f1 Driver Wrists

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The wrist of the formula 1 driver

Emmanuel H Masmejean, Hervé Chavane, Alain Chantegret, Jean-Jacques Issermann, Jean-Yves Alnot

Abstract

Objectives —During formula 1 driving,repetitive cumulative trauma may pro-voke nerve disorders such as nerve com-pression syndrome as well as osteoliga-ment injuries. A study based oninterrogatory and clinical examination of 22 drivers was carried out during the 1998formula 1 World Championship in orderto better define the type and frequency of these lesions. Methods —The questions investigatednervous symptoms, such as paraesthesiaand diminishment of sensitivity, and os-teoligamentous symptoms, such as pain,specifying the localisation (ulnar side,

dorsal aspect of the wrist, snuV box) andthe eV ect of the wrist position on theintensity of the pain. Clinical examinationwas carried out bilaterally and symmetri-cally. Results —Fourteen of the 22 drivers re-ported symptoms. One suV ered cramp inhis hands at the end of each race and onedescribed a typical forearm eV ort com-partment syndrome. Six drivers had effort“osteoligamentous” symptoms: threescapholunate pain; one medial hyperp-comression of the wrist; two sequellae of adistal radius fracture. Seven reportednerve disorders: two eV ort carpal tunnel

syndromes; one typical carpal tunnel syn-drome; one eV ort cubital tunnel syn-drome; three paraesthesia in all fingers atthe end of a race, without any objectivesigns.Conclusions —This appears to be the firstreport of upper extremity disorders incompetition drivers.The use of a wrist padto reduce the eV ects of vibration may helpto prevent trauma to the wrist in formula1 drivers.(Br J Sports Med 1999;33:270–273)

Keywords: wrist; trauma; cumulative trauma; nerve

compression; ligamentous distension; racing drivers

In the literature, the incidence of wrist and

hand injuries in the general sporting popula-tion is estimated to be about 25%. 1 In weightlifting for instance, wrist lesion occurs in 12%

of lifters.2 These injuries can be subdivided intofour categories: overuse, nerve (and vascular),traumatic, and the weight lifting injuries.1

Weight lifting lesions are more specific to gym-nasts. The other three kinds can be observed inother sports where wrists and hands areinvolved, such as competitive driving. In theformula 1 driver, cumulative microtrauma mayproduce diV erent pathologies at the level of the

upper extremities, such as hand-arm vibration

syndrome.3 It can be exhibited as nervedisorders, such as nerve compression as part of an overuse syndrome, or osteoarticular lesions.Nerve disorders of the upper extremities are inparticular represented by carpal tunnel syn-drome at the wrist and by cubital tunnelsyndrome at the elbow. Osteoligamentouslesions of the wrist, by progressive distension,are mainly represented by scapholunate liga-ment distension, but triquetrolunate ligamentinjuries as well as triangular fibrocartilagecomplex lesions may also be evoked.

For the formula 1 driver, the frequency andintensity of vibration are such that they mayprovoke these lesions. We have carried out an

epidemiological study based on interrogationand a bilateral clinical examination of the wristsand hands of formula 1 drivers. The goal was toevaluate the type and frequency of such injuriesin order to propose preventive measures.

Subjects and methodsSUBJECTS

During the 1998 French Grand Prix on theMagny-Cours track, 22 formula 1 drivers from12 diV erent nations were clinically examinedby the same independent doctor (EHM). Theycomprised 19 drivers taking part in the currentWorld Championship and three former for-mula 1 drivers, who were still driving in other

categories (rallying, endurance, etc). Eachdriver had raced in a mean of 63 formula 1Grand Prix (range 7 to 176).

The mean age of the drivers was 30.7 years:28.1 years for the drivers in the current cham-pionship and 37.3 years for the three formerdrivers.

Twenty drivers were right handed and twowere left handed.

METHODS

Questioning established medical and surgicalhistory and other sports played, especiallythose involving the upper extremities—forexample, tennis and golf. Nervous symptoms

were also investigated such as paraesthesia anddiminishment of sensitivity, and also osteoliga-mentous symptoms such as pain, with specifi-cation of the location (ulnar side, dorsal aspectof the wrist, snuV box) and the eV ect of thewrist position on the intensity of the pain. Theinterrogation also researched wrist instabilityand/or “clunk”.

The clinical examination was carried outbilaterally and symmetrically. The basic rulesof physical examination of a patient, namely,appearance, palpation, movement, and stressare especially important at the wrist level.4 Therange of motion of the digits and the wrist in

Br J Sports Med 1999;33:270–273270

Hopital Bichat HandSurgery Service, 46,rue Henri Huchard,75877 Paris Cedex 18,France

E H Masmejean J-Y Alnot

Hôpital EdouardHérriot, Pavillon T,OrthopaedicDepartment, Placed’Arsonval, 69437 LyonCedex 03, FranceH Chavane

Fédération Françaisedu Sport Automobile(FFSA), 17−21, avenuedu Général Mangin,75116 Paris, FranceA Chantegret

FédérationInternationale del’Automobile Sport(FIA Sport), MedicalDepartment,2, Chemin deBlandonnet, 1215Genève L5,Switzerland

J-J Issermann

Correspondence to:

Dr E H Masmejean.

Accepted for publication

19 April 1999

http://bjsm.bmj.com/



flexion-extension as well as in prosupinationwas noted. Palpation of the joints identifiedareas of tenderness, which were related to theintercarpal intervals—that is, the spaces be-tween the scaphoid and the lunate, and thelunate and the triquetrum. The Kirk Watsontest5 assessed scapholunate instability. TheReagan shuck test was used to look for peritri-quetral instability.6 Finally a midcarpal instabil-

ity sign was looked for.The mobility of the thumb column wasevaluated using the opposition scale of Kapandji.7

Grip strength was then measured with a gripdynamometer. The key pinch, which evaluatesthe thumb-index finger pinch, was measuredwith a special dynamometer.

Sensitivity of the tips of the thumb, the indexfinger, and the little finger was assessed withSemmes-Weinstein monofilaments.8

ResultsQUESTIONING AND CLINICAL EXAMINATION

All the drivers participated in other sports

(running, swimming, body building) as train-ing or entertainment. Ten of the 22 driversplayed a sport that involved the upperextremities—for example, tennis, squash, andgolf.

Among the medical histories, we noted thefollowing traumas, the causes of which werenot restricted to motor racing: one polytraumawith a trauma of the pelvic belt and both lowerlimbs; one fracture of the acetabulum; three legfractures (including one bilateral case compli-cated on one side by a compartment syn-drome); one bilateral knee fracture and oneknee anterior cruciate ligament tear; threeankle fractures (one bilateral); three clavicle

fractures; one elbow fracture and one elbowdislocation; one forearm fracture; three wristfractures; one dorsal ganglion cyst of the wrist(endoscopic removal); two carpal scaphoidfractures.

Only eight drivers did not report anyproblems with the wrists or hands. All driverswho raced before 1991 complained of palmirritation after each race resulting from usingthe gear change lever on the right hand side.Since the 1991–1992 season, when a semiauto-matic gear change on the steering wheel wasintroduced (fig 1), none of the drivers havereported pain at the base of the palm.

Tendinomuscular symptomsTwo drivers complained of muscular pain. Onedescribed cramps in the hand itself at the endof each Grand Prix. One former formula 1driver, who still competes in long distanceraces, described a typical forearm eV ortcompartment syndrome; he also complained of a bilateral eV ort cubital tunnel syndrome (seebelow). No tendinopathies or tenosynovitiswere observed.

Osteoarticular symptomsSix drivers reported such symptoms: threeinvolved the scapholunate ligament, two weresequellae of a distal radius fracture, and oneinvolved hypercompression of the medial com-partment of the wrist.

One driver described a typical syndrome of hypercompression of the medial compartmentof his non-dominant left wrist. The pain wasclassically reproducible on ulnar deviation of the wrist. This experienced driver said thatthese dorsoulnar pains were systematic at theend of each Grand Prix, with a maximum of discomfort after the Italian Grand Prix at

Monza, where there are many chicanes (zig-zags).The driver who had had a dorsal ganglion

cyst removed previously under endoscopy stillsuV ered dorsal pains after the eV ort of driving.During the clinical examination, we found painat the level of the scapholunate ligament and adiminution of range of motion in flexion-extension (150° v 170°).

Finally, two drivers reported bilateral dorsalpains around the scapholunate ligament spaceafter each Grand Prix. In the clinical examina-tion, there was only tenderness to palpation orsubjective complaints and pains without anyother objective symptoms.

No drivers tested positive in the scapholu-

nate (Kirk Watson test) or triquetrolunate(Reagan test) tests, nor was any midcarpalinstability observed.

One former driver who had had a right wristfracture complained of dorsal eV ort pain in hiswrist, with the range of motion in flexion-extension limited to 70°. Another former driverwith a previous right dominant wrist fracturehad dorsal eV ort pain without any objectivesign on clinical examination except for a dimi-nution of grip strength (56 v 58 kg).

Nervous symptomsSeven drivers reported paraesthesia in thefingertips. Symptoms were always bilateral.

Two drivers described paraesthesia in thethumb and index finger after each race, evokinga subjective form of an eV ort carpal tunnelsyndrome, without any objective sign in theclinical examination. Three drivers had paraes-thesia in all the fingertips at the end of eachGrand Prix, also with no objective symptoms inthe examination. One former driver describeda typical carpal tunnel syndrome, with pins andneedles at night and an irritative sign of themedian nerve at the wrist (Tinel’s sign).Another former driver had bilateral eV ortcubital tunnel syndrome after each race, withparaesthesia in the ring and little fingers. In the

Figure 1 Back view of the bear hand grip on the steering wheel.Note the semiautomatic gear change which iscontrolled with the long finger on the right hand.

Wrist injuries in formula 1 drivers 271




clinical examination, there was a sharp irrita-tive sign of the ulnar nerve at the level of theflexor carpi ulnaris arcade at the elbow.

No drivers reported subjective diminution of sensitivity of the fingertips.

OBJECTIVE VALUES

Range of motion of the digitsAll the drivers had the full range of motion for

all the fingers, except the thumb, in extensionas well as on making a fist. For the thumb, 16drivers presented full bilateral opposition(10/10 on Kapandji’s scale). For the remainingsix, the opposition was 9/10.

Range of motion of the elbow and wrist At the wrist, the mean flexion was 87.5° for thedominant hand and 89.8° for the non-dominant hand. Mean extension was found tobe 82.5° for the dominant side and 85° for theopposite side. Mean pronation was 87.2° forthe dominant side and 88.4° for the oppositeside. Mean supination was 87.7° on both sides.

Strength

The mean grip strength,evaluated with a Jamardynamometer, was 53.9 (range 41.5–67) kg forthe dominant hand and 50.6 (range 41.5–67)kg for the non-dominant hand. The key pinchstrengths between the thumb and index fingerwere 10.8 (range 8–12.5) kg for the dominanthand and 9.2 (range 7–12) kg for thenon-dominant hand.

Sensitivity measured with monofilamentsFour drivers had a value of 2.36 for all finger-tips. Two drivers had a value of 2.36 for all fin-gertips of the dominant hand and 2.44 for allfingertips of the non-dominant hand. For onedriver, it was the converse. Four drivers

presented a value of 2.44 for all fingertips onboth hands. One driver presented a value of 2.83 for all fingertips.The 10 remaining drivershad normal sensitivity of between 2.44 and2.83 on diV erent fingertips.

DiscussionIf the present discovery of nerve and osteoliga-mentous disorders in this group of high leveldrivers is predictable, the frequency of suchlesions can be considered important. No previ-ous papers have been found in the literaturethat mention upper extremity problems of rac-ing drivers.

The discovery in two drivers of “muscular”disorders after a race does not appear to us tobe a specific problem. In fact, the eV ortcompartment syndrome reported was found ina former driver who is now involved in longdistance races (rallying). The quasicompletedisappearance of symptoms such as crampsappears to be due to better adaptation of thewheel diameter to the driver’s hand using arubber grip as used for tennis players (fig 2).

Although there are many reports of soft tissueinjuries incurred in other sports,9 10 we did notobserve any in this group of racing drivers. Wealso found no cases of tendinitis or synovitis,such as is found in players of racket sports,repetitive motion of the wrist in extremepositions contributing to this condition.

Nerve disorders in sportsmen are now wellknown as part of cumulative trauma disorders,especially in cyclists1 and rock climbers.11 Forthe formula 1 driver, we found, like Weinsteinand Herring,12 that sports associated neuro-genic syndromes are usually incomplete, with-out severe motor or sensory deficits, with typi-cally subjective complaints of pain or vague

sensory disturbance. In our series, unfortu-nately it was not possible to carry outelectrodiagnostic testing. Although some au-thors recommend the systematic use of anelectromyogram in injured sportsmen,13 wethink that an electromyogram and nerveconduction velocity test would only need to beperformed on our two patients with nervecompression syndrome with objective symp-toms. On the one hand, the absence of electro-myogram and nerve conduction velocity ab-normalities is not unusual in sportsmen.12 14 Onthe other hand, with regard to hand-arm vibra-tion syndrome, Dasgupta and Harrison3 foundthat in miners the mean motor nerve conduc-tion velocity in the vibration exposed group was

significantly decreased. It would be worthwhile, with hand-arm vibration syndrome of amild degree, investigating further with a coldchallenge test and perhaps thermography aftera practice session. We consider that the firstpreventive treatment should be the use of apalmar wrist pad, as silicone rubber splinting isa well known treatment of sports related handand wrist injuries.15 16 Such a pad shouldpartially absorb the vibrations and prevent, oreventually reduce, the paraesthesia that ap-pears during eV ort.

Pain at the dorsal aspect of the wrist is oftenattributed to progressive distension of thescapholunate ligament as the result of repeti-

tive trauma, especially in boxers and volleyballplayers.17 The problem in sportsmen is todefine which paraclinical examination isrequired.18 We consider that, in the case of symptomatology evoking scapholunate disten-sion due to cumulative trauma, plain x rayexamination of the wrists, with anteroposteriorand lateral views, is the first step required. Tocomplement this, it is also important to obtaindynamic anteroposterior x ray pictures in ulnarand radial deviation, and a clenched fist view.In the case of a clinical syndrome of hypercom-pression of the medial aspect of the wrist, anarthro computed tomography or magnetic

Figure 2 Front view of the bear hand grip. Note thehypertrophy of the lateral thenar muscle and the adaptationof the steering wheel diameter by the use of a grip to avoid muscular symptoms such as cramps.

272 Masmejean, Chavane,Chantegret, et al




resonance imaging scan can be performed afterthe x ray examination. Arthroscopy remainsinteresting as a supplementary aid to diagnosis,and of course as a treatment with the aim of facilitating a rapid return to sport.1 As for gym-nasts, arthroscopy can be particularly pertinentfor triangular fibrocartilage complex injury.19

As for nerve disorders, the use of a wrist padmay help to prevent and/or reduce osteoarticu-lar symptoms. It is important to note that a

wrist pad would only be useful if it did not limitthe range of motion of the wrist required dur-ing a competition, which seems to be a realisticgoal for formula 1 drivers.

With regard to the objective results, weobserved a diminution of the range of motionin all sectors except supination on the domi-nant side.20 It is logical that the musculature of the dominant hand limits this range of motionby a few degrees. Eight drivers who exhibited alimitation of the thumb column opposition at9/10 showed hypertrophy of the lateral thenarmuscles through gripping the steering wheel(fig 2). In all the drivers, sensitivity of thefingertips could be considered normal.

CONCLUSION

The extent of nerve injuries and/or osteoliga-mentous disorders resulting from cumulativetrauma has been measured for the first time informula 1 drivers. In our series, 63% (13 of 22)of the drivers reported problems, either liga-mentous progressive distension or nerve disor-ders presenting essentially as eV ort compres-sive syndromes. However, this is a purelyclinical study, and a paraclinical examinationwill be required to define more precisely thepathoanatomy of the lesions. The use of a wristpad could reduce the consequences of thevibrations at the level of the wrist.

The authors wish to thank Professor Sid Watkins, Medical Del-egate for the Fédération Internationale de l’Automobile.

1 Howse C. Wrist injuries in sport. Sports Med 1994;3:163– 75.

2 Konig M, Biener K. Sport-specific injuries in weight lifting.Schweizeriche Zeitschrift für Sportmedzin 1990;38:25–30.

3 Dasgupta AK, Harrison J. EV ects of vibration on the hand-arm system of miners in India. Occup Med (Oxf) 1996;46:71–8.

4 Stanley J. The examination, imaging and investigation of wrist instability. In: Büchler U, ed. Wrist instability.London: Martin Dunitz, 1996:83–96.

5 Watson HK, Black DM. Instabilities of the wrist. Hand Clin1987;3:103–11.

6 Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetralsprains. J Hand Surg [Am] 1984;9:502–14.

7 Kapandji A. Clinical scale for opposition and contra-opposition of the thumb. Annals of Hand Surgery 1986;5:67–73.

8 Bell-Krotoski JA. Light-touch-deep pressure testing usingSemmes-Weinstein monofilaments.In: Hunter JM,Schnei-der LH, Mackin EJ, et al , eds. Rehabilitation of the hand , 3rded. St Louis: CV Mosby, 1990:585–93.

9 Osterman AL, Moskow L, Low DW. Soft-tissue injuries of the hand and wrist in racquet sports. Clin Sports Med 1988;7:329–48.

10 Halikis MN,Taleisnik J. Soft-tissue injuries of the wrist. ClinSports Med 1996;15:235–59.

11 Holtzhausen LM, Noakes TD. Elbow, forearm, wrist andhand injuries among sport rock climbers. Clin J Sport Med 1996;6:196–203.

12 Weinstein SM, Herring SA. Nerve problems and compart-ment syndromes in the hand, wrist and forearm. Clin Sports

Med 1992;11:161–88.13 Mosher JF, Peripheral nerve injuries and entrapments of the

forearm and wrist. In: Pettrone FA, ed. Symposium on upper extremity injuries in athletes. St Louis: American AcademyOrthopaedics Surgeons/CV Mosby, 1986:174.

14 Aulicino PL. Neurovascular injuries in the hands of athletes.Hand Clin 1990;6:455.

15 Canelon MF. Silicone rubber splinting for athletic hand andwrist injuries. J Hand Ther 1995;8:252–7.

16 Canelon MF, Karus AJ. A room temperature vulcanizingsilicone rubber sport splint. Am J Occup Ther 1995;49:244– 9.

17 Masmejean E, Dutour O, Touam C, et al . Bilateral SLACwrist: an unusual entity. Report of a 7000 year-old prehis-toric case. Annals of Hand Surgery 1997;16:207–14.

18 Belhobek GH, Richmond BJ, Piraino DW, et al . Specialdiagnostic procedures in sports medicine. Clin Sports Med 1989;8:517–40.

19 De Smet L, Claessens A, Fabry G. Gymnast wrist. ActaOrthop Belg 1993;59:377–80.

20 Mathiowetz V, Kashman N, Volland G, et al . Grip and pinchstrength: normative data for adults. Arch Phys Med Rehabil 1985;66:69–72.

Take home messageNerve injuries and/or osteoligamentous disorders of the wrist resulting from cumulativetrauma have been shown in formula 1 drivers. In our series, 63% reported problems, eitherligamentous progressive distension or nerve disorders mainly presenting as eV ort compressivesyndromes. The use of a wrist pad could reduce the consequences of the vibrationsexperienced by these drivers at the level of the wrist.

Wrist injuries in formula 1 drivers 273


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f1 Driver Wrists