For general information visit this page: Scaphoid Fractures.
Summary of the Condition1
The scaphoid is the most commonly fractured carpal bone. Depending on the type of fracture, interventions vary from conservative treatment via casting, to open surgery with internal fixation. In any case, patients are commonly immobilized in a cast until scaphoid union is observed, which can sometimes take up to four months. Physical therapy does not treat the fracture, but the complications of long term immobilization that accompany this diagnosis. Range of motion (ROM) is severely affected when a joint has been immobilized for a long period of time and atrophy of muscles in the forearm and hand will also occur. For this reason, rehabilitation can take several months.
Guide to PT Practice2
Included Practice Patterns
Pattern 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With Fracture
- Applicable impairments, functional limitations, or disabilities include: limited range of motion, muscle weakness from immobilization, and pain with functional movements and activities.
Pattern 4I: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery
- Applicable impairments, functional limitations or disabilities include: decreased range of motion, decreased strength and endurance due to inactivity, impaired joint mobility, limited independence in activities of daily living, pain, and swelling.
Suggested Management
Suggested management in "the Guide" varies depending on the practice pattern that applies to the patient. For instance, in Pattern 4G the patient only needs between 6 to 18 visits; however, in Pattern 4I the patient may need between 6 to 70 visits. Many interventions are suggested because these patterns cover such broad topics. For scaphoid fractures, the physical therapist will most likely select interventions to address the impairments and limitations listed above.
Physical Therapy Interventions
Because physical therapists are most often treating impaired ROM and strength associated with long-term immobilization there is little evidence that focuses on specific treatment of scaphoid fractures. This section will cover interventions in current literature that specifically deal with scaphoid fractures, and will, in a more general sense, discuss other topics that are not broadly covered in the literature.
Increasing Strength and Improving Range of Motion1,3
When strengthening Jaworski says that the patient should perform only active range of motion exercises to focus on flexion, extension, radial and ulnar deviation, and thumb movements during the first two weeks. After this phase, passive range of motion can begin along with strengthening exercises. As the patient progresses in ROM, the therapist can begin to increase strengthening activities to include weight training, weight bearing, plyometrics, and upper-body ergometers. Also, after the cast is removed, patients are often placed in a removable splint to assist with increasing ROM. Wong states that splinting can increase passive ROM by applying high doses of low-load stress at or near the available end of range.
The following is a protocol published by Kaiser Permanente Southern California Orthopedic PT Residency for both non-operative and post-operative rehab of scaphoid fractures:
Non-operative Rehabilitation4
Acute Stage / Severe Condition: Immediately following injury to Week 2
Goals: Protection with short-arm cast; Control pain and edema; Maintain range in uninvolved joints (fingers, elbow, shoulder); Incorporate basic activities of daily living (ADLs)
- Active range of motion (AROM) and passive range of motion (PROM) to the digits, except the thumb, which is immobilized
- AROM and active-assisted range of motion (AAROM) exercises to the elbow and shoulder
- At week 2, MD may repeat x-ray or choose a bone scan in the event of continued pain and tenderness over the snuffbox with negative x-rays
Sub Acute Stage / Moderate Condition: Week 3-6
Goals: Protection; Continue to control pain and edema as needed; Increase range of motion (ROM)
Incorporate activities of daily living (ADLs)
- Continue exercises as above
- Limit supination and pronation ROM exercises based on pain
Settled Stage / Mild Condition: Week 7-12
Goals: Full range of motion (ROM); Begin strengthening program ;Return to all activities (exception to contact sports and heavy labor)
- Remove short-arm cast at 6-8 weeks if fracture appears radiographically and clinically healed.
- May use wrist splint for protection
- Gentle AROM of the wrist and thumb
- Advance as tolerated to progressive resistive exercises (PREs) for all joints
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: As above; Return to optimum level of patient function
- Approaches / Strategies listed above
- External Devices: Protective equipment; Splint / Tape
Postoperative Rehabilitation for ORIF
Acute Stage / Severe Condition: Immediately following surgery to Week 3
Goals: Protection with cast or splint; Control pain and edema; Maintain range in uninvolved joints (fingers, elbow, shoulder); Incorporate basic activities of daily living (ADLs)
- Elevation and application of compressive dressing of the arm to assist in edema control
- AROM and PROM of digits consisting of blocking and composite exercises, except the thumb
- AROM and AAROM exercises to the elbow and shoulder
Sub Acute Stage / Moderate Condition: Week 4-7
Goals: Protection with cast or splint; Continue to control pain and edema as needed; Increase range of motion (ROM); Incorporate activities of daily living (ADLs)
- Continue fingers, elbow, and shoulder exercises as above
- At 6 weeks if fracture appears radiographically healed, cast or splint is removed for gentle AROM exercises of the wrist and thumb
Settled Stage / Mild Condition: Week 8-12
Goals: Full range of motion (ROM); Begin strengthening program; Return to all activities (exception to contact sports and heavy labor)
- Advance therapeutic exercises with gentle AROM of the wrist and thumb exercises
- Begin grip strengthening with use of silicone putty at 10 weeks
- Advance as tolerated to progressive resistive exercises (PREs) for all joints
- May use wrist splint for protection for all activities
Intervention for High Performance / High Demand Functioning in Workers or Athletes
Goal: As above; Return to optimum level of patient function
- Approaches / Strategies listed above
- External Devices: Protective equipment Splint / Tape
Relieving Pain, Decreasing Swelling, and Modality Use5,6
Waitayawinyu states that, although post-surgical pain is a consequence of any bone surgery, due to surgical procedures, continued pain at increased levels may me present in patients that were previously asymptomatic. Pain, as well as swelling, will most often be managed with pharmaceuticals such as NSAIDs or opioid based medications; however, there is research on distal radius fractures by Cheing, et al, that can be somewhat correlated to these cases that promotes ice therapy combined with pulsed electromagnetic field to more quickly reduce pain and reduce volume of edema.
There is no research on the use of physical agents in the specific treatment of scaphoid fractures. This, however, doesn't preclude one from using agents such as TENS, cryotherapy, or ultrasound to treat pain, or an agent such as NMES to treat attenuated muscle activity.
Interesting Research7,8
There is some interesting information coming from rehabilitation research. Warden, et al, found in an animal study that low intensity pulsed ultrasound increases the rate of fracture healing. This finding goes against the traditional belief that bone should not be exposed to excessive quantities of ultrasound energy. However, even though their data provides preliminary evidence supporting the use of conventional ultrasound units to promote fracture healing, they discourage its implementation until clinical trials can be conducted. In another study, Farthing, et al, found that strength training of one arm while the other is immobilized reduced strength loss in the immobilized arm. They believe their findings can help to prevent recurrence of injury.