General Guideline Principles for Hip and Groin Disorders
for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Hip and Groin Disorders.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Scaphoid Fracture of Hand, Wrist and Forearm Injuries

Among the most frequent fractures of the carpal bones are scaphoid fractures, also referred to as wrist navicular fractures. While most are not occupational, some are unquestionably related to the workplace.

A fall onto an extended hand or from an axial force is the main reason for the scaphoid injury. In an auto accident, loading with a closed fist might involve holding the steering wheel.

Scaphoid fractures, especially those involving the proximal third of the navicular and especially if displaced, are prone to non-union and avascular necrosis. The fracture plane’s disruption of the limited blood supply, which contributes to healing issues in the proximal third, has been identified as the cause.

Confirming a fracture, determining which patients have fractures that respond best to surgery, and providing apropriate splinting to those who have a high clinical suspicion of fracture are the three main initial tasks. Patients frequently complain of scaphoid-area tenderness and persistent swelling near the base of the thumb.|

1. Diagnostic Studies of Scaphoid Fracture X-Rays

   Diagnostic Studies of Scaphoid Fracture X-Rays is recommended for diagnostic purposes, with at least three to four views, one of which is a “scaphoid view.”

    

2. X-Rays

   X-Rays – Follow-up in two weeks is recommended for the assessment of possible scaphoid fractures,) especially in patients who have a strong clinical suspicion of fracture despite having negative initial x-rays.

    

3. MRI

   MRI is recommended when clinical suspicion is high despite negative x-rays for the diagnosis of occult scaphoid fractures in a small subset of patients.Indications – X-rays are negative despite clinical suspicion of a scaphoid fracture.

   Rationale for Recommendation -The majority of scaphoid fractures do not require MRI, but it may be recommended for patients who have a clinical suspicion of a scaphoid fracture despite having negative x-ray results.

    

4. CT Imaging

   CT Imaging is recommended to identify hidden scaphoid fractures when MRI is not recommended and clinical suspicion of fracture persists despite negative x-ray results.

    

5. Bone Scan

   Bone Scan is recommended for a select group of patients to detect occult scaphoid fractures when clinical suspicion is high and x-ray results are negative.Indications – At least 48 hours after the accident, as long as the clinic is still suspecting a scaphoid fracture.

   Motives for the Recommendation

   For the majority of patients with scaphoid fractures, bone scans are not necessary for evaluation; however, in patients who have a clinical suspicion of scaphoid fracture but negative x-rays, bone scans may help in securing an earlier diagnosis, obviating prolonged splinting in those without a fracture. Therefore, bone scans are advised for these particular patients.

Medications of Hand, Wrist and Forearm Injuries

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even though the majority of research indicates it is only marginally less effective than NSAIDs.

There is proof that NSAIDs are less dangerous and just as effective at treating pain as opioids, such as tramadol.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Scaphoid Fractures Pain

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Scaphoid Fractures Pain is recommended for the treatment of pain from scaphoid fractures that is acute, subacute, or chronic.Indications – NSAIDs are advised as a treatment for the acute, subacute, or chronic pain associated with Scaphoid fractures.First, try over-the-counter (OTC) medications to see if they work.

   Frequency/Duration: Many patients might find it reasonable to use as needed. warning signs ofDiscontinuation: discontinuation is necessary due to symptom resolution, ineffectiveness, or the emergence of side effects.

    

2. NSAIDs for Patients at High Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High Risk of Gastrointestinal Bleeding is recommended for patients at high risk of gastrointestinal bleeding to take misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors concurrently.Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a longer course of treatment is planned.

   Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk. Frequency/Dose/Duration:H2 blockers, misoprostol, sucralfate, and proton pump inhibitors are advised. dosage recommendations from the manufacturer. It is generally accepted that there are no significant differences in effectiveness for preventing gastrointestinal bleeding.

   Signals of Discontinuation Intolerance, the emergence of negative effects, or the stopping of NSAIDs.

    

3. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

   Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.

    

4. NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

    

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended as far as adverse cardiovascular effects go, acetaminophen or aspirin as first-line therapy seem to be the safest options.

      

   • NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

     NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended If necessary, non-selective NSAIDs are preferred to COX-2-specific medications.

     To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in patients receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.

      

5. Acetaminophen for Treatment of Scaphoid Fractures Pain

   Acetaminophen for Treatment of Scaphoid Fractures Pain is recommended for the treatment of scaphoid fracture pain, especially in patients who have NSAID contraindications.Indications: Patients with acute, subacute, chronic, and post-operative scaphoid fracture pain.

   Dose/Frequency: As per the manufacturer’s recommendations; can be used as required.Over four gm/day, there is evidence of hepatic toxicity.Indications for Discontinuation: pain, side effects, or intolerance are gone.

Opioids of Scaphoid Fracture

Opioids are Limited Use of Opioids for Acute and Post-operative Pain Management

Opioids are Limited Use of Opioids for Acute and Post-operative Pain Management is recommended for brief (less than seven-day) use as an adjunctive therapy to more powerful treatments for the management of acute and post-operative pain.

Indications: In addition to more effective treatments (especially NSAIDs, acetaminophen, elevation, and splinting), a brief opioid prescription is frequently needed for acute injury and post-operative pain management, especially at night.

Frequency/Duration: As needed during the day, only at night later, and finally completely discontinued.

Rationale for Recommendation: When NSAIDs are ineffective in relieving a patient’s pain, opioids should be used sparingly, especially at night. Opioids are advised for brief, selective use in postoperative patients, with nighttime use being the main recommendation for achieving postoperative sleep.

Treatments of Scaphoid Fracture

1. Wrist Splinting

   Wrist Splinting is recommended for the treatment of fractures of the scaphoid tubercle. Reasons forRecommendation – Splinting may be sufficient because these fractures heal quickly because of the good blood flow.

    

2. Cast Immobilization

   Cast Immobilization is recommended to treat scaphoid fractures that are stable and not displaced.Frequency/Duration – Casting should be applied for 6 to 8 weeks, followed by cast removal, clinical reevaluation, and a repeat x-ray to see if more casting is necessary.

    

3. Thumb Immobilization with Spica Casting

   Thumb Immobilization with Spica Casting is recommended In order to treat scaphoid fractures, the thumb and wrist are both immobilised simultaneously.Frequency/Duration – Casting should be done for 6 to 8 weeks, after which the patient should be evaluated clinically and have a new x-ray to see if more casting is necessary.

    

4. Spica Splints

   Spica Splints is recommended for patients whose x-rays are negative but who may have a scaphoid fracture.Duration: 2 weeks, with a follow-up clinical examination and follow-up x-ray. If the x-ray is negative, you might want to stop wearing the splint.

Rehabilitation of Scaphoid Fracture

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put forth an internal effort to finish a particular exercise or task. The interventions known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their part.

Passive interventions are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active interventions should be prioritised.

To maintain improvement levels, the patient should be advised to continue both active and passive therapies at home as an extension of the therapeutic process.

To facilitate functional gains, assistive devices may be used as an adjunctive measure in the rehabilitation plan.

Therapy: Active of Scaphoid Fracture

Therapeutic Exercise – for Post-operative Scaphoid Fractures

Therapeutic Exercise – for Post-operative Scaphoid Fractures is recommended for the treatment of post-operative scaphoid fractures

Frequency/Dose/Duration – With documentation of ongoing objective functional improvement, the total number of visits may be as low as two to three for patients with mild functional deficits or as high as 12 to 15 for those with more severe deficits.

If there is evidence of functional improvement toward specific objective functional goals, more than 12 to 15 visits may be necessary when there are persistent functional deficits (e.g., increased grip strength, key pinch strength, range of motion, advancing ability to perform work activities).

Part of A home exercise programme should be created as part of the rehabilitation plan and carried out alongside the therapy.

Surgery of Scaphoid Fracture

Surgical Fixation

Surgical Fixation is recommended in the case of displaced scaphoid fractures

Rationale for Recommendation It is thought that displaced fractures need surgical fixation for treatment.

Due to the increased risk of these fractures developing a nonunion, malunion, or degenerative joint disease, high-risk scaphoid fractures should be promptly referred to hand or orthopaedic surgical specialists for effective treatment.

Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures

1. Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures

   Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures are recommended for some patients who need a faster return to function.

    

2. Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures

   Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures is not Recommended cast immobilisation is typically the best course of treatment for non-displaced fractures.

   Rationale for Recommendation –Patients with non-displaced or minimally displaced scaphoid fractures who cannot or do not want to try non-operative treatment may benefit from surgical intervention.Athletes are included. Patients who are unable to work until the fracture heals may also be included.

   The orthopedist and patient must decide whether to operate on a non-displaced scaphoid fracture, and it is advised that they weigh the advantages of an earlier functional recovery against the long-term risks of osteoarthrosis.

    

3. Hardware Removal Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fracture

   Hardware Removal Surgical Intervention of Non-Displaced or Minimally Displaced Scaphoid Fractures are recommended Hardware removal is advised after it has been implanted in some cases, depending on the doctor’s and the patient’s preferences

   Indications: in situations where there is 1) protruding hardware, 2) pain related to the hardware, 3) broken hardware on imaging, and/or 4) positive anaesthetic injection response, as per the doctor’s or patient’s preference.

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