Kendall Marshall Injury: Medical Expert Explains UNC Guard's Prognosis

What had been a dream run through Greensboro with two dominant performances turned into a nightmare for the North Carolina Tar Heels, as sophomore point guard Kendall Marshall suffered a fractured right wrist during the team's 87-73 win over Creighton on Sunday. Marshall will have surgery Monday to repair a fractured scaphoid bone in the wrist, making it unlikely he will be able to suit up at a minimum for next Friday's Midwest Regional semifinal against Ohio University, if not the remainder of the NCAA Tournament.

Marshall, the engine of the ACC regular-season champion Tar Heels, suffered the injury with 10:56 left in Sunday's win after falling hard to the floor and bracing himself with his right wrist on a drive to the basket. Here's video of the play:

Although he played most of the remainder of the game, afterward Marshall admitted that he felt significant pain when dribbling the ball with his right hand, and the fracture was confirmed during a postgame X-ray. Marshall was placed in a cast as a preliminary measure. After seeking the advice of a hand specialist, the decision was made to have surgery. Ultimately it may be how well he is able to tolerate pain that will determine whether or not he can return to action this season.

It is the complex anatomy of the wrist and the scaphoid's specific location that make fractures of this particular bone so difficult to heal. The wrist is a joint composed of the end of the radius, the ulna, and the carpal bones. The scaphoid, which is the most commonly fractured carpal bone, is located on the thumb side of the wrist. Because the scaphoid has relatively poor blood supply compared to other bones of the wrist, a rapid diagnosis and treatment plan is crucial to ensure that the area does not risk permanent dysfunction due to prolonged loss of blood flow.

A scaphoid fracture most commonly occurs exactly as it did in Marshall's case: due to a fall onto the outstretched hand with the wrist bent back (extended) and towards the thumb (radially deviated). Once diagnosed, a number of key factors determine both whether the fracture requires surgical fixation and how long the recovery will take.

Is the fracture nondisplaced or displaced? A nondisplaced fracture means the bone surrounding the break remains perfectly lined up after the injury. These may be considered for treatment with a cast rather than with surgery. This is in contrast to displaced fractures, where the bone is not well-aligned following the injury. In the case of displaced fractures, surgery is usually recommended to align the fracture fragments into a normal position, increasing the rate of predictable healing of the fracture.

What is the location of the fracture? The fracture may be at the far end (distal pole) of the scaphoid, in the middle, or at the near end (proximal pole). The fractures at the near end (closer to the elbow) have a poorer blood supply and are less likely to heal without surgery.

If treatment without surgery is chosen, a cast or hard splint is placed that includes the thumb, wrist, forearm, and possibly the elbow. Typically, the total time in a cast is 8-12 weeks, or possibly longer depending on how fast the bone heals. When nondisplaced fractures are treated appropriately in a cast, there is a 95 percent chance of healing if treatment is started within a couple weeks after injury.

Treatment with surgery is generally appropriate for any scaphoid fracture that is displaced more than 1 mm or any fracture at the upper end (proximal pole). Surgery may also be considered for nondisplaced fractures, to lessen the time of cast immobilization and allow controlled range-of-motion right away. It is not clear at this point whether Marshall suffered a displaced fracture or whether the decision for surgery was made in hopes of getting him back on the court sooner.

The reason for choosing surgery for displaced fractures and fractures of the upper end is that treating these fractures in a cast carries up to a 50 percent risk of delayed union (taking a long time to heal), nonunion (not healing at all), or losing the blood supply to a bone fragment (avascular necrosis). Also, if the fracture heals in the wrong position ("malunion"), it may lead to continued wrist pain, loss of motion, or eventual arthritis. Any or all of these complications can threaten an athletic career and limit the ability for the athlete to return to the previous level of competition.

Depending on the fracture type, there may be an incision on the front or back of the wrist which is used to access the scaphoid to line up the fracture and place a metal screw to hold it in place. If the scaphoid fracture is a nonunion it may be necessary to place some bone graft as well, which may be taken from the radius (by the wrist), the iliac crest (by the hip), or from a cadaver.

After surgery, a splint or cast is typically applied, and then 1-2 weeks later, this may be changed to a removable brace or another cast may be used depending on the fracture type and competing sport. Return to sports must be individualized based on the type of fracture and what sports the athlete is involved in, so it may vary substantially between athletes. If the athlete is involved in noncontact sports, it may be reasonable to go back to sport 1-2 weeks after surgery with a brace or cast to protect the wrist. If the athlete is involved in contact sports, it may be reasonable to return to play in a cast 3-6 weeks after surgery, but there is some degree of risk involved with that decision. It is typically 3 months or longer before it is healed sufficiently to allow for sports without a brace or cast.

Based on all the data concerning proper management and healing of a scaphoid fracture with surgery, it would seem that in the absolute best-case scenario -- a perfect storm of favorable factors regarding the specifics of the fracture -- it is theoretically possible that Marshall could be fitted for a splint and play through the significant pain and risks associated with re-injury if the Tar Heels make the Final Four. Even if so, it's reasonable to wonder how effective Marshall would be given the discomfort he would likely experience and the loss of function that comes with wearing a splint.

To be clear, it is more likely that UNC, which was firing on all cylinders before losing Marshall, its most indespensible piston, will rely on reserve guards Stillman White and Justin Watts to run the point for Friday night's game against Ohio University, and possibly beyond, assuming the Tar Heels are able to advance that far.