1 Introduction

Hand and wrist injuries are one of the most common injuries in cricket, estimated to account for approximately 11–13% of all injuries, regardless of gender, age, format and level of competition.^1,2 These injuries often result in a player being unable to play for multiple weeks.^1,3 Hand injuries are most commonly a result of direct impact or collision with either the ball or the ground whilst fielding.¹ Injuries, including fractures, have been described to typically occur to the fingers,^1,4 particularly the little and ring finger.^1,5 Fractures of the fingers do not commonly require surgical fixation.⁶

Protective equipment for hand and wrist injuries includes batting and wicket keeping gloves. In training, players may also opt to wear gloves during fielding drills. Gloves are perceived to reduce the risk of hand fractures and other injuries, however design and quality vary and the efficacy is unknown.^7,8 There is an opportunity to improve gloves and other risk reduction strategies with increased understanding of how injuries occur and the location of injuries.

Research to-date has highlighted the burden of hand and wrist injuries in cricket, however more detailed insight is needed to inform clinical decision making. This study aims to contribute to this gap in knowledge with a specific focus on hand fractures in elite Australian cricket players.

2 Material and methods

3 Results

A total of 70 (17% of players; 43 male, 27 female) elite Australian cricketers sustained 90 hand fractures between December 2015 and December 2018 (Fig. 1). The mean age at time of injury was 26.7 ± 5.4 years for males and 25.4 ± 4.5 years for females. Fractures occurred during matches (61%; international n = 9, domestic n = 25, club n = 11) or training (39%).

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Fig. 1 Number of fractures by bone.

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The observed rate of hand fractures during matches (for which the denominator of total balls batted/fielded is known) was highest for the fielding team (p < 0.001 compared to batting team) (Table 1). In the field, females had a higher rate of hand fractures than males (p = 0.002).

Seventy-three (81%, 95% CI 72-89) fractures occurred whilst fielding the ball (i.e. catching or diving) including bowlers (n = 14) and wicket keepers (n = 10) in both matches and training. Eighty percent of the fractures sustained by fielders occurred in the infield (a central oval on the cricket field, the reference point for fielding restrictions, in contrast to the more distant outfield). Eight (9%, 95% CI 4-17) fractures occurred whilst batting. Forty-eight injuries (53%) occurred to the dominant hand for the specific skill during which the injury occurred (throwing or bowling arm, or lower hand when batting).

Eighty-four (93%, 95% CI 86-97) fractures occurred to the ‘exterior’ bones of the hand: distal phalanx, middle phalanx, first and fifth rays (Fig. 2). This was consistent across playing positions grouped by use of gloves (90-100%, all p > 0.4). Wicket keepers had a higher proportion of middle phalanx to distal phalanx fractures (67%, 95% CI 35-88) compared to batters (9%, 95% CI 2-38) (p = 0.017) and fielders/bowlers (30%, 95% CI 18-44) (p = 0.055). There were a total of 19 avulsion fractures.

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Fig. 2 Illustration of the ‘exterior’ bones of the hand.

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Seventy-seven (86%, 95% CI 77-92) fractures were managed non-surgically, including all avulsion fractures and less than five cases which required minimally-invasive procedures, such as surgical washout or removal of a small fragment only. Thirteen (14%, 95% CI 9-23) fractures were managed with surgery, all requiring internal fixation. Of these 13 surgically managed fractures, 11 were to the phalanges, most commonly at the proximal phalanx (n = 5, 36% of all proximal phalanx fractures) or fifth ray middle and proximal phalanges (n = 5, 42% of all fifth ray phalangeal fractures).

Fractures requiring surgical management typically had longer time injured (median 33 days, IQR 27-41) than fractures managed non-surgically (median 6 days, IQR 0-21) (p = 0.001) (Fig. 3). Total time to return to full unrestricted play was similar between surgical (49 days, IQR 45-52) and non-surgical (32 days, IQR 15-45) management (p = 0.197) (Fig. 4).

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Fig. 3 Days injured (unable to participate in any activity) by bone and management. MC = metacarpal, PP = proximal phalanx, MP = middle phalanx, DP = distal phalanx.

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Fig. 4 Days to return to full unrestricted activity by bone and management. MC = metacarpal, PP = proximal phalanx, MP = middle phalanx, DP = distal phalanx.

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4 Discussion

Hand fractures sustained by elite male and female Australian cricket players were found to display a pattern of occurring to the ‘exterior’ bones of the hand. This pattern was consistent regardless of playing activity and use of gloves. The exterior bones are more vulnerable to impact from a ball and hence this pattern may be characteristic of other ball and projectile sports.⁹ With sports such as rugby and ice skating where hand fractures often result from falling on a hard surface may show a different pattern of fractures, specifically to the ‘internal’ bones of the hand.⁹

Surgical management was required in approximately one in seven cases. This rate is consistent with that reported by Ahearn et al. in a cohort of professional county cricketers.¹ Fractures managed surgically resulted in more days injured with no activity, likely attributable to post-surgical wound care and implant restrictions. Interestingly, the time to return to full unrestricted training or match play was similar between surgical and non-surgical management, which may reflect the expected healing time of bone.¹⁰ This finding appears to differ from the longer duration noted for surgically managed fractures by Ahearn et al. however complete statistics were not provided to confirm.¹

Hand fractures were most frequently sustained when fielding the ball. It is not possible to compare the relative risk between matches and training as the number of balls fielded at training is unknown. Nevertheless, approximately eight fractures per year is a considerable injury burden which warrants attention. Risk reduction strategies which may be used when fielding in training but not matches include reducing the exposure (quantity of balls fielded), using gloves, or a softer ball. Players may wear gloves when fielding at training, however the current gloves are not designed to protect the exterior bones from fracture (Fig. 5). There is potential to improve the design of fielding gloves to reduce the risk of hand fractures.

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Fig. 5 Gloves used for fielding drills in training. Note ‘exterior’ bones of the hand are largely unprotected.

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An alternative risk reduction strategy is to improve skill proficiency. This strategy may be particularly applicable to female players who had a higher rate of hand fractures relative to balls fielded in matches compared to males. It has been suggested that increased fielding practice may have the potential to reduce the number of hand injuries in general.^3,11

The rate of hand fractures was significantly reduced for players when wicket keeping or batting with gloves. This suggests that gloves are somewhat effective as a risk reduction strategy, however, as fractures are still occurring there is potential for improvement. Wicket keeping gloves include specific protection of the distal phalanges. This may explain why more fractures were observed at the middle phalanges rather than the distal phalanges. Therefore, the design of wicket keeping gloves should aim to better protect all exterior bones of the hand including the middle phalanges.

When interpreting the findings of this retrospective descriptive study, readers should be aware of the robustness of the variables presented. Data relating to the individual (gender, age, handedness) and injury (bone, activity, management) are certain. Fielding position data was less reliably noted on clinical notes (73% complete) so is included for interest only. Days injured and days to return to full unrestricted activity are accurate, however may have been influenced by other factors independent of the hand fracture.

5 Conclusions

Hand fractures sustained by elite male and female Australian cricket players were found to display a pattern of occurring to the ‘exterior’ bones of the hand. Compared to non-surgically managed fractures, surgically managed fractures typically had a longer time injured but a similar time to return to full unrestricted play. The results of this study may inform clinical decision making with respect to non-surgical or surgical management and anticipated return to play times. Further effort is needed to address risk reduction strategies including gloves and skill proficiency.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.