- Comminuted or complex intra-articular fractures:
Highly comminuted articular fractures with dorsal
comminution and subchondral bone defects fre-
quently collapse and shorten thus requiring close
radiographic observation and remanipulation if nonop-
erative management is chosen. Fractures with articular
displacement greater than 2 mm often require external
fixation with or without limited internal fixation.
Accuracy of reduction may be assessed with either
open or arthroscopic visualization of the articular sur-
face to ensure anatomic restoration of the surface.
Bone grafting is often required to fill bony defects
especially in the subchondral region (Bass, Blair, and
Hubbard, 1995; Trumble et al, 1998; Geissler and
Freeland, 1996).
COMPLICATIONS
- Nonunion following distal radius fracture is a rare
occurrence while malunion is a common complication
(Harper and Jones, 1990; Cooney, Dobyns, and
Linscheid, 1980). Correction of malunion should be
undertaken when there is persistent pain and loss of
the functional wrist arc of motion.
RETURN TOSPORTS
- Stable fractures treated with splint or cast immobi-
lization should be maintained in a reduced position
until fracture healing is evident (4 to 8 weeks). The
athlete may then begin to rehabilitate the wrist using
a removable thermoplastic splint for the next 4 to 6
weeks until full pain-free range of motion and
strength has been achieved. Return to sports without
protection is usually not allowed until 3 months from
the time of injury. Fractures treated with rigid inter-
nal fixation can be protected by a thermoplastic
splint with early range of motion exercises. Once
radiographic evidence of healing is present, progres-
sive strengthening exercises may be begun but full
return to sport is not permitted before 3 months.
Unstable intra-articular fractures are often immobi-
lized for 6 to 12 weeks and full return to sports is
discouraged until motion and strength have been
restored (Morgan and Busconi, 1995; Christensen
et al, 1995).
SCAPHOID FRACTURES
- Scaphoid fractures are the most common carpal bone
fracture (1 in 100 college football players per year)
and often the result of apparently minor trauma
(Zemel and Stark, 1986). - Fracture mechanism is forced hyperextension with
ulnar deviation.- Extraosseous vascular supply enters the scaphoid at the
middle and distal poles while the proximal pole relies
on retrograde flow. This results in a high rate of avas-
cular necrosis and nonunion with proximal pole frac-
tures.
•Patient presents with pain in the anatomic snuff box. - Radiographs include PA, lateral, navicular, and closed
fist views. - Bone scan and MRI are useful in identifying nondis-
placed fractures.
•Treatment—Nondisplaced fractures (less than 1 mm
of displacement) - Immobilize in long-arm thumb spica cast with the
wrist in slight palmar flexion and radial deviation for
6 weeks followed by short-arm thumb spica cast
until healing is evident on radiographs, usually
within 3 months (Gellman et al, 1989). - If there is no evidence of healing by 3 to 4 months
then consider the use of bone grafting or electrical
stimulation to enhance healing. - Early operative intervention for nondisplaced frac-
tures with percutaneous compression screw fixation is
controversial but may allow the athlete an earlier
return to sports and lower risk of fracture displace-
ment and rehabilitation time (Koman, Mooney, and
Poehling, 1990; Geissler, 2001). - Athletes with snuffbox pain and negative radiographs
should be immobilized in thumb spica cast and
reassessed at 1–2-week intervals until the pain resolves
or the diagnosis is made radiographically (Geissler,
2001).
- Extraosseous vascular supply enters the scaphoid at the
TREATMENT—DISPLACEDFRACTURES- Most often requires open reduction and internal fixa-
tion to restore anatomic alignment and facilitate accu-
rate reduction with compression screws. - Compression screw fixation techniques have
improved and permit minimal immobilization of 2 to
3 weeks followed by early restorative therapy and
return to activities (Herbert and Fisher, 1984); how-
ever, with athletes susceptible to reinjury a 3- to 4-
month period of healing and rehabilitation may allow
a safer return to sports (Rettig et al, 1998).
RETURN TOSPORTS- Athletes may participate in sport with immobiliza-
tion; plastic, synthetic, and silastic casts have been
used effectively in contact sports (Reister et al,
1985). - Splint protection is continued for strenuous activities
for an additional 2–3 months following radiographic
healing until strength and motion approaches that of
the contralateral side (McCue, Bruce, Jr, and Koman,
2003).
312 SECTION 4 • MUSCULOSKELETAL PROBLEMS IN THE ATHLETE