All right, well, thanks for coming out this morning. My name is Andrew Willis. I've been working in the NFL for the last 16 years, and I'm fortunate to be taking care of a professional team. And my background is I did a fellowship in both sports medicine and hand and elbow surgery, which is likely why I've been charged with giving this talk this morning. The care of the professional athlete has been quite rewarding, but occasionally has its challenges. Let's see here. I can move forward. Especially when you're taking care of a wicked sassy quarterback who went to Harvard. And at least Roger Goodell has got my back, but in all honesty, taking care of a team requires a lot of people, takes a village. And it's really important to surround yourself with a group of good people to help you out because it's too much to do alone. I have no disclosures as it relates to this talk. Hand and wrist injuries as a whole account for about 25% of all athletic injuries. It's the second most common area of injury in youth football, behind the knee. It accounts for about a third of all fractures in high school football, which is the sport with the highest fracture rate. In the NCAA, football has been reported as the largest annual number of injuries and the highest competition injury rate. If we look specifically at hand and wrist injuries in men's football in NCAA, very interesting. Although the burden of injury is high, the amount of missed time is actually relatively low. And when you miss time, it tends to be a short period of time. And surgery is relatively infrequent or uncommon, less than 10%, and tends to, when needed, involve the metacarpal or phalanx fractures. Injuries to the ulnar collateral ligament, the thumb, or scaphoid fractures. About a third of all injuries of the NFL scout and combine occur in the hand, fifth most common site. In the NFL, it's been reported about 6% of all injuries over a 10-year period occur in the hand, first ray, and fingers. The most common injuries reported are metacarpal fractures, first ray fractures, phalangeal or finger fractures, and ulnar collateral ligament injuries. These account for about three-quarters of all lost time and occur across all positions, most commonly in alignment, offense, defense, and secondary defensive backs. Looking at professional athletes as a whole, there's this study looking at 15 different sports, professional athletes, and they reported the most common injuries in the hand and wrist are metacarpal fractures, thumb collateral ligament injuries, and phalangeal fractures and scaphoid fractures. Art Rettig and his son also reported, looking specifically at NFL players, similar findings. So part of our goal today is to share our experience in the NFL on the evolution of management of injury in the hand, and I'll tell you, I know it's cliche, it's been priceless for me, the value of my NFL experience. Why? Well, really the trickle-down effect, as Rob Brophy, who's a friend of mine, co-resident, said in a more articulate manner than I could say, understand the impact of musculoskeletal injury and treatment at the NFL level may help guide improved treatment and safe return to play timing expectations for college and even high school and youth football players. So the trickle-down effect, I think what we learn at the NFL level really drives our care and quality of care all the way down the line. It's important to remember that the universal principle we should go by is that provide proper treatment for injury, regardless of level of competition, and make sure that the focus of our care is to get the best long-term clinical results while in the athletic population, allowing players to kind of return to football or any sport safely. So I realize that in New Orleans, it's still Friday night. It's Saturday morning everywhere else. So before everyone falls asleep, I know it's early, I figured I'd skip ahead and give the key points of this talk, take-home messages, before everyone falls asleep. So what are those? So the majority, large majority of hand and wrist injuries can be treated non-operatively. Athletes will frequently, after these injuries, return to the pre-injury level performance after both operative and non-operative treatment. The return to play tends to be faster after hand and wrist injuries than other body sites. And the timeline, or return to play, has to be individualized. It has to be multifactorial and collaborative with a consistent message by all parties. And I think that's a really critical point, that don't leave yourself on an island unless you're Revis. And I would say that use second, third opinions, collaborate, don't go at it alone. It's too difficult. If we look at metacarpal flange and fractures, they account for about a third of all sports-related fractures and about just over half of all sports-related upper extremity fractures. Looking specifically at the NFL, about 17% of the hand, first ray, and finger injuries are metacarpal fractures. About 14% are phalanx fractures. Looking at the hand alone, if you have an injury in the hand in the NFL, it's about 80% chance it's a metacarpal fracture. The mechanism of injury is contact, most commonly tackling, blocking. It's sort of a direct load with maybe some rotation. These injuries are classified based on location, whether intra-articular, diaphysial, where they're located on the bone. Most of those in the NFL tend to be extra-articular, diaphysial. The sideline assessment in brief, really the key is inspection. What you're trying to do is figure out if there really is an injury that merits further workup. You need to see what is going on, and a lot of times they'll be covered up with gloves or tape. You really got to take a look and see, is there a deformity? What's the soft tissue integrity? Is it open or closed? Is there any swelling? Palpation, you can feel crevices or movement. Check bony stability. Check the neurovascular status. But a couple of key factors are if they can't fully extend their finger, they have a lag or they have scissoring or overlap as seen here, you're pretty much sure that it's time to get some more data before you send it back. Imaging is very, very important. At all levels, we do not have an NFL imaging of the stadium, and sometimes you got to make a decision based on your exam. But typically, if we suspect a fracture, we'll get a radiograph to determine, okay, what are we dealing with? Things we're looking for are shortening, mal-rotation, angulation, involvement of the joint. And so our decisions in terms of in-season management really is a unique balance between trying to restore skeletal alignment, re-establishing normal hand function on the one hand, while at the same time, minimize lost playing time. How early can we get them back, and can we get them back in a way that they do not have altered performance? And getting them back early, hopefully, we won't alter their performance long-term either. So some additional considerations are that factors outside of this medicine play a role in determination of return to play, timing in the season, other goals in terms of contract, their need to play for the contract, their position on the team, and how important it is to be available. And so career, future, potential issues do play a role in your decision making. Getting back to the fractures, though, non-operative management is the vast majority of what you'll be doing. And this here is one of our high school players who's a week out from a fracture of the fourth metacarpal. This is amenable to protective bracing and rapid return to play if you have a very good therapist or trainer that works with you that can help protect, and you can build custom braces. And this just shows you a bunch of different things that can be done to allow protection of the fracture, yet still allow the hand to do what it needs to do, especially with the advent of different casting materials and even the advances in technology such as carbon fiber splints, which are very lightweight and highly protective. So they can still function and do well, as we just saw. If they have some trouble in the situation, from a pain standpoint, and the situation merits, say, a playoff run or an important game, anesthetic blocks can be considered. That being said, I haven't done many of those because we really haven't had situations with the Jets that merit that, but we're kind of hoping that might change. And going back to the fractures here, most non-operative, but those that do require operative treatment tend to be those that are unstable, displaced, rotated, or inter-articular. And there are varying degrees and measurements that sort of dictate that. But I would say that when they need to have surgery, advances in procedural techniques, implant design, have really made, in recent years, made it possible to rapidly get people back in a predictable and safe manner. What are those advances in brief surgical strategy in the athlete as opposed to others tends to be internal stabilization. We're not trying to make the fracture heal faster because we can't do that. We're doing biomechanics, not biology here. And we're trying to get better resistance to forces to allow early motion, hand function, and lessen the time out of the sport. With advances in implant design and strength, as well as technique, which allows for increased stability and compression, and there's multiple, a lot of different options available. The results of earlier and earlier sets return to play are sort of evolving and being published. In brief, this is a little summary for lack of time. Longer plates, neutralization plates, greater number of screws, additional lag screws, intramedullary screws, have all been a factor in earlier return to play reported at the college and professional level up to one to two weeks after surgery. Usually with bracing, but some have reported without. Excellent outcomes, meaning low complications rates for stiffness, refracture, and wound healing have been reported in multiple studies looking at early surgical intervention for these fractures to minimize lost time. Most recent data out of the NFL looking particularly at metacarpal fractures concluded that in the NFL, most metacarpal fractures result in less than three weeks of missed time and return to play in the same season is very predictable. If the severity of the fracture merits, surgery will not necessarily accelerate return to play. They were unable to show that. It doesn't necessarily prolong the timeout, but doesn't necessarily accelerate return to play except in the case of thumb metacarpal fractures, which were shown to have a significantly greater likelihood for a need for surgery. And what are these? These are Bennett fractures. They're intra-articular fractures at the base of the thumb. And these typically happen from contact like tackling, but also in quarterbacks from injury when they're throwing at the end of the throw, hitting a helmet. And these can be a little tricky sometimes, pain, swelling, subtle instability if you feel a click. And these require usually a more advanced workup such as a CT scan. These are inherently unstable and because they involve a joint, like the principles in orthopedic surgery in general, restore articular congruity, joint stability, and recent trends tend to be favoring operative intervention, internal fixation over KOR fixation almost universally. It's just more predictable. It's more reliable and a faster recovery. In terms of ligament injuries, the most common is the ulnar collateral ligament. It's about 4% of all injuries of the hand. Average time lost in the NFL is about three weeks. In NCAA you can expect about two or just over two of these per football team per year. The thumb ulnar collateral ligament has two bundles, just like the elbow, proper and accessory ligaments. And these both are important for the exam. The proper is tight in flexion. The accessory is tight in extension. And there are important connections to the vulva plate and dorsal capsule forming a box around the joint itself. These typically occur from a hyperabduction or extension injury, contact following an outstretched hand, or getting your hand, like in this case, wrenched back. It's important to realize that these come in different degrees. There's partial, complete. There's those that involve significant deformity in which the tissue gets, other tissue gets interposed between the ligament and the bone on the proximal phalanx as 90% of these are pulled off distally. And that can form a standard lesion which doesn't heal. Bony avulsions oftentimes rotate and don't heal. So these tend to be ones that require surgery and need to be identified. Again, the assessment of radial stress of the thumb at 0 and 30 degrees of flexion. Tend to get imaging to look for a vulvar sag, which is the injury to the vulva plate, and avulsion fracture. And very importantly, Bob Hodges pointed out in a study recently in the NFL, about 25% of the lung-clot ligaments also involve the radial-clot ligament. These are inherently unstable, require surgery. And these combined injuries can be subtle. And therefore, I tend to get MRIs in my higher level athletes to make sure that both sides are okay. The radial-clot ligament is similar. It has two bundles. It does the same thing, accessory and proper. However, it's not a mirror image. Important considerations are that the aponeurosis is different. It comes from a different angle. And standard lesions don't really occur on the side. The location of the injury tends to be proximal, meaning a pull-off of the metacarpal rather than the phalanx. And that has to do with just the difference in anatomic atresin sites. These injuries occur as a result of a sudden adduction force, and tend to clinically present a little differently. Not so much with instability, but pain. That pain can be a little tricky. It's a little bit more proximal. It throws you off the scent. You don't really think of it right away, and it tends to linger, and it's circular to scratch your head. Typically, they're very painful, and they have difficulty with depression, like pushing down a button or opening a door. And it kind of persists. And these tend to have a great difficulty healing, even though there's no interposed tissue. You can assess these, again, the same way, at 0 and 30 degrees of flexion, although usually I examine these in extension, because at flexion there's too much rotation at the CMC joint, so you can't figure it out. It tends to be harder to do. I tend to get routine x-rays, same reason, look for avulsion injuries, vulva sag. On MRI, I tend to find these not super helpful. I do get them. They're very subtle, and you have to know how to look at them. They'll often be read as normal. But they tend to be a pull-off, and just sitting there, not sticking down to bone, proximally. So they're less severe. Be aware. High index of clinical suspicion. And usually, if it persists, and there's pain in that area, that's what it is. And they get better with a procedure ridiculously quickly. So ligament injuries, same thing applies as the metacarpal and proximal, and the finger fractures. Procedural techniques, implant design have all made surgical intervention and return to play very predictable, with good outcomes. Innovative technology, anchor design, the biomechanics and fixation strength of these new anchors. Techniques, surgical techniques in terms of anatomic reconstruction, both bundles, augmenting the ligament repair, sometimes with an internal brace, can allow for increased strength of biomechanical fixation and earlier rehab, which has led to advances in more accelerated rehab. Better bracing and technology, such as materials, carbon fiber, allow for earlier safe return to play. So in general, what we can conclude from surgical intervention of a ligament is that surgical intervention actually is more predictable than non-operative intervention. The re-injury rate and the revision rate is lower. Complications are rare. Excellent long-term predictable outcomes reported in the NFL and the collegiate level. Patient satisfaction and activity and return to performance. So acute intervention versus delayed for surgery, once thought to be a big deal, doesn't seem to make a difference. If you look at football specifically, in-season management, you can expect, if you perform surgery early, to get players back about four weeks, both skill and non-skill. College skill took a little longer, about seven versus four weeks. If you look at outcomes, reliable return to the same level of play can be expected. Studies looking at performance, pre- and post-op performance, career longevity, no differences, and this held with analysis per player and player position. Again, acute and delayed surgery don't seem to make a difference, so it may affect how you approach players in-season and waiting to get to the end of the season. So finally, the magic words were almost there. Not the same magic words I'm looking for. However, scaphoid fractures, the last topic, which we'll get through in about 10 seconds here. The bottom line is these are bad actors, and as Fitzsimmons would say, these are suspect. In the youth, low-energy trauma, they tend to be minimally to non-displaced. We typically diagnose these not only by exam, but with clinical radiographs. Most remediable non-operative treatment in the young, young population, and radiographic healing and clinical healing is how we follow these. The ones that are concerning are high school, college, and NFL. Higher energy goes to the wrist. These are almost all displaced. They must all require operative intervention, and diagnosis is not only radiographs, but advanced imaging, MRI, CT, very helpful. What's the return to play following surgery? Well, I'm much more conservative. These will burn you. These are suspect. I get CTs routinely to make sure they're healed. A criteria tends to be 50% or greater healing or bridging, and a grip strength of 80% on the other side. And I think that they can get back. But these are very challenging. When you think you got it right, you don't. So in summary, injuries to the hand and wrist are common in football athletes. They can have a significant impact on participation and performance. The vast majority are amenable to non-operative management, and a high percentage of return to sport to the same pre-injury level and high level of performance can be expected with both operative and non-operative treatment. And when we manage athletes, it's always a little different. We have to incorporate the goal of trying to get them back rapidly to play. We want to do so without losing function. And we want to minimize lost playing time, altered performance in the short and long term. And in-season surgery, if needed, for hand injuries in general can be very predictable, safe, and with appropriate shared decision-making can lead to minimal lost time. The take-home message, the paramount, number one message from this talk would be that these decisions for surgery have to involve collaboration, all parties, excellent communication, consistent communication. And that means talking to families, agents, get second opinions. Don't do this on your own. There's too much at stake. Overall, these people can do very well, these players. So I appreciate everything. Thank you for your time.

NFL

hand injuries

wrist injuries

treatment

surgery

ligament injuries