12 Jun Discussing hand injuries in goalkeepers
Football is one of the most popular world sports, with FIFA estimating there to be around 270 million active players.(1) Injuries, therefore, are extremely commonplace, with evidence to show injury incidence is around 8 injuries/1000 hours.(2) Owing to the feet being the most utilized body part in the sport, lower extremity injuries are common and count for around 80% of total injuries within football.(2) As a result, most of the literature focuses on preventative measures in such injuries.(3)
There is very little published data on hand injuries in football. However, considering upper extremity injuries as a general entity it is known that goalkeepers are five times more likely than outfield players to suffer from one.(4) This is particularly significant due to goalkeepers requiring longer lay-off times from upper limb injuries as functional hand use is necessary as opposed to outfield players. Hand injuries can also be overlooked due to the fact they can initially be passed off as mildly debilitating. However, failure of recognition of such injuries can have potentially disastrous functional sequelae; especially for elite level goalkeepers. This review article focuses on hand injuries goalkeepers are likely to suffer from and makes a case for an injury database to guide possible future prophylactic measures and evidence-based treatment options.
FRACTURES AND DISLOCATIONS
Fractures of the metacarpals and phalanges are one of the most common in sport in general.(5) Usage of the hands by goalkeepers in actions such as ‘shot-stopping’ gives a clear mechanism by which goalkeepers are prone to fractures and dislocations involving the hand. Phalangeal and metacarpal fractures are common and can cause goalkeepers to be on the sidelines for a median time of 26 and 55 days respectively.(4) Fractures of the metacarpals/phalanges can be managed conservatively if stable/undisplaced otherwise operative fixation with Kirschner wires or open reduction internal fixation should be performed (Fig 1,2,3).
Scaphoid fractures are notoriously difficult in their management due to the high rates of non-union from the retrograde blood supply to the bone. There are cases in the literature of not only acute fractures but also stress fractures, which can lead to elongated immobilisation periods of 12 weeks.(6) If an acute scaphoid fracture is present in the elite sports population we would advocate surgical fixation with a percutaneous approach which has been shown to reduce time to union and an earlier return to work.(7)
The base of thumb metacarpal fractures, which can be simple or comminuted, often result in a deformity which cannot be controlled with a splint and often lead to operative fixation. There is no good evidence to show if conservative vs surgical management of these fractures results in faster union times or earlier return to function, however, mal-reduction has been shown to lead to post-traumatic arthritis.(8)
Goalkeepers are also predisposed to dislocations, in particular dorsal dislocations of the phalanges owing to a hyperextension mechanism from impact to the palmar surface to the hand. These would usually be managed by pitchside reduction and buddy strapping of the finger (Fig 4,5), however, if unstable or irreducible then surgery is required. Recurrent dislocations are rare but have been documented in goalkeepers, causing the need for surgical repair.(9)
TENDON AND LIGAMENTOUS INJURIES
Goalkeepers are also susceptible to soft tissue injuries of the hand. Saving/ punching the ball alongside collisions with other players or the goalposts are clear aetiologies of such injuries. Among these are tendon ruptures.(10) , for which we would recommend surgical fixation followed by a period of rehabilitation. Mallet-finger injuries (avulsion of the extensor mechanism at the distal interphalangeal joint with or without a bony fragment) can occur; sometimes simultaneously in multiple digits.(11) and can be treated with either a mallet splint or if closed reduction cannot reduce the deformity, operative stabilisation. (Fig 6,7)
Sprains (collateral ligament injuries) respond well to immobilisation and early motion for most digits. However, ligament injuries of the thumb metacarpophalangeal joint, often known as skiers thumb, can occur with forceful abduction of the thumb, resulting in a tear in the ulnar collateral ligament of the thumb. In such cases, we would most often advocate surgical fixation owing to a faster return to competition.(12)
We have discussed a non-exhaustive list of potential injuries a goalkeeper may suffer from and our preferred methods of treatment. However, the evidence for treatment is often not highly powered due to several references being single case reports and otherwise poor studies. Cricket is another sport where functional use of the hand is of utmost importance and the England and Wales Cricket Board (ECB) alongside the county clubs have an extensive database of injuries. We have previously looked at this database, studied the injury patterns and published recommended actions as a result.(13)
As previously stated, hand injuries in goalkeepers can be significant and may result in lengthy lay-offs. With the current capital in professional football, these lay-offs could have large financial implications. Owing to this we would welcome a detailed injury database, such as that seen in professional cricket, in which research could be done to establish best treatment protocols for goalkeepers to optimise outcomes and guide physician advice for future injuries.
Raj regularly treats professional sportsmen and sportswomen in his Bristol Clinic. His research interests include the prevention and treatment of hand and wrist injuries in professional sport. He is widely published in his field.
FIFA Big Count 2006: 270 million people active in football (download pdf)
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