Upper Extremity Injuries P

Upper Extremity Injuries

P

V

, R

P

, M

G

, C

B

Introduction

Upper limb injuries in association with football have been increasing in recent years [1, 2]. Goalkeepers, of course, are afflicted by typical chronic dis- orders. Among the other players, however, there is a disturbing incidence of acute traumas, including forearm and metacarpal fractures and acromio- clavicular and gleno-humeral dislocations. The upper extremities, in fact, are exposed to significant risks from falls occasioned by the speed at which tack- ling takes place and certain fouls resulting in the knocking down of an oppo- nent heading for the goal. These impacts are very similar to those associated with American football, which is a contact sport par excellence, so much so that its players wear specific protective devices. Falling after a header tackle, too, is a relatively frequent cause of upper limb injury [3].

A goalkeeper’s actions are primarily founded on the use of the upper limbs. Goalkeepers must be in possession of special gifts brought to perfec- tion by training in the art of falling without injury, especially since they are likely to fall on their shoulders as many as 200 times a week. The sliding mechanism employed to protect joints on these occasions ensures that the stresses are distributed over several points of the shoulder. A fully trained goalkeeper, in fact, does not land directly on the shoulder but curves it to spread the impact over a round surface. When catching the ball during a save, too, flexed hands are set in such a way that the forces exerted on the palms are transmitted to the forearms and elbows.

Although the goalkeeping role mainly exposes the player to direct injuries

as the result of contact with opponents, the ground, and the goal posts,

injuries also occur without contact. Modern tactics, in fact, sometimes place

the goalkeeper in the position of the last open-field defender. In this respect,

the incidence of injuries is similar to that of other players in addition to those

peculiar to the particular actions and movements associated with this posi-

tion.

Generic Upper Limb Injuries (Field Players and Goalkeepers)

Field players are essentially prone to acute lesions (bruises, lacerations, and sprains) whereas fractures and dislocations are less common. Gleno-humeral dislocation is certainly not rare on a football pitch though it is more frequent in other sports (skiing, judo, rugby). It is usually anterior, with displacement of the humeral head resulting in damage to the labrum, ligaments, capsule, and bone. Common causes are a fall on an arm in external rotation, a direct fall, or a tackle with abnormal traction of the arm by the opponent. In goal- keepers, it may be the outcome of a dive save against an opponent, with the arm abducted and laterally rotated and often with posterior impact on the ground. The altered profile of the shoulder, loss of movement, and acute pain indicate the correct diagnosis and call for immediate treatment. Radiographic confirmation of the diagnosis is followed by reduction by expert hands, usu- ally those of an orthopaedic specialist at a first-aid station. Immobilisation with a brace for 20–25 days followed by rehabilitation to recover full efficien- cy is normally sufficient though recurrences cannot be entirely ruled out. In very carefully selected cases, surgery (usually arthroscopic) is undertaken after the first episode to suture and ensure better reestablishment of the labrum and anterior ligaments and hence reduce the risk of recurrences. Re- education begins a month of relative safeguarding of the shoulder, and sport is resumed after 3 months. Recurrent dislocations demand arthroscopic or open-field management.

Acromio-clavicular dislocations are due either directly to a fall on the shoulder with the arm adducted or indirectly to a fall on an extended arm. Six degrees of injuries (sprains, subluxation, and dislocation) are distinguished in accordance with the anatomical damage they cause. Pain at the anterior surface of the shoulder, sharp pain provoked by pressure on the joint, and alteration of the profile of the lateral end of the clavicle (typical of disloca- tions) indicate the correct diagnosis prior to radiographic confirmation.

Surgery followed by resumption of sport after 2 months is recommended.

Goalkeepers, especially after many seasons, may display chronic joint pain due to repeated traumas or microscopic lesions.

Elbow dislocations, generally posterior, are not common. They are pro- voked by contact with an opponent when running or by a fall after a header.

The elbow may be injured directly though dislocation is often caused indi- rectly by a fall on the palm with the arm extended and retroposed. Deformity, functional impotence, and pain indicate the correct diagnosis and call for radiographic confirmation and immediate reduction.

Metacarpal fractures are caused when a player’s hand is trodden on while it is on the ground. The studs of the other player’s boots usually cause a shaft fracture, sometimes with concomitant bruising and laceration. Pain and

124 P. Volpi, R. Pozzoni, M. Galli, C. Bait

swelling are immediately evident. Radiography is always advisable. Four weeks in plaster are usually sufficient. Surgical reduction and union is pre- ferred in the event of displacement, shortening in excess of 2 mm, and angu- lation greater than 15°. Field players need not give up playing completely.

They can continue their general physical training until the resumption of sport, which will be promptly achieved when the hand is protected with a brace. Goalkeepers are more prone to fractures of the shaft or neck of the third metacarpal since this is the longest bone and is exposed to direct injury when the ball is driven back into play during a save.

Specific Goalkeeper Injuries

As already mentioned, in modern soccer, goalkeepers use their hands to catch or punch back the ball in their penalty area and are thus exposed to injuries similar to those of the other players in addition to specific acute and chronic lesions, particularly of the upper limbs.

Reception of the ball brings the hands with the fingers open to block it and the fingers closed to repel it. The palms and second, third, and fourth metacarpo-phalangeals may thus be injured. The name “goalkeeper’s thumb”

[4] is used to describe subluxation of the metacarpo-phalangeal joint of the thumb with rupture of the ulnar collateral ligament (UCL) and possible frac- ture of the base of the first metacarpal. The force of the ball when caught is concentrated on the proximal phalanx of the thumb and subjects the ligament to heavy stress.

An acute injury results in pain accompanied by functional limitation and swelling. Rupture of the ligament renders the joint unstable. The diagnosis is clinical and radiographic. Treatment is non-operative (4 weeks in plaster) in the case of partial lesions whereas surgery is mandatory in the event of com- plete rupture of the ligament and bone detachment with displacement of the fragment.

Distal phalanx fractures are unusual whereas fractures of the base due to avulsion of the flexor [5] or extensor [6] tendon are more common. This type of injury, especially detachment of the deep flexor tendon, often necessitates surgical reduction and re-instatement of the bone fragment. Sprains of the (usually proximal) inter-phalangeal joints are relatively frequent while involvement of the collateral ligaments may result in instability. The joint is swollen and locally painful, with occasional loss of congruity.

The wrist and its many bones are the site of sprains, lunate dislocations,

and scaphoid fractures usually due to falling with the hand in a defensive atti-

tude. Scaphoid fractures are the most frequent, though uncommon, because

goalkeepers mainly stress their metacarpals. Chronic fractures and pseudo-

arthroses sometimes escape notice. During a save, in fact, the scaphoid is between two convergent forces, one due to the impact of the ball on the palm with the fingers extended and the other due to the forward movement of the radius in the direction of the ball [7]. All types of scaphoid fractures require long abstention from sport. Clinical and radiographic healing enables com- petitive play to be resumed after 3–6 months.

A goalkeeper’s elbow is mainly subject to sprains. Serious injury is unlike- ly as the result of contact with the ground even though the elbow pads used in other sports are not worn. There are, however, rare instances of capitulum humeri lesions due to abnormal falls with the hand in a defensive attitude, as well as isolated olecranon fractures. Overuse disorders include olecranic bur- sitis, often accompanied by oedema owing to continuous direct micro-trau- mata, together with insertion disorders of the triceps tendon caused both by direct repetitive traumata in flying saves and by the forces of reception of the ball with the elbows flexed. This disorder may eventually give rise to a typical olecranic spur varying in shape and size, which becomes evident at the end of a player’s career.

Chronic shoulder disorders that disable goalkeepers from playing and specific daily training include the various forms of rotator cuff tendinopathies, traumatic derangement of the tendon of the long head of the biceps, and micro-traumatic instability with the various features of a “slap lesion”.

References

1. Schmith-Olsen S, Jorgensen U, Kaalund S, Sorensen J (1991) Injuries among young soccer players. Am J Sports Med 19:273–275

2. Volpi P (2000) Soccer injury epidemiology. J Sports Traumatol 22:123–131 3. Volpi P (1992) Indagine epidemiologica dei trauma nel 1° Mondiale di Calcio Under

17. J Sports Traumatol 14:1–7

4. Bowers WH, Hurst LC (1977) Goalkeeper’s thumb: evaluation by arthrography and stress roentgeography. J Bone Joint Surg Am 59:519–524

5. Wanger DR (1973) Avulsion of the profundus tendon insertion in football players.

Arch Surg 106:145–149

6. Curtin J, Kai NRM (1976) Hand injuries due to soccer. Hand 8:93–95

7. Giorgi B (1961) Fratture e pseudoartrosi dello scafoide carpale nel giocatore dei cal- cio: lesioni caratteristiche dei portieri. Arch Putti Chir Organi Mov 14:229–240

126 P. Volpi, R. Pozzoni, M. Galli, C. Bait