Upper Extremity Injuries in Soccer

THE HAND/FINGERS/THUMB

Almost a quarter of upper extremity injuries in professional soccer players were reported to involve the hand, fingers, and thumb. A quarter of them were classified as severe injuries requiring >28 days of absence from playing soccer.¹Specifically, hand metacarpal and phalanx fractures are the most common reported injuries in sports in general,²⁶ and in soccer,¹ and account for 14% of all upper extremity injuries¹ in professional soccer players. Goalkeepers require a functional hand to play, whereas an outfielder can play with protection on the injured area; thus, the period of absence from soccer in these injuries is significantly different between goalkeepers and outfielders with more than 4 times longer absence from soccer for a goalkeeper compared with an outfielder. The fifth ray has been shown to be the most frequently fractured ray in the hand in soccer with 51.7% of all hand fractures reported.²⁶ The common mechanism is a full hit on the hand, and a direct hit from the ball is another possible mechanism in goalkeepers.

In general, the diagnosis of hand injuries requires evaluation of the mechanism of injury and injury symptoms, proper and comprehensive physical examination of the whole extremity, and prompt imaging. In most cases, plain radiographs in several projections will suffice for the diagnosis of obvious fractures, but CT scan is an additional modality that allows for improved appreciation of occult or complex and comminuted fracture patterns. MRI or ultrasound can be used additionally whenever associated soft tissue injury is suspected. Optimal management of the hand is based on the specific characteristics of the fractures, which include location, direction of the fracture line, presence of comminution, displacement, articular involvement, and associated soft tissue injury. Nondisplaced extra-articular fractures often can be treated with buddy taping or splinting, whereas intra-articular fractures often require surgical treatment. Displaced fractures of the hand have a tendency to angulate volarly because of attachments of the interosseous muscles. Marginal fractures or avulsion fractures involving the metacarpals or phalanges can be sentinels of serious associated soft tissue injuries.²⁷

Phalangeal fractures can potentially affect the function of the entire hand; therefore, no malrotation is acceptable for phalangeal fractures because they can lead to overlap and malalignment of the digit. Displaced or malrotated fractures should be reduced either by closed or open techniques. Acceptable reduction is <6 mm of shortening, <15° of angulation, and no rotational deformity.^27,28 Nondisplaced phalangeal fractures can be treated nonoperatively with buddy taping and splinting with good results.²⁷ Interphalangeal (IP) dislocations can be reduced on the sidelines and then taped or splinted. Any injury with a force significant enough to cause joint dislocation indicates further evaluation for associated fractures and ligamentous injury or tear. The proximal interphalangeal (PIP) joint is the most common IP joint dislocation and is usually a dorsal dislocation. Reduction is often achieved by traction and flexion of the middle phalanx,²⁷ followed by splinting of the finger with the PIP in 30° of flexion or an extension block splint.²⁹ Successful reduction with no associated intra-articular fractures involving more than a third of the joint can be further managed nonoperatively with the splint, allowing 2 to 4 weeks for the volar plate, joint capsule, and collateral ligaments to heal. Additional 2 to 4 weeks of splinting with buddy taping to the adjacent finger is usually recommended.²⁹

The “Mallet finger” injury can be observed in goalkeepers and is caused by a flexion force on the tip of the finger while the distal interphalangeal (DIP) joint is extended. This force results in tearing of the extensor tendon or an avulsion fracture at the tendinous attachment on the dorsal lip of the distal phalangeal base. The classic mechanism of injury is an extended finger struck on the tip by a ball. Physical examination will indicate loss of DIP joint active extension, and the joint rests in an abnormally flexed position. Treatment typically consists of splinting the DIP joint in extension for 6 to 8 weeks. Operative treatment is reserved for severe injuries or fractures involving greater than one-third of the articular surface of the DIP joint or with failed nonoperative treatment.²⁷

Metacarpal fractures can be subdivided into distal, metacarpal neck, metacarpal shaft, and metacarpal base fractures. Metacarpal shaft fractures raise a specific concern regarding rotation, because even a small degree of rotation can create a substantial degree of deformity at the fingertip. This concern must be addressed during evaluation of the player. Fractures of the metacarpal base most commonly involve the fourth and fifth metacarpals and are often reduced easily but have a tendency to re-subluxate, which may indicate operative treatment. Most fractures of the metacarpals are low energy and result in simple fracture patterns that can be treated nonoperatively. Open reduction is reserved for high-energy trauma, fractures with excessive angulation, or multiple fractures.²⁷

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