Distal Radius Fractures in the Athlete

Although the technical details of distal radius fracture fixation in athletes are largely similar to the general population, the issues surrounding the injury, desire to return to sport, and rehabilitation require specialized attention. Athletes are generally healthy, with a drive to recover and must balance the risk of long-term consequences of returning to play too early with the potential loss of scholarship, salary, or opportunities for advancement. Outcomes after nonoperative and operative treatment of distal radius fractures are generally excellent in athletes and return to the same level of sport occurs in most patients.

Key points

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Athletes have specialized needs surrounding the diagnosis and treatment of distal radius fractures.
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Return to play is a point of emphasis for athletes, especially those at high levels of sport.
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Early return involves frank conversation with the treating surgeon to ensure an understanding of the risks by the patient.
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Prompt and proper rehabilitation is critical to achieving the best outcome.

Introduction

Distal radius fractures are common injuries that are seen in younger and older populations. Although treatment options of distal radius fractures vary depending on many factors including age, bone quality, functional demand, and fracture characteristics, there are unique subsets of patients that require specialized approaches and care to attain the best possible outcomes.

Athletes are motivated and healthy individuals who engage in activities that often directly require the use of their hands and wrists or place them at higher risk for sustaining wrist injuries. These patients are usually focused on the most expeditious return to function and competition. Treating surgeons must keep this need in mind and consider the level of competition when balancing the risks and benefits of timing the athletes’ return to play. Conventional surgical and nonsurgical options are often appropriate, but there are instances where this may not be the case. This article discusses the presentation and treatment of distal radius fractures in athletes.

Epidemiology

Distal radius fractures are the most common upper extremity fracture in the United States, accounting for nearly 25% of all upper extremity fractures. Distal radius fractures are becoming more frequent over the past five decades. ^, Patients younger than the age of 18 and older than 50 years are the most affected, although the reasons for sustaining distal radius fractures in these populations are quite disparate. Younger patients typically sustain distal radius fractures during sports or play and older patients typically have lower-energy mechanisms, such as ground-level falls resulting in fragility fractures. Distal radius fractures account for 23% and 17% of all sport-related fractures in adolescents and adults, respectively. Athletes with distal radius fractures are often younger and healthier than the general population with the same injury because, like the younger population in general, they have higher bone density and fracture their distal radii only through higher energy mechanisms.

The risk of an athlete suffering a distal radius fracture varies by sport. Eighty-seven percent of all sport-related fractures result from athletes participating in only 10 sports, with 31 other sports resulting in the remaining 13% of the fractures. Distal radius fractures are more common with in-line skating, badminton, gymnastics, ice-skating, snowboarding, football, and horseback riding and in less-competitive athletic activities, such as riding hoverboards. The relative risks of fracture by sport likely varies across populations because studies have reported soccer contributing from 20% to 50% of distal radius fractures sustained during sport. Despite the high energy collisions, only 5% of all injuries in professional football players are distal radius fractures, making it only the seventh most common upper extremity injury from the elbow to hand in this sport.

The complexity of the type of distal radius fracture can vary based on the sport involved. Skiing and horseback riding often result in more complex fractures given falls at higher speeds and from larger heights, whereas fractures from soccer and rugby are typically extra-articular. Even within the same sport, fracture patterns can differ in subgroups of athletes. Experienced snowboarders sustained more intra-articular fractures than beginners, which was likely related to the expert snowboarders performing more jumps.

Prevention

Wrist guards have been shown to decrease the strain at the distal radius during impact by sharing load and absorbing energy. Biomechanically, this can translate into different patterns of and potential less severe wrist injuries. ^, Clinically, the use of wrist guards reduced the incidence of distal radius fracture during snowboarding by 85% and resulted in an approximately 10-times lower risk of wrist injury in in-line skaters. However, not all sports permit or can accommodate the use of personal protective equipment and younger athletes typically discard this equipment because it is cumbersome or unfashionable. In these instances, focusing on education and building skill is protective against sustaining a distal radius fracture based on the protective effect of heightened athletic prowess.

Distal radius anatomy

The distal radius articulates with the distal ulna, lunate, and scaphoid, but given its morphology, affords limited bony constraint to these structures. Forearm pronosupination and load transmission occurs through the sigmoid notch of the radius as part of the distal radioulnar joint. Appropriate congruity and contact between the radius and ulna is imperative for painless motion. The lunate and scaphoid articulate with the lunate and scaphoid fossae on the radius, which are often involved in intra-articular fractures of the distal radius. Normal anatomic alignment of the distal radius involves assessment of standard radiographic parameters, such as height, inclination, tilt, and length. Radius height refers to the proximodistal distance from the ulnar portion of the lunate facet to the tip of the radial styloid (normal 12 mm). Radial inclination is the angulation of a line from the ulnar portion of the lunate facet to the tip of the radial styloid in relation to a line perpendicular to the longitudinal axis of the radial metaphysis starting at the ulnar portion of the lunate facet (normal 22°) ( Fig. 1 ). Volar tilt is the angulation on the lateral radiograph of the articular surface of the distal radius in relation to a line perpendicular to the axis of the radial shaft (normal is about 11° volar) ( Fig. 2 ). Radius length is the variance in proximodistal distance between the radial-most portion of the ulnar head and the ulnar most portion of the lunate facet (neutral is typically normal) ( Fig. 3 ). These average normal values may not perfectly describe each individual, so comparison with the contralateral wrist is helpful to detect subtle fracture displacement. Re-establishment and maintenance of these radiographic parameters and joint congruity is a principal goal of distal radius fracture treatment.

Besides the osseous architecture, stability and function of the wrist is conferred by stout ligamentous and other soft tissue structures. Carpal stability is afforded by volar radiocarpal ligaments (radioscaphocapitate, radiolunate), which originate across and obscure the volar margin of the distal radius articular lip and insert onto the scaphoid, capitate, and lunate and dorsal radiocarpal ligaments that originate on the dorsal rim of the radius and insert into the dorsal lunate and triquetrum. Assessment of the volar lip of the distal radius is critical because there may be a separate fracture fragment encompassing this small, but important component of the bone ( Fig. 4 ). Displacement of this volar bony support produces changes in the “teardrop angle,” carpal translation, lunate subsidence, and length of the volar lip fragment. Although these fragments are small, specialized plates or fixation constructs should be used because standard locking plates placed distal and volar past the “watershed” line risk flexor tendon irritation and possible rupture. Distal radioulnar joint stability is afforded by the triangulofibrocartilage complex (TFCC) and associated radioulnar ligaments. These stabilizing structures are frequently injured in distal radius fractures and careful consideration to their treatment may improve patient outcomes.

The radial and ulnar arteries give main contributions to the deep and superficial palmar arches, respectively, but there are numerous anastomoses between the two systems along the course of the hand. The median nerve runs between the flexor digitorum profundus and flexor digitorum superficialis in the forearm and becomes more superficial as it runs distally to pass into the carpal tunnel in a volar and radial position. Before entry, the palmar cutaneous nerve branches off 5 cm proximal to the wrist flexion crease and this branch typically becomes superficial, piercing through the antebrachial fascia, between the palmaris longus and flexor carpi radialis tendons. The palmar cutaneous nerve often makes its way into a separate fascial tunnel superficial to the carpal tunnel as it passes to the palm. These relationships are important because fractures of the distal radius can increase carpal canal pressure, leading to compression on the median nerve and acute carpal tunnel syndrome and the flexor carpi radialis approach to the radius can injure the palmar cutaneous nerve, which at times courses within the flexor carpi radialis sheath.

Patient evaluation

Depending on the acuity and nature of the injury, a formal trauma evaluation may need to be performed on the patient. For example, a fall from a large height in a skateboarder or motocross racer requires an on-field primary survey, which involves an assessment of airway, breathing, circulation, and neurologic status, whereas a badminton player with wrist pain after diving for a shuttlecock may require a more focused examination. Once the patient is stabilized, the wrist is assessed noting skin integrity, deformity, tenderness, and neurovascular status. After ruling out acute compartment syndrome or carpal tunnel syndrome in high-energy injury mechanisms, one can proceed with a semielective approach to treatment with ultimate choices made depending on fracture and patient characteristics.

Orthogonal radiographs are necessary to determine the personality of the fracture. The previously discussed radiographic parameters are used as guides defining acceptable reductions, which ultimately impacts the choice of operative versus nonoperative treatment. Intra-articular incongruity may be readily apparent on radiographs, but is clarified by computed tomography scan when necessary. Intra-articular displacement is typically surgically corrected because of its association with post-traumatic arthritis. Dorsal tilt more than 10° from neutral can lead to loss of wrist flexion in addition to adaptive midcarpal instability and pain. Radial shortening can result in ulnar-positive variance and ulnocarpal impaction.

Ligamentous wrist injuries frequently occur in the setting of a distal radius fracture. Mehta and colleagues determined that the prevalence of ligamentous injury is 69% in the setting of distal radius fractures. Provocative wrist testing is often difficult to perform because pain from the fracture can preclude wrist motion or confound feedback from palpation. If there is concern for scapholunate ligament injury, an MRI is helpful to confirm the presence of this injury, although intraoperative fluoroscopy or arthroscopy are alternatives. TFCC injuries are more common, comprising 61% of the soft tissue injuries in the athlete presenting with distal radius fractures. Despite the high incidence of concomitant carpal soft tissue injuries, it does not seem necessary to treat most of these. ^, However, we believe that the athlete with associated completed scapholunate ligament rupture or TFCC tear associated with gross distal radial-ulnar joint instability should have those injuries treated surgically.

Finally, talking with the athlete and determining their goals for recovery is the final step before making any recommendation for treatment. There are many additional considerations when treating athletes, such as their current level of play, commitment to advancing to or staying at the highest level of play, contract negotiations, time left in-season, available time for recovery, and risk of secondary surgeries or complications with early return to play. All of these must be discussed frankly and openly to set expectations and achieve the desired outcome.

Treatment options

Nonoperative Treatment

Most athletes are younger, active patients that have a desire to return to sport quickly without permanent dysfunction. Nondisplaced fractures are typically indicated for nonoperative management in all patients and in the athlete, this is generally true as well. However, displaced fractures with excellent postreduction alignment present a unique decision point. Questions to ask are:

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Is the athlete able to maintain a cast for 4 to 6 weeks and potentially longer weight-bearing restrictions?
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Will the time immobilized and the associated muscular atrophy result in significant rehabilitation and delay in returning to sport?
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Does the athlete’s sport allow return to play in a cast?
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Is the athlete able to have weekly follow-up radiographs to determine if the fracture has maintained its alignment?

After reduction and splinting, initial treatment should involve weekly radiographs for 3 weeks to assess fracture alignment. Splints are transitioned to casts after fracture stability is confirmed and removable orthoses may be initiated after 6 weeks. Nondisplaced fractures may be transitioned to a removable brace at 4 weeks. These guidelines are general, with decreasing pain and tenderness and radiographic signs of osseous bridging assisting the decision making. Strengthening is delayed until there is no tenderness at the fracture site and radiographs demonstrate fracture line resolution.

It is not advisable for athletes to attempt nonoperative management with displaced distal radius fractures in the hopes of having “off season surgery.” Unless the season is ending within a week or 2 and surgery can be delayed until then, a longer postponement is not recommended because fracture malunion repair would require an osteotomy. Compared with primary fracture surgery, malunion correction is associated with outcomes that are less predictable and more modest.

Operative Treatment

Open reduction with internal fixation of all other distal radius fractures is the mainstay in adult athletes. The timing of this procedure is similar to nonathletes; it is ideally performed within 2 weeks after the injury. If the patient is comfortable and has no neurovascular compromise, it is possible to delay surgical intervention by placing the athlete in a cast in order for them to return to sport before their operative procedure. This is usually only considered in patients at the highest level of sport and follows an honest discussion of the risks of play. Although returning to sports that do not require wrist involvement rarely risks substantial reinjury, repeat falls or unintended collisions could risk more extensive injury.

The choice of the ideal internal fixation construct is generally based on fracture morphology. Most fractures are fixed with volar locking plates ( Fig. 5 ). Although many studies show no difference in results at 1 to 2 years between methods of fixation, ^, there is evidence that volar plating has fewer complications and improved functional outcomes when compared with external and dorsal plate fixation. Intra-articular fractures with depressed fragments are best accessed via a dorsal approach because the surgeon can visualize the articular surface directly ( Fig. 6 ). Volar rim fractures must be addressed to provide stability to the carpus and these fractures often require specialized fixation distal, such as hook plates placed distal to the watershed line to capture the osteoligamentous fragments. Occasionally, a combination of fixation strategies is indicated to achieve stable reduction ( Fig. 7 ). Finally, severely comminuted fractures may require spanning fixation for indirect reduction purposes.