Abstract
Background:
Metacarpal and phalanx fractures are common among professional athletes. There is a paucity of data to guide team physicians on expected return to play after hand fractures. The purpose of this study was to examine the epidemiology and return to play times after hand fractures in NCAA athletes. We hypothesized that surgical management of fractures may expedite return to play times.
Methods:
The NCAA Injury Surveillance Program database was queried for metacarpal and phalanx fractures during the 2009-2014 seasons in all sports. Injury rates per 100,000 athleteexposures (AEs) were calculated. Student’s t-test, Wilcoxon Rank sum tests, Chi-Squared tests, and Fisher Exact Test were used. Statistical significance was set to p<0.05.
Results:
Sports with the highest rates of phalanx and metacarpal fractures included Men’s Football, Men’s Ice Hockey, Men’s Wrestling, and Women’s Field Hockey. Multiple sports had participants with no hand fractures over the study period. Male student-athletes with metacarpal fractures treated operatively returned to play at a mean of 31.8±29.4 days versus 13.8±23.6 days for those treated non-operatively. 92% of male student-athletes were able to return to sport in the same season without operative management versus 67% with operative management. Female student-athletes had a cohort too small for statistical analysis. Return to play times for male student-athletes with phalanx fractures were not significantly different between operative and non-operative groups (16.1±21.5 days versus 7.1±13.3 days).
Conclusions:
Hand fractures are relatively common among NCAA student-athletes participating in contact sports. Student-athletes with metacarpal fractures returned to play at an average of 2-4 weeks after injury; those with phalanx fractures returned at an average of 1-2 weeks. The return to play times illustrated within this study can be used to counsel athletes, athletic trainers, and coaches.
Level of evidence: IV
Keywords: hand, fracture, athlete, NCAA, epidemiology
Introduction
Fractures of the phalanges and metacarpals of the hand are common among athletes,1-9 particularly among male athletes who participate in contact sports.1,3,5,6,8,9 Recent data estimate that 54% of sports-related hand injuries involve the phalanges, and 34% involve the metacarpals.1 Sports-related hand fractures may be managed non-operatively with splints or protective casts in the vast majority of patients (estimated 80–90% of cases).1,5-9 Non-operative management was originally thought to allow athletes to return to sport with little time-loss and without the risk of complications of wound healing or development of tendon or joint adhesion that may follow operative fixation of metacarpal and phalanx fractures. 5, 6, 9 Recent studies suggest that operative fixation of metacarpal fractures in athletes has increased over time, from an estimated 5–10% of cases in 20039 to upwards of 20% in 2014.7 Stern10 and Fufa et al.5 have also made note of the recent increase in procedures available for metacarpal fracture fixation.
Current literature surrounding operative fixation of metacarpal and phalanx fractures is dichotomous. There are multiple studies5,6,8,11 suggesting that open reduction and internal fixation (ORIF) of metacarpal fractures may provide increased fracture stability relative to a splint or cast, thereby allowing for earlier range of motion at the surrounding joints, decreased joint stiffness, and ultimately, a reduction in time-loss from sport participation. Other studies have suggested the opposite, demonstrating increased time-loss following operative management of metacarpal and phalanx fractures.12
There has been minimal investigation into the epidemiology of hand fractures and time-loss following fractures of the phalanges and metacarpals in National Collegiate Athletic Association (NCAA) student-athletes. There is a paucity of data to guide NCAA team physicians on expected time-loss and return to play after hand fractures treated operatively or non-operatively. The purpose of this study was to examine the epidemiology and return to play time frames after hand fractures in NCAA student-athletes. We hypothesized that rates of hand fractures would be higher amongst studentathletes participating in contact sports. Additionally, we hypothesized that surgical management of phalanx and metacarpal fractures may shorten time-loss and expedite return to play.
Methods
The study was approved by the Institutional Review Board at our institution, as well as by the NCAA. The NCAA Injury Surveillance Program database was queried for metacarpal, phalanx, and volar plate/avulsion fractures during the 2009–2010 to 2013–2014 academic years in all available contact and non-contact sports. Game and practice scenarios were queried. The NCAA Injury Surveillance Program (ISP) is a prospectively collected injury surveillance database managed by the Datalys Center for Sports Injury and Prevention. The methodology of the NCAA-ISP has been previously described.13-15 Data collected before the 2009 season were available in the NCAA-ISP but were not utilized in this study due to methodological differences in collection methods that had the potential to bias analysis of return to sport rates and times.13-15
Data Collection
The NCAA-ISP collects data from over 150 national colleges and universities that field collegiate athletic teams at the Division I–III levels. Data are collected and reported to the NCAA-ISP by certified Athletic Trainers (ATs) at participating institutions that are present during school-sanctioned games and practices.13-15 Such data is collected at the time of the injury.19 Data that is reported by the ATs includes exposure variables for all athletes participating in each respective event and injury variables for athletes that sustained an injury during each respective event. Additionally, ATs are able to return to records for the purposes of updating them as needed, i.e., if an athlete were to return to full participation after undergoing treatment for an injury.19 The validation process for data accepted into the NCAA-ISP has been described in detail in previous studies. 13-15
The database was queried for exposure and injury variables pertaining to all available metacarpal, phalanx, and volar plate fractures in all available sports: Men’s Baseball (BA-M), Men’s and Women’s Basketball (BB-M, BB-W), Men’s and Women’s Cross Country (CC-M, CC-W), Men’s Football (FB-M), Women’s Field Hockey (FH-W), Women’s Gymnastics (GY-W), Men’s and Women’s Ice Hockey (IH-M, IH-W), Men’s and Women’s Lacrosse (LX-M, LX-W), Women’s Softball (SB-W), Men’s and Women’s Soccer (SO-M, SO-W), Men’s and Women’s Swimming (SW-M, SW-W), Men’s and Women’s Tennis (TE-M, TE-W), Men’s and Women’s Indoor Track (IT-M, IT-W), Men’s and Women’s Outdoor Track (OT-M, OT-W), Women’s Volleyball (VB-W), and Men’s Wrestling (WR-M). Exposure variables queried included the academic year (season) and sport in which the athlete was participating. Injury variables collected included the academic year (season) and sport in which the injury occurred, number of days lost from participation due to the injury, if participant returned to play within the same season, type of injury (discussed below), and if surgery resulted from injury.
Definitions
Hand fractures were defined as metacarpal fractures of the fingers and thumb, phalanx fractures of the fingers and thumb, and volar plate/avulsion fractures of fingers. Return to sport was defined as a continuous variable, ranging from 0 days (no time lost from participation) to being out of participation for the remainder of the season. Return to sport within the same season as injury was defined as a binary yes or no variable. An athlete exposure was defined as one student-athlete’s participation in a game or practice event in which he or she was exposed to potential injury.
Statistical Analysis
Injury rates per 100,000 athlete-exposures (AEs) and return to play times for athletes treated with operative and non-operative management of the above fractures were calculated. Student’s t-test and Wilcoxon Rank sum tests were used for continuous variable and Chi-Squared tests and Fisher Exact Test were used for categorical variables to determine significance, set to p<0.05.
Results
Epidemiology and Rates of Hand Fractures
From the 2009–2010 to 2013–2014 seasons, 288 hand fractures (225 men, 63 women) were reported in NCAA athletes in 3,739,004 AEs [Table 1]. Sports with the highest rate of hand fractures were Men’s Ice Hockey, Men’s Football, and Men’s Wrestling [Table 2]. Participants in Men’s and Women’s Cross Country, Women’s Swimming, Men’s and Women’s Tennis, Men’s Indoor Track, and Men’s and Women’s Outdoor Track had no reported hand fractures during the 2009–2010 to 2013–2014 seasons. Sports with the highest rates of phalanx fractures were Men’s Ice Hockey, Women’s Field Hockey, and Men’s Baseball [Table 2]. Sports with the highest rate of metacarpal fractures were Men’s Wrestling, Men’s Football, and Men’s Basketball [Table 2]. Sports with the highest rate of volar plate/avulsion fractures were Women’s Ice Hockey, Men’s Wrestling, and Men’s Soccer [Table 2].
Table 1.
Epidemiology of Hand Fractures in NCAA Athletes
| Metacarpal | Phalanx | Volar Plate/Avulsion | All Fractures | |||
|---|---|---|---|---|---|---|
| Finger | Thumb | Finger | Thumb | |||
| Male | 83 | 27 | 83 | 25 | 7 | 225 |
| Female | 16 | 3 | 32 | 10 | 2 | 63 |
| Total | 99 | 30 | 115 | 35 | 9 | 288 |
Table 2.
Rates of Hand Fractures by Sport
| Sport | Metacarpal | Phalanx | Volar Plate/Avulsion | |||
|---|---|---|---|---|---|---|
| Rate* | 95% CI | Rate* | 95% CI | Rate* | 95% CI | |
| BA-M | 1.69 | (1.68, 1.69) | 6.18 | (6.17, 6.19) | 0.56 | (0.56, 0.57) |
| BB-M | 4.17 | (4.16, 4.18) | 1.85 | (1.85, 1.86) | 0.00 | -- |
| BB-W | 1.54 | (1.53, 1.55) | 4.62 | (4.61, 4.63) | 0.00 | -- |
| FB-M | 5.12 | (5.11, 5.12) | 3.23 | (3.22, 3.23) | 0.45 | (0.44, 0.45) |
| GY-W | 2.21 | (2.19, 2.22) | 0.00 | -- | 0.00 | -- |
| FH-W | 0.00 | -- | 10.73 | (10.70, 10.76) | 0.00 | -- |
| IH-M | 3.89 | (3.88, 3.89) | 12.01 | (12.00, 12.02) | 0.00 | -- |
| IH-W | 1.77 | (1.76, 1.78) | 0.88 | (0.88, 0.89) | 1.77 | (1.76, 1.78) |
| LX-M | 3.74 | (3.73, 3.75) | 1.25 | (1.24, 1.25) | 0.00 | -- |
| LX-W | 0.00 | -- | 1.89 | (1.89, 1.90) | 0.00 | -- |
| SB-W | 1.86 | (1.85, 1.87) | 4.34 | (4.33, 4.35) | 0.00 | -- |
| SO-M | 1.88 | (1.87, 1.89) | 1.88 | (1.87, 1.89) | 0.63 | (0.62, 0.63) |
| SO-W | 2.78 | (2.77, 2.79) | 1.85 | (1.85, 1.86) | 0.00 | -- |
| SW-M | 0.00 | -- | 1.03 | (1.03, 1.04) | 0.00 | -- |
| IT-W | 0.00 | -- | 0.99 | (0.98, 0.99) | 0.00 | -- |
| VB-W | 0.64 | (0.63, 0.64) | 2.55 | (2.54, 2.56) | 0.00 | -- |
| WR-M | 6.35 | (6.33, 6.37) | 1.27 | (1.26, 1.28) | 1.27 | (1.26, 1.28) |
Rate of respective fracture per 100,000 AE’s. Sports with no fractures are omitted from the table. CI - confidence interval; M- mens’s; W - women’s; BA - baseball; BB - basketball; FB - football; GY - gymnastics; FH - field hockey; IH - ice hockey; LX - lacrosse; SB - softball; SO - soccer; SW - swimming; IT - indoor track; VB - volleyball; WR - wrestling
Time-Loss and Rates of Return to Sport
Of the 288 hand fractures reported, 225 (78.1%) occurred in male student-athletes; 110 of these fractures were metacarpal fractures, 108 were phalanx fractures, and 7 were volar plate/avulsion fractures. Overall, 181 of these fractures had data pertaining to time-loss available. Rates of operative treatment and time-loss in male student-athletes are demonstrated in Table 3. Female student athletes had 63 (21.9%) reported hand fractures; 19 of these fractures were metacarpal fractures, 42 were phalanx fractures, and 2 were volar plate/avulsion fractures. In total, 45 of these fractures had data pertaining to time-loss available. Rates of operative treatment and time-loss for female student-athletes are demonstrated in Table 4.
Table 3.
(a-b) – Rates of Operative Treatment and Time-loss in Male Student-Athletes
| a. Metacarpal fractures of the fingers | |||||
|---|---|---|---|---|---|
| Time-loss (days) | |||||
| n | Mean | SD | Median | Range | |
| Non-operative | 67 | 13.8 | 23.6 | 3.0 | 0.0-148.0 |
| Operative | 12 | 31.8 | 29.4 | 25.0 | 0.0-87.0 |
| b. Phalanx fractures | |||||
|---|---|---|---|---|---|
| Time-loss (days) | |||||
| n | Mean | SD | Median | Range | |
| Non-operative | 89 | 7.1 | 13.3 | 0.0 | 0.0-66.0 |
| Operative | 8 | 16.1 | 21.5 | 4.5 | 0.0-57.0 |
p=0.02, statistically significant. SD – standard deviation.
p=0.17, no significant difference between groups. SD – standard deviation.
Table 4.
(a-b) – Rates of Operative Treatment and Time-loss in Female Student-Athletes
| a. Metacarpal fractures | |||||
|---|---|---|---|---|---|
| Time-loss (days) | |||||
| n | Mean | SD | Median | Range | |
| Non-operative | 12 | 16.7 | 17.0 | 16.5 | 0.0-42.0 |
| Operative | 3 | 50.0 | 73.9 | 14.0 | 1.0-135.0 |
| b. Phalanx fractures | |||||
|---|---|---|---|---|---|
| Time-loss (days) | |||||
| n | Mean | SD | Median | Range | |
| Non-operative | 27 | 4.3 | 9.0 | 0.0 | 0.0-39.0 |
| Operative | 1 | 0.0 | 0.0 | 0.0 | 0.0-0.0 |
No statistical analysis perfomed secondary to small sample size. SD – standard deviation.
No statistical analysis perfomed secondary to small sample size. SD – standard deviation.
Examining metacarpal fractures of the thumb in male student athletes, 19 fractures had time-loss data available; 12 of 19 (63.2%) were treated non-operatively, and 7 of 19 (36.8%) were treated operatively. Fractures treated non-operatively returned at a mean of 22.6±41.9 days (median, 4.0 days; range, 0–148.0 days); those treated operatively returned at a mean of 27.3±30.7 days (median, 23.0 days; range, 0–87 days) (p=0.55). Data of return to sport within the same season was available for 24 fractures of the thumb. Male student-athletes were able to return at similar rates, with 13 of 15 (86.7%) and 7 of 9 (77.8%) metacarpal thumb fractures treated non-operatively and operatively were able to return in the same season, respectively (p=0.62).
Rates of return to sport in the same season for metacarpal and phalanx fractures in male and female student-athletes are demonstrated in Table 5.
Table 5.
(a-b) – Rates of Return to Sport Within the Same Season for Male and Female Student-Athletes
| a. Male student-athletes | ||
|---|---|---|
| Rate of Return to Sport Within Same Season | ||
| Location | Metacarpal | Phalanx |
| Non-operative | 92.2% (71/77)* | 97.9% (92/94)^ |
| Operative | 66.7% (14/21)* | 90.9% (10/11)^ |
| b. Female student-athletes | ||
|---|---|---|
| Rate of Return to Sport Within Same Season | ||
| Location | Metacarpal | Phalanx |
| Non-operative | 92.3% (12/13) | 96.6% (28/29) |
| Operative | 60.0% (3/5) | 50% (2/4) |
Metacarpal fractures p=0.01, statistically significant.
Phalanx fractures p=0.29, not statistically significant.
No statistical analysis perfomed for metacarpal or phalanx fractures secondary to small sample size.
Male student-athletes sustained 7 volar plate/avulsion fractures, while female student-athletes sustained 2 of these fractures. All 9 volar plate/avulsion fractures were treated non-operatively. Only 5 fractures in male student-athletes had time-loss data available. The mean time-loss for male student-athletes was 0.2 days (range, 0–1 days), and the mean for female student athletes was 2.0 days (range, 1–3 days). All (9 of 9) male and female student-athletes that sustained volar plate/avulsion injuries returned to sport in the same season.
Discussion
Hand fractures are relatively common among NCAA student-athletes, with an incidence of 4.90 injuries per 100,000 AEs (range, 0.00–21.19 injuries/100,000 AEs) across all sports combined. However, there is a large degree of sport-to-sport and gender variation. Studentathletes participating in contact sports, such as ice hockey, football, and wrestling, as well as sports that may involve some degree of incidental contact with other players or apparatuses, such as basketball and field hockey, had a higher incidence of hand fractures relative to student-athletes participating in non-contact sports. Additionally, some sports (Men’s and Women’s Cross Country, Women’s Swimming, Men’s and Women’s Tennis, Men’s Indoor Track, and Men’s and Women’s Outdoor Track) had participants with no hand fractures over the five seasons of study. Male student-athletes participating in basketball and ice hockey experienced higher rates of metacarpal and phalangeal fractures relative to their female counterparts; however, rates of hand fractures in the remaining sports were similar between genders. These findings are in contrast to prior studies that have demonstrated an increased rate of hand fractures in male athletes relative to female athletes.7, 11
In male student-athletes, we found a statistically significant difference in return to play times in metacarpal fractures treated non-operatively relative to those treated operatively (13.8±23.6 days versus 31.8±29.4 days, respectively). No significant difference was noted in return to play times in phalangeal fractures treated operatively and non-operatively. Currently, there is no consensus regarding treatment modality and early return to play times in metacarpal and phalangeal fractures.5,6,8,11,12 For stable metacarpal and phalangeal fractures, non-operative management in well-padded cast or splint with return to play as tolerated has been demonstrated to be an effective and relatively ubiquitous treatment option.1,5,16,17 However, operative fixation of metacarpal and phalangeal fractures in athletes has been increasing in popularity in recent years.5,9,16,18 Morgan et al.16 and Capo et al.18 suggested that ORIF of unstable metacarpal fractures may allow rigid fixation leading to earlier return to play relative to non-operative management for a similarly unstable fracture. Additional studies have further supported this suggestion.5,19 However, there has been a recent trend towards consideration of ORIF for any metacarpal or phalangeal fracture in contact sports athletes, stability notwithstanding.6,7 Geissler and McCraney19 described ORIF of metacarpal fracture using a cage plate, followed by return to play in a protective splint 1–2 weeks after surgery. A series of 8 patients has been described using this technique, with adequate fracture healing achieved in all patients.6 Kodama et al.7 described a series of 20 athletes with metacarpal and phalangeal fractures who underwent ORIF with plate and/or screw fixation and who were allowed to return to full-sport participation 2 weeks following surgery. All 20 patients went on to radiographic union within 3 months. A recent review by Fufa et al.5 discussed aiming for athlete return to play at 2–3 weeks following ORIF of a metacarpal shaft fracture.
The metacarpal of the thumb has greater range of motion relative to metacarpals of the other digits. As such, larger deformity in metacarpal fractures may be tolerated without a loss of function.5,6 However, intra-articular fractures of the thumb metacarpal, including Bennett and Rolando fractures, often require extended periods of immobilization and delays in return to sport relative to fractures of the base of non-thumb metacarpals. In the present study, there was no difference in time or rate of return to sport within the same season between operatively and non-operatively treated thumb metacarpal fractures. Metacarpal fractures of the thumb did have a higher rate of operative fixation relative to non-thumb metacarpal fractures (37% versus 15%); however, this comparison is significantly limited by a small cohort of thumb metacarpal fractures. Because of this, no statistical analysis between the groups was performed, and we report only descriptive statistics. Additionally, without data on individual fractures, the contribution of each of these phenomena on the effect of return to play rates and times in thumb metacarpal fractures is unknown.
Treatment of hand fractures is largely contingent on injury and patient-specific factors, including fracture pattern, fracture stability, athlete handedness, and athlete sport. No information regarding fracture pattern and fracture stability is available in the NCAA-ISP database, and is therefore not included in this study. As such, the effect of fracture type and stability on return to play time in this study is unknown, but it is thought to be significant. Additional studies examining the influence of fracture characteristics on return to play are needed before specific treatment recommendations can be made.
Rates of return to play within the same season also warrant consideration when making treatment decisions regarding metacarpal and phalangeal fractures in student-athletes. The present study found that 93% of male student-athletes with metacarpal fractures treated non-operatively were able to return to play in the same season versus 67% of those treated with operative management; this difference was statistically significant. A difference in rates of return to play within the same season was not seen in phalangeal fractures in male student-athletes. As noted previously, selection bias in the form of more severe injuries being selected for surgical management is likely to contribute to this disparity. However, a recent study by Bannasch et al.20 showed a complication rate of 15% following ORIF of metacarpal and phalangeal fractures. These complications, in tandem with the aforementioned selection bias, may contribute to lower rates of return to play within the same season seen in metacarpal fractures treated with ORIF relative to fractures treated non-operatively. Common complications with ORIF of metacarpal fractures include metacarpophalangeal joint stiffness, implant dissociation, non-union, and need for additional surgery.3,9,20
There are several limitations to this study. First, this was a retrospective study utilizing data from multiple institutions, thereby making data vulnerable to inaccuracies in data collection. Sample sizes were relatively limited, especially in regards to metacarpal fractures of the thumb. This study did not include any data regarding an index of fracture severity or stability as noted previously. Further, there may be a treatment bias present in the current study design, as the worst fractures may have been treated operatively. Injury severity, therefore, may be a confounder contributing to increased return to play rates after operative management. The impact on handedness and the methods of stabilization in the non-operative groups could not be assessed. Recommendations regarding return to play following treatment of metacarpal and phalangeal fractures are physician-dependent and likely to be highly variable, and such variation may have a direct influence on the study results.
Conclusion
This study demonstrates that hand fractures are relatively common among NCAA student-athletes participating in contact sports. Student-athletes with metacarpal fractures returned to play at an average of 2-4 weeks after injury; those with phalanx fractures returned at an average of 1-2 weeks. Additional studies examining the influence of fracture characteristics on return to play are needed before specific treatment recommendations can be made.
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