How do wrist injuries like Bradley Beal’s happen and what is the timetable for recovery?

Sports injuries are something players, their teams and fans hate. They can alter a team’s postseason hopes and alter individual careers. But from a writer’s perspective, they offer us an opportunity to learn more about these injuries from medical experts.

As you know, Washington Wizards guard Bradley Beal is out for the season due to left wrist surgery to repair a torn scapholunate ligament. On the surface, Beal can still go out for a run and be at least somewhat active on the court. So why would he have to take the rest of this season off?

To help us learn more about Beal’s wrist injury, we once again reached out to The Centers for Advanced Orthopaedics where we already have interviews with Dr. Lucas Wymore about Washington Mystics forward Elena Delle Donne’s back injury and Dr. Damian Roussel on Mystics forward Alysha Clark’s Lisfranc injury in her right foot.

This time, we interviewed Dr. Leo Rozmaryn, one of CAO’s hand and wrist surgeons. His practice is located in Rockville where he works regularly with athletes and performing musicians. Dr. Rozmaryn is also the Chief of Orthopaedics at Shady Grove Adventist Hospital, also in Rockville.

As a disclaimer, the answers Dr. Rozmaryn gave should be considered as general trends among people in a similar situation as Beal’s, and are not to be taken as medical advice. The information below is also not an indication of what Beal himself has experienced or is experiencing. Please consult your doctor for your specific situation.

And now the Q&A. Some of the text was edited for clarity.

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Bullets Forever: What is the scapholunate ligament and how does that affect the hand from a functional perspective?

Dr. Leo Rozmaryn: The scapholunate ligament provides stability to the proximal carpal row. These are four small bones: the scaphoid, lunate, triquetral and pisiform. These bones connect to the forearm and the hand. Ultimately, they create a “symphony” of sorts because every bone has to move in a specific way as the wrist is turned — and they can’t be fractured. The tiny ligaments between these bones also have to be intact.

If there is a fracture, the bones will start moving in directions that they’re not supposed to move.

Now, the scapholunate ligament is critically important. If this ligament is torn, it throws the whole wrist off balance. And so that scaphoid, which is the bone over all the way into the base of the thumb starts rotating down and also twists in an awkward direction.

This injury can cause chronic pain at a minimum. If untreated, this can lead to something called Scapholunate Advanced Collapse (SLAC), a form of arthritis that comes from this. This can even happen in a young person.

Worst case scenario, SLAC can be career-ending for athletes. So it’s very important to fix the scapholunate ligament as soon as possible, especially for somebody who is high functioning like Beal. It’s not one of those things where a doctor can’t simply say to a player, “Well, come back in four weeks and let’s see how you’re doing.” With a torn scapholunate ligament, you get an MRI to document the damage and then you have to take the patient to the operating room to put it back together.

BF: From what you are saying, is the scapholunate ligament is the one that keeps that wrist structurally sound? Would it be the wrist ligament equivalent of an ACL (anterior cruciate ligament) in a knee?

Dr. Rozmaryn: It’s the most important ligament in the wrist and the most frequently injured ligament in the wrist. So it is somewhat, but not entirely analogous to the ACL in that respect.

BF: When Beal decided to have the surgery, he first missed about 10 days to get rehab on it. Would the Monumental Basketball medical staff have known that this ligament was already torn during this 10 day period? If they knew it was torn, why did they not shut him down earlier instead of just offering palliative care (in this case, we mean something to address pain, not hospice care obviously?) From what you have indicated, a torn ligament makes surgery necessary.

Dr. Rozmaryn: If the ligament is torn and the staff sees it in the x-rays, Beal has to go to the operating room, period. The reason why Monumental Basketball waited 10 days before moving to surgery is that they needed to wait until the swelling came down.

There’s no harm in waiting 10 days. You just don’t want to wait a month or two. Ten days is just enough time to get the swelling down. This makes surgery easier and more effective.

BF: So are these procedures done rather quickly like knee surgery from an ACL tear?

Dr. Rozmaryn: Even ACL surgeries aren’t done that quickly after the initial tear. In the past, people used to do that really quickly. And then we found that they were really operating on a completely raw knee. That makes surgery harder and more painful when a surgeon is cutting a swollen knee. So there’s no harm done in waiting a couple of weeks for the ACL too.

These days, we tend to wait a couple of weeks to let the swelling go down and then operate. So in that regard, the scapholunate ligament on the wrist is similar to an ACL on the knee given their importance on how the scapholunate ligament allows the wrist to function.

BF: Beal shoots with his right hand but he is out for the season due to his left hand, which would guide the ball as he shoots the basketball. Why would this injury be serious enough to sideline him for the season even though it is not on his shooting hand?

Dr. Rozmaryn: As you said, basketball is a lot more than shooting a ball with the dominant hand. You block with your hands, you pass with them, so you need both hands to be effective. Furthermore, there would be some plays where a player like Beal would use his only his left hand to pass, block or defend.

Any time a player like Beal moves that injured wrist, if there’s pain or stiffness, it’s going to distract him from his game. A torn scapholunate ligament during play is going to either be painful at a minimum. And at worst, make him lose control of his wrist.

Let me put this in a game context. The Wizards are playing a close game with less than a minute left. A player, Beal or otherwise moves his non-shooting wrist in an awkward way where he has a loud clank or pop that hurts. How is he going to continue to play? It is going to be problematic.

Now, let’s just say that this player with an injured non-shooting wrist continues playing despite the pain. There are now three seconds left on the clock, the Wizards are down by two and the player gets the ball to take a three for the win. The player’s shooting hand is fine. But with the guiding hand, there will be searing pain at the injured non-shooting wrist, and the player is more likely to miss the shot because the guiding hand may touch the ball differently due to the pain.

BF: Not Wizards related, but the late Kobe Bryant had a wrist injury on his shooting hand in 2011. Is it possible for players to play through a minor injury on the shooting hand?

Dr. Rozmaryn: It depends on which ligaments are torn in the wrist. Kobe might have had a scapholunate ligament injury, but I’m not sure. If this ligament was partially torn, it might cause some pain and he could play through those. But a complete tear requires surgery and I don’t think a player can play through that.

[Editor’s Note: After the interview, we checked to see which specific ligament(s) Bryant injured in 2011. According to Jeannine Stein of the Los Angeles Times, Bryant tore lunotriquetral ligaments in the right wrist which give the wrist mobility. The article stated that Bryant’s injury was relatively minor. Torn lunotriquetral ligaments generally do not require surgery because they don’t affect the wrist’s stability. The scapholunate ligament, as we’ve learned from our time with Dr. Rozmaryn, does affect the wrist’s stability.]

BF: What is the success rate of various types of surgical procedures to repair the scapholunate ligament?

Dr. Rozmaryn: I’m not sure exactly what repair Beal had, and there are about 20 different procedures to address it. And I’m going to startle your readers, but the success rate of scapholunate ligament surgery is only 75 to 80 percent, even with the best of hand surgeons. The thing is that many of these repairs fall apart. They may fall apart a year or five years after surgery.

The good news in Beal’s case is that the medical staff diagnosed and operated on his injury quickly.

BF: What is the timetable for someone to recover from scapholunate ligament surgery if one suffers a complete tear? Both from a medical standpoint and a return-to-play standpoint?

Dr. Rozmaryn: It takes about three to four months for the wrist to fully recover from this procedure. At this point, the wrist can be put into ordinary use for daily, low-stress activities. For sports, the timetable is no less than six months.

Assuming there are no setbacks, Beal may be ready for training camp in September.

BF: How does this injury happen in basketball and other sports?

Dr. Rozmaryn: In basketball, the wrist could hit the court after a fall or hit a hard surface. In baseball, a center fielder could fall down on his wrist running after a line drive.

Football is certainly a contact-heavy sport due to tackling and hits at most positions from linemen, to receivers, quarterbacks, etc. In volleyball, a setter could hurt his or her wrist while going for a dig.

Hand injuries are the most common injury in soccer, contrary to popular belief because most players aren’t allowed to use their hands during play. They do jump and slide often which put them at risk for these injuries.

BF: Which age group of people is more susceptible to tearing a scapholunate ligament? For example, older people are more susceptible to falls and seem to be more at risk for injuring their wrists. Are they more likely to tear their scapholunate ligaments when they injure their wrists?

Dr. Rozmaryn: A 55 or 60 year old who falls on their wrist is rarely at risk of tearing the scapholunate ligament. For any fall, the weakest section of an injured body part is most likely to break. Older adults are more likely to break their radius, or one of the forearm bones because bone density decreases due to their age.

A scapholunate ligament injury is most likely going to affect men and women ages 18-45. Their bones are stronger which make the ligaments the weak point during a fall.

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A big thanks to Dr. Rozmaryn for taking his time to speak with us. As Wizards and Mystics player injuries happen, we will continue to reach out to The Centers for Advanced Orthopaedics so we learn more about these injuries in detail.