1

Rehabilitation

following

Fractures of the Distal Radius

APTA Combined Sections Meeting 2015

Nancy M. Cannon, OTR, CHT

Hand to Shoulder Therapy Center

Indianapolis, Indiana

Topics for Discussion

Course of Therapy Volar Plate

Case Example

Effective Treatment

Approaches

Outcomes

Initial 5-7 Days Postop

Bulky Compressive Dressing

Excellent edema control

Less edemaless pain!

Optimal Time to Begin Therapy

Clinical experience

Therapy Initiated 5-7 Days Postop

Customized Based On:

Prescribed Orders - Surgeon

Initial Evaluation - Therapist

Ideal Review the Operative Note

Identify Concerns or Complications

Reduction or internal fixation

Bone grafting

Other bony/soft tissue structures injured/repaired

Ideal Review the X-Ray Fracture

Intra-articular vs. extra-articular

Fracture pattern & # fracture fragments

Fracture Fixation

Joint Space

2

Course of Therapy Case Example

60 y/o Retired Electrician

Fell Roller Skating

Comminuted, Intra-articular Distal Radius

Fracture (dominant hand, right wrist)

Fluoroscan Images Internal Fixation

ORIF - Volar Plate

Joint space well-preserved post reduction & plating

Therapy Initiated 5 Days Postop

Bulky Dressing Removed

Initial Evaluation

Wound Care & Edema Control Initiated

Exercise Instruction

Immobilization Wrist & Hand Orthosis

Edema Control

Light Compressive Dressing

Continue 10 14 Days (until suture removal)

Significantly reduces the edema

4 Kerlix

2 Gauze

2 Coban

Exercises

Active ROM Shoulder

Become symptomatic 3-4 weeks postop

Pain and slight decrease in motion

Exercises

Active ROM Forearm

Supination/pronation

Slow, deliberate motion, long stretches

Hold end-range 10-15 seconds

3

Exercises

Active ROM Wrist

Flexion/extension

Radial/ulnar deviation

Fist with Flexion & Extension

Isolate wrist flexors/extensors

Avoids tendency activate EDC extend wrist

Exercises

Active & Passive ROM Fingers

Exercises

Blocking PIP & DIP Joints

Emphasis on the index & long fingers

Tendon excursion FDS & FDP

Exercises

Active & Passive ROM Thumb

Exercises

Blocking for the FPL

Orthotics

Wrist Immobilization Orthosis

Bivalve Clamshell

Provides excellent external support

Extremely helpful in reducing the edema

4

10-14 Days Postop

Pain Management Reassessed

Sutures or Staples Removed

Scar Mobilization

Edema Control Continued

Active-Assist (Self-Passive) ROM Exercises

Wrist & forearm

Out of Orthosis for Light Activities

Meals, dressing, reading books, etc.

Begin emphasizing functional tasks

Persistent Generalized Pain

Pain Reassessed Physician Team

Pain medication

Anti-inflammatory

Non-steroidal

Steroid Persistent pain & edema

Medrol Dose Pack

Localized Wrist Pain

Ulnar Radial

Supination Pronation

Ulnar Side

DRUJ

TFCC

Early Intervention Therapy

Less painbetter progress with restoring motion

Avoid long term, chronic pain

Ulnar Sided Wrist Pain

Most Common Sites: DRUJ and/or TFCC

Therapy Treatment Approaches

Orthotics & exercise

Orthotic Intervention

Distal Wrist Strap

Manufacturer

TETRA

Wrist Squeeze Wrist Widget

Customize Wrist Strap

Orthotic Material

Low temperature thermoplastic brand: Taylor

5

Elastic Wrist Strap

Provides Circumferential Support

Reassuring to the patient (protecting the fracture)

Provides a pain dampening effect

Supports the DRUJ

Ligaments & TFCC

Preserves the relationship of radius & ulna distally

Enhances DRUJ stability

Predictably Effective

Utilize on 75% of all wrist fracture patients

90% find the wrist strap helpful

Avoid Chronic Wrist Pain

Residual Wrist Pain after Volar Locking Plate

Fixation of Distal Radius Fractures

Kurimoto, et.al. Acta Orthopaedica Belgica

Oct. 2012

122 Patients; 57 Patients (47%) Wrist Pain

36.9% Radial Side; 20.5% Ulnar Side

Risk Factors predispose the pt. to pain:

Female & intra-articular DR fx = radial side

Bone grafting = ulnar side

Scar Mobilization

Massage with Lotion

Length of incision initially

Scar Pads

Silicone Gel Sheeting

Edema Control

Edema Glove

Elastic Stockinettes

Exercise Common Problem

Limited Tendon Gliding of the FPL

Blocking exercises IPJ Thumb

Limited Tendon Gliding - FPL

Ultrasound 3.3MHZ, 100% cont., intensity varies 1.0 W/cm2, 8 min.

NMES

6

Exercises

Self Passive Wrist

Flexion/extension

Ulnar/radial deviation

Exercises

Self Passive Forearm

Secure the Forearm

Proximal to the Wrist

Do NOT Twist the Hand NO!

3 - 4 Weeks Postop

Out of Wrist Orthosis

Light activities (under 5 lbs.)

Weighted Stretches

Wrist/forearm

Dynamic or Static Progressive Orthoses

Wrist/forearm

Dependent on fracture stability/healing

Consult with surgeon ensure safe to initiate

Weighted Stretches - Wrist

Hold a Weight

Suspend a Weight

over the Hand

Weighted Stretches Wrist

Weighted Hand Gloves

Practice gloves - boxers

Cuff Weights

Weighted Stretches - Forearm

Hammer Stretches

Avoid wrist pain

7

Hammer Stretches

Applies a torsional load

or torque on the wrist

Pronation: strains the DRUJ dorsal capsule

& ligaments

Supination: strains the DRUJ volar capsule

& ligaments

Avoid, wrist pain present

Orthotics - Wrist

Custom Dynamic Wrist

Extension, flexion or both

Prioritize flexion over extension [function]

Personal hygiene

Orthotics - Wrist

Custom Static Progressive

Orthotics - Forearm

Custom Dynamic Supination or Pronation

Prefer the Joint Active System

Joint Active System

Custom-Fabricate - Forearm/Wrist Component

Biomechanical Perspective

Creates an Effective Forearm Rotation

Patients Markedly more Comfortable!

8

6-8 Weeks Postop

Strengthening

Elbow

Forearm

Wrist

Hand

Patient Priority Function

ROM over Strength

Weeks 2-6

Elbow Strengthening

Hand-Held Weights

Tubing

Forearm Strengthening

Prefer Hand-Held Weights vs. Tubing

Less torque on wrist

Forearm Strengthening

Ulnar-Sided Wrist Pain

Strengthen pronator quadratus

Dynamic stabilizer of the distal radioulnar joint

Deep Head

Superficial

Head

Forearm Strengthening

Pronator Quadratus

Isometrics and/or hand held weights

Hand Strengthening

May Initiate within the 1st Month Postop

Avoid:

In presence of wrist pain [axial loading]

Flexor tenosynovitis [wrist/digital flexors]

20% force ulna

80% force radius

9

10-12 Weeks Postop

Gradual Return to Normal Activities

Advise Patient to Limit:

Compressive loading to wrist

Torque (twisting) to wrist

against resistance

High impact sports

4 Months

Outcomes

Therapy NOT Superior to Surgeon Directed

Home Program

94 patients

ROM, strength, DASH scores

3 and 6 months

Patient Preference - Therapy-Guided Program

JBJS 2011

Outcomes

JBJS, Oct. 2014

Accelerated Group

PROM 2wks vs 6wks; Strengthening 4wks vs 6

Accelerated Group Better than Standard

ROM, DASH - function, strength [initial 8 wks]

Expense Therapy Visits

Control the Cost of Therapy

Begin therapy within 5-7 days

23 Patients

Group I: Began therapy 1 week postop

Averaged 6.57 visits

Group II: Began therapy 6 weeks postop

Averaged 17.0 visits

JHT Oct/Dec 2009

Summary

Prioritize pain & edema management the initial 3 weeks postop

Prioritize therapy visits 3rd to the 6th week

Measure each visit! When negligible ROM gains identified (particularly weeks 2-3):

Advance exercise & orthotic regimen

Consult with the surgeon

Emphasize tendon gliding FPL

Resolve wrist pain early to facilitate restoration of motion & avoid chronic pain

Enjoy Indianapolis!

# 1 Best Convention City

USA Today Readers Choice Poll 2014