12 Jan Rising acute wrist injuries in goalkeepers
Approximately 25% of all sports-related injuries involve the hand or wrist.(1) These incidents are on the increase, not only due to the increasing physical demands athletes face but also due to the increased activity level noticed amongst the general population.(2)
Lower limb injuries predominate in football players and therefore much of the published literature focuses on the lower limb, with data on the upper limb being sparse.
However in goalkeepers hand and wrist injuries are the most common upper limb injuries, and goalkeepers are five times more likely than outfield players to sustain such an injury.(3) Goalkeepers require a high level of hand and wrist function in their role and injuries to these sites leads to a longer non-playing period than an outfield player.
This article follows on from our previous article discussing hand injuries in goalkeepers.(4) We now turn our attention to acute wrist injuries in players, more specifically goalkeepers. As poorly treated or undiagnosed injuries can be catastrophic and career-ending for them. We will focus on the commonest injuries and discuss our preferred treatment options, to reduce non-playing time and increase functional recovery.
The wrist is a complex joint that is made up of two carpal rows, the distal ends of the radius and ulna and the bases of the metacarpal bones. Stability is provided by the osseous anatomy and ligaments and these work in concert to provide movement in different planes. The ligaments can be divided into intrinsic and extrinsic. The most important intrinsic ligaments are the Scapholunate and lunotriquetral of which the Scapholunate is the most commonly injured.
The triangular fibrocartilage disc (TFC) attaches to the base of the ulnar styloid and the ulnar head of the distal radius. It forms part of the triangular fibrocartilage cartilage complex (TFCC). The TFCC supports the carpus, absorbing and transmitting axial force across the ulnar aspect of the wrist, as well as stabilizing the distal radio-ulnar joint (DRUJ). The TFC is particularly prone to injury.
Falling on an outstretched hand following a collision or direct impact of the football against the hand and wrist can lead to fracture, joint injury, ligament injury or a combination of injuries.
Distal radius fractures
In a study assessing the epidemiology of sports-related distal radius fractures, football accounted for 50% of the fractures.(5) Furthermore playing football on synthetic pitches increased the likelihood of a distal radius fracture by a factor of ﬁve.
In another study investigating professional football players, wrist fractures were the seventh most commonly reported upper limb injury, representing 17% of all wrist injuries. These players lost an average of 42 days playing time, or about one-third of the season.(6)
Non-operative treatment can be considered in the non-displaced, extra-articular fracture or the stable, reduced fracture. However, the risk of re-displacement persists and this often means a prolonged period in a cast and a delayed return to playing. In a professional football player, we believe open reduction and internal ﬁxation of the fracture using a volar locking plate (Fig 1a,b) should be considered as long as the risks of surgery are fully explained. Following surgery, we commence physiotherapy two weeks later when the wound has healed. An outﬁeld player can play after 2 weeks with a splint. For a goalkeeper, we would wait six weeks before allowing impact on the wrist.
For all multi-fragmented, displaced fractures we would recommend immediate ﬁxation with a locking plate.
Fig 1a. Comminuted intraarticular distal radius fracture
Fig 1b. Fracture ﬁxed with a volar locking plate, enabling early motion
Ulnar shaft fracture
Ulnar fractures are often called nightstick fractures as they classically result from warding off an overhead blow (nightstick being the colloquial name for a policeman’s baton in the USA). Goalkeepers can sustain these injuries when colliding with a post or colliding with an outfield player with the outer aspect of their forearm.
These injuries are classically mid-shaft and transverse and have a slightly increased rate of non-union. In the majority of cases, these fractures show no significant shortening or angulation. Unlike other forearm fractures, the proximal and distal radio-ulnar joint is intact. This injury can be managed in an ulnar gutter splint and or functional brace. For displaced, shortened or angulated nightstick fractures, open reduction and internal fixation with a plate are required.(7)
The scaphoid is the most commonly injured carpal bone, with the incidence of scaphoid fractures increasing among both elite and amateur footballers.(8)
Scaphoid fractures can be notoriously difﬁcult to diagnose clinically and on X-ray and are often missed. This can lead to non-union and subsequent arthritis termed scaphoid nonunion advanced collapse (SNAC). This occurs due to poor retrograde blood supply to the bone principally the proximal pole.
When treating professional footballers one must maintain a high index of suspicion. Clinically the player may only complain of mild non-speciﬁc pain and may not remember a fall or collision. It is important to remember that goalkeepers are particularly prone to scaphoid fracture when stopping a shot as this is the same as falling on an outstretched hand.
On examination, the player may or may not be tender in the anatomical snuff box, however axially loading the thumb could re-produce the pain. We recommend radiographic scaphoid views and if these do not show a fracture then an MRI scan should be obtained.
All acute proximal pole fractures should be treated with percutaneous ﬁxation because of high rates of non-union in this fracture pattern. Waist and distal pole fractures can be treated in a cast for 8-12 weeks, however, this can lead to increased wrist stiffness and longer time off playing. We would recommend operative ﬁxation of all acute scaphoid fractures with a headless compression screw (Fig 2). This enables early physiotherapy and a return to football.
SOFT TISSUE INJURIES
Scapholunate ligament injury
The scapholunate ligament sits between the scaphoid and the lunate bones in a horseshoe fashion tightly binding these bones together and is important in carpal stability. Injuries to this ligament usually occur after a fall, typically the wrist is extended ulnar deviated and supinated, although the player never remembers how they fell.
An X-ray can show a gap between the scaphoid and lunate (Fig 3). However, the radiographs can be normal and a diagnosis of a wrist sprain is usually made.(9) Treatment of acute, scapholunate ligament injuries have better outcomes than chronic injuries.(10) Therefore if a player complains of dorso-central wrist pain and the X-rays are normal, then one has to be highly suspicious of a scapholunate ligament injury. MRI can be utilized to help with diagnosis, but is not always accurate and may not define the extent of the injury. We find a wrist arthroscopy to be the best modality for evaluation of intrinsic wrist ligament injuries, and this remains the gold standard.(11) Arthroscopy allows the grade of the ligament injury to be defined and concomitant injuries such as triangular fibrocartilage injuries and joint cartilage damage to be assessed and debrided if necessary.
Partial stable scapholunate ligament injuries as defined by arthroscopy can be treated with physiotherapy and the player can play once the wounds have healed (5-7 days). He/She may require a splint for up to 4 weeks whilst playing.
Unstable Scapholunate injuries require open repair and a goalkeeper can be out of action for up to 3 months.
If a scapholunate ligament injury is missed the player will continue to complain of pain, weakness, clicking in the wrist and inability to take a load on the wrist. Goalkeepers will have pain when shot-stopping. If the situation is left undiagnosed this will lead to early arthritis in a predictive pattern termed scapholunate advanced collapse or SLAC wrist.
Lunotriquetral ligament injury
Lunotriquetral ligament injury is not as common as a scapholunate injury but similarly under-diagnosed. After an acute injury, the player will complain of pain and swelling in the dorsal and ulnar aspect of the wrist. X-rays can be normal in the acute phase. MRI may be helpful in diagnosis, but arthroscopy remains the gold standard for diagnosis and treatment. Arthroscopic assisted reduction and percutaneous pinning with Kirschner wire ﬁxation is our preferred treatment choice in complete lunotriquetral ligament tears.(12)
Triangular ﬁbrocartilage tears (TFC)
A TFC tear often occurs following a fall on a pronated extended wrist, which leads to impaction of the carpus on the ulnar and damage to the intervening TFC. The player experiences pain on the dorsal ulnar aspect of the wrist. The pain is exacerbated by wrist rotation and gripping, actions which are important in goalkeeping.
Radiographs are normal and MRI is commonly used to conﬁrm diagnosis. However, MRI sensitivity and speciﬁcity for TFC tears can be as low as 80%.(13)
TFC tears which are diagnosed on MRI scan should be treated initially with rest and immobilization as well as taking non-steroidal medication. Should symptoms not settle within 4 weeks then we would recommend a steroid injection.
In players with persistent ulnar sided wrist pain, we would recommend wrist arthroscopy for evaluation and debridement or repair of the tear. Central tears of the TFC are not amenable for repair as the central portion of the disc is avascular (Fig 4). Only peripheral tears are amenable to repair as they are in the vascular zone, but are much less common.
Triangular ﬁbrocartilage complex injury (TFCC)
Isolated TFC tears are not to be confused with an injury of the TFCC. The TFCC is a complex structure composed of the TFC, as well as the dorsal and palmar radioulnar ligaments, the ulnar collateral ligament and the extensor carpi ulnaris sheath.
A greater force is required to injure the TFCC and therefore TFCC injuries are not as common as isolated TFC tears. TFCC injuries can lead to DRUJ instability or dislocation.
An acutely subluxed or dislocated DRUJ needs to be reduced immediately and held in place with k wires for up to 6 weeks. Sometimes the DRUJ cannot be reduced closed because the extensor carpi ulnaris tendon can become interposed in the joint and then an open surgical approach is required.
Chronic DRUJ instability is often due to damage to several components of the TFCC. The players can experience pain over the DRUJ, weakness in grip, snapping of the distal ulnar and loss of forearm rotation. Treatment usually takes the form of reconstruction of the dorsal and palmar radioulnar ligaments using a free tendon graft.
Injuries to the TFCC and consequent instability of the DRUJ are debilitating injuries for goalkeepers leading to a prolonged time away from football.
Given the greater susceptibility of football players and especially goalkeepers to developing wrist injuries, we advise having a high index of suspicion for ligamentous injuries and occult fractures.
The aim is accurate and timely diagnosis as acute repair of the injured ligament or fixation of bone is preferred, owing to improved recovery times, less pain and more predictable outcomes. The goal of any treatment is to stabilise the wrist and expedite return to the pre-injury functional level.
As previously discussed in our article looking at hand injuries, a database of such injuries amongst this elite group of athletes would serve to guide future research and provide a more evidence-based approach in the management of amateur and professional football players.
Amadio PC. Epidemiology of hand and wrist injuries in sport. Hand Clin 1990 (6); 379-381
Avery, D. M., Rodner, C. M., & Edgar, C. M. (2016). Sports-related wrist and hand injuries: a review. Journal of orthopaedic surgery and research, 11, 99
Ekstrand J et al. Upper extremity injuries in male elite footballers. Knee Surg Traumatol Arthrosc. 2013, Jul 21(7); 1626-32
Haines and Bhatia. Hand Injuries in Goalkeepers. Football Medicine & Performance. 2018(25); 15-17
Lawson CM, Hadjucka C, McQueen MM. Sports fractures of the distal radius epidemiology and outcome. Injury 1995, Jan 26(1); 33-36
Court-Brown, C., Wood, A. and Aitken, S. (2008). The epidemiology of acute sports-related fractures in adults. Injury, 39(12), pp.1365-1372
Ali, Mohammed & I. Clark, D & Tambe, Amole. (2019). Nightstick Fractures, Outcomes of Operative and Non-Operative Treatment. Acta Medica (Hradec Kralove, Czech Republic). 62. 19-23
Fowler J, Hughes. Scaphoid fractures. Clinics in Sports Medicine. 34(1); 37-50
Paci, G. and Yao, J. (2015). Surgical Techniques for the Treatment of Carpal Ligament Injury in the Athlete. Clinics in Sports Medicine, 34(1), pp.11-35
Rohman, E., Agel, J., Putnam, M. and Adams, J. (2014). Scapholunate Interosseous Ligament Injuries: A Retrospective Review of Treatment and Outcomes in 82 Wrists. The Journal of Hand Surgery, 39(10); 2020-2026
Andersson, J., Andernord, D., Karlsson, J. and Fridén, J. (2015). Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2014, 31(10);1-7
Osterman A, Seidman G. The role of Arthroscopy in the treatment of L-T injuries. Hand Clinic 1995, 11; 41-50
Blazar, Chan et al. The effect of observer experience on magnetic resonance imaging interpretation and localization of triangular fibrocartilage complex lesions.J. Hand Surg (Am) 2001.