Scaphoid Injury Treatment & Management

Physical therapy

General principles for the rehabilitation of wrist injuries, including the rehabilitation of scaphoid fractures, include the following:

• All of these injuries require some form of rehabilitation. ^[23] Specific limitations apply to rehabilitation. Pain is one limiting factor, because it dictates the duration of immobilization and limits exercise designed to mobilize and strengthen the wrist.

• Edema of the injured wrist is present to some degree and may involve the hand or entire upper extremity. Functional disuse in itself results in edema. The most important preventive measures are elevation and active motion of the uninjured joints. Modalities (eg, Jobst intermittent compression units, massage) may be used later for chronic edema associated with traumatic wrist injuries.

• The wrist is always stiff after immobilization for more than a few weeks. Mobilization cannot be started until the injured tissue has healed enough to provide some degree of stability. Active wrist ROM exercises should be started as soon as the cast is removed. Pronation and supination should not be overlooked.

• Mobilizing the joint is desirable before the bone and soft tissues have healed completely. Various splints are required to protect and support the wrist in its final stage of healing.

• The muscles crossing the wrist must be strengthened after the wrist has healed, edema has been controlled, and motion has improved. Functional activities and progressive resistive exercises are employed. The wrist flexors and extensors are contracted actively against maximum resistance through a full arc of motion.

Rehabilitation considerations immediately following injury to 1 week

• For casted fractures

  • 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 shoulder

  • Isometric exercises to the biceps, triceps, and deltoid muscles

• Following open reduction internal fixation (ORIF) surgery

  • Elevation of the arm to treat dependent edema

  • AROM and PROM of digits, except the thumb

  • AROM and AAROM exercises to the elbow and shoulder

  • Isometric exercises to the biceps, triceps, and deltoid muscles

  • Limitation of supination and pronation

Rehabilitation considerations in 2 weeks

• The clinician may obtain bone or CT scans in the event of continued pain and tenderness over the snuffbox with negative radiographic findings.

• Bone stimulators have been increasingly used for stable, nondisplaced fractures and for suspected scaphoid fractures with negative radiographic findings, although both uses are still somewhat controversial.

• A short-arm cast is indicated for a suspected fracture, while a long-arm cast is used for a known fracture.

• The patient should continue ROM exercises for casted fractures and ORIF, as above.

Rehabilitation considerations in 4-6 weeks

• For casted fractures

  • Continue exercises as above.

  • Limit supination and pronation.

  • Change the long-arm cast to a short-arm cast (bridging callus indicates stability).

• Following ORIF surgery

  • Advance therapy with gentle AROM of the wrist and gentle opposition and flexion/extension exercises to the thumb.

  • Continue elbow and shoulder exercises.

  • Remove the short-arm cast at 6 weeks if the fracture appears to be radiographically healed.

  • Use a wrist splint for protection.

Rehabilitation considerations in 8-12 weeks

• For casted fractures

  • Remove the short-arm cast at 10-12 weeks if the fracture appears to be radiographically and clinically healed.

  • A wrist splint may be used for protection

• For casted fractures and following ORIF

  • Consider pulsed electrical stimulation if no evidence of union is noted by 8 weeks, and consider surgery with bone grafting if progress is not observed by 12-14 weeks.

  • Advance therapy with gentle AROM of the wrist and with thumb exercises.

  • Begin grip strengthening with the use of silicone putty at 10 weeks.

  • Advance as tolerated to progressive resistive exercises (PREs).

Occupational therapy

The patient usually needs retraining in the performance of activities of daily living (ADL). The occupational therapist provides the patient with compensatory strategies to use when completing ADL tasks. Either physical or occupational therapy is necessary for regaining strength and ROM in the affected wrist and hand. The guidelines for rehabilitation are discussed above in the Physical Therapy section.

See the list below:

• Scaphoid injuries and prolonged casting - These result in missed workdays and decreased work efficiency.

• Nonunion of scaphoid fracture ^{[24, 25]}

  • This complication is influenced by delayed diagnosis, gross displacement, associated injuries of the carpus, and impaired blood supply. Of these fractures, 40% are undiagnosed at the time of original injury.

  • Nonunion is 20% more common in smokers. ^[26]

  • The incidence of avascular necrosis is approximately 30-40%, occurring most frequently in fractures of the proximal third.

  • Scapholunate disassociation is a well-known complication of scaphoid fracture.

Indications for immediate surgical referral include the following:

• Fracture of the proximal pole
• Fracture displaced more than 1 mm
• Delayed presentation of acute fracture
• Fracture associated with scapholunate ligament rupture
• Carpal instability (lunate tilt on radiograph)
• Work considerations, when early return is desired in cases of nondisplaced fracture
• Evidence of nonunion or osteonecrosis

Displaced or unstable fractures require percutaneous pin fixation or compression screw fixation to prevent malunion. Internal fixation is accomplished with either smooth Kirschner wires or a Herbert screw. ^[6]

A literature review by Dunn et al indicated that scaphoid staple fixation is associated with a 94.7% union rate, with 95.7% of patients returning to work after 9.8 weeks, on average. The complication rate in the study was low (9.0%), with hardware removal required in 7.5% of cases. ^[27]

Surgery is increasingly used for patients (especially athletes) who will not tolerate prolonged casting.

Nonunions of the scaphoid are treated in one of the following ways:

• Radial styloidectomy
• Excision of the proximal fragment
• Proximal row carpectomy
• Traditional bone grafting
• Total or partial arthrodesis of the wrist

Because of the significant time required for the union of proximal pole fractures, some surgeons recommend primary fixation of these fractures even when they are not displaced.

The Matti-Russe procedure involves treatment of nondisplaced fractures by excavation of the scaphoid and placement of a volar corticocancellous bone graft.

If the proximal pole is avascular and no significant radiocarpal arthritis is present, revascularization of the scaphoid bone with a vascularized bone graft from the radius may be attempted. A review of more than 5000 cases found that vascularized bone grafting (with or without internal fixation) was 91% successful, that nonvascularized bone grafting with internal fixation was 84% successful, and that nonvascularized bone grafting without internal fixation was 80% successful. ^[28]

A silicone carpal implant is no longer recommended.

Once degenerative arthritis is evident at the radiocarpal joint, salvage procedures include proximal row carpectomy, scaphoid excision, and intercarpal or total wrist arthrodesis.

In general, consultation with a hand specialist or an orthopedic surgeon should be obtained for an open or unstable scaphoid fracture or for a scaphoid fracture that requires fixation.

Please see the Physical Therapy section.

• Nondisplaced fractures

  • Initially, nondisplaced fractures are treated with a long-arm thumb spica cast with the wrist in neutral position for 6 weeks, followed by a short-arm spica cast for an additional 6 weeks, until roentgenographic union is evident. If there is a displacement or widening of the fracture line after 6 weeks, the patient should be referred for surgical evaluation.

  • After immobilization, active ROM exercises to the forearm, wrist, and thumb should be performed 6-8 times daily.

  • A wrist-and-thumb static splint with the wrist in neutral should be worn between exercise sessions and at night.

• Displaced fractures

  • These usually require ORIF using wires and screws.

  • Then, a short-arm thumb spica is needed for 8-12 weeks until roentgenographic union is evident.

  • At 4 months after surgery, dynamic wrist flexion and extension may be initiated.

  • At 6 months, the patient usually resumes normal use of his/her hand.

• Electrical stimulation, or pulsed electromagnetic stimulation, has been proposed as beneficial in cases of nondisplaced scaphoid nonunion; however, this technique remains controversial, because no study has been conducted to compare the results of employing PES alone with those of using only cast immobilization.

Related Medscape Reference topic:

Thumb Spica Splinting