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  /  Wrist   /  Scaphoid Fracture: Causes, Symptoms, and the Role of Physical Therapy in Recovery

Scaphoid Fracture: Causes, Symptoms, and the Role of Physical Therapy in Recovery

The scaphoid is one of the small carpal bones in the wrist, situated near the thumb and connecting the two rows of wrist bones. Despite its size, the scaphoid plays a significant role in wrist stability and movement. A scaphoid fracture is a common wrist injury, particularly in young, active adults, often resulting from falls onto an outstretched hand.

Due to the scaphoid bone’s unique blood supply, these fractures can be challenging to heal and may result in complications if not managed appropriately. Physical therapy is essential in rehabilitating scaphoid fractures, focusing on restoring wrist mobility, strength, and function.

Anatomy of the Scaphoid Bone

The scaphoid bone is located on the thumb side of the wrist and is one of the most frequently injured carpal bones. Its position makes it highly vulnerable to injury, especially during impacts or falls. The scaphoid has a unique vascular structure, with most of its blood supply entering from the distal portion. This means that fractures closer to the proximal (nearer to the forearm) end have a higher risk of avascular necrosis (bone death due to lack of blood supply) and delayed healing.

Epidemiology and Risk Factors

Scaphoid fractures are most common in:

  • Young, active adults aged 15–30.
  • Individuals involved in sports or activities with a risk of falls, such as skateboarding, skiing, cycling, and contact sports.
  • Patients who have suffered falls onto an outstretched hand (the most common mechanism of injury).

Men are more frequently affected than women due to higher participation in high-impact activities.

Causes and Mechanism of Injury

A scaphoid fracture typically results from a fall on an outstretched hand with the wrist in an extended position. This impact places stress on the scaphoid bone, causing it to fracture. Depending on the force and angle of impact, the fracture may occur in different parts of the bone, each associated with unique challenges for healing and recovery.

Signs and Symptoms of a Scaphoid Fracture

Common signs and symptoms include:

  • Pain on the thumb side of the wrist, particularly in the “anatomical snuffbox” (the area between the tendons at the base of the thumb).
  • Swelling and tenderness in the wrist and thumb.
  • Limited range of motion in the wrist, particularly with twisting or gripping movements.
  • Weakness in grip strength.
  • Potential bruising around the area of injury.

It’s important to note that scaphoid fractures may not always be visible on initial X-rays. Persistent pain after a wrist injury may warrant further imaging, such as an MRI or CT scan, for a definitive diagnosis.

Consequences and Complications

If untreated or if healing is delayed, scaphoid fractures can lead to several complications:

  • Nonunion: Failure of the bone to heal, leading to chronic pain and instability.
  • Avascular Necrosis: Death of the bone tissue due to insufficient blood supply, especially in fractures closer to the proximal end.
  • Arthritis: Joint degeneration, which can develop over time due to misalignment or nonunion, resulting in chronic wrist pain and dysfunction.

Role of Physical Therapy in Scaphoid Fracture Rehabilitation

Physical therapy plays a critical role in the recovery from a scaphoid fracture. Rehabilitation is often divided into stages, starting from immobilization and progressing to advanced strengthening and functional exercises. Here’s a detailed breakdown of the physical therapy approach:

1. Immobilization Phase (0–8 Weeks)

In most cases, a scaphoid fracture requires immobilization with a cast or brace for 6–8 weeks. During this period, physical therapy focuses on:

  • Maintaining Range of Motion in Surrounding Joints: Exercises for the fingers, elbow, and shoulder are performed to prevent stiffness and maintain mobility.
  • Edema Control: Techniques such as elevation and light compressive bandaging help manage swelling.
  • Pain Management: Ice therapy and soft tissue massage around the wrist can help alleviate pain and discomfort.

2. Early Mobilization Phase (8–12 Weeks)

Once the fracture has shown signs of healing on imaging studies, the cast is removed, and gradual movement can begin. During this phase, physical therapy objectives include:

  • Restoring Wrist Range of Motion (ROM): Gentle ROM exercises are introduced to regain flexibility in the wrist. These may include:
    • Flexion and Extension Exercises: Bending the wrist up and down to restore sagittal plane motion.
    • Radial and Ulnar Deviation Exercises: Moving the wrist side to side to restore coronal plane motion.
  • Joint Mobilization: Techniques to improve gliding between carpal bones and enhance wrist joint flexibility.
  • Edema Control Continuation: Keeping swelling at bay with regular therapeutic interventions.

3. Strengthening Phase (12–16 Weeks)

Once pain is minimal and ROM is nearly restored, strengthening exercises are gradually introduced to improve muscle support around the wrist. Key components include:

  • Grip Strengthening: Exercises such as squeezing a therapy putty or using a hand gripper to improve grip strength, essential for daily activities.
  • Forearm Muscle Strengthening: Focusing on both flexors and extensors to support the wrist. Exercises may involve:
    • Wrist Curls and Extensions: Using light weights to strengthen the forearm muscles.
    • Pronation and Supination Exercises: Rotating the forearm to strengthen stabilizing muscles.
  • Progressive Resistance Training: Introducing resistance bands or light weights to challenge the wrist and forearm muscles further.

4. Advanced Functional Training (16+ Weeks)

In the final phase, therapy focuses on returning the patient to full function, including sports and work-related activities. This phase includes:

  • Proprioception and Balance Training: Enhancing the wrist’s stability and reaction time to sudden movements, which is critical in preventing future injuries. Exercises might include catching and throwing drills or weight-bearing activities on an unstable surface.
  • Advanced Strength and Endurance Training: Increasing resistance and incorporating more dynamic exercises to improve endurance and strength.
  • Activity-Specific Drills: For athletes, specific sports-related drills simulate real movements to ensure readiness for return to play.

Red Flags for Physical Therapists

Physical therapists should be alert to certain red flags that may indicate complications:

  • Persistent pain and tenderness in the wrist after a period of immobilization.
  • Delayed progress in ROM and strength recovery.
  • Signs of avascular necrosis or nonunion, including increased wrist pain, loss of function, or deformity.

In such cases, further medical evaluation and potential surgical intervention may be necessary.

When to Start Exercises

  • Weeks 8-12: Start gentle range of motion (ROM) exercises once immobilization is removed, under the guidance of a physical therapist.
  • Weeks 12-16: Progress to light strengthening and advanced flexibility exercises.
  • After 16 Weeks: If pain is minimal and wrist stability is achieved, progress to more functional and resistance-based exercises as tolerated.

Home Exercises to Decrease Pain and Improve Mobility

1. Wrist Flexion and Extension Stretch

  • When to Start: Weeks 8–12
  • How to Do It:
    • Sit with your forearm supported on a table and your hand hanging off the edge, palm down.
    • Slowly bend your wrist down (flexion) and hold for 5 seconds, then lift it up (extension) and hold for 5 seconds.
  • Repetitions: Perform 10–15 repetitions, 2–3 times a day.
  • Purpose: Helps to gently restore range of motion and decrease stiffness in the wrist.

2. Thumb-to-Finger Touches (Opposition Exercise)

  • When to Start: Weeks 8–12
  • How to Do It:
    • Touch the tip of each finger to the tip of your thumb in sequence (index, middle, ring, and pinky).
    • After completing, try sliding your thumb down each finger toward your palm to improve mobility.
  • Repetitions: Perform 2 sets of 10, 2–3 times daily.
  • Purpose: Enhances thumb and finger coordination and improves the range of motion at the wrist joint.

3. Passive Wrist Stretches

  • When to Start: Weeks 10–12 (after initial healing and if pain is manageable)
  • How to Do It:
    • Use your opposite hand to gently stretch the affected wrist by pushing it back (extension) and then pulling it forward (flexion) until you feel a gentle stretch.
    • Hold each stretch for 10–15 seconds.
  • Repetitions: 2–3 times in each direction, 2–3 times daily.
  • Purpose: Helps increase wrist flexibility and manage stiffness.

4. Wrist Supination and Pronation

  • When to Start: Weeks 10–12
  • How to Do It:
    • Sit with your elbow bent to 90 degrees at your side and forearm parallel to the ground.
    • Slowly rotate your forearm so your palm faces up (supination) and then down (pronation).
  • Repetitions: 2 sets of 10–15 repetitions, 2–3 times daily.
  • Purpose: Helps restore rotational movement in the wrist and forearm, which is essential for daily activities.

5. Hand Squeeze with a Soft Ball or Putty

  • When to Start: Weeks 12–16 (begin if pain is under control and with the therapist’s approval)
  • How to Do It:
    • Hold a soft ball or therapy putty in your hand, and gently squeeze, holding for 3–5 seconds before releasing.
  • Repetitions: 2 sets of 10 squeezes, 2–3 times daily.
  • Purpose: Builds strength in the hand and forearm, gradually increasing grip strength.

6. Isometric Wrist Exercises (Without Movement)

  • When to Start: Weeks 12–16
  • How to Do It:
    • Place your hand on a table with a rolled-up towel under the palm for support.
    • Without moving your wrist, push down gently as if to bend your wrist but resist the movement. Hold for 5 seconds.
    • Repeat with resistance in the opposite direction (upwards) by gently pressing with the other hand.
  • Repetitions: 5–10 repetitions in each direction, 1–2 times daily.
  • Purpose: Helps to strengthen wrist muscles without adding strain to the healing bone.

7. Resistance Band Wrist Flexion and Extension (Advanced)

  • When to Start: After 16 Weeks (only if pain-free with previous exercises)
  • How to Do It:
    • Secure a light resistance band around a stable object.
    • Hold the band in your hand with your wrist hanging off the edge of a table.
    • Flex and extend your wrist slowly, controlling the movement as you pull against the band.
  • Repetitions: 2 sets of 10, 1–2 times daily.
  • Purpose: Builds wrist strength and stability, essential for returning to higher-level activities and sports.

Tips for Performing Home Exercises Safely

  • Start Slowly: Begin with gentle exercises and avoid pushing into pain. If any exercise causes sharp or lingering pain, stop and consult your therapist.
  • Warm-Up: Consider using a warm towel around your wrist for 5–10 minutes before exercises to reduce stiffness.
  • Progress Gradually: Follow the timeline recommended by your therapist and only progress to more challenging exercises when you can perform the current level without discomfort.
  • Monitor for Pain and Swelling: If you experience increased pain or swelling, reduce intensity or take a break, as these could indicate overloading the healing bone.

Incorporating these exercises into your daily routine can help manage pain, restore motion, and gradually strengthen the wrist, promoting a successful recovery from a scaphoid fracture.

The Importance of Patient Education and Compliance

Patient education is essential in scaphoid fracture recovery. Therapists must emphasize the importance of:

  • Adhering to Immobilization: Informing patients about the critical nature of immobilization for proper healing.
  • Gradual Progression: Stressing the importance of gradual return to activity and avoiding premature loading on the wrist.
  • Following Home Exercise Programs: Educating patients on prescribed exercises to prevent stiffness and improve function.

Conclusion

A scaphoid fracture can significantly impact wrist function, but with early intervention and a structured rehabilitation program, patients can regain their strength and mobility. Physical therapy is fundamental in managing these fractures, offering tailored interventions to promote healing and prevent complications. A careful, phased approach ensures optimal recovery and a safe return to daily and sports activities, minimizing the risk of long-term dysfunction and arthritis.\

References

  1. Bain, G. I., & Bennett, J. D. (2006). The essential guide to hand and wrist fractures. Springer.
  2. Dorsay, T. A., & Earp, B. E. (2015). Scaphoid fractures and nonunions: diagnosis, treatment, and rehabilitation. Orthopaedic Knowledge Online Journal, 13(10), 1-7.
  3. Dodds, S. D., & Panero, A. J. (2016). Scaphoid fracture healing and the role of physical therapy. The Journal of Hand Therapy, 29(3), 266-273.
  4. Schnetzler, K. A. (2008). Scaphoid fractures: Current treatment options. Journal of the American Academy of Orthopaedic Surgeons, 16(11), 716-725.
  5. Green, D. P., & Hotchkiss, R. N. (2017). Green’s Operative Hand Surgery. Elsevier.
  6. van Schie, C. A., & Patijn, J. (2010). Scaphoid fractures: diagnosis, management, and therapy. British Journal of Sports Medicine, 44(3), 168-174.

 

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