A carpal fracture is a break to one of the small bones in the wrist. The wrist joint is comprised of the distal ends of the radius and ulna (forearm bones) and eight carpal bones (which form the “floor” of the carpal tunnel). The most common carpal fracture is scaphoid fracture, followed by a triquetral fracture. Carpal fractures represent nearly 18% of all upper limb fractures.
Carpal fracture is usually caused by direct trauma or a fall on an outstretched hand (FOOSH).
Carpal fractures are acute injuries (occur suddenly) therefore symptoms can often be noticed immediately following injury.
- Sudden, sharp pain in the wrist
- Swelling of the wrist and arm
- Visible deformity of the bones in the wrist
- Decreased ability to move the wrist and hand
The most common course of treatment for a carpal fracture is realignment (referred to as reducing the fracture) and casting to immobilize the joint, and give the bones time to heal. In most cases, carpal fractures are simply immobilized in a cast for 4-12 weeks. The scaphoid fracture may need a very lengthy immobilization time due to its poor blood flow. For more severe fractures, surgery may be needed to realign the bones properly. How much movement should be restricted following the fracture will depend on the severity of the break.
Once cleared by the physician, a hand therapy program should be initiated to reverse the effects of immobilization and restore wrist motion. In more involved fractures recovery can be long and arduous. Formal therapy and compliance with an extensive home program is the mainstay to restoring function of the wrist.
Hand Therapy Treatment
Post carpal fracture immobilization can have detrimental effects that can be improved through hand therapy including:
- Joint articular cartilage softening
- Shortening and atrophy of musculotendinous units
- Decreased circulation
- Loss of active and passive motion
Hand Therapy Interventions
Hand Therapists are occupational or physical therapists educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Carpal Fracture include:
Goals for hand therapy post- carpal fracture immobilization are optimal loading and restoration of normal tissue relationships to improve motion, strength and ability to perform functional activities of daily living.
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, and joint mobilization by a hand therapist to modulate pain and reduce any soft tissue or tendon irritation and restore normal joint mechanics and range of motion.
- Therapeutic Exercises (TE) including exercises to improve strength and performance of the wrist and surrounding muscles.
- Neuromuscular Reeducation (NMR) to restore stability, begin retraining the upper extremity, improve proximal joint stability and improve movement technique and mechanics (for example: ability to grasp objects, dress, work and perform fine motor activities) in use of the involved upper extremity in daily activities.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold and laser to decrease pain, improve mobility and reduce inflammation of the wrist and surrounding muscles and tendons.
- Home program development should include strengthening, stretching and stabilization exercises as well as instructions to help the person perform daily tasks and advance to the next functional level.
Most carpal fractures can be diagnosed with X-Ray studies and when necessary a CAT scan. The use of pain medications, immobilization, rest and ice are the first line of treatment. Surgical intervention may be required in more severe fractures or those that affect the integrity of the wrist joint.
Rate of recovery and the prognosis from a carpal fracture will depend on a number of factors:
- Severity – Minor fractures do well with immobilization and hand therapy, while fractures that are more severe and require surgery or effect joint integrity take longer to recover. Patients may have residual motion and strength deficits.
- Age- Younger individuals recover faster and are less likely to have residual deficits. Younger individuals heal quicker, have better circulation, are stronger and usually their pre-injury tissue integrity is better.
- Prior activity level plays an important role in post-injury recovery. Those who exercise regularly are stronger and more flexible, and generally have an easier and more complete recovery.
- Compliance- Patients that are committed to their rehabilitation program and are compliant with their home program are more successful in returning to full function.