3Objectives1. Understand the therapist’s or trainer’s role in acute management of scaphoid fractures2. Identify the progression of the post immobilization rehab program for conservative and surgical interventions3. Appreciate the critical components of returning an individual to sport
4Acute Management* ANY contact sport athlete who is complaining of radial wrist pain should be considered to have a scaphoid fracture until proven otherwise.
5Scaphoid Clamp SignWhen athlete shows you where pain is, he may show you this sign.
6Acute Managment Acute Management includes: Edema and Pain Control Elevation, Ice, Kinesiotape, ROM ( digital and elbow only)Immobilization:Thumb Spica cast or splintReferral to MD, Team Physician, Hand Surgeon to confirm/differentiate diagnosis
9Conservative or Surgical Treatment? Treatment of acute scaphoid fracture in the athlete depends on:location and stability of the fracturesport and positiondesires of the athlete and his or her family.
10Conservative vs. Surgical Options include:Cast treatment with no sports participation until healedCast treatment plus use of a playing cast/splint in sports where applicableInternal fixation of the fracture with return to play as surgeon permits.
11ImmobilizationProximal Pole: LA or SA thumb spica for weeks w/wrist in slight extension and radial deviation.Central third: LA thumb spica for 6 weeks, then SA thumb spica for 6 more weeks.Distal third: LA or SA thumb spica for 6-8 weeks(Indiana Protocol) – MD to determine positioning
13Conservative Treatment 0 – 6 weeksPlace in thumb spica as directed by MD with IP freeWrist in neutral, thumb between palmer abduction and radial abductionEdema managementElevation, Compression, Kinesiotape, ROM ( digital and elbow only)ROMAROM to digits and thumb IP ( emphasize passive extension and flexion of thumb IP)Gentle PROM to digits to preserve joint mobility and decrease edemaPatient education/Precautions
14Conservative Treatment 6-20 weeksBegin gentle AROM of wrist, thumb, and digits as well as forearm supination and pronation.Continue splinting between exercises and night until MD releasesOnce full AROM of digits, wrist, and forearm, begin gentle strengtheningBegin weight bearing once full strength is achieved and wrist is pain freeCustomize rehab to integrate back into sport position
15Post-Surgical Treatment MD will provide guidance for rehab protocol based on stability of fracture and/or surgery performed.
16Surgical Protocol Initial Visit 10-14 days: Fabrication of a custom short arm thumb spica with IP freeBegin scar management 48 hours after sutures removedAROM and PROM to fingers and IP joint of thumbPROM to thumb IP
17Surgical Protocol 4-16 Weeks Post Op Immobilization is totally dependent on:locationbone graft utilizedmethod of internal fixationstability of fx post sx reduction
18Surgical Protocol 4-16 weeks: ( MD directs initiation) AROM to wrist (clinically anatomical snuffbox point tenderness is resolved)1 week post AROMAAROM and gentle PROM to wrist 4-6 times a day3-4 weeks laterProgressive strengthening to entire UE
19Post Immobilization Edema Control Kinesiotaping MLD Scar management continuesROMAROM/AAROMPROMStatic Progressive/Dynamic Splinting as neededProgressive StrengtheningJoint Mobilization
20Post ImmobilizationHowever the fracture is treated, goals once immobilization is complete are the same.Increase mobility, strength, functionDecrease pain, edema, joint stiffnessRehab and return to sport are determined by:Type of fractureSport
22BiomechanicsScaphoid absorbs ~ 80% of load through radius in weight bearing, Ulna ~20%.Using electrogoniometric studies, Ryu et al.(1990) have shown that most daily activities can be performed with 40°of wrist extension, 40° of flexion, and a 40° arc of radial and ulnar deviation.ATHLETES REQUIRE A GREATER ARC OF MOTION
23Why is it important to regain motion in wrist for athletes?
24Basketball Free Throw: 50 degrees of wrist extension required on average ( range degrees )
25Basketball End range of motion for free throw: 70 degrees of wrist flexionTOTAL ARC of motion needed for free throw is 120 degreesWhat are some other sports that you can think of the require a certain amount of wrist motion to perform?Baseball throw ( pitching, throwing), Golfing ( gripping club), Tennis ( gripping raquet), Gymnasts ( tumbling), Hockey (gripping stick, shooting)
26Baseball and Golf BASEBALL GOLF ( right handed golfer) Cocking phase, neutral to 32 degrees, followed by rapid flexion over 94 degrees during acceleration phase.GOLF ( right handed golfer)103 degrees of total motion required in the right wrist71 degrees of total motion required in the left wrist***45 degrees of total radial and ulnar excursion is required in both wrists
27Concluding Critical Points Early and accurate diagnosis for optimal outcome.Foundation of your rehab program is a thorough assessment and communication with entire team throughout scope of care.Without appropriate therapy to restore ROM and strength, the athlete may have impaired function even with an acceptable radiographic record.Goal – Healed fracture and elimination of wrist pain. Avoid aggressive programs that result in persistent wrist pain.
28THANKS Susan Brown, OTR/L, CHT Proaxis Hand Specialists 2 Doctors DriveGreenville, SC
29ReferencesBelsky,M., Leibman, M., Ruchelsman,D. (2012). Scaphoid fracture in the elite athlete. Hand Clinics 28,269–278. Rettig, R. (2003). Athletic injuries of the wrist and hand: Part I, Traumatic injuries of the wrist. American Journal of Sports Medicine,31, Rettig,A. (2004). Athletic injuries of the wrist and hand: Part II, Overuse injuries of the wrist and traumatic injuries to the hand. American Journal of Sports Medicine ,32,262. Skirven, T., Osterman A., Fedorczyk, J., Amadio, P., eds. (2011). Rehabilitation of the Hand and Upper Extremity. 6th ed. Philadelphia, PA: Elsevier Mosby Inc.