Its Just a Wrist Sprain

by Charles Goldfarb, MD

A Wrist Sprain seems like such an innocent diagnosis.  And I would expect that almost every possible wrist injury has been called a Wrist Sprain at some point.

The classic Wrist Sprain patient in my office is the teenager who comes in about 2 months after the high school football season is over with a wrist that is still sore.  The story is predictable- a fall during a game and immediate pain in the wrist.  The parents and the trainer do not notice any real deformity and only a little or no swelling.  The pain gets better fast.  And the player returns to playing football.  But the pain never quite goes away completely. The pain lingers and eventually he finds his way to my office.  Unfortunately, this all-too-common situation is rarely a Wrist Sprain may not actually be a sprain.

The definition of a sprain is an injury to a ligament around a joint.  More information can be found here or here.  Ligament injuries are a big part of sports medicine because every single joint is stabilized by a ligament.  When an ankle is twisted or an elbow is dislocated or a knee is 'blown out', these are all ligament injuries.  It is impossible to read the sports section of the local newspaper or scan through the sports sites on the Internet without reading about a sports star with a ligament injury.  The injury occurs when a force is placed across the joint and the liagment is needed to stabilize the joint.  If the force is too much, the ligament (or ligaments) tear.

The wrist is different than some of the other joints because many injuries around the wrist are not actually sprains. But occassionally, a Wrist Sprain may really be just that- a ligament injury to the wrist.  The classic wrist ligament injury is to the scapholunate ligament.  An injury to the scapholunate ligament is a serious injury as we, the hand surgeons, do not have a perfect treatment.  Sometimes we can put sutures into the ligament and sometimes we can move ligaments around to support it.  But often times, we do not have a perfect treatment.  Other possible ligament injuries include the lunotriquetral ligament, the volar radiocarpal ligaments, and others.
One other common wrist injury is to the TFCC- the triangular fiborcartilage complex.  The cartilage is similar to a ligament as it is a supporting structure  on the pinky side of the wrist which provides support and stability in a way similar to the knee meniscus.    Future blog posts will review each of these injuries.

The reason that the wrist is different from other joints is that because many patients labeled as having a Wrist Sprain do NOT, in most cases, actually have a wrist sprain.  Instead they often have a fracture of the bones around the wrist.  Most common in this situation is a fracture of the scaphoid bone.  Such patients may have some pain at the base of the thumb and they may have limited wrist motion.  The proper diagnosis can be made with an x- ray although more advanced imaging (CT scan or MRI) may be required.  Or the may have a radius fracture, an ulna fracture, or a fracture to one of the other bone is the wrist (the carpal bones).  Here are two examples of a scaphoid bone fracture.

The scaphoid bone is the wrist bone at the base of the thumb.  The arrow marks the fracture.

A close up view of another scaphoid bone fracture.

So a Wrist Sprain may not really be a wrist sprain.  It can also be a fracture or a cartilage injury. While not every patient with a Wrist Sprain needs to see an orthopedic surgeon or a hand surgeon, if the pain lingers for more than 1-2 weeks, I would recommend that the patient see the pediatrician or the orthopedic specialist.

Charles A. Goldfarb, MD

My Bio at Washington University
congenitalhand@wudosis.wustl.edu

What is baseline testing for a concussion?

By: Mark Halstead, MD
Washington University Orthopedics

With so much attention these days to concussions in sports, I think it is helpful to explain what exactly baseline testing is all about as I find there is much confusion over what it actually does. The term baseline testing is also often not used correctly in the media so I hope to clarify some of that as well.

A baseline test can be one of several tests currently available to assess someone after they have had a concussion to either help determine if someone has had a concussion or to help determine if they have recovered from their injury to return to play. 

Several examples of sideline baseline tests include the SCAT3 (Sport Concussion Assessment Tool, 3rd edition), the King-Devick test, SAC (Standardized Assessment of Concussion), and BESS (Balance Error Scoring System) just to name a few of the more commonly utilized tests.

The SCAT3 actually incorporates the SAC and the BESS into its testing protocol. The goal is to test someone with one or more of these tests preseason and then to test them after a suspected concussion has occurred. If someone performs worse after a suspected concussion than they did on their baseline test, that increases the likelihood significantly that the person being tested did sustain a concussion.

Example of SCAT3 test which is freely downloadable to any individual free of charge

There are versions of the SCAT3 for athletes over the age of 12 and also a Child SCAT3 for those from 5-12 years of age. Unfortunately at this time, the Child SCAT3 has not had many of the components included validated for use in this age group and assumptions were made by the group who created these modified tests that these would be able to be applied to this age group. Research still needs the be conducted on the reliability of assessing for concussion with the use of these tests in athletes under the age of 12. For the SCAT3 that is used over the age of 12, the majority of the test components have been extensively researched although no published standard exists for determining, with absolute certainty, as to how poor one needs to perform to truly be diagnosed with a concussion.

The King-Devick test is another test that may be used to assess for a concussion on the sidelines. It is a test that requires the athlete to read through three cards with numbers printed on them in a left to right fashion. The test is timed and is recommended to be conducted as a pre-season assessment and then potentially be used when assessing for a concussion. Originally developed as a screening test for reading difficulties in children, it was first shown to have some application for screening for concussions in boxers and MMA fighters in a study published in 2011 in the journal Neurology by Galetta, et al. Since then several other studies have been published evaluating its use. To date, limited studies have been published in the use of this test in athletes middle school age and below and for those that have been published, in this blog authors' opinion, have had some questionable methods and conclusions made regarding the use of this test. While this test may have some utility in the evaluation of concussions in athletes, more research needs to be conducted to ensure other factors do not effect performance on the test. This test is not available for free and the company does charge for the materials, whether they be in hand test booklets or handheld tablet version of the test.

Example of the King-Devick Test

Finally, the tests that probably are recognized most commonly by the public as a baseline test are the computerized neuropsychological tests such as ImPACT, Concussion Vital Signs, ANAM (primarily a military assessment), to name a few. These tests are conducted as a preseason assessment for an athlete and take about 20-25 minutes to complete. If an athlete sustains a concussion, these are tests that are primarily designed more to determine the recovery after an injury rather than being a tool to diagnose a concussion. Different providers, schools and clinics may have different protocols for the use of these tests following an injury. Dr. Halstead will use them once an athlete is very minimally symptomatic or symptom free to see if the athlete, on a post injury test, has returned to their baseline performance. Dr. Halstead does not typically use these types of tests in athletes who have not had a previous baseline assessment. 

Example of one test in the ImPACT test battery

Unfortunately, some consider these computerized tests as the 'gold standard' for concussion assessment. These tests are just one tool in the management of a concussion and concussions can be managed without their use. These tests also have an annual cost to the schools or organizations who are administering the tests. Test results are ideally interpreted by a physician or neuropsychologist who are trained in the interpretation of these results. They should not be interpreted by the coach or parent and these are not considered a 'red light/green light' type of test as far as returning an athlete to play following a concussion. 

Currently, the majority of these computerized tests are valid for use in athletes as young as 12. They must be repeated annually until the 10th grade due to increasing scores as a child gets older. Performance on these tests has been found to be affected by ADHD (Attention Deficit Disorder), depression, prior night's sleep, prior computer use, administration at home as opposed to controlled testing environment and race. You cannot "fail" a baseline test, but very poor test performance may be considered an invalid test and an athlete may be asked to repeat their baseline assessment. The test afterwards is not called a 'baseline' but actually a post injury test, which is often described incorrectly in the media. Again, an athlete cannot 'fail' a post-injury test but if they do not perform as well as they did on their baseline, and athlete is described as having 'not returned to their baseline.'

Dr. Halstead is the director of the Washington University Sports Concussion Clinic. He currently oversees the concussion programs for 8 local high schools, Washington University and the St Louis Rams. He also acts as the primary concussion consultant for the St Louis Blues. He is the lead author on two American Academy of Pediatrics statements about concussions entitled "Sport-Related Concussions in Children and Adolescents" and "Returning to Learning following Concussion."

If you would like your child evaluated following their sport-related concussion by the Washington University Concussion Clinic, please call 314-514-3500. Dr. Halstead also performs in office baseline assessments on individual athletes over the age of 12 who may be involved with teams that do not have a concussion program already in place. 

Football and the Young Athlete

By: Matthew J. Matava, MD
Washington University Orthopedics

American tackle football has become one of the most popular sports in the United States replacing baseball in the minds of many Americans as the “national pastime”. Approximately, 2.8 million children age 6 to 14 play organized youth tackle football and another 1.3 million play at the high school level, making it among the most popular youth sports in the U.S.

Despite the millions of children and adolescents who gain the physical, social and psychological rewards that youth football provides, many parents and other interested adults continue to ask, “Is youth football safe?” This seemingly simple question is one that does not have a simple answer. Parents and administrators are debating this openly – a testament to the major shift in public sentiment recognized over the past three years. While no sport is perfectly safe, the question is whether it can be made relatively safe and if the long-term consequences of any sport are worth the risk. It may surprise parents to know that at the youth level, organized football among 5 to 15 year-olds has 12% fewer injuries per player than organized soccer in the same age range, 50% fewer injuries than bicycle riding, and 74% fewer injuries than skateboarding. In general, football-related injuries tend to vary inversely with the players’ age (and associated size and force exerted through contact) in that youth players sustain less than one-third the injuries of high school football players, less than one-fifth the injuries of collegiate players, and less than one-ninth those seen in professional football players.

Despite the perception that that the majority of football participants will eventually sustain an injury, a recent study by USA Football which included more than 60,000 individual athletic exposures (participation in a practice or game) for nearly 2,000 youth football players, found that more than 90 percent of the youth players did not suffer an injury that restricted participation; fewer than 10 percent of players incurred an injury, and of those injuries, two-thirds were minor allowing athletes to return to play on the same day.

The majority of football-related injuries occur to the musculoskeletal system, most notably the lower leg, ankle, and foot. The most common injuries among high school football players are ligament sprains. Fortunately, most of these are relatively minor and are effectively treated by nonoperative means of rest, ice, compression, and elevation of the injured area. Some ligament injuries may be season ending for a number of youth football players.

Non-orthopedic conditions are also seen in football. With summer training camps comes an increased awareness and vigilance for exertional heal illness. Young athletes account for approximately half of all heat-related injuries. High school athletes, especially males, are at the highest risk for requiring emergency treatment for this avoidable condition. Unfortunately, approximately two-thirds of football players sustaining heat illness are either overweight or obese. Other risk factors for heat illness include: practicing in the mid-day heat, wearing dark-colored uniforms, donning full pads and helmet at all times, limiting water breaks, diabetes, and sickle cell trait in African Americans. Frequent water breaks to replenish lost fluid are imperative to prevent heat-related illness. Athletes should be weighed before and after activity to replace fluid losses. An athlete should not be allowed to return to play if he has lost over 3% of his body weight following activity until those fluid losses replaced. In conclusion, football, under its current rules, will never be entirely safe and free of the risk for injuries. Therefore, it is important that there is always the proper available care to treat mild injuries with continued surveillance for more significant injuries. Instruction in proper tackling and blocking techniques, use of well-fitted equipment, and adherence to the rules of the game, are necessary means to reduce the risk for serious injury to youth players. At a minimum, first-aid training should be considered for at least one coach or league official present at all youth football practices and competitions. Given the limited resources of many youth leagues, it is imperative for those health care professionals with an interest and expertise in sports medicine to do what they can at the local level to help maintain the safety of the game so that today’s youth players can continue to enjoy all of the positive benefits of American football.