Upper Extremity Injuries in Soccer

THE WRIST

Ekstrand and colleagues¹ reported that 5% of all upper extremity injuries in their cohort of professional soccer players are wrist injuries, of which, only 2% are considered severe injuries that require >28 days of absence from playing soccer. The more common wrist injuries in soccer, which is considered a high-impact sport, are fractures (distal radius, scaphoid, capitate), and less reported injuries are dislocations (lunate, perilunate) and ligamentous injuries or tears (scapholunate ligament).²³

Distal radius fractures in high-impact sports, like soccer, usually occur as a result of a fall on an out-stretched hand and will usually be more comminuted, displaced, and intra-articular compared with low-impact sports.²³ All these aforementioned characteristics usually indicate surgical management of open reduction and internal fixation, which will allow for rapid start of rehabilitation and return to play.

Scaphoid fracture is the most common carpal bone fracture and presents unique challenges in terms of diagnosis and optimal treatment²⁴ in professional athletes. A typical injury scenario would be a player falling on an outstretched hand and sustaining a scaphoid fracture during a match or training session. The player may acknowledge some wrist pain but will often continue to play with minimal or no limitation. As wrist pain and swelling become more evident after the match/training session, the player will seek medical evaluation.²⁴ A complete wrist and upper extremity examination should be performed in addition to a specific assessment, which includes palpation of the distal scaphoid pole at the distal wrist flexion crease, palpation of the scaphoid waist through the wrist snuff box, and palpation dorsally just distal to the Lister tubercle at the scapholunate joint. Any wrist injury that results in decreased range of motion, snuff box swelling, and scaphoid tenderness should be further evaluated with imaging. Plain radiographs with special scaphoid views are the initial preferred imaging studies, but occult fracture will require an additional study such as a bone scan, CT, or MRI. Several studies have validated the benefit of MRI and the fact that it may outweigh the costs associated with lost productivity from unnecessary cast immobilization, especially in elite athletes.^23-25Casting the patient with a nondisplaced scaphoid waist fracture has been the traditional treatment; however, stiffness, weakness, and deconditioning that can occur with long-term casting required for scaphoid fractures are significant impairments for the professional athlete and usually end the player’s season. Surgical treatment, which was traditionally indicated for displaced or proximal pole fractures, is currently also considered for non-displaced scaphoid waist fractures in professional athletes. This treatment allows for a rapid return to the rehabilitation of the extremity and possible early return to professional sport. In view of the known complications (eg, malunion, nonunion, and avascular necrosis), return to soccer can be considered when imaging confirms advanced healing, which some consider as at least 50% of bone fracture bridging on CT scan, no pain, excellent motion, and at least 80% of normal grip strength.²⁴ Outfield players can return to play with a protective cast or brace until full healing is observed on imaging.

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