Scaphoid Fracture Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for scaphoid fractures. The program is divided into three phases: Protection, Loading, and Return to Function. Progression through each phase is based on clinical presentation, pain levels, and objective measures, not strictly on time. It is crucial to consult with the referring physician and closely monitor the patient's response to treatment.

Pathophysiology

The scaphoid bone is the most commonly fractured carpal bone, typically resulting from a fall onto an outstretched hand (FOOSH). Its unique retrograde blood supply, entering distally, makes it vulnerable to avascular necrosis (AVN), especially with fractures in the proximal pole. Delayed union or non-union is also a significant concern. Scaphoid fractures are classified based on location (distal pole, waist, proximal pole) and stability. Diagnosis is confirmed by radiographs and potentially advanced imaging (CT or MRI).

Phase I: Protection (0-6 weeks) - Immobilization and Early Edema Control

Goals:

• Protect the fracture site and promote healing.
• Control pain and edema.
• Maintain range of motion (ROM) in uninvolved joints.
• Prevent muscle atrophy.

Interventions:

• Immobilization: Strict adherence to physician's immobilization protocol (typically a thumb spica cast or removable splint) is paramount. This is typically worn full-time.
• Edema Management:
  • Elevation: Keep the hand elevated above heart level as much as possible.
  • Retrograde Massage: Gentle massage to encourage lymphatic drainage.
  • Cold Therapy: Ice packs applied to the wrist and hand for 15-20 minutes several times a day. Ensure protection of skin with a towel.
• Pain Management:
  • Modalities: TENS, ultrasound (if cleared by physician and not directly over fracture), or other pain-relieving modalities may be used.
  • Medication: Patients should follow their physician's prescribed pain medication regimen.
• Range of Motion (ROM):
  • Active ROM exercises for uninvolved joints (fingers, elbow, and shoulder). Focus on full flexion and extension of the fingers.
  • Gentle tendon gliding exercises to prevent tendon adhesions in the hand and fingers.
• Isometric Exercises:
  • Gentle isometric exercises for wrist flexion/extension, radial/ulnar deviation, and pronation/supination within the cast/splint (if tolerated and approved by physician). These should be pain-free.

Precautions:

• No active wrist ROM.
• No gripping or lifting activities.
• Strict adherence to weight-bearing restrictions outlined by the physician.

Phase II: Loading (6-12 weeks) - Gradual ROM and Strengthening

Goals:

• Increase wrist ROM and flexibility.
• Improve grip and pinch strength.
• Begin progressive strengthening exercises.
• Reduce residual pain and edema.

Interventions:

• Splinting: The patient may transition to a removable splint, especially when performing exercises. Physician guidance is crucial for splint weaning.
• ROM Exercises:
  • Active and active-assisted ROM exercises for wrist flexion/extension, radial/ulnar deviation, pronation/supination. Emphasize pain-free movement.
  • Joint mobilization techniques may be used to address specific ROM limitations (performed by a qualified therapist).
• Strengthening Exercises:
  • Begin with gentle isometric exercises (wrist flexion/extension, radial/ulnar deviation) and progress to isotonic exercises using light resistance (TheraBand, light dumbbells).
  • Progressive grip strengthening exercises using a soft ball or hand exerciser.
  • Pinch strengthening exercises using clothespins or therapy putty.
  • Forearm strengthening exercises (pronation/supination) using light dumbbells or resistance bands.
• Edema Management: Continue with edema management techniques as needed (elevation, contrast baths, retrograde massage).
• Scar Management: If surgical incision is present, begin scar mobilization techniques to prevent adhesions.
• Proprioception Exercises: Begin proprioceptive exercises to improve wrist stability and coordination (e.g., wobble board exercises).

Precautions:

• Avoid activities that cause pain or swelling.
• Monitor for signs of instability or re-injury.
• Gradually increase activity levels.

Phase III: Return to Function (12+ weeks) - Advanced Strengthening and Functional Activities

Goals:

• Restore full wrist ROM and strength.
• Return to pre-injury activity level.
• Improve functional use of the wrist and hand.
• Prevent re-injury.

Interventions:

• Advanced Strengthening:
  • Progress to higher resistance exercises using weights, resistance bands, or weight machines.
  • Plyometric exercises to improve power and explosiveness (e.g., ball toss, wrist flips).
  • Sport-specific or activity-specific training exercises.
• Functional Activities:
  • Simulate work-related or recreational activities to gradually return to full function.
  • Gradually increase the duration and intensity of activities.
• Proprioceptive Training: Continue with proprioceptive exercises to maintain wrist stability and coordination.
• Endurance Training: Incorporate endurance exercises to improve the ability to sustain activity for longer periods.
• Activity Modification: Educate the patient on activity modification techniques to prevent re-injury.

Precautions:

• Avoid overtraining or pushing through pain.
• Monitor for signs of re-injury.
• Gradually increase activity levels to prevent setbacks.

Common Special Tests

• Scaphoid Shift Test (Watson Test): Assesses scaphoid stability. The therapist applies pressure to the distal pole of the scaphoid while passively moving the wrist from ulnar to radial deviation. Pain or a clunk indicates instability.
• Scaphoid Compression Test: Axial compression applied to the scaphoid tubercle. Pain elicited is indicative of fracture/injury.
• Finklestein's Test: Primarily used to rule out De Quervain's tenosynovitis, but can also elicit pain in the scaphoid region due to associated wrist irritation.
• Radiographic Examination (X-ray): Essential for confirming the fracture and monitoring healing progress.

Note: This protocol is a guideline and should be adapted to meet the individual needs of each patient. Close communication between the physical therapist, physician, and patient is essential for successful rehabilitation.