Wrist injuries are frequently seen in athletics and may affect sport performance. Fractures are the most common wrist injuries, with the scaphoid being the most frequently fractured carpal bone and constituting 60–90% of all carpal fractures (17,22). Scaphoid fractures usually result from a fall on an outstretched arm with the wrist in hyperextension (more than 90° extension and 10° of radial deviation) (7,17,22). However, other mechanisms have been reported, such as hyperflexion of the wrist or by a closed-fist “direct blow” in sports such as boxing (17,19).
The most frequent sign of a scaphoid fracture is pain within the anatomical snuffbox (ASB). The ASB is the region between the extensor pollicis brevis and extensor pollicis longus tendons (Figure 1). Differential diagnosis for pain and tenderness in the ASB include fracture to the radial styloid, lunate, or trapezium bones and injury to other soft tissues (17,22). A thorough evaluation is needed to rule out other possible diagnoses. Other signs associated with a scaphoid fracture include point tenderness of the scaphoid tubercle, pain with forced ulnar deviation and resisted radial deviation, and pain upon thumb movement (primarily opposition to the little finger and pincer grip of the thumb against the index finger) (5,20). Athletes may also have severe pain, mild to moderate swelling, and occasional bruising around the fracture site.
This injury can be troublesome for the athletic population because of the risks or history of nonunion and avascular necrosis (7,10,27,30). Nonunion (failure of normal healing in a fractured bone) and avascular necrosis (death or decay of the tissue due to ischemia) can both occur if the fracture is not treated properly. This can potentially cause longer recovery periods and a longer return to sports participation. The purpose of this article is to discuss the rehabilitation management of a scaphoid fracture and postrehabilitation training considerations. A variety of exercises will be illustrated for these purposes. It is to be emphasized that this program is for those with full consolidation healing of the bone and under no circumstances be used during the early phases of bone healing.
A radiograph is needed if a scaphoid fracture is suspected; however, the initial radiograph may not be conclusive in showing if a fracture is present. One study noted radiography sensitivity as high as 86% on the initial radiographs; however, there is great variability in the literature (20,21,29,31). The radiograph may be normal in the first few days and up to 25% of fractures are not visible on initial radiographs (12,17,20,31). It is then recommended to take a second radiograph 10–14 days postinjury. If an individual is suspected of having a fracture, but has not been confirmed radiologically, he/she will be treated as having a “clinical” scaphoid fracture and immobilized until the second radiograph confirms the diagnosis (4,19). Other methods of assessing a scaphoid fracture are used, including, magnetic resonance imaging (MRI), computed tomography, and bone scintigraphy. MRI has become the gold standard in assessing scaphoid fractures with studies showing up to 100% sensitivity and detecting fractures at an average of 2.8 days postinjury compared with the 10–14 days with plain radiographs (1,6). Very few false negatives present itself when using MRI as a diagnostic tool for scaphoid fracture diagnosis.
Because of the unique vascularity of the scaphoid bone, a fracture leaves it susceptible to nonunion and avascular necrosis (7,9,17,23,30). This is primarily dependent on the location of the fracture. Eighty percent of fractures occur about the waist (middle-third), with the remaining equally at the distal and proximal poles (17,21). The fracture location can also affect the course of treatment by determining whether casting or surgical intervention is needed.
Casting may be recommended for nondisplaced or minimally displaced fractures with an 8- to 12-week immobilization period (8,11,19,25,27). Although a potentially long period, casting has been shown to have a union rate of more than 90% (8,21). If there is a nonunion or displaced fracture, fracture to the proximal pole of the scaphoid, or any associated carpal instability, surgical repair is necessary. Between 5 and 15% of all scaphoid fractures result in nonunion (16,17,25). Studies show that surgical fixation can decrease the healing time compared with conservative casting methods (18,24). Casting after surgery is a key component in the healing process; however, it is at the physician's discretion to use either a short arm cast or long arm cast. Although most physicians usually prefer a short arm cast, some studies have shown that long arm casts yield better results (8). Rhemrev et al. (25) developed a case-specific protocol that looked at several factors to treat scaphoid fractures. Their treatment involves a short arm cast for 6 weeks, which is then removed and reevaluated for fracture healing (25). Another 2-week period of immobilization is used if the fracture is not healed. If healing has not occurred by 12 weeks, the case will be considered for operative management (25).
With any type of fracture, an individual might experience complications with cast immobilization or surgery. Complications with cast immobilization include nonunion, avascular necrosis, muscle atrophy, joint contracture, and disuse osteopenia. Surgery may result in complications, such as hypertrophic scars, nonunion, avascular necrosis, infection, hardware failure, reflex sympathetic dystrophy, and potential risks associated with the anesthesia (2,9,30). An individual with complications from cast immobilization or surgery may need to be referred to an experienced rehabilitation specialist (licensed physical therapist or occupational therapist) to assist in areas of manual therapy, scar control techniques, modality applications, and management of dystrophic responses.
Early recognition of scaphoid fractures is crucial in helping an athlete have a successful outcome because of the risk of nonunion and avascular necrosis. Without early medical intervention, the frequency of nonunion and avascular necrosis increases when the time to onset of treatment increases. When an individual presents with a fracture more than 8 weeks after the initial injury, nonunion rates increase to 88% compared with those with early recognition of 5–12% (16,18). Avascular necrosis is estimated to occur between 2 and 9% of all scaphoid fractures and, however, occurs up to 40% in untreated fractures (2). These types of complications can lead to long-term pain and disability and result in arthritis later in life. It is extremely important that full fracture healing has occurred before beginning a rehabilitation program. Many times, initial radiographs do not reveal scaphoid fractures, so it is vital that a proper management plan has been made to ensure an accurate diagnosis.
The wrist plays a major role in an athlete's ability to perform not only sport-specific activities but also activities of daily living (ADL). Without normal wrist range of motion (ROM) and strength, the athlete will have difficulty in performing tasks, such as grasping and picking up objects. As the beginning phases of rehabilitation are the most crucial, it is highly recommended to enlist the care of rehabilitation specialists. Following an appropriate care plan, the rehabilitation specialist can also deal with any potential complications that may arise. The rehabilitation program for the management of scaphoid injuries is divided into 3 phases, including ROM, strengthening exercises, and sport-specific exercises/drills. The athlete will progress from one phase to the next as the goals of each phase are reached and achieved. Initially, a high repetition, low-intensity program with no weight will be performed to help reestablish neuromuscular control.
The Daily Adjusted Progressive Resistance Exercise System (DAPRE) model will be used for determining resistance training sets, repetitions, and loads before progressing to the traditional progressive resistance type of training to include strength, power, and plyometric activities (Table 1) (33). The goals of rehabilitation of the wrist are restoration of ROM and to improve and restore hand and wrist function, with attention to power grip, pincer grip, activities associated with thumb abduction, flexion, and opposition, and ADL, such as grooming, self-care, writing, and opening doors. A summary of the program is described in Table 2.
Before initiating the rehabilitation program, there are a few cautions and considerations that must be addressed. Scaphoid fractures have a high rate of reoccurrence and complications (16); therefore, the rehab specialist should pay close attention to the increased signs of pain and inflammation at the injury site when introducing new exercises and activities. Progress the exercises in a more conservative manner, based on impairment and function, not a specific time line. If the athletes exhibit the following signs and/or symptoms, increased pain, increased swelling, and loss of ROM and/or function, they may need to stop the rehabilitation program or go back to an earlier phase in the program. In some instances when pain does not resolve, nonunion occurs with limited ROM or pain, avascular necrosis occurs, or when athletes perform exercises too aggressively causing re-injury, the athlete may not be permitted to return to athletic endeavors and emphasis will be on ADL.
The rehab specialist will need to continually reassess and evaluate the athlete's progression and limitations because not all athletes will advance through all the exercises and some may not return to their sport because of functional limitations. To return to sports, such as gymnastics or weightlifting, you will need to complete the entire rehabilitation program because of the impact activities associated with the sport. Other sports, such as baseball, basketball, tennis, or lower-extremity–dominant sports may not progress to the plyometrics exercises before return to sport activity.
PHASE I—RANGE OF MOTION EXERCISES
For athletes to return to normal functional activity, they must first regain mobility in the wrist and thumb. Usually, active range of motion (AROM) is performed first and requires the athlete to move their wrist through its available motion on his or her own volition. The purpose of AROM exercise is to prevent the loss of available movement at the joint because of immobilization or surgery. Active assistive ROM is most commonly used in instances of weakness or inhibition of motion because of pain or fear or to increase the available ROM when they are unable to move the joint throughout the full range. To perform this type of exercise, the athlete is directed to use his or her own muscle contraction to move the wrist while the treating professional provides additional or assistive force. PROM and joint mobilizations may also be needed in the early stages to assist with restoring ROM.
Flexion and extension ROM exercises of the wrist can each be performed in 2 different ways. To stretch the wrist extensors, hold the wrist in front with the arm straight and fingers pointed down to the floor. Use the other hand to pull down on the wrist until a stretch is felt (Figure 2a). A variation of this exercise is to place the back of the hand on a table with the shoulder turned in and fingers facing away from the body (Figure 2b). Slight pressure should be given to bend the wrist and straighten the elbow until a stretch is felt. Athletes should be cautioned that this is a partial weight-bearing exercise and not to be performed until later stages of rehabilitation. Similar exercises are used to stretch the wrist flexors. Begin again with the arm straight in front, palm facing down, and using the other hand, pull back the fingers until a stretch is felt (Figure 3a). Another way to stretch the wrist flexors is to place the palm of the hand flat on a table with the fingers pointing backward (Figure 3b). Then, press down slightly on the wrist by straightening the elbow, causing the wrist to bend until the stretch is felt (11). The variations of these exercises require some weight bearing through the wrist and should be used during the second stage of rehabilitation after initial restoration of motion and no increase in pain.
When an athlete fractures their scaphoid, radial and ulnar deviation will be painful for them. During the rehabilitation process, the athlete should be able to actively deviate his or her wrist. They should place their forearm on a table with their hand lying as flat as possible. Without moving their forearm, the athlete should slide their hand toward the thumb (radial deviation) to the point of stretching or resistance felt on the ulnar side (Figure 4a). The athlete should then straighten his or her hand back up and then slide it to the little finger (ulnar deviation), again to the point of stretching or resistance is felt on the radial side (Figure 4b). Deviation of the wrist can also be performed by moving it up and down, as in a handshake motion (11).
The other ROM exercises that an athlete must be able to perform after a fracture of the scaphoid are pronation and supination of the forearm, and thumb flexion. When performing pronation and supination, the athlete needs to make sure to hold his or her elbow bent at 90°. The athlete can then turn his or her palm upward for supination and downward for pronation, doing this until the point of feeling a stretch. When the athlete gets to the stretching point, that position should be held for about 10–30 seconds (11,26). Whenever an athlete fractures the scaphoid, their thumb will most likely be immobilized in the cast. When the cast is taken off, the thumb will be very stiff and it will be very difficult for them to flex it. Having a mobile thumb is necessary for performing functional sporting tasks. The last ROM exercise that is important to the hand is thumb flexion. First, the athlete begins with the thumb positioned outward. They can then move the thumb across the palm and back to the starting position (18).
PHASE II—STRENGTHENING EXERCISES
It is essential that the fracture has healed before beginning strengthening exercises because resistance can cause too much strain on the newly healed structures. During the first 4–6 weeks postinjury, a soft callus is formed over the fracture site and, although may be mechanically stable, is still very weak to external forces, which requires the protection of a cast or splint (14,15). Adequate strength is achieved by 3 months, but remodeling continues to take place. Mechanical stress placed on the bone, as with strengthening exercises, helps to facilitate this remodeling in the areas of the bone that receive the most stress.
When an athlete can perform the previous stretching exercises without pain, resistance can be added to the exercises to help build the strength in their fingers, wrist, and forearm, such as the Digi-flex hand gripper (Figure 5). An athlete can begin by using resistance tubing and then progress to 1- to 3-pound dumbbells. Although resistance tubing can be highly variable, tension can be adjusted to allow the full ROM to occur at the beginning stages before adding dumbbell resistance. Strength should be assessed using a hand dynamometer to determine if goals have been met and if intensity should be increased. Only when an athlete shows increased strength with no pain or signs of inflammation should weight be added. When adding resistance to the program, the healthcare professional should use the DAPRE as a way to develop the program and to help the athlete increase strength without progressing too rapidly and cause inflammatory delays, such as redness, swelling, heat, pain, and loss of function (33). As the athlete's strength increases to 3 or more sets of 10 repetitions, transition is made to normal progressive resistance training principles. During the strengthening phase of rehabilitation, focus should be placed on the muscles of the wrist and thumb and include the abductor pollicis longus and brevis, extensor pollicis brevis, flexor pollicis longus and brevis, flexor carpi radialis, and flexor carpi ulnaris (13). As the treatment course may differ for some individuals, the expected duration of rehabilitation is 3–6 months (13).
REHABILITATION EXERCISES FOR THE SCAPHOID
Examples of exercises that may be used during various phases of the scaphoid rehabilitation program are described in Tables 3–5. These exercises encompass hand and wrist strength, push-up progressions, and plyometric activities. Light plyometric activities, such as ball tossing, can be introduced into phase II, with the majority of the high-impact, high-intensity exercises that would be involved in the sport-specific activities added in phase III.
MEDICINE BALL ACTIVITIES
Before an athlete begins medicine ball exercises, they must be able to throw and catch nonweighted or light balls, such as the Cando, or other small balls that are easy to grip and vary in weight (3). The idea is to retrain the athlete with the mechanics of throwing and catching without pain before loading the muscles. Once this is achieved, the athlete can begin to load the joint with weighted medicine balls. These exercises may be performed for 3 sets of 6–8 repetitions. Examples of some, but not all, of these exercises are described in Table 5.
Push-ups are a great upper-extremity functional exercise. There are many variations of the push-up, with only a few described as a progression for rehabilitation and return to sport performance for wrist-related injuries. It may be necessary to modify the push-up exercise for a slower progression before initiating full body weight push-ups. This may include beginning with wall push-ups then to table push-ups and modified push-ups until the progression reaches full body weight push-ups. Those who tolerate the progression well can increase the intensity by adding high-intensity plyometric push-ups in the last stage of rehabilitation. When landing these exercises, the low back has a tendency to extend if the rectus abdominus musculature does not remain contracted and as a result can cause strain on the low back.
RETURN TO PLAY
To return to sports participation, the athlete should have full ROM, strength equal to the uninjured extremity, minimal to no pain, and the ability to meet the demands of the sport while displaying correct biomechanics. The skill components of the sport must be addressed for each individual athlete to develop an individualized exercise program and to meet certain criteria for return to play status. Athletes, in many instances, must wear appropriate protective devices to help support and limit excessive ROM (28). The protective devices may include one or any combination of bracing, casting, or taping.
The scaphoid is one of the most often-injured wrist bones in athletics. Because it is seen often by those in athletics, it is important to recognize the signs and symptoms with early diagnosis and a more conservative intervention to avoid the avascular necrosis that can occur when not managed appropriately. A sample of an appropriate care plan and rehabilitation program that demonstrates the need for continual assessment and reassessment was explained. The advancement through rehabilitation and return to play criteria demonstrate a progressive overload approach with continual monitoring of pain and inflammation to move forward in an accelerated manner. It is of extreme importance that safety be a top priority to which it is assured that there is full fracture consolidation before beginning the program. If any complications do arise or if the athlete is not progressing as should, appropriate referral should be made. This program may be used and monitored by allied health professionals and strength and conditioning professionals to assist the athlete in returning to full function in daily activity and sport performance.
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Keywords:© 2012 National Strength and Conditioning Association
scaphoid fracture; rehabilitation; wrist exercises; thumb exercises; navicular fracture; exercise progression; return to play