Transcript Proaxis Therapy - Hawkins Foundation

Scaphoid Fractures:
Rehab and Return to Sport
Susan Brown, OTR/L, CHT
SHCC Symposium
June 7, 2013
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Disclosures
➔
None 
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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
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Acute Management
* ANY contact sport athlete who is
complaining of radial wrist pain should be
considered to have a scaphoid fracture
until proven otherwise.
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Scaphoid Clamp Sign
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Acute Managment
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
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Kinesiotape for Edema
Dorsal View
Volar View
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Immobilization
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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.
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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.
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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
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Forearm based thumb spica
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Conservative Treatment
➔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
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Conservative Treatment
➔
6-20 weeks
o
o
o
o
o
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
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Post-Surgical Treatment
MD will provide guidance for rehab
protocol based on stability of fracture
and/or surgery performed.
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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
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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
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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
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Post Immobilization
➔
➔
➔
➔
➔
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
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Post Immobilization
➔
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:
Type of fracture
Sport
o
o
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Splinting
➔ Static
Progressive/Dynamic Splinting
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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
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Why is it important to regain
motion in wrist for athletes?
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Basketball
Free Throw:
50 degrees of wrist
extension required on
average ( range 40-56
degrees )
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Basketball
End range of motion for free
throw:
➔70
degrees of wrist flexion
➔TOTAL ARC of motion
needed for free throw is 120
degrees
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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
o
o
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
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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.
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THANKS
Susan Brown, OTR/L, CHT
Proaxis Hand Specialists
2 Doctors Drive
Greenville, SC
864-797-7320
[email protected]
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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.
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