What treatment is recommended for a patient with unresolved right wrist issues post-scaphoid and tendon repair surgery?

Management of Post-Surgical Right Wrist Issues Following Scaphoid and Tendon Repair

Physical therapy is strongly recommended as the first-line treatment for patients with unresolved right wrist issues following scaphoid and tendon repair surgery to improve function, muscle strength, and reduce pain. 1

Initial Assessment and Imaging

• A right wrist X-ray is appropriate as the first diagnostic step to:

  • Assess healing status of the scaphoid repair
  • Evaluate alignment of the carpal bones
  • Rule out complications such as nonunion or hardware issues
  • Identify any signs of scaphoid nonunion advanced collapse (SNAC) 2, 3

• If X-rays are inconclusive but symptoms persist, consider:

  • MRI without contrast (highest sensitivity for detecting occult fractures, bone marrow edema, and soft tissue injuries) 2
  • CT without contrast (excellent for visualizing bone detail and fracture classification) 2

Physical Therapy Protocol

1. Early Phase (Weeks 1-4):

   • Gentle active and passive range of motion exercises
   • Light isometric strengthening
   • Edema control techniques
   • Pain modulation modalities (cryotherapy for 10-minute periods) 1
   • Patient education on ergonomic principles and activity pacing 1

2. Intermediate Phase (Weeks 4-8):

   • Progressive resistive exercises
   • Eccentric strengthening (shown to be effective for tendinopathy) 1
   • Proprioceptive training
   • Functional activities that simulate daily tasks

3. Advanced Phase (Weeks 8-12):

   • Task-specific training
   • Work/sport-specific rehabilitation
   • Progressive loading to improve grip and pinch strength 4

Orthotic Management

• Consider wrist orthoses for symptom relief, particularly if there is thumb base involvement 1
• Long-term use of orthoses is advocated for persistent symptoms 1
• Protective devices that allow controlled mobilization are beneficial 1

Pharmacological Management

• Topical treatments should be considered first due to safety reasons:

  • Topical NSAIDs are the first pharmacological treatment of choice 1

• Oral medications for short-term symptom relief:

  • NSAIDs for limited duration (already prescribed omeprazole 20mg QAM is appropriate for gastric protection) 1
  • Consider chondroitin sulfate for pain relief and functional improvement 1

Monitoring and Follow-up

• Regular assessment of:

  • Pain levels using validated scales
  • Range of motion measurements
  • Grip and pinch strength compared to unaffected side
  • Functional outcomes using DASH or PRWE questionnaires 4, 5

• Long-term follow-up should be adapted to the patient's individual needs 1

Potential Complications to Monitor

• Scaphoid nonunion (occurs in approximately 14% of surgically treated cases) 5
• Tendon adhesions or ruptures 3
• Development of carpal tunnel syndrome 3
• Progression to scaphoid nonunion advanced collapse (SNAC) 6

When to Consider Surgical Revision

Surgery should be considered if:

• Physical therapy and conservative measures fail after 3-6 months 1
• Imaging shows nonunion, malunion, or hardware complications
• Functional limitations persist despite appropriate rehabilitation 1

Key Pitfalls to Avoid

• Delaying physical therapy initiation (should begin as soon as medically cleared)
• Progressing too rapidly through rehabilitation phases
• Failing to address ergonomic factors that may contribute to symptoms
• Overlooking the psychological aspects of chronic wrist pain and dysfunction
• Relying solely on passive treatments without active patient participation

Physical therapy combined with appropriate orthotic management and short-term pharmacological interventions provides the best opportunity for recovery of wrist function and pain reduction following scaphoid and tendon repair surgery.