Abstract
Background:
Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers.
Methods:
Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed.
Results:
Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort.
Conclusions:
Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.
Keywords: metacarpal fracture, Major League Baseball, professional athlete, performance, return to sport
Introduction
Major League Baseball (MLB) is one of the foremost throwing sports in the world, 1 and players depend on full function of their hands for optimal performance. 2 However, with a 162-game schedule over a 6-month season, 3 players are at significant risk for acute or chronic injury to the hand and wrist, which may result in prolonged time on the injured reserve. 4 From 2011 to 2016, there were 4478 hand and 1748 wrist injuries throughout the MLB and Minor League Baseball (MiLB), resulting in a total of 105 246 days out of play (the equivalent of 575 individual MLB player seasons). 4 These injuries often result from contact with the baseball, ground, other players, bat, or outfield wall, with 40% occurring during batting and 30% during fielding. 4
Metacarpal fractures are the most common hand fracture encountered by MLB players, 4 often resulting from a direct blow to the dorsum of the lower hand on the bat by an errant pitch. 5 Less commonly, a fracture may occur while sliding headfirst into a base. 5 The risk of functional hand impairment following metacarpal fracture may negatively impact a player’s return to previous athletic performance. 6
While some studies have reported on return to play following a metacarpal fracture,7,8 few have assessed the effect of this injury on future athletic performance among professional athletes.2,9,10 The purpose of this study was to evaluate performance before and after injury in MLB positional players who sustain metacarpal fractures and to compare their postinjury performance to control-matched peers. We also sought to evaluate the impact of nonoperative and operative treatments on performance outcomes and time to return to sport.
Materials and Methods
The study group contained MLB players who sustained an acute metacarpal fracture during a 17-year time period between the 2001 and 2017 seasons. The study cohort was identified using a comprehensive online injury database (www.prosportstransactions.com) cross-referenced with team press releases, online injury reports, and player profiles (www.mlb.com and www.baseballreference.com). This methodology has been validated in multiple studies across multiple sports.2,11-15 Given the public nature of these data, this study was exempt from Institutional Review Board approval and did not require informed consent.
All MLB players with acute metacarpal fractures within the study period were initially identified. Pitchers were excluded from analysis as our study focus was performance among positional players. Players were included for analysis if they had played in at least 2 MLB seasons before and 2 MLB seasons after the index injury season. Given the inherent variability season-to-season among performance in professional baseball players, this criterion was set in an effort to gain an accurate representation of players’ performance over the long term. A smaller sample size would likely not be a reliable measure of performance and could result in type I or type II error. This criterion has been used in prior published studies examining upper extremity fractures in professional athletes.1,2
Forty-five players with acute metacarpal fractures were initially identified, representing all MLB players who sustained a metacarpal fracture during our study period. Of these 45 players, 10 were pitchers and were excluded from analysis. Of the 35 remaining players, 2 were in their first or second year in the MLB and were excluded due to a lack of performance data before the injury. Nine players did not play for 2 full seasons following injury and were excluded. Of these players, just 1 did not return to sport as he was suspended due to off-field conduct and eventually released. Four players returned to sport during their injury season, then retired, and 4 players returned to sport the following season, then retired. None of these players cited their hand injury as their reason for retirement. The remaining 24 players had complete statistical performance data and were included in the study. A flowchart demonstrating our selection process is depicted in Figure 1.
Figure 1.
Flow diagram depicting the selection process of included MLB players.
Note. MLB = Major League Baseball
A one-to-one matched control group was selected based on similarity scores provided by a comprehensive online database (www.baseballreference.com). These scores identify players whose careers are most similar according to performance data and seasons of play. Players in the control cohort were additionally matched according to position and all efforts were made to select controls without a significant injury history. A cohort group was used for comparison to minimize potential confounding variables inherent in the career path of MLB players as their performance may be affected by increasing age and experience. The index injury season was defined as the season in which the subject player sustained the metacarpal injury. Controls were assigned an index season, matched to the age of the individual at the time of injury.
Demographic data including player age, position, career experience, date of injury, body mass index (BMI), mechanism of injury, handedness, and whether the player underwent surgical treatment of his metacarpal fracture were recorded. Wins Above Replacement (WAR), the main performance variable, was recorded for 2 seasons preceding and 2 seasons following injury for individuals and index for controls. Wins Above Replacement is used by baseball statisticians to quantify a player’s total contributions to their team in 1 statistic. This comprehensive metric allows for comparison between players. Additional performance data, from regular season games only, were recorded for the season preceding and the season following injury for individuals and index for controls. These parameters included isolated power (ISO), on-base plus slugging (OPS), 16 batting average (BA), and rates for doubles, triples, home runs, strike-outs, base on balls, and runs batted in. Statistics were reported as rates per at bat to allow for comparison between seasons while controlling for changes in plate appearances, games played, and variations in team dynamics. This methodology has been previously published. 12
Performance variables were presented as the mean difference between preinjury and postinjury statistics for players with metacarpal fractures and preindex and postindex statistics for matched controls. Comparisons were made using paired-samples Student t tests with significance set at P < .05. Multivariate regression analysis was performed to assess the impact of age, career experience, handedness, BMI, and treatment method on postinjury performance.
Results
Average age at the time of metacarpal fracture was 29.2 years for all players, and mean MLB career experience at the time of injury was 7.3 years (Table 1). The player’s throwing hand was involved in 9 of the 24 total cases (37.5%). The most common mechanism of injury was hit by pitch (18/24, 75%). The fifth metacarpal was most commonly fractured (14/24, 58.3%). Eleven players with metacarpal fractures were treated with surgery (45.8%) and 13 (54.2%) were treated nonoperatively.
Table 1.
Demographic and Injury Characteristics of MLB Players With Metacarpal Fractures.
| Demographics and Injury Characteristics | All | Nonoperative | Operative |
|---|---|---|---|
| No. of players, n (%) | 24 (100) | 13 (54.2) | 11 (45.8) |
| Age, y (mean) | 29.2 | 29.8 | 28.4 |
| BMI (mean) | 27 | 26.9 | 27.3 |
| Career experience, y (mean) | 7.3 | 8.4 | 6 |
| Throwing hand involved, n (%) | 9 (37.5) | 2 (15.4) | 7 (63.6) |
| Involved metacarpal, n (%) | |||
| 2 | 2 (8.3) | - | 2 (18.2) |
| 3 | 2 (8.3) | 1 (7.7) | 1 (9.1) |
| 4 | 6 (25) | 4 (30.7) | 2 (18.2) |
| 5 | 14 (58.3) | 8 (61.5) | 6 (54.5) |
| Position, n (%) | |||
| Catcher | 4 (16.7) | 2 (15.4) | 2 (18.2) |
| Infield | 11 (45.8) | 6 (46.2) | 5 (45.5) |
| Outfield | 9 (37.5) | 5 (38.5) | 4 (36.3) |
| Injury mechanism, n (%) | |||
| Hit by pitch | 18 (75) | 12 (92.3) | 6 (54.5) |
| Self-inflicted | 3 (12.5) | - | 3 (27.3) |
| Fielding | 1 (4.2) | - | 1 (9.1) |
| Sliding | 1 (4.2) | - | 1 (9.1) |
| Foul tip | 1 (4.2) | 1 (7.7) | - |
Note. MLB = Major League Baseball; BMI = body mass index.
There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts (Table 2). Comparing players treated operatively with those treated nonoperatively, no significant differences were found regarding change in WAR, ISO, OPS, BA, and performance variables per at bat following injury (Table 3). Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). Mixed effects regression analysis demonstrated that player age but not career experience, handedness, BMI, or treatment method was significantly associated with decline in WAR 1 and 2 seasons postinjury (P < .01).
Table 2.
Performance Comparison Preinjury and Postinjury Among MLB Players With Metacarpal Fractures Treated Nonoperatively and Operatively.
| All | Nonoperative | Operative | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | P value | Mean | SD | P value | Mean | SD | P value | |
| WAR ± 1 | 0.0125 | 2.2555 | .979 | 0.6231 | 2.3321 | .354 | −0.7091 | 2.0290 | .273 |
| WAR ± 2 | 0.5458 | 2.6994 | .332 | 1.3692 | 2.3785 | .060 | −0.4273 | 2.8369 | .628 |
| ISO | 0.0014 | 0.0751 | .930 | 0.0055 | 0.0773 | .800 | −0.0036 | 0.0759 | .879 |
| OPS | 0.0145 | 0.1379 | .611 | 0.0340 | 0.1658 | .474 | −0.0085 | 0.0982 | .779 |
| BA | 0.0054 | 0.0412 | .529 | 0.0033 | 0.0438 | .790 | 0.0078 | 0.0398 | .530 |
| 2B rate | 0.0011 | 0.0201 | .790 | −0.0033 | 0.0172 | .504 | 0.0063 | 0.0227 | .379 |
| 3B rate | −0.0004 | 0.0055 | .712 | 0.0009 | 0.0049 | .521 | −0.0020 | 0.0059 | .295 |
| HR rate | 0.0004 | 0.0206 | .932 | 0.0023 | 0.0204 | .686 | −0.0020 | 0.0215 | .766 |
| RBI rate | −0.0003 | 0.0368 | .971 | 0.0030 | 0.0443 | .814 | −0.0041 | 0.0270 | .626 |
| SO rate | −0.0005 | 0.0534 | .962 | −0.0098 | 0.0576 | .550 | 0.0105 | 0.0482 | .487 |
| BB rate | −0.0020 | 0.0337 | .779 | −0.0017 | 0.0363 | .870 | −0.0023 | 0.0321 | .819 |
Note. Performance variables presented as mean difference between preinjury and postinjury statistics. Positive numbers indicate postinjury decline, while negative numbers indicate improvement. MLB = Major League Baseball; WAR = Wins Above Replacement; ISO = isolated power; OPS = on-base plus slugging; BA = batting average; 2B = rates of doubles; 3B = rates of triples; HR = homerun; RBI = runs batted in; SO = strike out; BB = base on balls.
Table 3.
Comparing Performance Change Following Injury Between MLB Players With Metacarpal Fractures Treated Nonoperatively and Operatively.
| Operative | Nonoperative | ||||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | P value | |
| WAR ± 1 | −0.7091 | 2.0290 | 0.6231 | 2.3321 | .153 |
| WAR ± 2 | −0.4273 | 2.8369 | 1.3692 | 2.3785 | .105 |
| ISO | −0.0036 | 0.0759 | 0.0055 | 0.0773 | .774 |
| OPS | −0.0085 | 0.0982 | 0.0340 | 0.1658 | .698 |
| BA | 0.0078 | 0.0398 | 0.0033 | 0.0438 | .796 |
| 2B rate | 0.0063 | 0.0227 | −0.0033 | 0.0172 | .252 |
| 3B rate | −0.0020 | 0.0059 | 0.0009 | 0.0049 | .207 |
| HR rate | −0.0020 | 0.0215 | 0.0023 | 0.0204 | .619 |
| RBI rate | −0.0041 | 0.0270 | 0.0030 | 0.0443 | .650 |
| SO rate | 0.0105 | 0.0482 | −0.0098 | 0.0576 | .364 |
| BB rate | −0.0023 | 0.0321 | −0.0017 | 0.0363 | .698 |
| Games missed (mean) | 52.6 | 23.3 | 35.5 | 15.5 | .043 |
Note. Performance variables presented as mean difference between preinjury and postinjury statistics. Positive numbers indicate postinjury performance decline, while negative numbers indicate improvement. Bold outline denotes statistical significance. MLB = Major League Baseball; WAR = Wins Above Replacement; ISO = isolated power; OPS = on-base plus slugging; BA = batting average; 2B = rates of doubles; 3B = rates of triples; HR = homerun; RBI = runs batted in; SO = strike out; BB = base on alls.
Comparison of the fracture cohorts to the control cohorts revealed that controls were well matched preindex as there was no significant difference in age, career experience, BMI, or performance measures (Table 4). There were no statistically significant differences between the fracture and control cohorts regarding ISO, OPS, BA, and performance variables per at bat postinjury (Table 5). Players with metacarpal fractures treated nonoperatively had a significant decline in their WAR 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort. Performance data in Tables 2, 4, and 5 are presented as the difference between preinjury and postinjury performance; therefore, positive numbers indicate performance decline, while negative numbers indicate improvement.
Table 4.
Demographic and Performance Comparison Before Injury for Players With Metacarpal Fractures and Matched Controls.
| All | Matched controls | ||||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | P value | |
| Age, y | 29.167 | 3.266 | 29.167 | 3.266 | >.999 |
| BMI | 27.039 | 1.660 | 26.584 | 2.902 | .457 |
| Career experience | 7.292 | 3.850 | 6.708 | 3.196 | .162 |
| WAR (1 season before injury season) | 2.067 | 1.921 | 2.346 | 2.158 | .522 |
| WAR (2 seasons before injury season) | 1.938 | 2.047 | 1.996 | 1.883 | .885 |
| Preinjury ISO | 0.157 | 0.072 | 0.144 | 0.062 | .430 |
| Preinjury OPS | 0.741 | 0.096 | 0.732 | 0.118 | .677 |
| Preinjury BA | 0.270 | 0.028 | 0.258 | 0.039 | .150 |
| Position, n (%) | |||||
| Catcher | 4 (16.7) | 4 (16.7) | |||
| Infield | 11 (45.8) | 11 (45.8) | |||
| Outfield | 9 (37.5) | 9 (37.5) | |||
| Nonoperative | Matched controls | P value | |||
| Mean | SD | Mean | SD | ||
| Age, y | 29.846 | 3.693 | 29.846 | 3.693 | >.999 |
| BMI | 26.855 | 1.957 | 27.032 | 3.206 | .856 |
| Index season | 8.385 | 4.445 | 7.769 | 3.655 | .242 |
| WAR 1 season prior | 2.338 | 1.830 | 2.531 | 2.202 | .766 |
| WAR 2 seasons prior | 2.323 | 1.939 | 2.469 | 2.091 | .794 |
| Preindex ISO | 0.166 | 0.057 | 0.159 | 0.063 | .700 |
| Preindex OPS | 0.752 | 0.113 | 0.734 | 0.142 | .623 |
| Preindex BA | 0.259 | 0.030 | 0.251 | 0.042 | .372 |
| Position, n (%) | |||||
| Catcher | 2 (15.4) | 2 (15.4) | |||
| Infield | 6 (46.2) | 6 (46.2) | |||
| Outfield | 5 (38.5) | 5 (38.5) | |||
| Operative | Matched controls | P value | |||
| Mean | SD | Mean | SD | ||
| Age, y | 28.364 | 2.618 | 28.364 | 2.618 | >.999 |
| BMI | 27.257 | 1.284 | 26.054 | 2.544 | .094 |
| Index season | 6.000 | 2.646 | 5.455 | 2.067 | .441 |
| WAR 1 season prior | 1.745 | 2.064 | 2.127 | 2.191 | .539 |
| WAR 2 seasons prior | 1.482 | 2.169 | 1.436 | 1.508 | .942 |
| Preindex ISO | 0.146 | 0.057 | 0.125 | 0.059 | .509 |
| Preindex OPS | 0.728 | 0.075 | 0.729 | 0.089 | .949 |
| Preindex BA | 0.284 | 0.020 | 0.267 | 0.035 | .283 |
| Position, n (%) | |||||
| Catcher | 2 (18.2) | 2 (18.2) | |||
| Infield | 5 (45.5) | 5 (45.5) | |||
| Outfield | 4 (36.3) | 4 (36.3) | |||
Note. BMI = body mass index; WAR = Wins Above Replacement; ISO = isolated power; OPS = on-base plus slugging; BA = batting average.
Table 5.
Comparing Performance Change Following Injury Between MLB Players With Metacarpal Fractures and Matched Controls.
| All | Matched controls | ||||
|---|---|---|---|---|---|
| Mean | SD | Mean | SD | P value | |
| WAR ± 1 | 0.0125 | 2.2555 | 0.1808 | 2.2962 | .787 |
| WAR ± 2 | 0.5458 | 2.6994 | −0.6417 | 1.9500 | .127 |
| ISO | 0.0014 | 0.0751 | −0.0235 | 0.0533 | .234 |
| OPS | 0.0145 | 0.1379 | −0.0394 | 0.1329 | .206 |
| BA | 0.0054 | 0.0412 | −0.0076 | 0.0508 | .397 |
| 2B rate | 0.0011 | 0.0201 | 0.0035 | 0.0201 | .678 |
| 3B rate | −0.0004 | 0.0055 | −0.0016 | 0.0053 | .461 |
| HR rate | 0.0004 | 0.0206 | −0.0079 | 0.0167 | .176 |
| RBI rate | −0.0003 | 0.0368 | −0.0150 | 0.0379 | .201 |
| SO rate | −0.0005 | 0.0534 | 0.0005 | 0.0364 | .931 |
| BB rate | −0.0020 | 0.0337 | −0.0019 | 0.0359 | .997 |
| Nonoperative | Matched controls | ||||
| Mean | SD | Mean | SD | P value | |
| WAR ± 1 | 0.6231 | 2.3321 | 0.5415 | 2.6862 | .929 |
| WAR ± 2 | 1.3692 | 2.3785 | −0.8385 | 1.8342 | .021 |
| ISO | 0.0055 | 0.0773 | −0.0225 | 0.0669 | .417 |
| OPS | 0.0340 | 0.1658 | −0.0517 | 0.1530 | .194 |
| BA | 0.0033 | 0.0438 | −0.0155 | 0.0558 | .363 |
| 2B rate | −0.0033 | 0.0172 | 0.0025 | 0.0235 | .493 |
| 3B rate | 0.0009 | 0.0049 | −0.0015 | 0.0060 | .397 |
| HR rate | 0.0023 | 0.0204 | −0.0073 | 0.0206 | .343 |
| RBI rate | 0.0030 | 0.0443 | −0.0094 | 0.0398 | .514 |
| SO rate | −0.0098 | 0.0576 | 0.0011 | 0.0466 | .433 |
| BB rate | −0.0017 | 0.0363 | 0.0029 | 0.0321 | .745 |
| Operative | Matched controls | ||||
| Mean | SD | Mean | SD | P value | |
| WAR ± 1 | −0.7091 | 2.0290 | −0.2455 | 1.7603 | .601 |
| WAR ± 2 | −0.4273 | 2.8369 | −0.4091 | 2.1445 | .989 |
| ISO | −0.0036 | 0.0759 | −0.0247 | 0.0338 | .368 |
| OPS | −0.0085 | 0.0982 | −0.0249 | 0.1102 | .765 |
| BA | 0.0078 | 0.0398 | 0.0017 | 0.0450 | .803 |
| 2B rate | 0.0063 | 0.0227 | 0.0047 | 0.0163 | .843 |
| 3B rate | −0.0020 | 0.0059 | −0.0018 | 0.0048 | .894 |
| HR rate | −0.0020 | 0.0215 | −0.0086 | 0.0117 | .318 |
| RBI rate | −0.0041 | 0.0270 | −0.0216 | 0.0362 | .179 |
| SO rate | 0.0105 | 0.0482 | −0.0003 | 0.0209 | .581 |
| BB rate | −0.0023 | 0.0321 | −0.0076 | 0.0407 | .631 |
Note. Performance variables presented as mean difference between preinjury and postinjury statistics for players with metacarpal fractures and preindex and postindex statistics for matched controls. Positive numbers indicate postinjury performance decline, while negative numbers indicate improvement. Bold outline denotes statistical significance. MLB = Major League Baseball; WAR = Wins Above Replacement; ISO = isolated power; OPS = on-base plus slugging; BA = batting average; 2B = rates of doubles; 3B = rates of triples; HR = homerun; RBI = runs batted in; SO = strike out; BB = base on balls.
Discussion
Major League Baseball players are highly skilled athletes who depend on both hands to perform at the highest level of competition. Metacarpal fractures are among the most common fractures of the upper extremity17-19 and roughly 22.4% are sustained during athletic competition.18,20,21 Metacarpal fractures represent the fifth most common hand and finger diagnosis among MLB and MiLB players, trailing hand contusions, ulnar collateral ligament sprain or rupture of the thumb, blister, or other nonfracture injury. 4
The primary purpose of this study was to evaluate performance before and after injury in MLB positional players who sustain metacarpal fractures and to compare their postinjury performance to control-matched peers. Our data demonstrate that overall, professional baseball players who sustain metacarpal fractures can expect to return to their preinjury performance levels, with no difference in comparison to control-matched peers. Second, we examined whether the rate of return to play and postinjury performance differed based on operative versus nonoperative treatment. In our study, return to play was significantly faster for those treated nonoperatively compared with those who underwent operative fixation. Major League Baseball players treated nonoperatively experienced worse performance scores at 2 years compared with matched controls, while those treated operatively did not. However, on mixed effects regression analysis, only player age was associated with a significant decline in performance 1 and 2 seasons following injury. These findings are important for surgeons to recognize when counseling patients and making treatment recommendations.
Most metacarpal fractures can be treated nonoperatively with buddy taping, splinting, or casting followed by early range of motion. 6 As most metacarpal fractures in baseball players are of the nondominant hand, a splint may be worn inside the glove and return to play is dependent on pain control and range of motion. 5 However, the threshold for operative fixation may be lower in professional athletes 8 as surgery and anatomic reduction may afford these players perceived optimal hand function and quicker return to play. 6 Interestingly, we found a 46% rate of operative intervention in our study, which is higher than has been previously reported in the athletic population.7,8 In our study, return to play was significantly faster for those treated nonoperatively compared with those who underwent operative fixation (35.5 vs 52.6 missed games). However, these findings must be interpreted with caution as numerous confounding factors could influence this result such as timing of injury (off-season vs in-season), player contracts, and team priorities.
Rettig et al 7 reported on 56 metacarpal fractures in 53 athletes (average age, 16.3 years) of various sports. The operative intervention rate was 14%, and the average number of missed days in the surgically treated cohort was 13.6 days. In comparison, those treated nonoperatively with casting or splinting missed an average of 12.3 days. All baseball players were treated nonoperatively (n = 3) and missed a range of 0 to 28 days. Similarly, a recent systematic review and meta-analysis demonstrated delayed return to sport for operatively managed metacarpal fractures (22 days vs 28.5 days). 10 In a study of National Collegiate Athletic Association athletes with metacarpal fractures (n = 94), 22 the operative intervention rate was 16% and male student athletes treated nonoperatively returned to play roughly 2 weeks sooner than those treated with surgery (13.8 days vs 31.8 days). In addition, 93% of those treated nonoperatively were able to return within the same season versus 67% of those treated with operative management. Common complications following open reduction internal fixation of metacarpal fractures include metacarpophalangeal joint stiffness, implant failure, nonunion, and need for additional surgery.23,24 Thus, while disparity in return to play among the treatment cohorts was likely confounded by selection bias, one must be mindful that operative complications may contribute to delayed return. Kodama et al 8 retrospectively reviewed 105 athletes (average age, 20 years) with metacarpal or phalangeal fractures. Twenty of these athletes required early return to sport because of an impending important game within 1 month after injury. Of the 8 patients with metacarpal fractures treated surgically, each returned to sport within 4 weeks of the operation. It is important to note that each of these studies included younger athletes of various sports who did not play professionally. Thus, wide variability in return to sport and operative intervention rates of metacarpal fractures may be attributed to the type of sport being played, level of play, and overall expectations of the players and coaching staff. 6
Injury burden in professional athletes impacts not only their short-term competitiveness but also their longevity. 1 Expeditious return to play must therefore be weighed against long-term performance. 1 Guss et al 2 reported on performance outcomes after metacarpal fractures in 32 National Basketball Association players (average age, 27 years). Similar to our study, the rate of operative intervention was high (44%). Players returned to their preinjury performance levels following both operative and nonoperative treatment, and players who underwent surgery did not experience a significant decrease in performance when compared with control-matched peers. Similarly, Yalizis et al 9 found no difference in performance outcomes after surgically treated nonthumb metacarpal fractures in 16 Australian rules football players (average age, 25 years) when compared with preinjury performance levels. Our study is unique in that we also compared performance outcomes of the nonoperative cohort with control-matched peers. We found that MLB players treated nonoperatively experienced worse performance scores at 2 years compared with matched controls, while those treated operatively did not.
This study has several limitations. First, injury characteristics regarding the location and stability of the metacarpal fracture, nonoperative or operative treatment technique, rehabilitation protocol, or compliance measures were not available for inclusion. Data collection in this study involved publicly available online injury reports. Protected medical records and injury radiographs were not accessible, and therefore, we could not confirm specific fracture characteristics such as classification, open versus closed, or articular versus nonarticular. Second, confounding variables such as concomitant injuries, player trades, personal obligations, coaching changes, and changes to team strategies were not controlled for and may influence a player’s motivation to return to competition or performance. Finally, our study included a small sample size of a very specific patient population and thus lacks widespread applicability. Nonetheless, this study equips hand surgeons with quantifiable evidence to aid in managing athlete expectations and treatment recommendations.
Our findings demonstrate that MLB players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, while players treated nonoperatively may return more rapidly to competition, they may also experience a decline in their performance compared with their peers over the long term. Orthopedic surgeons treating MLB players with metacarpal fractures should consider this potential outcome when counseling their patients and making treatment recommendations.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: The study was based on publicly available information and therefore did not require institutional review board approval.
Statement of Informed Consent: Informed consent was obtained when necessary.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Suleiman Y. Sudah 
https://orcid.org/0000-0003-4412-4753
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