User:Lewis Toffolo/Fractured Scaphoid w/Carpal Tunnel Syndrome

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 using her dominant hand to break the fall. MRI scans reveal a fractued scaphoid that requires a splint to allow for a 6-8 week healing period. The GP refers Annie to an occupational therapist who suggests that the previous wrist pain was from carpal tunnel syndrome. The OT has referred Annie to an orthotist for a thermoplastic cast for 6/52, which can be adjusted with Velcro strapping for the increased swelling.

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
The orthotic goals of the wrist and thumb spica/plaster cast require adequate immobilization of the wrist, carpometacarpal and metacarpophalangeal joints. Depending on the displacement of the fracture will determine the treatment method. In this scenario the wrist has been held with slight wrist extension (10-20 degrees) and ulnar deviation using a POP cast for the first 2 weeks and low temperature thermoplastic there after. The associated swelling from oedema while the fracture undergoes the reparative stage of bone repair, may alter the circumferential pressure distribution. After the 2 weeks low temperature thermoplastic with replicate the same position but with less than 10 degrees of wrist extension. This should reduce pressure on the ulnar nerve whilst the client is pregnant. As stated previously in the Orthotic Treatment section, Page, Massey-Westropp, O’Connor & Pitt, 2012 outline that maintaining a neutral position does not affect the rate of union but does reduce pressure on the ulnar nerve, thus preventing pains and symptoms from Carpal Tunnel Syndrome. The client has requested that she wants to be able to still complete basic daily activities such as cooking and cleaning, whilst also being able to cradle and breast feed her future child. Therefore, the orthosis will provide comfort and not produce any pressure areas, while also conforming the anatomy of the hand with smooth/rolled trim lines. The Velcro straps will be placed at the most appropriate distal and proximal positions whilst the central trap will oppose wrist movement. To increase the immobilization of the wrist, the strap that crosses the joint will use a padded compressive layer that will restrict further movement while also maintaining comfort.

Design
The presentation of a client with a fractured scaphoid requires orthotic intervention to promote bone remodelling and repair. Maintaining the wrist in a functional position with 5-10 degrees and slight ulnar deviation is the typical functional design for this pathology, however the increasing swelling from pregnancy has caused previous symptoms of carpal tunnel syndrome to arise. As outlined by Jacobs and Austin (2013), with the wrist in anymore than 10 degrees of extension increased pressure on the ulnar nerve will result in these symptoms. Fess, Gettle, Janson, and Philips (2005) gather that maintaining the thumb in palmar adduction will create a functional benefit while also opposing the mechanism of injury to promote healing. In summary the design will include: 1. LTT WHO extending from the 2/3 forearm to distal palmar crease and extend to proximally at the proximal interphalangeal joint with rolled edges. 2. Velcro straps placed over the proximal forearm, dorsal wrist, distal metacarpal bones. 3. EVA foam over wrist strap limits movement and prevents discomfort 4. Trimlines to cover 1/2 the circumference of the forearm. 5. Low temperature thermoplastic will be used. A 3 point force system is applied through this cast:

Orthotic goals of the device should include:
 * No pressure areas that dig in on the subjects skin
 * Circumferential
 * 2/3rds the length of the patients arm
 * Create the greatest lever arm with the straps located at the most proximal and distal position
 * Rolled edges to prevent skin breakdown
 * Flared proximal end to allow full elbow flexion
 * Included a low density EVA foam under strap of wrist to further immobilize wrist.
 * Rounded edges on straps and smooth edges on device further add to the aesthetics of the device.

Manufacturing process
Manufacturing process: The manufacturing process was completed over a 4 hour period from start to finish and consisted of the following steps:
 * Equipment: Chux, permanent marker, scissors, LLT, electric frying pan, water, heat gun, Velcro, low density EVA, sewing machine
 * With the client rested in a comfortable position for both them and yourself trace an outline of the injured arm on the chux marking the distal palmar crease, IP joints, wrist, and 3 fingers distance away from the cubital fossa.
 * Using the template design seen in figure A, place it over the traced arm noting the design around the thumb and copy the design onto the LLT
 * The distal end of the template design should match up with the distal palmar crease.
 * Place the LTT into the electric frying pan to increase malleability but only to the point where it is easily cut but does not loose shape easily (approx. 20 seconds)
 * Place the cut design back in the water for 45 seconds
 * With the client seated and in the molding position (elbow flexed, wrist 10 degrees extension, slight ulnar deviation) that resembles a sock-puppet, the LTT can be removed and then molded around the anatomy being careful not to create any abnormalities in the device.
 * Once set remove the device and place distal end in the hot water to allow rolling around the palmar crease and IP joint of the thumb.
 * Proximal end should also be flared to allow full elbow flexion
 * Begin to mark areas where the straps will be placed; most distal and most proximal position and also over the centre of the wrist.
 * The white Velcro hook at the proximal end will need a ‘V’ shape cut in it to allow the Velcro a slight curvature as it extends around the forearm.
 * The medial side of the distal strap requires a heat gun to fix it to that location.
 * All other attachment points will be on the Velcro hook
 * The centre strap requires a piece of low density EVA foam approximately the width of the Velcro and 3-4cm long under the strap.
 * A piece of leather is placed under foam and using the sewing machine, sew the foam in place in between the two.
 * Clean remaining pen marks with acetone.
 * Inspects for abrasive edges and remove if needed using sandpaper

Critique of fit
Annie Prophet is a 32 year old female who has suffered a bad fall fracturing her scaphoid in her left hand. Annie has also mentioned she suffers from a pins and needles feeling in this hand prior to the accident when writing for long periods. Pain scales where used as a subjective assessment and it was noted that with no immediate wrist movement the pain was at a level of 6/10 but as she attempted to use a pen, placing the wrist in slight extension, pain levels increased to 8/10.

The referring doctor has requested MRI scans of the site, which has been examined, revealing a transverse fracture of the scaphoid. The doctor has recognized the severity of the fracture and suggested orthotic intervention during pregnancy. Palpation of the hand revealed tenderness at the base of the thumb and swelling around the carpal bones. Active and passive range of motion tests revealed limited wrist extension only being able to achieve 30 degrees until the pins and needles sensation began and pain became severe. 40 degrees of wrist flexion was recorded until pain levels increased.

Annie has requested that the orthotic device does not interfere with her ability to hold her child after birth and be able to perform other activities like breastfeeding her child.

Acknowledging the goals of the client whist also maintaining a functional benefit is a key concern as a clinician and as a result I have suggested a custom made LTT short arm thumb spica that maintains the wrist in a position of 10 degrees of wrist extension to reduce pressure on the ulnar nerve.

After the device was appropriately cut and adapted to the arm, some areas of concern where acknowledged. The position of the wrist was not put in the desired 10 degrees of extension and some movement was noted. To correct this I have added a piece of 5mm low density EVA foam with a leather sheath over the wrist strap to further limit any movement while maintain comfort. Opposition of the first 2 digits with the thumb was achieved however the 3rd digit could not be touched. This highlights the need for the device to be refitted again to increase thumb adduction to create an improved functional position. Others areas of concern include having the rolled edges of the IP joint at the thumb too distal limiting range of motion, having the proximal strap too distal which limits the advantage of the lever arm and not creating a strong anchorage of the distal strap onto the device which appears to have lifted off. These minor problems suggests that further care is needed when preparing the device next time, however its functional benefit is still achieved and the device should allow for a successful union of the fracture site.

Various outcome measure tests where performed to determine the functional ability of the device after it was fitting. The upper extremity functional index (UEFI) reported a score of 65/80 with the device after only achieving a score of 54 prior to orthotic intervention. Improvements in these simple activities highlights the positive benefits of the device however achieving the clients desired goals will only be identified once she has given birth and performs the tasks.

Outcome measures
Determining the functional benefit of an orthotic device is best achieved using various outcome measures that contain different scales to assess the client’s satisfaction before and after application. The Disabilities of the Arm, Shoulder and Hand (DASH) is an appropriate measure that uses a questionnaire to determine physical function and symptoms in subjects with musculoskeletal disorders. The advantages of using this outcome measure lie in its high responsiveness and ability to reflect many activities of daily life (Schoneveld, Wittink & Takken, 2009). The Patient Rated Wrist-Hand Evaluation (PRWE) has a greater focus on pain and function with a low number of items but a higher number of response options when compared to the DASH. The outcome measure has a higher rate of reliability and a greater response rate than using the DASH (MacDermid &Tottenham, 2004). A combination of the two measures will supply a better understanding of the patient’s satisfaction before and after orthotic intervention.

The DASH consists of 30 questions on a disability/symptom scale scored 0 (no disability) to 100 (complete disability) (Gummesson, Atroshi & Ekdahl, 2003). Prior to the orthotic device the client scored 72 demonstrating a great interference with daily activities particularly ones involving greater amounts of wrist movements such as tightening a jar and doing household chores. After the short arm thumb spica was used the client scored 25 noting greater improvements in the daily activities with less ‘tingling’ wrist pain. The PRWE covers two main categories addressing pain and function; applicable for subjects with specific diseases such as carpal tunnel syndrome (Changulani, Okonkwo, Keswani & Kalairaja, 2008). The patient noted greater amounts of pain prior to the device with activities that required greater hand movements when ‘putting shoes on’ and ‘preparing meals’. With the device in place it was noted that less pain occurred in the wrist throughout the day but also limited function when it came to daily chores.

The outcome measures were performed 1 week after injury and again 6 weeks later after the device had been implemented at 3 weeks. The results were as expected and the pain levels decreased with use. Improvements in some aspects of the criteria are noted and this proved the practical significance of the device. However these outcome measures do not cover all aspects of the client’s requirements, only the patient will be able to measure their success based on a subjective opinion when completing daily activities that might not be covering in these measures.

Referral Letter
Mr. Neil McNeil East Bundoora Physiotherapy Centre

Date: 29th May 2014

Dear Mr McNeil,

I am writing to refer my client, Mrs Prophet, for your clinical evaluation for management of chronic carpal tunnel syndrome.

After suffering a bad fall on her outstretched dominant hand she has incurred an acute fracture on her scaphoid and required orthotic intervention to manage the fracture. Management of the fracture with a short arm thumb spica has been successful, however, the symptoms of the carpal tunnel syndrome are yet to subside. There is significant swelling at the extremities due to pregnancy and bone remodelling and is creating a compressive force on the median nerve and requires physiotherapy to treat the pain.

Mrs Prophet is a relatively active 32-year-old female, who works as a secondary school teacher at the local high school. She has indicated previous symptoms of wrist pain after long periods of writing and typing. Onset of the tingling sensation remains persistent throughout her third trimester.

Treatment for the fractured scaphoid required three sessions over a period of 6 weeks to cast, fit and evaluate the treatment progression. The short arm thumb spica maintained the wrist between 0 and 10 degrees of extension to minimise compression on the median nerve and enables the development of a complete union at the fracture site. The positioning of the thumb in palmar adduction maintains functionality in the cast to achieve simple tasks at home. Palpation of the proximal pole of the scaphoid has revealed a reduction in tenderness at the fracture site and suggests complete union.

Assessment of outcome measures using the disability/symptoms scale (DASH) and the patient rated wrist-hand evaluation (PRWE) has demonstrated improvements in the patient’s quality of life. DASH scores of 72 prior to orthotic intervention demonstrated great interference in daily activities with notable pain in the hand and wrist. Post orthotic management recorded scores of 25 indicating great improvements, however scores allocated for tingling sensation indicate further attention is required. The PRWE reinforced these results suggesting further treatment is necessary for complete rehabilitation.

Orthotic intervention has been successful however further treatment is required to manage symptoms associated with chronic carpal tunnel syndrome. This involves improving joint ROM and maintain functionality at home without orthotic management suitable for child caring.

Yours sincerely, Lewis Toffolo Bundoora Hand Therapy

Reference List
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Page, M. J., Massy-Westropp, N., O’Connor, D., & Pitt, V. (2012). Splinting for carpal tunnel syndrome (Review). Cochrane Database of Systematic Reviews. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22786532

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