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Therapy techniques and activities are based on principles of fracture healing and fixation.
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Validated self-report outcome questionnaires capture dimensions of the patient that are not always obvious by more traditional physical measures such as range of motion (ROM) with a goniometer.
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Pain can be a major obstacle to the return of motion and function.
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The goal during the mobilization phase is to restore as much motion as possible, but at least functional wrist range of motion.
Management of distal radius fractures (DRFs) has evolved considerably over the past decade, mostly due to stable fixation techniques that permit early motion of the wrist (e.g., during the first 2 to 4 weeks after fracture reduction). Therapy goals after wrist fracture are to control edema and pain, restore (realistic) ROM, and promote the use of the involved extremity for grip, torque, and weight-bearing activities. This chapter discusses the therapy strategies to optimize motion and function after DRF.
Surgeon’s Management of DRFs
There are a vast number of classification systems for surgeons to use to describe the nature of DRFs, and these are generally based on fracture fragment patterns. Using these classifications should theoretically serve as a foundation for the surgeon’s intervention. Some knowledge of the most popular fracture classification paradigms can be helpful when communicating with surgeons. Fracture management by the surgeon may be done with the intent to reduce and stabilize fracture fragments and include the following: orthosis or plaster cast for minimally displaced fractures, bridging external fixation devices with or without pinning and arthroscopically assisted reduction for intra-articular fracture fragments, indirect reduction and percutaneous fixation and open reduction and internal fixation with volar fixed-angle plates with or without locking mechanisms, and a low-profile dorsal plate (fragment-specific fixation or intermedullary nailing). The preceding chapter and this chapter should be used together to understand a comprehensive approach to the treatment of a patient with a DRF.
Progression of activity related to specific fracture management techniques is detailed later in this chapter.
Examination of the Patient With a DRF
The principles for examining the patient and selecting outcome questionnaires for patients with hand and wrist disorders are well covered in Chapter 16 . Results of an examination assist the hand therapist in establishing goals for rehabilitation and determining prognosis for functional recovery. Patient values and expectations should be considered when developing goals and therapy strategies. Patients with minimal complications who are self-directed and motivated and have an understanding of body functioning may be best served with one or two supervised therapy sessions with instruction in a home exercise program. Those with less body awareness, more severe injury, and complications usually require a supervised therapy program. During evaluation and treatment planning, these factors should be kept in mind.
Patient Factors Including Medical History
The therapist should collect information from the patient regarding work and daily demands including avocations, particularly those activities involving weight-bearing such as pushing up from the floor or pushing heavy loads and torque-related activities or working with heavy equipment. Patients who had a high-impact injury such as a fall while snowboarding or riding a motorcycle may have a significant number of related soft-tissue injuries such as scapholunate ligament or triangular fibrocartilage complex tears. Co-morbidities such as diabetes mellitus, low hemoglobin, systemic lupus erythematosus, and immunosuppressive disorders should be documented because these conditions can delay healing or reduce expectations for the final outcome. Medication use should be documented and any side effects noted (e.g., blood thinners can result in excessive bruising) ( Fig. 70-1 ).
Patient-Rated Self-Report Measures/Questionnaires
When assessing the patient who has had a DRF, outcomes measures should be selected that are representative of the limitations and disabilities associated with consequences of this injury. Pain scales such as the visual analogue scale, which reflects pain during rest and activity, should be administered. Pain can be a major obstacle to the return of motion and function.
Region-specific outcomes questionnaires such as the Patient-Rated Wrist Evaluation (PRWE) have a certain percentage of questions that directly assess pain. The PRWE has 5 questions related to pain and 10 questions related to function (usual and specific activities). The pain questions address pain at rest, during activity requiring repeated wrist motion, and when lifting a heavy object and ask when the pain is worst. The frequency of pain is also rated on the same 0 to 10 Likert scale. The specific activities include such items as turning a doorknob and pushing up from a chair using the involved wrist and hand. The usual activities include personal care, household chores, work, and recreational activities. Pain and function are weighted at 50% each, and the scale is graded from 0 (not disabled) to 100 (most disabled). ,
Validated questionnaires such as the PRWE, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the Michigan Hand Outcomes Questionnaire can capture dimensions of the patient that are not always obvious by more traditional physical measures such as ROM with a goniometer. These measures are responsive to changes in the patient during early (within the first few months) and late (at 1 year after injury) recovery. The greatest changes in DASH and PRWE scores occur during the 3- to 6-month period after fracture but will continue to improve over the first year. These region-specific questionnaires can be more responsive and specific in measuring recovery after DRF than a global measure such as the SF-36 Health Survey. Knowledge of these time frames can assist the therapist in educating the patient about expected milestones for recovery of function and often alleviate some of the patient’s concerns about recovery.
ROM
Passive and active motion measures are indicators of impairment after wrist fracture. It is important to discern which structures are involved in limiting motion. Differential motion loss (e.g., active versus passive) is addressed in this chapter in the “Mobilization/Motion Phase” section. Particular attention should be paid to wrist extension, supination, and pronation—motions that may be most difficult to restore after DRF. Restoration of those motions has been correlated with higher function as measured by DASH scores. Therapy strategies should focus on restoration of functional wrist and forearm motion. Hand function, as measured by the Jebson Taylor Hand Function Test, has been shown in normal persons to be reduced when elbow, forearm, wrist, and finger motions are limited. We may be able to extrapolate these results to patients after wrist fracture. Digital motion can be markedly limited after high-impact injuries, after falls in the elderly, and in patients who have osteoarthritis ( Fig. 70-2 ). Therefore, careful monitoring of finger and thumb motion is important.
Loading Across the Wrist: Grip, Pinch, and Push-off
Reduction in the ability to grip and twist and to bear weight on the palm, needed when pushing open a door or pushing up from a chair, are common functional complaints in persons recovering from wrist fractures. Grip and pinch strength can be tested when fracture healing has progressed to the point where weight-bearing activities are permitted on the hand. Testing can usually begin 6 to 8 weeks after fracture, if the fracture is healed. It is prudent to check with the surgeon regarding the status of fracture healing.
The push-off test is used to quantify the ability to bear weight through the palm ( Fig. 70-3 ). This has been tested and found to be reliable in normal subjects and also in a patient population after wrist and elbow fractures. The uninjured side can be used for comparison because weight-bearing ability is not dependent on hand dominance.
Radiographic Outcome
There is some evidence that the amount of wrist and forearm motion as well as functional outcomes gained after fracture is related to the success of anatomic reduction. In the patient who may have less demand during activities of daily living, failure to restore anatomy may not be as critical to the final outcome. Therefore, each patient’s outcome must be assessed individually and goals established with the patient’s input, particularly in younger adults. It is not clear whether this is as important in an elderly population. ,
Measuring Outcome of Intervention After Wrist Fracture
To compare therapy interventions, each clinic should consider a standardized battery of measures (e.g., a core outcome dataset). These measures should be selected from those that reflect the problems of patients with the injury, are reliable (e.g., can be reproduced with minimum amount of error), and are responsive to change (e.g., will change in response to change in patient status). A suggested testing paradigm is presented in Box 70-1 . Some measures may be better to use during certain time periods after injury. For example, volumetric or girth measures can be useful to monitor edema during the early motion phase, but are less useful later in recovery when edema has stabilized or resolved. Before it is safe to test grip strength, patient-reported outcomes such as those included on the PRWE or DASH may give information that highlights areas of concern that should be included in goal setting and addressed during therapy.
Early Testing After DRF
Pain using VAS or PRWE
Function with self-report outcomes questionnaires (PRWE or DASH)
Light touch with monofilaments to screen for nerve compression (median, ulnar, dorsal radial nerve)
Figure-of-eight measurement or volume displacement (if no external fixation device or cast)
ROM (if wrist is still immobilized measure adjacent joints)
Later Testing After DRF (From 6 to 8 Weeks Onward)
ROM
Grip strength
Pinch strength
Push-off test
Function with outcomes questionnaires (PRWE or DASH)
DASH, Disability Arm, Shoulder, and Hand questionnaire; DRF, distal radius fracture; PRWE, Patient-Related Wrist Evaluation; ROM, range of motion.
Most recovery can be expected to occur within the first 6 months after fracture, although supervised therapy is often provided only during the early period after immobilization (e.g., 4 to 6 weeks). When assessing long-term outcomes in patients who have had surgical treatment for DRF, it is important to be aware of factors that have been shown to have adverse affects on recovery such as increased age and lower income. The injured worker should be assessed based on physical work demands. Those who have jobs that involve heavy lifting, pushing, and pulling may be expected to have a longer time out of work. Overall outcomes can be expected to be better in patients who have higher DASH scores or patient perceived outcomes, greater grip strength, and better radiographic evidence of restoration of anatomy.
Therapy Guidelines and Progression
DRFs are not all the same; therefore, why should therapy be all the same? Progression of activities is discussed in each phase of rehabilitation with guidelines, techniques, and precautions. These, of course, should be used as guidelines and modified for particular circumstances. Initiation of motion and progression to joint mobilization techniques, strengthening, and weight-bearing activities should be undertaken when fracture healing permits. This is a determination made by the surgeon during successive follow-up office visits and reexamination and communicated to the therapist with an updated therapy referral.
Realistic goal planning for improvements in wrist ROM and hand function requires assessment of any residual deformities. The DRF may be a well-healed, essentially nondisplaced extra-articular fracture, but it may also be a dorsally displaced DRF with a combination of displacement, radial shortening, dorsal angulation, and even intra-articular involvement. Implications for ultimate outcome and use of therapy techniques may be different in both examples. In the latter, it may be less likely to restore as much ROM.
Therapy techniques and activities are based on principles of fracture healing and fixation. We must consider progression on an individual basis, and this can be influenced by a number of factors. These can include some of the following:
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Success of reduction of fracture and restoration of anatomy. There is some evidence that the amount of wrist and forearm motion and the functional outcomes gained after fracture are related to the success of anatomic reduction in younger adults. It is not clear whether this is as important in an elderly population. ,
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The time frame for healing (e.g., when can wrist motion begin and when can resisted and weight-bearing exercises begin)?
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Complications such as nerve compression, tendon rupture, stiffness, and pain can reduce function and can lower final outcome. Some complications that occur after DRF can be addressed through a therapy program (e.g., stiffness) and some may not (e.g., fracture malunion or delayed union), resulting in debilitating pain and decreased strength. More details about complications are addressed later in this chapter.
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Pain can be a major obstacle to return of motion and function. The source of pain, whether it be physiologic or psychosocial, should be addressed by the appropriate practitioner. If there is evidence of complex regional pain syndrome (CRPS), then pharmacologic intervention managed by a physician pain specialist may be used in conjunction with therapy modalities such as heat, cold, and electrical stimulation.
Phases of Rehabilitation
Activities during healing can be divided into the following phases: early protective phase (or during immobilization or protected motion), motion or mobilization, and function and strengthening. These are summarized in Table 70-1 . Educating the patient regarding the healing process should be done in a way that will be meaningful to that person’s status and daily life requirements. Patient compliance and its importance in the rehabilitation partnership need to be emphasized. The roles of joint mobilization and orthotic wear to increase ROM are included in the discussion.
| Early Protective Phase | Motion/Mobilization Phase | Function/Strength Phase | |
|---|---|---|---|
| Time frame | 1–6 weeks depending on fracture fragment stability | Starts immediately after immobilization | Begun with proven healing/bone fixation |
| Goals and priorities | Protect fracture, control swelling and pain, avoid pin-site infections | AROM and PROM of digits, elbow, shoulder; AROM of wrist; forearm rotation | Increase ROM to WFLs; increase strength to WFLs for activities of daily living |
| Techniques | Cast, orthosis, surgical fixation/stabilization; edema control (elevation including overhead fisting, retrograde massage, compression wraps); regular pin-site cleaning (for percutanous pinning); tendon-gliding exercises, particularly after ORIF | AROM of shoulder, elbow, forearm, wrist, digits; AROM/gentle PROM of forearm, wrist, digits; dynamic orthoses | Isometric progressing to isotonic exercises; resisted exercises with putty or grippers |
| Comments and precautions | Digit ROM should be attained in this phase; signs of CRPS (significant edema and/or pain, redness) should be monitored and addressed; abnormal paresthesias should be recorded | Pain, swelling due to excessively vigorous ROM exercises; avoid excessive ROM if there are indicators of delayed healing or instability; wrist extension with digit flexion is a priority | Excessive overload, irritated tissues, increased pain after exercises, functional activities |
Early Protective Phase
Ideally a hand therapist can see a patient within the first week after wrist fracture management for home instruction for symptom management (e.g., pain, edema, finger stiffness) and education regarding functional limitations and abilities. Due to a number of circumstances, we often see a patient after the first follow-up visit at the surgeon’s office and that patient has fingers that are stiff and swollen and well on the way to residual loss of motion (see Fig. 70-2 ).
Early on after fracture, it can be common for the patient to hold the injured upper extremity in a protected position with the shoulder adducted and internally rotated and the elbow flexed. The use of a sling should be minimized because it does not properly elevate the extremity; it promotes shoulder and elbow stiffness and discourages functional use of the hand and arm. Slings may be used for short periods when protection is needed in crowded public situations.
Active motion of the digits, elbow, and shoulder (and wrist and forearm, if permitted) and “overhead fisting” should be encouraged to be performed several times daily. A stringent effort of elevating the hand and wrist above heart level may be successful in controlling pain and edema. If necessary, retrograde massage and compression wraps may be used for edema control. Cold packs or wraps may also be used after exercise if swelling has increased. But if swelling increases after each exercise session, then perhaps the vigor of the exercises should be reduced to alleviate undue stress on already inflamed tissues.
It is important to acknowledge that the pain is real for the patient. Most patients have never experienced a DRF. In addition to being frightened and in pain, the sudden interference with loss of independence increases the patient’s anxiety level. Along with reassurances that the pain will get better, it is important to reinforce strategies that will decrease the pain, such as elevation, massage, heat or cold modalities, and active exercises. In most patients, pain will fade as stable fracture fixation is achieved. However, treatment of pain is given priority if it seems to be a greater problem than the stiffness. It is difficult to use treatment techniques to address the stiffness and dysfunction if the pain cannot be controlled. Attempts should be made to determine whether the pain stems from possible median nerve compression, is sympathetically mediated, or is related to joint tightness or an ill-fitting immobilization cast or orthosis.
If a program of early wrist motion (e.g., within 2 to 4 weeks) is instituted, an orthosis that fits and allows full digit mobility should be worn between exercise sessions. If a well-fitted prefabricated orthosis cannot be supplied, then the therapist has the option of a custom-molded thermoplastic orthosis ( Figs. 70-4 and 70-5 ). The orthosis may require the therapist to monitor and modify on a regular basis (e.g., weekly) to accommodate changes in edema and motion.
How do you know early on if things are not going so well for the patient? Early predictors of difficulty in recovery can include the following: metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint pain and swelling, tingling in digits, and rapid change in swelling with position change. We have observed that patients who have osteoarthritis may notice their first difficulty with finger stiffness after a fall on an outstretched hand. The common comment that we hear from patients is “Well, I did not have arthritis before my injury.” In some patients, palmar nodules and bands may develop with a subsequent decrease in palmar mobility. This may be indicative of Dupuytren’s contracture.
An early sign of trouble observed by the authors is the patient who has red and painful PIP joints and fluctuating hand edema. We have observed that CRPS develops in some of these patients. Pin insertion on the radial side of the wrist may irritate the superficial branch of the radial nerve and result in hyperesthesia or causalgia.
Mobilization/Motion Phase
The goal during this phase is to restore as much motion as possible, but at least functional wrist ROM, defined as 40 degrees of flexion and 40 degrees of extension of the wrist and a total of 40 degrees of radial and ulnar deviation. Supination and wrist extension can be challenging to restore after DRF. However, regaining finger flexion can be equally if not more challenging, particularly in the person who has osteoarthritis.
Most motion gains will be made during the first 3 months after fracture. There can be motion gains up to 1 year, but the rate and magnitude of these changes lessen and patients would rarely need to be in supervised therapy for such an extended period of time.
Techniques to Restore Motion
A summary table ( Table 70-2 ) is provided to assist in decision making related to restoring motion after DRF. When determining and prioritizing therapy strategies for improving motion, the techniques selected should to be matched with the tissues restricting motion. For example, if passive and active motion values are equally limited, then this more likely can implicate a joint as a source for the loss of motion. The motion can be lost due to obliteration of the joint space or an adaptively shortened joint capsule. The former cannot be improved by therapy, but the latter can. Selective tissue-tensioning maneuvers must be done to differentiate loss of motion. If passive PIP joint flexion is restricted, it can be caused by stiffness from osteoarthritis (which may be exacerbated after trauma), joint contracture, or reduction of extensor tendon excursion (i.e., lengthening). Scar or pin sites on the dorsum of the hand can limit extensor tendon gliding and lead to intrinsic muscle tightness. Selective tissue tensioning is discussed in more detail in Chapters 6 and 67 .
| Testing | Characteristic Findings | Suggested Intervention to Increase Motion | |
|---|---|---|---|
| Joints | Passive ROM (and compare with uninjured side) | Active and passive motion may be equal | Joint mobilization grades 3 and 4 glides; traction grade 3 (if there was an intra-articular fracture, check imaging studies for joint space) |
| Tendons | Compare passive with active ROM | With loss of tendon gliding, active motion will be less than passive motion in the direction of the motion measured; flexor tendon adherence can limit passive extension | Active motion of agonist; NMES of agonist muscle; resisted exercise of agonist |
| Intrinsic muscles | Bunnell–Littler test | More PIP joint flexion with MCP joints flexed, then with MCP joints extended | Intrinsic muscle stretching (MCP joints extended and PIP joints flexed) |
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