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DON’T JUST RECOVER. CONQUER. Scaphoid Fractures: Rehab and Return to Sport Susan Brown, OTR/L, CHT SHCC Symposium June 7, 2013.

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Presentation on theme: "DON’T JUST RECOVER. CONQUER. Scaphoid Fractures: Rehab and Return to Sport Susan Brown, OTR/L, CHT SHCC Symposium June 7, 2013."— Presentation transcript:

1 DON’T JUST RECOVER. CONQUER. Scaphoid Fractures: Rehab and Return to Sport Susan Brown, OTR/L, CHT SHCC Symposium June 7, 2013

2 DON’T JUST RECOVER. CONQUER. ➔ None Disclosures

3 DON’T JUST RECOVER. CONQUER. 1. Understand the therapist’s or trainer’s role in acute management of scaphoid fractures 2. Identify the progression of the post immobilization rehab program for conservative and surgical interventions 3. Appreciate the critical components of returning an individual to sport Objectives

4 DON’T JUST RECOVER. CONQUER. * ANY contact sport athlete who is complaining of radial wrist pain should be considered to have a scaphoid fracture until proven otherwise. Acute Management

5 DON’T JUST RECOVER. CONQUER. Scaphoid Clamp Sign

6 DON’T JUST RECOVER. CONQUER. Acute Management includes: ➔ Edema and Pain Control o Elevation, Ice, Kinesiotape, ROM ( digital and elbow only) ➔ Immobilization: o Thumb Spica cast or splint ➔ Referral to MD, Team Physician, Hand Surgeon to confirm/differentiate diagnosis Acute Managment

7 DON’T JUST RECOVER. CONQUER. Kinesiotape for Edema Dorsal ViewVolar View

8 DON’T JUST RECOVER. CONQUER. Immobilization

9 DON’T JUST RECOVER. CONQUER. Treatment of acute scaphoid fracture in the athlete depends on:  location and stability of the fracture  sport and position  desires of the athlete and his or her family. Conservative or Surgical Treatment?

10 DON’T JUST RECOVER. CONQUER. Options include:  Cast treatment with no sports participation until healed  Cast treatment plus use of a playing cast/splint in sports where applicable  Internal fixation of the fracture with return to play as surgeon permits. Conservative vs. Surgical

11 DON’T JUST RECOVER. CONQUER.  Proximal 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 Immobilization

12 DON’T JUST RECOVER. CONQUER. Forearm based thumb spica

13 DON’T JUST RECOVER. CONQUER. ➔ 0 – 6 weeks o Place in thumb spica as directed by MD with IP free Wrist in neutral, thumb between palmer abduction and radial abduction o Edema management Elevation, Compression, Kinesiotape, ROM ( digital and elbow only) o ROM AROM to digits and thumb IP ( emphasize passive extension and flexion of thumb IP) Gentle PROM to digits to preserve joint mobility and decrease edema o Patient education/Precautions Conservative Treatment

14 DON’T JUST RECOVER. CONQUER. ➔ 6-20 weeks o Begin gentle AROM of wrist, thumb, and digits as well as forearm supination and pronation. o Continue splinting between exercises and night until MD releases o Once full AROM of digits, wrist, and forearm, begin gentle strengthening o Begin weight bearing once full strength is achieved and wrist is pain free o Customize rehab to integrate back into sport position Conservative Treatment

15 DON’T JUST RECOVER. CONQUER. MD will provide guidance for rehab protocol based on stability of fracture and/or surgery performed. Post-Surgical Treatment

16 DON’T JUST RECOVER. CONQUER. Initial Visit days:  Fabrication of a custom short arm thumb spica with IP free  Begin scar management 48 hours after sutures removed  AROM and PROM to fingers and IP joint of thumb PROM to thumb IP Surgical Protocol

17 DON’T JUST RECOVER. CONQUER. ➔ 4-16 Weeks Post Op Immobilization is totally dependent on:  location  bone graft utilized  method of internal fixation  stability of fx post sx reduction Surgical Protocol

18 DON’T JUST RECOVER. CONQUER weeks: ( MD directs initiation)  AROM to wrist (clinically anatomical snuffbox point tenderness is resolved) 1 week post AROM  AAROM and gentle PROM to wrist 4-6 times a day 3-4 weeks later  Progressive strengthening to entire UE Surgical Protocol

19 DON’T JUST RECOVER. CONQUER. ➔ Edema Control o Kinesiotaping o MLD ➔ Scar management continues ➔ ROM o AROM/AAROM o PROM o Static Progressive/Dynamic Splinting as needed ➔ Progressive Strengthening ➔ Joint Mobilization Post Immobilization

20 DON’T JUST RECOVER. CONQUER. ➔ However the fracture is treated, goals once immobilization is complete are the same. o Increase mobility, strength, function o Decrease pain, edema, joint stiffness ➔ Rehab and return to sport are determined by: o Type of fracture o Sport Post Immobilization

21 DON’T JUST RECOVER. CONQUER. ➔ Static Progressive/Dynamic Splinting Splinting

22 DON’T JUST RECOVER. CONQUER. ➔ Scaphoid 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 Biomechanics

23 DON’T JUST RECOVER. CONQUER. Why is it important to regain motion in wrist for athletes?

24 DON’T JUST RECOVER. CONQUER. Basketball Free Throw: 50 degrees of wrist extension required on average ( range degrees )

25 DON’T JUST RECOVER. CONQUER. Basketball End range of motion for free throw: ➔ 70 degrees of wrist flexion ➔ TOTAL ARC of motion needed for free throw is 120 degrees

26 DON’T JUST RECOVER. CONQUER. Baseball and Golf ➔ BASEBALL o Cocking phase, neutral to 32 degrees, followed by rapid flexion over 94 degrees during acceleration phase. ➔ GOLF ( right handed golfer) o 103 degrees of total motion required in the right wrist o 71 degrees of total motion required in the left wrist o ***45 degrees of total radial and ulnar excursion is required in both wrists

27 DON’T JUST RECOVER. CONQUER. ➔ 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. Concluding Critical Points

28 DON’T JUST RECOVER. CONQUER. THANKS Susan Brown, OTR/L, CHT Proaxis Hand Specialists 2 Doctors Drive Greenville, SC

29 DON’T JUST RECOVER. CONQUER. Belsky,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. References


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