Rehabilitation following Fractures of the Distal Radius

Rehabilitation
following
Fractures of the Distal Radius
APTA Combined Sections Meeting 2015
Topics for Discussion
 Course of Therapy – Volar Plate
 Case Example
 Effective Treatment
Approaches
 Outcomes
Nancy M. Cannon, OTR, CHT
Hand to Shoulder Therapy Center
Indianapolis, Indiana
Initial 5-7 Days Postop
 Bulky Compressive Dressing
 Excellent edema control
 Less edema…less pain!
Therapy Initiated 5-7 Days Postop
 Customized Based On:
 Prescribed Orders - Surgeon
 Initial Evaluation - Therapist
 Optimal Time to Begin Therapy
 Clinical experience
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
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Course of Therapy… Case Example
 60 y/o Retired Electrician
 Fell Roller Skating
 Comminuted, Intra-articular Distal Radius
Fluoroscan Images – Internal Fixation
 ORIF - Volar Plate
 Joint space well-preserved post reduction & plating
Fracture (dominant hand, right wrist)
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
4” Kerlix
2” Gauze
2” Coban™
 Continue 10 –14 Days
(until suture removal)
 Significantly reduces the edema
Exercises
 Active ROM – Shoulder
Exercises
 Active ROM – Forearm
 Supination/pronation
 Become symptomatic  3-4 weeks postop
 Pain and slight decrease in motion
 Slow, deliberate motion, long stretches
 Hold end-range 10-15 seconds
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Exercises
 Active ROM – Wrist
Exercises
 Active & Passive ROM – Fingers
 Flexion/extension
 Radial/ulnar deviation
 Fist with Flexion & Extension
 Isolate wrist flexors/extensors
 Avoids tendency – activate EDC → extend wrist
Exercises
 Blocking – PIP & DIP Joints
Exercises
 Active & Passive ROM – Thumb
 Emphasis on the index & long fingers
 Tendon excursion – FDS & FDP
Exercises
 Blocking for the FPL
Orthotics
 Wrist Immobilization Orthosis
 Bivalve –“Clamshell”
 Provides excellent external support
 Extremely helpful in reducing the edema
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10-14 Days Postop
Persistent Generalized Pain
 Pain Management Reassessed
 Sutures or Staples Removed
 Scar Mobilization
 Edema Control Continued
 Active-Assist (Self-Passive) ROM Exercises
 Pain Reassessed – Physician Team
 Pain medication
 Anti-inflammatory
 Non-steroidal
 Steroid
Persistent pain & edema
Medrol Dose Pack
 Wrist & forearm
 Out of Orthosis for Light Activities
 Meals, dressing, reading books, etc.
 Begin emphasizing functional tasks
Localized Wrist Pain
 Ulnar › Radial
 Supination › Pronation
 Ulnar Side
Ulnar Sided Wrist Pain
 Most Common Sites: DRUJ and/or TFCC
 DRUJ
 TFCC
 Early Intervention – Therapy
 Less pain…better progress with restoring motion
 Avoid long term, chronic pain
 Therapy Treatment Approaches
 Orthotics & exercise
Orthotic Intervention
 Orthotic Material
 Distal Wrist Strap
 Low temperature thermoplastic – brand: Taylor
 Manufacturer
 TETRA
Wrist Squeeze
Customize – Wrist Strap
Wrist Widget
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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
Edema Control
 Edema Glove
 Elastic Stockinettes
 Scar Pads
 Silicone Gel Sheeting
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
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Exercises
 Self Passive – Wrist
Exercises
 Self Passive – Forearm
 Flexion/extension
 Ulnar/radial deviation
 Secure the Forearm
Proximal to the Wrist…
Do NOT “Twist” the Hand
3 - 4 Weeks Postop
 Out of Wrist Orthosis
 Light activities (under 5 lbs.)
 Weighted Stretches
NO!
Weighted Stretches - Wrist
 Hold a Weight
 Suspend a Weight
over the Hand
 Wrist/forearm
 Dynamic or Static Progressive Orthoses
 Wrist/forearm
 Dependent on fracture stability/healing
 Consult with surgeon – ensure safe to initiate
Weighted Stretches – Wrist
 Weighted Hand Gloves
 Practice gloves - boxers
Weighted Stretches - Forearm
 “Hammer Stretches”
 Cuff Weights
 Avoid – wrist pain
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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
Orthotics - Wrist
 Custom – Dynamic Wrist
 Extension, flexion or both
 Prioritize flexion over extension [function]
 Personal hygiene
 Avoid, wrist pain present
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!
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6-8 Weeks Postop
 Strengthening




Elbow
Forearm
Wrist
Hand
Elbow Strengthening
 Hand-Held Weights
 Tubing
 Patient Priority → Function
 ROM over Strength
 Weeks 2-6
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
Superficial
Head
Deep Head
Forearm Strengthening
 Pronator Quadratus
 Isometrics and/or hand held weights
Hand Strengthening
 May Initiate within the 1st Month Postop
20% force  ulna
80% force  radius
 Avoid:
 In presence of wrist pain [axial loading]
 Flexor tenosynovitis [wrist/digital flexors]
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Outcomes
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
JBJS 2011
 Therapy NOT Superior to Surgeon Directed
Home Program
 94 patients
 ROM, strength, DASH scores
 3 and 6 months
 Patient Preference - Therapy-Guided Program
Outcomes
 JBJS, Oct. 2014
Expense – Therapy Visits
 Control the Cost of Therapy
JHT Oct/Dec 2009
 Begin therapy within 5-7 days
 Accelerated Group
 PROM 2wks vs 6wks; Strengthening 4wks vs 6
 Accelerated Group Better than Standard
 ROM, DASH - function, strength [initial 8 wks]
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):
 23 Patients
 Group I: Began therapy 1 week postop
 Averaged 6.57 visits
 Group II: Began therapy 6 weeks postop
 Averaged 17.0 visits
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 Advance exercise & orthotic regimen
 Consult with the surgeon
 Emphasize tendon gliding – FPL
 Resolve wrist pain early to facilitate restoration
of motion & avoid chronic pain
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