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

2. Disclosures
None 

3. 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

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

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

6. 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

7. Kinesiotape for Edema
Dorsal View
Volar View

8. Immobilization

9. 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.

10. 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.

11. Immobilization
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

12. Forearm based thumb spica

13. 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

14. 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

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

16. 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

17. 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

18. 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

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

20. 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

21. Splinting
Static Progressive/Dynamic Splinting

22. 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

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

24. Basketball Free Throw:
50 degrees of wrist extension required on average ( range degrees )

25. 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)

26. 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

27. 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.

28. THANKS Susan Brown, OTR/L, CHT Proaxis Hand Specialists
2 Doctors Drive
Greenville, SC

29. 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, 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.