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Examining Dawson Knox’s right-hand fracture

How many games will Knox miss?

NFL: Buffalo Bills at Kansas City Chiefs Denny Medley-USA TODAY Sports

Following Monday night’s loss to the Tennessee Titans, the Buffalo Bills were delivered the news that added injury to the already insulting loss.

Tight end Dawson Knox, in the midst of a breakout season, suffered a right-hand fracture late in the third quarter. While a hand injury is one of the more significant injuries for a tight end, this doesn’t exactly spell an absence expected to greatly affect his season.

Detailed below is the general anatomy of the hand, the possible area he broke, how this can affect his performance, comparable players, and the timeline to return. Looking at the information that we currently know, things appear quite favorable to both Knox and the Buffalo Bills.


The Play

The injury appeared to occur with 1:40 left in the third quarter. During the play, Knox crossed over towards his left and fell down at the line of scrimmage with his arms extended to break his fall.

Following the play, it wasn’t apparent anything happened as the team ran a couple plays that led to a touchdown then, of course, a successful two-point conversion where Dawson Knox shot-put the ball to Josh Allen in the end zone.


Anatomy of the hand

The hand is made up of many bones categorized into three sections. They are phalanges, metacarpals, and carpals.

Example of the bones of the hand
murdochorthopaedic.com.au

The phalanges are also known as fingers and start from the tip of your finger going down to your knuckle, which is visibly seen when you make a fist.

The metacarpals are long bones that attach the phalanges to the carpals and provide stability through the palm of the hand.

Finally, the carpals are a series of eight small bones that articulate with each other to provide mobility to allow for the variety of movements seen within the wrist. They also articulate with the radius and ulna of the forearm.

Knox’s Injury

Dawson Knox fell to the turf with a common mechanism of injury known as a fall on an outstretched hand (FOOSH). This type of mechanism of injury causes a variety of injuries including to the fingers, hand, wrist, elbow, and shoulder based on where the most stress ultimately gets absorbed.

When Knox fell, he appeared to hit his right hand first, bracing his impact. This is the most likely scenario for the fracture. However, as soon as he was down on the ground, Tennessee Titans linebacker Rashaan Evans nearly collided with him and had to step over him with his left leg.

The sideline view appears to show that Evans stepped on his hand, which would certainly cause a fracture, but the broadcast view shows him stutter-step and potentially miss stepping on the hand.

Regardless of how the fracture occurred, it appears as though he suffered it on that play. Knox favored the hand for the remainder of the series and then eventually left the game afterward.


Surgery

Ian Rapoport of NFL Network reported Wednesday that Knox had surgery to repair the fracture and that the goal was to return to the field as soon as possible. Fellow reporter Mike Garofalo updated that this should be a few weeks to return to play.

Reports continue to emphasize a broken hand, which is key. This eliminates any finger fractures or any fractures within the distal radius or ulna of the forearm. Based on the anatomy detailed above, this leaves the metacarpals and carpals.

Initially, when I saw the mechanism of injury, I began thinking about the bones of the wrist, most notably the scaphoid, triquetrum, and hamate bones. These are the most common bones to fracture in the wrist during a FOOSH injury.

Overall, most of these procedures take anywhere from 4-6 weeks with immobilization to the area, plus the rehab. These bones are also involved with much more complex wrist movements requiring longer healing times.

As noted above, the reports continue to identify the hand as the area of concern. This leaves the metacarpals as the likely area of injury. Based on his fall he either injured the fourth or fifth metacarpal or both, which is the ring and pinky finger areas. This may be why he had difficulty gripping the football, forcing him to shot put it. The index and middle finger metacarpals could also be in play, but it’s impossible to say without looking at imaging.

Working off the knowledge that this is a hand fracture, which means a metacarpal fracture, significantly changes the timeline for a quicker recovery.

According to the procedures available for metacarpal fractures, a common technique requires a plate with screws, which is an ORIF (open reduction and internal fixation) to set the bone and stabilize it.

An example of the procedure and hardware for a metacarpal fracture.
Highimpact.com

In limited case studies, high school and college athletes were able to return to play as quickly as three days, though the average was nine days. This doesn’t mean it was fully healed, but that they could return to play. Fortunately, the metacarpal doesn’t require a lot of movement within the hand, allowing for a quicker recovery.

It’s important to note in the study that all returned to play with protective equipment on the hand ranging anywhere from a padded glove, cast splint, or club. The equipment was used for 21 days on average. The study also noted that elite football players could return within a week with or without padding. Knox could return with a padded glove, but I am not certain if this would dramatically affect his catching abilities without trial and error first.

While this and all studies are varied in size, it at least indicates a realistic outcome for Knox.


Comparable player injuries

Looking at similar injuries, former Bills LB Ramon Humber suffered a similar injury in 2017, though this was closer to his thumb, forcing him to miss three games plus the bye week. Bills WR Jordan Matthews also suffered a thumb injury that same season requiring surgery and he was able to return after missing one game while using the bye week.

This season, Taron Johnson suffered a right-hand fracture in the preseason, forcing him out of the Chicago Bears and Green Bay Packers preseason games, but he played the first three regular-season games with a brace on the hand. It’s likely that he too suffered a metacarpal fracture. He missed Week 4 against the Houston Texans with a groin injury before returning to play against the Kansas City Chiefs without the brace. It was not reported that he had surgery. Considering the position that he plays, the team figured they could treat the fracture conservatively.

Other NFL position players to suffer a broken hand and return quickly are former Dallas Cowboys running back DeMarco Murray who did not miss any games following surgery in 2014. Colts back Marlon Mack suffered a broken hand in 2019 requiring surgery, missing two games.

JJ Watt broke his hand and played in an NFL game 4 days later, though Bills fans don’t have to be reminded of the physical specimen he is playing through his pectoral repair in the playoffs.

The only players who took considerable time to return from a broken hand were if it involved their thumb, which is a totally different conversation considering the functions of the joint. These include Jay Cutler, missing five games, and Clay Matthews, missing five total games but breaking the bone twice with those both having thumb fractures.

Corey Coleman is the only one who suffered a broken hand that was out for an extended time in 2016 and 2017, but details of his injury are not available and he was placed on injured reserve, having to sit out eight games.


Return to play

This is where things get tricky. I speculate that he has a metacarpal fracture, but it’s possible that this is a wrist injury that they called a hand. The team has historically been rather truthful with body part designations reflecting back, though there is some vagueness at times especially with Cole Beasley’s proximal fibular fracture last year.

On Good Morning Football, it was announced Saturday that Knox is expected to miss about three weeks with that being a fluid timeline. They went on to say that they found an additional fracture in the hand, which shouldn’t drastically change the timeline, but is still worth noting.

Knox can return once the wound is fully healed, that he has no pain during basic activities, and that his grip strength is fairly close to that of his left hand. An x-ray of the area to ensure proper healing is also necessary. There may be a slight difference in grip strength naturally based on hand dominance.

Once he meets those initial goals, I’d want to see if he can catch balls from the JUGS machine and engage with blockers without pain. Finally, could he catch footballs from Josh Allen without pain?

However, one additional variable to consider is the team having the ability to time the announcement of placing players on injured reserve. Last year when John Brown went on IR for his high ankle sprain, he was not placed on injured reserve until the Saturday before Week 12.

If the Bills feel that he is still a ways off, then they could place him on IR then. That would suggest that this is more of a carpal injury or that he had a big setback. I will be very, very surprised if he goes to IR prior to Week 8.

What it boils down to is: How will the healing proceed? The above timeline is fluid, but he will have 18 days to heal in Week 9 and 27 days to heal in Week 10.

I believe he will miss one game and then return in Week 9 against the Jacksonville Jaguars, giving him 18 days to rehab.

The Bills want to ensure that Knox can get back out there as close to 100 percent as possible, but also effectively catch each target. He may be initially slow to return to peak pre-injury performance, but games against the Jaguars and New York Jets will allow him to get back into rhythm.

This is an unfortunate injury for a player finally living up to his potential. Fortunately, the bye is well-timed and the training staff has traditionally done well with getting guys healthy to continue their effective performance.