The Overly-Curious UnDoctor: Wrists

The Overly-Curious UnDoctor Is In! This week’s subject: Wrists and Playing Post-Injury With the constant stream of owies and ouchies that the Red Sox encounter, it can all get a bit confusing for us non-medical types. What’s just a minor scrape that’s nothing to worry about? And what’s a severe 4-alarm injury that warrants a true freakout?

That’s where our resident health professional, MHCranberry, MPH, is here to help. She’ll be stopping by on occasion to give you all the nitty gritty on the Sox DL.

The wrist is a fragile thing indeed. Wrist injuries have felled Dustin Pedroia, Big Papi and now Jed Lowrie — and given the state of play of one Julio Lugo, Jed’s wrist injury is of major concern to Sox fans everywhere. So what’s going on with all the Red Sox wrists? And how long will it take for them to be healthy? Help us, Overly-Curious UnDoctor!

Follow me after the jump for all the questions you have but were afraid to ask…

I was going to write about Jed’s wrist sooner, but there wasn’t much information coming out, and the world of Undoctors lately has been quite stressful and and the non-baseball-related people have to come first, and it has left me with very little desire to do any writing except for updating my resume. But with the clamoring for Jed to replace you-know-who, and with people asking about Papi’s wrist strength, I figured it might just be time to start typing.

Really, the only thing I can say about it is this: wrists are tricky. Jed Lowrie’s experience—oh-wait-I’m-not-healed-after-all revelations, dull pain that turns out to be a serious problem, and tremendously frustrating prolonged healing times—is far from rare. Especially if you live in New England, where the seemingly permanent ice coating on every inch of ground this winter was the enemy of wrist bones everywhere, which we’ll get to in a minute.

I also want to remind all of you of another wrist injury that was kind of surprising—remember how Dustin Pedroia played his astoundingly good rookie postseason in 2007 with a broken hamate bone? That injury was around from early September on through the World Series, and he just played right through the pain.

So how is this possible? How can some people have broken bones and not know it? Why do those bones take so damned long to heal? And why would someone have surgery—or choose not to?

I do have a little bit of experience in the trickiness of wrists. In January, I slipped on some ice (while carrying a ten-pound bag of rock salt, ironically) and tried to break the fall with only my left hand. Not surprisingly, I found myself in quite a bit of pain. Once I realized I had no grip strength to open a plastic bag for some ice, it was off to the Emergency Department.

Then the fun started.

I had one doctor tell me that there were two hairline fractures, one on the radius and one on the scaphoid. I had another doctor tell me that there was no fracture on the radius and almost certainly one on the scaphoid. And then, a week later, I got a CT scan and the orthopedist told me there was a hairline fracture on the radius and though the scaphoid “looked funny” there was no fracture there. A month later, I got more x-rays and it was revealed that the radius fracture was not hairline after all, and there was a crack in the scaphoid.

Meanwhile, the bone was healing, and ultimately, it didn’t matter what crack was where, because everything was in the right place. I was lucky. If some piece of bone had been knocked out of place, I would have required surgery. In the meantime, I had been going about my daily business, although in a limited fashion, wondering if whatever it was I was doing was going to leave my wrist bones crumbling, avoiding any situation that looked like it might hurt.

I’d put money on this journey being similar to Jed’s. It is endlessly frustrating.

First things first– the clinical picture. Jed actually wound up having two injuries in his wrist, both fixed in the surgery. First, he fractured the ulnar styloid– the little piece that juts out and caps the ulna in the diagram below, marked “styloid process”. Second, there actually was a sprain in the whole mess. He damaged his S-L (scapholunate) ligament, which is the ligament attaching the scaphoid and lunate bones down at the base of the wrist.

The styloid process creates a little notch for tendons to move around in, so fracturing this would cause some instability. And damage to the S-L ligament creates a major instability in your grip– including grip on bat and ball.

All this has been fixed now surgically, and he should be fine with time. But Jed’s injury is one in a series of wrist injuries to the Sox, so let’s consider the big picture.

The wrist is a very complex piece of anatomy. Look at yours—move your hand around in a circle, twist it, bend it—think about all the pieces that have to coexist in that little tube-like structure. There are bones for each of your fingers and your thumb that meet there, plus the heads of the two forearm bones (the radius and ulna). That’s seven bones that all need to move smoothly. Then on top of those, you have eight tiny bones called the carpals—the trapezium, the trapezoid, the capitate, the hamate, the scaphoid, the lunate, the triquetrum and the pisiform—with four joints. You also have all the cartilage and ligaments and tendons that tie all these pieces together. That is a lot to have going on in that amount of space.

But from an evolutionary standpoint, it is magnificent. If you break one of the bones in your forearm or in your wrist, frequently, at least part of your hand will still function. There are people who go years without even knowing they have broken a bone, thinking it is just chronic pain. Your wrist can rotate in all directions. It enables your hand to do multiple things at one time: for example, gripping a baseball while flexing the wrist to make a throw, or allowing a bat to shift smoothly in the hand, maintaining control over a chunk of wood being swung around as violently as possible.

The wrist is a masterpiece of engineering in nature.

When one piece of the machinery of your wrist is broken or snapped, it doesn’t stop functioning. There are some angles that could break up a certain motion, or some soft tissue damage–a tear in a ligament, for example–will disrupt the ability of the tendons and nerves to smoothly work around the joints or disconnect the muscle from the bone, affecting mobility. But a fracture alone won’t do it.

The swelling has to be kept down–easily done by a professional baseball team with a cortisone shot and tons of ice–as swelling will put pressure on damaged tissues, make everything full of fluid, inflexible and infinitely more painful.

Diagnoses are incredibly difficult, because with so much going on, and such small parts, x-rays won’t necessarily show a wrist fracture. To illustrate how much can be missed, compare the various imaging options available. All of these are sample images of human wrists.

X-ray

CT scan

MRI

With each type of scan, you can see more detail, but the images become increasingly complex and difficult to read. As I mentioned, even a CT scan was insufficient to diagnose my wrist fracture.

The complexity of the wrist makes diagnosis– to say nothing of prognosis, which is the issue with Lowrie– quite difficult.

Even now, about five months after my original injury, there are lingering symptoms of my fracture. I get occasional pins and needles in the tip of my thumb because some scar tissue somewhere or a damaged ligament is putting pressure on a radial nerve. Because everything in the wrist is so close together and the system of ligaments and nerves and everything is so intricate, when one thing gets damaged, things around it get damaged too. And if scar tissue develops, it’s going to be taking up space, possibly pushing structures out of place.

Now, my pins and needles are improving– but VERY slowly. Frustratingly slowly. Scar tissue is stubborn, unyielding stuff. In fact, a month or two ago, I wouldn’t have been able to tell you with certainty that my wrist had healed normally–it was that debilitating, and that confusing and scary. What if I had permanently damaged the nerve? What if I needed surgery after all?

Which brings me to our beloved Papi, whose wrist is healed. It is entirely possible that Papi’s wrist doesn’t feel completely right–clicks, tingles, soreness, stiffness, who knows. The injury he had could easily cause scar tissue that he can feel somehow, and even though the actual injury is healed and his wrist is healthy, a prior injury can have lingering effects even this far out.

So whether Papi or Jed knows it, their injury likely is and was affecting their play.

The only problem with playing injured, however, is the “guarding” phenomenon. It’s a stunningly primal response to injury. Pedroia, of course, stops at nothing, so even the wrath of God himself would not stop him from hitting a leadoff homerun in the World Series, or pouncing like a ravenous if small-ish mountain lion on a grounder. And he paid the price: when surgeons finally got in there, his hamate bone crumbled, having been knocked around so much.

But normal human beings reflexively protect injured parts of their body. Walking with a limp is a perfect example of this–any reaction in which you flinch or curl away from something you know is going to hurt. Losing your appetite when you have food poisoning is an even better example. Your brain learns what is going to hurt it and avoids it. It’s a phenomenon seen in every animal species, from lab rats avoiding electrical shocks all the way to birds learning which bugs are poisonous to eat. It’s a powerful impulse and one that is almost impossible to control, even if you are conscious of it.

Now, this is getting into some details of neuropsychology, so I won’t go into more detail (though I love it having studied it in college), but the basis is this: even when healed on a cellular or structural level, the neurological side effects and cognitive behaviors of injury linger.

When Mike Lowell’s hip was hurting, it affected his swing significantly, since pitchers would throw low and inside, almost forcing his own reflexes to distract him from hitting. No matter how much he tries for mind over matter, Jed Lowrie with a painful wrist is not going to swing as hard at a fastball, if at all, if the shock from impact with the ball makes his wrist hurt at all. He won’t be as quick to make a diving catch.

Sadly, these guarding behaviors can last well beyond the actual time required to heal the physical wound. A long-term injury that alters behavior will yield habits. I think that’s what’s going on with Papi, really. He spent so much time worrying about his wrist, worrying about whether it is strong enough and worrying about reinjury that he cannot break the habit. It isn’t that he’s weak or afraid of the ball or flinching: he’s afraid of missing months of yet another season.

And sorry to say it, I wish this was the situation with Lugo too–that he’s guarding his knee and it’s mucking up his timing–but I cannot say with any certainty at all that it’s anything besides him sucking.