Week 5 Category 2 questions

• What nerve roots and peripheral branches do you need to eliminate in this of potential 4th
and 5th digit involvement?
C8 nerve root
Ulnar nerve

• Describe what you see

• Decreased disc height C4/5, C5/6
• Posterior osteophytes of C4, C5
• Posterior disc bulge C4/5, C5/6

• Does this correlate with the case

No. The case would likely affect C7/T1 vertebra, not T2 as per the image. Additionally, there is
lateral stenosis of L side, not R as per the history
• If we assume this image is C7/T1 level
• How common are disc injuries at this level?
Typically very uncommon
• What sensory distribution may be disturbed?
Decreased sensation over medial hand (i.e. 4th & 5th digits), as well as medial forearm
• What reflexes may be impacted?
Finger flexion reflex
• What muscle tests could be affected?
Finger flexion, abduction & adduction
• What neuro tests would you perform?
Sensory, motor and reflexes
• What orthopaedic tests would you perform?

• What do you see here?

Scaphoid fracture
Possible calcification in TFC
• What is the injury identified in the image?
Scaphoid fracture
• If this presentation was acute and the x-ray was clear, what would be your management
plan?
Refer to management plan below
• What other associated problems do we need to manage?
Osteonecrosis
• What systemic issues could complicate this case?
Osteonecrosis
• Who are our specific risk groups?
Elderly & athletes (due to FOOSH)
• Would you conservatively manage this?
Scaphoid fractures require cast immobilisation for proper healing and realignment. Surgery
may also be warranted.

• What would be your rehab plan with timeframes?

• After 4-6 weeks in a cast perform PROM movements
• After approx. 8 weeks, introduce mild resistance exercises of the wrist (i.e. water
resistance in pool)
• Eventually progress to grip strength exercises
• Return to ADL's
• What would be your triggers to on refer?
A suspected scaphoid injury should always be referred for imaging & surgery consultation.
A typical presentation would include:
• Typically a traumatic fall (FOOSH)
• Pain worse with radial deviation & extension
• Pain better with rest & immobility
• Patient will often experience grip weakness
• Often difficulty with thumb movements

• What are important follow up markers for this type of presentation?

• How is this injury managed when non-union occurs?
 Outline a management plan including a rehabilitation protocol for one for your serious MSK
differentials.

Management plan
Refer for surgical consultation - cast immobilisation will likely occur

Weeks 1-6
• Cast immobilisation
• Manage pain with NSAID's (short term, preferably only first week)
• Encourage elbow and shoulder ROM

Weeks 6-8
• Cast immobilisation typically removed between weeks 6 & 8
• Begin wrist PROM movements, in pain free range

Weeks 8-10
• Wrist PROM movements, increasing range
• Start mild resistance exercises of the wrist (i.e. water resistance)
• Once minimal pain with wrist resistance, begin grip strength exercises (i.e. squeezing ball)
• Begin to return to ADL's