Scaphoid Fractures: Rehab and Return to Sport Susan Brown, OTR/L, CHT SHCC Symposium June 7, 2013

Disclosures None 

Objectives 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

Acute Management * ANY contact sport athlete who is complaining of radial wrist pain should be considered to have a scaphoid fracture until proven otherwise.

Scaphoid Clamp Sign When athlete shows you where pain is, he may show you this sign.

Acute Managment Acute Management includes: Edema and Pain Control Elevation, Ice, Kinesiotape, ROM ( digital and elbow only) Immobilization: Thumb Spica cast or splint Referral to MD, Team Physician, Hand Surgeon to confirm/differentiate diagnosis

Kinesiotape for Edema Dorsal View Volar View

Immobilization

Conservative or Surgical Treatment? 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 vs. Surgical 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.

Immobilization Proximal Pole: LA or SA thumb spica for 16-20 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

Forearm based thumb spica

Conservative Treatment 0 – 6 weeks Place in thumb spica as directed by MD with IP free Wrist in neutral, thumb between palmer abduction and radial abduction Edema management Elevation, Compression, Kinesiotape, ROM ( digital and elbow only) 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 Patient education/Precautions

Conservative Treatment 6-20 weeks Begin gentle AROM of wrist, thumb, and digits as well as forearm supination and pronation. Continue splinting between exercises and night until MD releases Once full AROM of digits, wrist, and forearm, begin gentle strengthening Begin weight bearing once full strength is achieved and wrist is pain free Customize rehab to integrate back into sport position

Post-Surgical Treatment MD will provide guidance for rehab protocol based on stability of fracture and/or surgery performed.

Surgical Protocol Initial Visit 10-14 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 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 4-16 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

Post Immobilization Edema Control Kinesiotaping MLD Scar management continues ROM AROM/AAROM PROM Static Progressive/Dynamic Splinting as needed Progressive Strengthening Joint Mobilization

Post Immobilization However the fracture is treated, goals once immobilization is complete are the same. Increase mobility, strength, function Decrease pain, edema, joint stiffness Rehab and return to sport are determined by: Type of fracture Sport

Splinting Static Progressive/Dynamic Splinting

Biomechanics 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

Why is it important to regain motion in wrist for athletes?

Basketball Free Throw: 50 degrees of wrist extension required on average ( range 40-56 degrees )

Basketball End range of motion for free throw: 70 degrees of wrist flexion TOTAL ARC of motion needed for free throw is 120 degrees What 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)

Baseball 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 wrist 71 degrees of total motion required in the left wrist ***45 degrees of total radial and ulnar excursion is required in both wrists

Concluding 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.

THANKS Susan Brown, OTR/L, CHT Proaxis Hand Specialists 2 Doctors Drive Greenville, SC 864-797-7320 susan.brown@proaxistherapy.com

References 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, 1038. 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.