related hand fractures Fracture
Sport Football
Carpus Metacarpus Phalanges Total Total (%)
Rugby
Skiing
Snowboarding
Hockey
Basketball
17 36 62
5 23 27
2 17 13
4 7 13
0 6 12
2 1 14
0 5 7
0 2 6
115
55
32
24
18
17
12
8
17.2
10.0
35.9
7.5
5.6
5.3
Martial arts
3.8
Cricket
2.5
Table 6 The top eight sports associated with hand fractures, showing injury distribution (%) between rays is shown, as well as the absolute number of ray fractures Ray
Sport Football
Rugby
Skiing
Snowboarding
Hockey
Basketball
Martial arts
Cricket
1st 2nd 3rd 4th 5th
17.3 14.3 9.2 12.2 50.0
40.0 12.0 8.0 20.0 20.0
30.0 3.3 23.3 16.7 26.7
30.0 0.0 10.0 35.0 25.0
44.4 16.7 5.5 16.7 16.7
0.0 26.7 26.7 26.7 19.9
0.0 16.7 25.0 25.0 33.3
12.5 0.0 12.5 0.0 75.0
Total (n)
98
50
30
20
18
15
12
Sporting activity is a frequent cause of fractures in the general population. Court-Brown et al. have shown that sport accounts for 12.8% of all fractures, with simple falls among elderly people (45.3%) and direct blows/assault (14.1%) being the two major causes.2 In sport, upper limb fractures are much more common than lower limb and axial skeleton fractures, accounting for 76.7% of sports fractures seen. Of these sporting upper limb fractures, a large proportion occurs in the hand (54.8%). If hand fractures from all causes are analysed, sporting activity accounts for 22.4% of these injuries, which can often be appropriately and successfully managed on an outpatient basis. This would appear to be so in our series, with only 12.8% of cases requiring admission for operative intervention. Further follow-up of the cases analysed was beyond the scope of this study, but it is important to be aware of the potentially disabling complications that can occur with fractures of the carpus, metacarpus and phalanges of the hand.6
8
It is accepted that the epidemiology of any sports-related injury will vary between countries, and even between regions within the same country. In relation to the remainder of the UK, Edinburgh is an affluent city that has in past years hosted a number of major sporting events such as the Commonwealth Games in 1970. There is a wide variety of sports clubs, schools and associations in the city, and many different sports are represented. Football and rugby remain the most popular, and so the results of our study at Edinburgh Royal Infirmary are thought to be representative of the majority of the UK. It is likely that they will also be applicable in many other countries where the pattern of sports participation is similar to our own. Football was the commonest cause of sportsrelated hand fracture in our study, accounting for 35.9% of the total number. It has been shown already that fractures in this sport often affect the distal radius (19.1%), and this might sensibly be attributed to falling onto the outstretched hand
Table 7 Prevalence, average age and gender ratio of all sports-related hand fractures treated on an inpatient basis in 2000 Fracture
Sports-related (n)
Inpatient (n)
Inpatient (%)
Average age (years)
M:F (%)
Carpus Metacarpus Phalanges
39 108 173
6 18 17
15.4 16.7 9.8
22.7 28.1 25.3
100:00 83:17 100:00
Total
320
41
12.8
26.1
93:70
M, male; F, female.
1382 during play.2 However, carpal, metacarpal and phalangeal fractures are also commonly seen, accounting for 5%, 10.6% and 17.6% of football fractures, respectively. The fifth ray is by far the most frequently injured ray in the hand, being affected in 51.7% of these hand fractures. The hand is seldom used (legally) in football, except to help maintain balance on the ball; there is very little ball carrying or contact between players, and so it is likely that the pattern of hand injury on football also may be attributed to falling. Rugby was responsible for 17.2% of sports fractures seen. It would seem from previous work that, although lower limb injuries are frequent, it is the bones of the hand that are most frequently fractured, accounting for 53.6% of all rugby fractures.2,4 In comparison with football, rugby is a very physical sport, with more ball handling, catching and grappling between players during the course of a game. As a result, the ray of the hand predominantly affected is the first, with a relatively high number of first metacarpal fractures. The third ray seldom suffers bony injury and may be protected by its position within the hand. Skiing accounted for 10.0% of sports-related hand fractures, with snowboarding responsible for 7.5%. Sasaki et al.15 and Matsumoto et al.10 have all shown that injury is three times more likely in snowboarding than in skiing, but our series did not demonstrate such a clear difference between the sports. CourtBrown et al.2 have demonstrated that the prevalence of hand phalanx fractures is very similar in both sports, accounting for approximately 23% and 28% of all skiing and snowboarding fractures, respectively, but that metacarpal fractures are more common in skiing. The mechanism of injury in skiing is likely to be related to falling, but might also be attributed to the use of ski poles, as we have demonstrated that the first ray is involved in 34.6% of skiing hand fractures. Snowboarding showed a relatively even fracture distribution across the rays and was associated with more carpal injuries than skiing, suggesting that falling onto the outstretched hand predominates. Field hockey accounted for only 5.6% of the sports-related hand fractures identified, but for 50% of the open fractures seen in the phalanges. Court-Brown et al. have shown that fracture of the hand phalanges is common in hockey, accounting for 48.0% of hockey fractures in their study.2 This is likely to be due to accidental contact between the hand and either a hockey stick or a hockey ball travelling at speed. The first ray was most commonly injured, in particular the metacarpal; this might be explained by the pattern of grip around the stick.
S. Aitken, C.M. Court-Brown Basketball is less popular in the UK than in many other European and North American countries, but accounted for 5.3% of fractures in our series. Injury almost exclusively involved the index, middle and ring fingers, with only one metacarpal fracture seen and no involvement of the first ray. These longer fingers are most at risk when attempting the catch a ball with the arms and hands outstretched. Basketball was the only activity in this series where the third ray was significantly represented when compared with its neighbours. Martial arts and cricket caused 3.8% and 2.5% of sports-related hand fractures, respectively. Falling is likely to account for the majority of martial arts hand fractures, as the ray distribution of injury displayed similarities to those of football and snowboarding. It is accepted, however, that these numbers are small and accurate analysis may not be possible. Fractures due to cricket predominantly affected the fifth ray, suggesting that the pattern of grip around the cricket bat leaves the ulnar border of the hand more exposed. Unlike hockey, however, this did not seem to be associated with an increased prevalence of open fractures. It is of interest that batsmen are likely to be wearing protective gloves.
Conclusions In sport as elsewhere, the focus must be on prevention of injury. In football, rugby and basketball for example, it is likely that hand fractures will always remain a risk for participants. It is difficult to imagine how protective equipment might be worn without limiting the freedom of hand movement that is so often required in these activities. Perhaps there is room for some improvement in the prevention of open fractures in field hockey, where the use of gloves might afford the wearer some protection from direct blows, similar to the assumed protection offered to batsmen playing cricket. The use of gloves is almost universal in skiing and snowboarding, the purpose of which is heat retention, rather than injury prevention. More robust glove design might protect winter sports enthusiasts from hand fractures, but it is accepted that this may simply shift the focus of injury to a different anatomical location.
Acknowledgements The authors are indebted to Mr. Benjamin Caesar, Specialist Registrar in Trauma and Orthopaedics, for his work in collating the 2000 database of acute fractures.
Incidence and epidemiology of acute sports-related hand fractures
Conflict of interest The authors have no conflicts of interest to declare.
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