Abstract
Injuries to the hand and wrist are commonly
encountered in athletes. Decisions regarding the most appropriate
treatment, the timing of treatment, and return to play are made while
balancing desires to resume athletic activities and sound orthopedic
principles. Little recognition in the literature exists regarding the
need for a different approach when treating these injuries in elite
athletes and the timing to return to play.
This study explored the complexities of treating hand and wrist
injuries in the elite athlete. Thirty-seven consultant hand surgeons for
teams in the National Football League, National Basketball Association,
and Major League Baseball completed a brief electronic survey about the
management of 10 common hand injuries. Notable variability existed in
responses for initial management, return to protected play, and return
to unprotected play for all injuries, aside from near consensus
agreement (94%) that elite athletes with stable proximal interphalangeal
dislocations could immediately return to protected play. Basketball
surgeons were less likely to recommend early return to protected play
than non-basketball surgeons. Baseball surgeons were more likely to
recommend early unprotected play after scaphoid fixation. Football
surgeons were more likely to recommend earlier return to protected play
after thumb ulnar collateral ligament injuries, whereas basketball
surgeons were less likely to recommend earlier return to protected play.
This study demonstrated wide variability in how consultant hand
surgeons approach the treatment of hand and wrist injuries. The findings
emphasize the need to individually tailor treatment decisions to the
patient’s desires and demands, particularly in high-performance
athletes.
The authors are from the Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, New York.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Michelle Gerwin Carlson, MD, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 E 72nd St, 4th Floor, New York, NY 10021 (carlsonm@hss.edu).
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Michelle Gerwin Carlson, MD, Division of Hand and Upper Extremity Surgery, Hospital for Special Surgery, 523 E 72nd St, 4th Floor, New York, NY 10021 (carlsonm@hss.edu).
Injuries to the hand and wrist are commonly encountered in athletes.1–3
After arriving at a diagnosis,
the treating physician must address the many considerations that make
treating an athlete different than caring for other patients. Decisions
regarding the most appropriate treatment, the timing of treatment, and
circumstances surrounding return to play are made while balancing
desires to resume athletic activities and sound orthopedic principles.4
The same complexities that
differentiate the treatment of athletes from nonathletes are what
distinguish the management of injuries in elite athletes.5
High-performance athletes are
likely to have a different perspective than casual athletes, placing
greater importance on return to play given the implications on their
livelihood. Given these differences, expectations for treatment outcomes
in elite athletes are likely to be higher than those of casual
athletes. Although the literature is replete with case series and expert
opinions regarding the management of hand and wrist injuries in
athletes, little recognition exists regarding the need for a different
approach when treating injuries in elite athletes and timing to return
to play.
To further explore the complexities of treating hand and
wrist injuries in elite athletes, the authors conducted a survey of
consultant hand surgeons for professional football, basketball, and
baseball teams in the United States. Physicians were asked about their
practice of timing of surgery and return to play (both protected and
unprotected) for 10 common hand injuries. The authors hypothesized
opinions would vary widely regarding the treatment of hand and wrist
injuries in elite athletes, with notable differences based on experience
with athletes from different sports.
Materials and Methods
To generate the study cohort, team physicians for every team in the National Football League, National Basketball Association, and Major League Baseball were contacted and asked for the contact information for their consultant hand surgeon. Those 78 hand surgeons were requested to complete a brief electronic survey with questions about the management of metacarpal shaft fractures, scaphoid fractures, pisiform fractures, hamate hook fractures, thumb ulnar collateral ligament injuries, and dislocations of the proximal interphalangeal joint. This survey included questions about indications for surgery, return to protected play, and return for unprotected play (Table ). The survey items were derived from the senior author’s (M.G.C.) experience in treating professional athletes, including primary coverage of a National Basketball Association team. Invitations to complete the anonymous survey were distributed via e-mail using third-party software (SurveyMonkey, Palo Alto, California). One reminder to complete the survey was sent after the initial invitation. The research protocol was approved by the authors’ institutional review board prior to survey administration.
Table: Return to Play and Treatment Recommendations According to Hand and Wrist Injury
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Results
Thirty-seven consultant hand surgeons completed the survey, all of whom were affiliated with at least 1 professional sports team. Respondents were asked which sport they were currently affiliated with and were allowed to list more than 1 sport. Fifteen respondents reported that they treated elite athletes in only 1 sport and 22 reported that they treated elite athletes from more than 1 sport. The most commonly treated sports were baseball (n=22) and football (n=22), followed by basketball (n=19) and hockey (n=12). Eighteen of the respondents treated more than 12 elite athletes in 1 year, whereas 19 treated less than 12 elite athletes in 1 year.Metacarpal Fractures
Protected Play. Slightly more than half (n=21; 56.8%) of the 37 respondents allow elite athletes with nondisplaced metacarpal fractures to return to protected play at 3 to 4 weeks after injury, whereas 14 (37.8%) allow immediate return to protected play. Surgeons who treated basketball players were less likely to recommend early return to protected play than non-basketball surgeons (P=.047).Unprotected Play. Most respondents (n=27; 73%) waited until 4 to 8 weeks after injury for unprotected play to resume.
Scaphoid Fractures
Protected Play. Slightly more than half of the 37 respondents (n=19; 51.4%) allow elite athletes to return to protected play 4 to 6 weeks after treatment of a nondisplaced a scaphoid fracture. Twelve surgeons (32.4%) allow elite athletes to return to protected play immediately.Unprotected Play. Opinions regarding return to unprotected play were more variable: 9 (24.3%) allow return to unprotected play after 4 to 6 weeks, 18 (48.6%) after 6 to 12 weeks, and 10 (27%) wait more than 12 weeks. Surgeons who treated baseball players were more likely than non-baseball surgeons to recommend their patients to unprotected play earlier after treatment of a nondisplaced a scaphoid fracture (P=.005). Surgeons who treated athletes from more than 1 sport were also more aggressive in recommending earlier unprotected play after treatment of a non-displaced a scaphoid fracture (P=.042).
Pisiform Fractures
Treatment Decision. For elite athletes with pisiform fractures, 11 (29.7%) surgeons allow immediate return to play, 7 (18.9%) recommend immediate excision, 8 (21.6%) recommend splinting for 4 weeks followed by return to sport, 3 (8.1%) recommend excision after 4 weeks if not healed, and 8 (21.6%) recommend excision after 8 weeks if not healed.Surgeons who treat more than 12 elite athletes in 1 year are more likely to recommend immediate treatment (either immediate return to play or immediate excision), whereas surgeons who treat less than 12 elite athletes in 1 year are more likely to explore delayed treatment options (P=.043).
Hamate Hook Fractures
Protected Play. Following excision of hamate hook fractures, 11 (30.6%) of 36 surgeons allow immediate return to protected play, 19 (52.8%) allow return to protected play after 2 weeks, and 6 (16.7%) of surgeons allow return to protected play in 6 weeks.Unprotected Play. More than half of the 37 surgeons (n=20; 54.1%) allow return to unprotected play at 6 weeks, 15 (40.5%) allow return to unprotected play at 2 weeks, and 1 (2.7%) allows immediate return to unprotected play.
Thumb Ulnar Collateral Ligament Tears
Treatment Decision. For an elite athlete with a complete thumb ulnar collateral ligament tear, 14 (37.8%) of the 37 surgeons recommended immediate repair, 12 (32.4%) recommended repair at the end of the season (if within 6 weeks), 3 (8.1%) recommended repair at the end of the season (if within 3 months), 7 (18.9%) recommended repair at the end of the season (even if beyond 6 months from injury), and 1 (2.7%) surgeon recommended nonoperative treatment.Protected Play. For return to protected play after thumb ulnar collateral ligament injury, 5 (13.9%) of 36 surgeons recommended immediate return, 20 (55.6%)recommended waiting 2 weeks, 10 (27.8%) recommended waiting 6 weeks, and 1 (2.8%) recommended waiting 3 months. Surgeons who treat football players are more likely to recommend earlier return to protected play than non-football surgeons (P=.023), whereas surgeons who treat basketball players are less likely to recommend earlier return to protected play than non-basketball surgeons (P=.021).
Unprotected Play. For return to unprotected play, most of the 36 surgeons (n=23; 63.9%) recommended waiting 3 months.
Stable Proximal Interphalangeal Joint Dislocation
Protected Play. Almost all 36 (n=34; 94.4%) surgeons recommended immediate return to protected play for elite athletes with stable proximal interphalangeal dislocations, whereas 2 (5.6%) surgeons recommended waiting 4 weeks.Unprotected Play. More than one-quarter (n=11; 29.7%) of the 37 surgeons recommended returning to unprotected play after 4 weeks, 14 (37.8%) recommended waiting 4 to 8 weeks, and 3 (8.1%) surgeons recommended a period of more than 3 months before return to unprotected play.
Discussion
Increasing awareness of the influence of patient expectations on treatment outcomes6 indicates that surgeons need to be more cognizant of what patients desire and expect from treatment. This is particularly true when treating athletes who not only participate in sports for recreational or fitness pursuits but also rely on their athletic abilities for their livelihood. Recognition of elite athletes as a distinct patient population is important in allowing surgeons and patients to participate in shared decision making that balances the desires of immediate return to play with long-term sequelae.4 In the current study, the authors demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The individual experiences of the respondents have shaped their approaches to management, as the current results indicate that those who care for athletes of different sports occasionally have significantly different thresholds for return to protected and unprotected play. Treatment is tailored to the demands of the individual athletes and their sports, as evidenced by instances of more conservative management among surgeons who treat basketball players, whose sport requires distinct dexterity with a short interval between games.Although this survey provides a glimpse into the decision making of consultant hand surgeons, it is beyond the scope of this investigation to indicate whether these treatment recommendations predict outcomes, and this research needs to be done. Surgeons must carefully counsel patients about the risks and benefits of each nuanced aspect of treatment and, in situations where athletic performance has deep-seated career or financial implications, informed and shared decision making is critical to ensure satisfactory outcomes.
As the authors demonstrated, a major challenge in treating elite athletes is determining the appropriate time frame for return to play. The benefits of early return must be weighed against the consequences of potential complications. Although all patients with fractures who return to play too early may experience delayed healing or nonunion, the difficulty in treating these sequelae vary depending on the type of fracture. Metacarpal shaft nonunions or malunions can be readily treated with internal fixation and bone grafting (if needed), whereas pisiform nonunions can be treated with excision. However, premature return to play after scaphoid fracture can create unnecessarily challenging treatment scenarios because an acute fracture that is easily treatable may develop into a difficult-to-treat nonunion. Because the latter may have substantial negative short- and long-term effects, return to play after scaphoid fractures should be approached with more caution. For example, the authors prefer to confirm at least 50% healing with computed tomography before allowing return to play. Conversely, for proximal interphalangeal dislocations, the risk of a redislocation is small, especially with buddy taping, and the likelihood of being able to reduce a redislocated joint is high. Surgeons have a low threshold to allow immediate return to play for this injury.
The main limitations of the current study are centered on the survey tool. The injuries included in the survey are those that were felt to be commonly encountered, but with at least mild to moderate controversy regarding treatment. The survey was not designed to assess actual treatment decisions, but rather to demonstrate variability in decision making among consultant hand surgeons. A formalized validation process was not undertaken, but the survey was internally piloted among the hand surgery faculty of the authors’ academic institution. The response rate of the study cohort was 47% (37 of 78 consultant hand surgeons), which is less than desired but acceptable when compared with other surveys of professional surgeon groups.7–11 It is possible that the results may have been different if a larger proportion of the study cohort had completed the survey. Despite these limitations, the authors believe that the study has demonstrated the amount of variability in the decision making of consultant hand surgeons.
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