Hand Fracture

Position	Average % Difference PPG Change From Pre-Injury Compared to 1st Game After Injury	Average % Difference PPG Change From Pre-Injury Compared to Games 2-3 After Injury	Average % Difference PPG Change From Pre-Injury Compared to Games 4-6 After Injury
QB	N/A	N/A	N/A
RB	+44.4%	-3.2%	+1.4%
WR	-32.5%	+47.5%	-35%
TE	-46.2%	+50.4%	+47.7%

Position	Average Change in Snap% From Pre-Injury Compared to 1st Game After Injury	Average Change in Snap% From Pre-Injury Compared to Games 2-3 After Injury	Average Change in Snap% From Pre-Injury Compared to Games 4-6 After Injury
QB	N/A	N/A	N/A
RB	-0.8%	+10.7%	-3.7%
WR	+22.5%	+7.5%	+54%
TE	-9.3%	-20.9%	-8.6%

Anatomy Of A Hand Fracture

The hand is one of the most complex regions of the body, comprised of 27 different bones, with hundreds of associated structures such as ligaments, muscles, tendons, and nerves.¹ The most common fractured bones are the metacarpals and the scaphoid bone. For this article, we will focus on the metacarpals and scaphoid. Still, readers should know the hamate and the pisiform bones are other commonly fractured and have similar causes of injury and healing times.^2,3 

There are three distinct sections of the hand: the carpals, which are the small bones that form the bottom half of the wrist joint; the metacarpals, which are the long bones in your hand that form the rest of your palm; and finally the phalanges, which are your fingers.¹ 

The carpals have two rows, the proximal row, which is the row closest to your forearm, consists of the scaphoid, lunate, triquetrum, and pisiform bones. The next row comprises the trapezium, trapezoid, capitate, and the hamate bones. The metacarpals are named 1st through 5th, with the first metacarpal attaching to the thumb and the 5th attaching to the pinky.¹ The phalanges are named the same way. The main difference between the phalanges is that the thumb only has two (top and bottom), whereas the rest have three (top, middle, and bottom).¹ 

Of course, many other structures within the hand can be injured, such as ligaments, muscles, fascia, nerves, arteries, and veins. This article will focus on bone fractures, which are more commonly reported in the NFL. 

Cause Of A Hand Fracture

Metacarpals: 

80% of all hand injuries in the NFL are metacarpal fractures, with the most at-risk positions being lineman on both sides of the ball.² Other common positions at risk are wide receivers and defensive backs. The most common cause of a metacarpal fracture is during a tackle, either as an offensive or defensive player. 27% of fractures occurred when tackling, 22% when being tackled, and 14% when blocking.⁴ Those actions lead to massive forces directed axially (the same forces on the hand during a punch) into the bones, increasing risk for fracture.

Other causes of injury are falls, a player’s hand getting caught in a jersey, getting stepped on, or direct contact to the bone by an object like a helmet or the ball.⁴

Scaphoid:

Scaphoid fractures are highly associated with playing football and are the most commonly fractured carpal bone. Some have estimated that 1 out of 100 college football players will suffer a scaphoid fracture. Commonly, this fracture occurs when a player falls or is tackled and lands on their wrist with their hand in the “stop sign” position.⁵

Scaphoid fractures are rampant throughout all positions in football due to football inherently causing falls on every play. Interestingly, defensive backs were the only position that demonstrated significant carpal arthritis post-injury.⁶

Hand Fracture Rehab Process

In general, metacarpal and scaphoid fractures follow a similar rehab process, though the different bones inherently have differing healing capacities.  The portion of the fractured scaphoid plays a big role in the healing capacity. The variation in healing is due to different amounts of blood flow to different areas of the bone.  The proximal pole of the scaphoid (closest to the wrist) has very little blood supply, and fractures at this location will take much longer to heal.⁷

Depending on the severity of the fracture, it may require surgery to heal correctly. In surgical cases, a protocol will likely be designed by the surgeon and the physical therapist to guide the rehab process. Both non-operative and operative approaches show good results, but fixation of the fracture with surgery yields a faster return-to-sport time and allows for early mobilization and exercise. This can decrease rehabilitation time, reduce complications, and reduce the risk that the player will see a decline in production.⁸ 

Acute stage/Phase 1: 

Similarly to all acute phases, any pain, swelling, or inflammation is treated with rest, ice, compression, and elevation (RICE). There will also be a period of immobilization in the acute phase, regardless of operative status. 

While the hand is immobilized, rehab will focus on range of motion in the fingers and elbow to prevent stiffness in these joints. For metacarpal fractures treated nonoperatively, the casting period is typically four weeks, whereas scaphoid fractures are casted for 8-12 weeks, but can be as many as 16-20 weeks if the proximal pole in involved.^7,8,9

Once the immobilization period is over, passive range of motion (PROM) of the wrist and hand is initiated, and then progressed to active or active assistive range of motion (AROM or AAROM).⁸ Pain-free isometric strengthening will also be utilized in this stage. In phase 1, it is always important to be cautious with the amount of pressure applied to the joint due to the fragile nature of healing bone.⁹

Intermediate/Phase 2:

Progression to the intermediate phase is decided based on pain tolerance of AROM exercises. In phase 2, rehab can progress more aggressively because the bone is much stronger at this stage of healing.

Strengthening exercises are progressed from isometric exercises to full ROM strengthening, grip training, wrist curls, hammer exercises for radial/ulnar deviation (waving hand side to side), and pronation/supination (turning the wrist up and down as if turning a door handle). 

Additionally, more aggressive stretching is performed in this stage.⁹ If any ROM deficits remain, this will also be addressed with soft tissue mobilization to the wrist muscles and joint mobilizations to the wrist and individual joints/bones of the hand.

Towards the end of this phase, light plyometric ball tosses can be performed to further strengthen the wrist and hand and prepare for sport-specific training. It is also important to gradually progress weight-bearing on the bone, which helps strengthen the healing bone.⁹

Return to sport phase: 

Progression to this phase is decided by the involved side having no pain, along with symmetrical strength and ROM compared to the uninvolved side.⁹ 

In this phase, strengthening, stretching, and plyometric exercises are all progressed further. As with all return to sport programs, the player will begin with non-contact drills based on their position, then progress to contact drills within their position group, and finally to full participation. Most athletes with these injuries are often required to wear a temporary cast, splint, or tape during the game to further protect from re-injury.⁹

Interestingly, many players will play through a metacarpal injury by wearing a cast, depending on the position.  Running backs with less of a pass-catching role will commonly do this.  Miles Sanders in 2021 is a prime example. 

Rehab Phases	Treatment	Criteria to Enter Phase
Early Phase	RICE, NSAIDs, casting. ROM of fingers, elbow, and shoulder.  Post casting:  PROM progressing to AROM. Isometrics.  Soft tissue mobilization.	Physician determined the bone is healing properly.
Intermediate Phase	ROM and strength progressed. Joint mobilizations for pain and/or ROM. Initiate weight-bearing activities and light plyometrics.	Physician determined the bone is healing properly. Pain-free with ROM and isometrics.
Return to Sport	Continue to progress strength. ROM. Plyometrics, and weight-bearing activities. Initiate contact position-specific drills. Full participation.  Fitting for in-game splint/cast.	Pain free. Symmetrical ROM and strength.  Physician will continue to screen the bone for proper healing.

Regarding fantasy lineup management, the manager would much rather their player suffer from a metacarpal fracture than a scaphoid fracture. Metacarpal fractures required 3 days on average to return to play in college athletes. Similar timeframes can be implied for NFL athletes.⁸ Scaphoid fractures, however, require a much longer recovery period due to a longer duration of casting. Similarly to many other injuries, surgical fixation of both fractures improves recovery time.⁹

References

1. Lowe R. Wrist and hand. Physiopedia. https://www.physio-pedia.com/Wrist_and_Hand. Accessed July 14, 2022. 
2. https://pubmed.ncbi.nlm.nih.gov/18502939/
3. Rettig AC. Hamate and pisiform fractures in the professional football player. Hand Clin. 2012;28(3):305. doi:10.1016/j.hcl.2012.05.011 
4. Elzinga KE, Chung KC. Finger injuries in football and Rugby. Hand Clin. 2017;33(1):149-160. doi:10.1016/j.hcl.2016.08.007
5. Winston MJ, Weiland AJ. Scaphoid fractures in the athlete. Curr Rev Musculoskelet Med. 2017;10(1):38-44. doi:10.1007/s12178-017-9382-y
6. Knapik DM, Tu LA, Sheehan J, Salata MJ, Voos JE, Malone KJ. Scaphoid fracture repair does not significantly diminish short-term participation in the National Football League. HSS J. 2019;15(2):137-142. doi:10.1007/s11420-018-9640-6
7. ​​Dutton M. Orthopaedic Examination, Evaluation and Intervention. 4^th edition. Chicago: McGraw Hill; 2012.
8. Etier BE, Scillia AJ, Tessier DD, et al. Return to play following metacarpal fractures in football players. Hand (N Y). 2015;10(4):762-766. doi:10.1007/s11552-015-9769-4
9. Binkley H, Smith DL, Wise S. Rehabilitation and return to sport after scaphoid fractures. Strength & Conditioning Journal. 2012;34(5):24-33. doi:10.1519/ssc.0b013e318263f845