By Abby Sims
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J.R. Smith is readying to come back from surgery for what was termed a “complex thumb fracture,” sustained on Dec. 20 while trying to swipe a ball from an opponent.
Will the former Knick and current guard for the Cavaliers be on the court Friday, which has been said to be a possibility? Or might Cleveland have to continue to find a way without him for a bit longer despite some other serious losses to injury?
I’m not sure why Smith is listed as questionable for Friday night’s game when it was just revealed that he had been listed as cleared to participate in full-practice activities. If he’s out there, it isn’t likely that it will be for significant minutes, at least at the outset?
So what is a complex fracture? The term complex fracture implies that there is more damage to the bone and surrounding soft tissues than a simple fracture would entail. Essentially, the bone breaks into smaller fragments rather than cleanly into two segments. Another term for this is a comminuted fracture. These generally occur with a high-impact trauma.
Proper treatment of fractures and fracture dislocations promotes healing, restores alignment, and minimizes instability, pain and the development of osteoarthritis, while optimizing joint mobility and functional outcomes.
While no mention of Smith’s particular type of fracture is really known, there is one in particular that is most common.
Bennett’s Fracture tops the list. This occurs within the joint at the base of the thumb — the carpometacarpal joint. The fracture begins on the pinky side of the base of the thumb (the ulnar side) and is generally the result of a force transmitted to the metacarpal when the joint is slightly flexed. For instance, this would be the case if injured while punching with a clenched fist.
The pattern of the fracture to the metacarpal is on an oblique angle and X-rays reveal distinct fragments, some of which remain attached to ligaments in the region. Most concerning is the fact that a fragment comprised of the joint surface of the metacarpal becomes displaced as does the metacarpal itself. This is as a result of the pull of muscles (abductor and adductor pollicis) that connect to the bone.
Several factors are considered in order to gauge the expected recovery: The specific location of the fracture, the degree of displacement, the bone damage from impact, and whether any shearing injury is identified on the outer (radial) side of the joint surface of the carpal bone (trapezium).
The treatment plan is dictated by the degree of displacement. If it is less than 3 millimeters the bones are generally realigned using manual traction and positioning (closed reduction), to allow for healing once immobilized. This is augmented by fixation with a pin if certain conditions are met, the fragments are smaller and the joint surface (the dome of the metacarpal) remains intact. When it is not possible to achieve reduction of the fracture in this manner, surgery is indicated.
Likewise, when displacement at the fracture site is greater than 3 millimeters, surgical intervention becomes necessary. The fracture is reduced and fixated (Open Reduction Internal Fixation — ORIF). Wires are used to secure smaller fragments and in the case of a more sizable fragment, a screw is also utilized. Generally a six-week period of immobilization follows before a hand rehab program is initiated when only wires are utilized. Earlier rehab intervention may be appropriate — around the four-week mark — especially in the presence of more elaborate fixation.
The rehab process begins with simple range of motion exercises and progresses to incorporate strengthening and functional activities. Hopefully with the playoffs just ahead, Smith is ready to play when he does return to competition.
Long-term follow-up studies of those with Bennett’s fractures revealed that with appropriate treatment, patients achieved normal mobility and good functional outcomes. The presence of osteoarthritis down the road was the primary finding that did not consistently correlate with the success of fracture reduction and treatment.
Another, far less common type of complex thumb injury is Rolando’s Fracture. This three-part fracture also occurs within the joint (intra-articular) at the base of the first metacarpal. A primary distinction of this fracture is a sizable fragment that is toward the back of the hand and Y and T shape fractures within the joint itself. The prognosis is not as good for that of the Bennett’s fracture, and it, too, can be treated non-operatively or surgically depending on specific circumstances.
Abby Sims is a licensed physical therapist with vast experience evaluating and treating orthopedic, sports and dance injuries. Follow her on Twitter @abcsims