User:Lewis Toffolo/Case Study

Case Scenario Annie Prophet is a 32 year old pregnant female who practices secondary teaching at a local high school. During her first trimester Annie notices an increasing numbness and the sensation of pins and needles in her right (dominant) hand, after extensive periods of writing on the whiteboards. During her second trimester Annie decides to take maternity leave to reduce stress levels and her wrist injury. Unfortunately Annie takes a bad fall after getting out of the shower and breaks her fall with her dominant hand. X-ray scans reveal a broken scaphoid that requires a splint to allow for a 6-8 week healing period. The GP refers Annie to an occupational therapist who performs a Phalens test which she test positive for suggesting the previous wrist pain is a result of a localized oedema in the wrist putting pressure on the carpel tunnel. The OT has put Annie in a thermoplastic cast for 6/52, which can be adjusted with Velcro strapping for the increased swelling. Treatment is aimed towards maintaining the thumb enclosed to the interphalangeal joint positioned to allow for the pinch grip with wrist held in 30 degrees of flexion. The goals of this intervention are to allow Annie full recovery and to allow her to carry and breastfeed her child once born.

Introduction The scaphoid bone is one of the carpal bones of the wrist that accounts for 50%-80% of all carpal bone fractures (Alshryda et al., 2012). Three of the six surfaces of the scaphoid articulate with both proximal and distal carpal rows, acting as a strut that confers considerable stability (Tan, Craigan & Porter, 2009). The mechanism of injury results from outstretching the hand in order to break one’s fall, with the wrist extended causing the majority of force to be transferred through the carpal bones and place considerable force through the scaphoid potentially causing a fracture (Alshryda et al., 2012). The localized oedema associated with the reparative phase of the fractured scaphoid causes swelling whilst osteoblast cells produce woven bone to bridge the fracture site (Brighton & Hunt, 1997). The complication of accommodating carpal tunnel syndrome with a fractured scaphoid in this scenario requires a holistic approach that maintains a comfortable wrist position that limits compression on the median nerve whilst also immobilizing the wrist. Functional goals of the client are to achieve stability in the wrist, while maintaining function of phalanges and thumb for nursing her child (i.e. feeding, changing diaper etc.)

Evidence Orthotic treatment for a scaphoid fracture requires a prognosis for its type of classification. Medical imaging using X-ray and MRI scans reveal that the client has a displaced fracture of the scaphoid waist. As concluded by Olerud & Lonnquist (1984), fractures in the carpal area can be associated with extensive haemorrhage that can result in compression of the median nerve in the carpal tunnel. The researchers go onto suggest, “decompression relieves the patient of the intense pain and is vital for a fast and complete recovery of the nerves function.” The management of Annie’s broken scaphoid requires extra attention since the presence of a “tingling” sensation in her fractured wrist has returned, which can be linked back to previous symptoms experienced from extensive writing at her job.

Repetitive use of the upper extremity throughout occupational use has been linked to carpel tunnel syndrome (Gerr, Letz & Kandrigan, 1991). Higher rates of CTS are more common among occupations that involve high force and/or high repetitive gripping jobs (Hagberg, Morgenstern & Kelsh 1992). High repetitions of hand movements that are involved with teaching are a relevant factor for the occurrence of CTS.

Withdrawing from work to undertake maternity leave has reduced pain, however during her second trimester CTS symptoms have returned. Pregnancy often develops an alteration in fluid balance and can result in compression of the median nerve in the wrist, resulting in CTS (Viera, 2003). The culmination of her swelling due to haemorrhage and the additional swelling due to pregnancy in the fractured wrist, requires a client specific approach to the orthotic design that encompasses aspects of the clients comfort and the optimal position for bone healing.

Reflecting on the symptoms associated with the two disorders allows the clinician to further design the orthotic device. Pain, numbness and tingling throughout the volar aspect of the hand and the dorsal aspect of the thumb and first two digits are initially noticed, which may worsen during night (Viera, 2003). A fractured scaphoid presents symptoms of tenderness and a small area of swelling at the base of the thumb around the anatomical snuff box, on the inferior medial aspect of the hand and is commonly mistaken for a sprained wrist (Guly, 2002). MRI scans can reveal the extent of damage done to the scaphoid and highlight the vascularity of the proximal pole, detecting impingement of the radial artery, which can lead to osteonecrosis (Steinmann & Adams, 2006). Recognition of these complications allows the orthotist to consider various treatment options to produce a client specific device.

Orthotic treatment options The orthotic treatment of a scaphoid fracture whilst managing CTS is a difficult task, as both conditions require interventions that may hinder the effectiveness of each method. Cast immobilization of a fractured scaphoid are hard to manage as most motions of the hand, wrist and forearm require a degree movement from this bone which can lead to non-union (Rhemrev, Ootes, Beeres, Meylaerts & Schipper, 2011). The study also suggested that the immobilization should include slight wrist extension and radial deviation. Immobilizing a wrist with CTS however requires the wrist to held in a neutral position that minimizes carpal tunnel pressure to minimize pain and facilitate healing (Page, Massey-Westropp, O’Connor & Pitt, 2012). The clinician has a wide variety of treatment options that can be used in this scenario. Scaphoid and Colles casts are both commonly used to immobilize a scaphoid fracture, the difference being that a Colles cast allows full ROM of the thumb while the Scaphoid cast only allows interphalangeal flexion (Karantana, Downs-Wheeler, Webb, Pearce, Johnson & Bannister, 2006). Typical scaphoid casts are now made using low temperature thermoplastics that are easily conformed and provide adequate immobilization in short-term application (Anderson, 2014). This material conforms easily to the anatomy and is recommended in this scenario because a compromise can found between a neutral wrist to accommodate the pain relief from CTS and the suggested wrist flexion. Comparison of orthotic treatment options The purpose of clinical intervention is to achieve fracture consolidation and functional recovery whilst avoiding non-union (Rhemrev, Ootes, Beeres, Meylaerts & Schipper, 2011). Treatment options for a scaphoid fracture most often include cast immobilization and operative treatment. A systematic review by Alshryda et al., 2012, evaluated the effectiveness of no-operative and operative interventions. In summation research did not demonstrate any significance of using a colles’ cast versus a scaphoid cast; having the cast above or below the elbow joint or having the wrist in a flexed or extended position. The article goes onto mention that “there was no difference in union rate between operative and non-operative treatment.” An article from Herbert and Fisher (1984) found a compelling argument for the use of operative treatment over cast immobilizing. The prospective trial demonstrated in 158 operations that the use of a double-threaded bone screw provided “such a good fixation” that a plaster cast is rarely required. A systematic review by Modi (2009) found that operative treatment resulted in faster union rates by approximately 5 weeks and allowed subjects to return to work by approximately 7 weeks. Research also revealed higher non-union rates in cast treatment. The high complication rate of 30% in operative treatment suggests that ORIF should be reserved for patients that are unable to use a cast. A review of credible literature suggests various treatment options for scaphoid fractures but few account for co-morbidities such as carpal tunnel syndrome. A study performed by Olerud and Lonnquist (1984) concluded that early decompression of the median nerve with a scaphoid fracture relieves the patient of the intense pain and is vital for a fast and complete recovery.

Search Strategy The search strategy that I developed involved using databases such as Cochrane, Medline, CINAHL and Google scholar, which allowed me to access a broad variety of scaphoid and carpal tunnel syndrome related journal articles. Keywords that I used throughout my search strategy involved; Scaphoid fracture, Acute AND scaphoid fracture, Treatment of carpal tunnel syndrome, Symptoms of carpal tunnel syndrome, Wrist positions for carpal tunnel syndrome AND scaphoid fracture. Articles I found most beneficial originated from large scaled randomized controlled trials and systematic reviews. Some lesser credible articles helped consolidate key points despite being aged. Conclusion After reviewing a broad variety of secondary sources, the patient with a scaphoid fracture whilst also suffering from carpal tunnel syndrome has been referred from a doctor to an orthotist to help reduce pain and evoke bone healing. A synthesis of both areas of research into CTS and a displaced scaphoid suggests that an MRI scan should be performed to reveal the severity of the fracture. In my clients scenario the fracture is not acute with no signs of necrosis and can be treated with non-operative methods. The wrist should be cast in a neutral position as it provides the least amount of pressure on the median nerve compared to both flexed and extended positions and does not affect the rate of union (Gelberman, Szabo & Mortensen, 1984). A low temperature thermoplastic will be moulded into a short arm thumb spica cast with the wrist in a neutral position, immobilizing the thumb to the interphalangeal joint. After 6 weeks a CT scan should be performed to reveal the stage of healing to re-evaluate orthotic treatment.

Functional Aims and Goals
Give a detailed description of the goals outlining the specific movements/activies that your orthosis is required to provide use the evidence described above to support this.

Design
Outline the design of your orthosis, this should include but is not limited to: technical drawings, force system diagrams (3 planes), materials of choice, attachment methods, trimlines and manufacturing procedure. Within this section, if you would choose to make your device from something other than LTT explain why and how this may affect the function of the device you manufacture.

Manufacturing process
Document the manufacturing process of your device. This should be a step by step “how to guide” including photographs, patterns, fittings, adjustments etc.

Critique of fit
You should base this critique on the your understanding of the critique process and the lecture you will receive in week 8. You will need to provide photographic or video evidence of the fit, function and operation of the force systems. Written support for your critique is fine if you choose to not video this.

Outcome measures
There are a variety of outcome measures available for the upperlimb functional ability. Choose an appropriate measure (if you are having trouble finding some the TAC website for clinical resources here may be useful.

Complete this for your client (using your clinical knowledge and judgement) for before and after the client receives the orthosis. Choose activies that you believe the client would have improved on and video your client undertaking these whilst wearing their orthoses. Outline your finding. Provide images of the completed Outcome measure on your wikipage.