Management of distal radius fractures

Is Therapy Needed After Distal Radius Fracture Treatment, What Is the Evidence?

The role of hand therapy in management of distal radius fractures remains unclear. Some evidence demonstrates that initiating early range of motion and urging patients to return to routine activities of daily living as soon as possible may produce favorable outcomes that are as effective as formal supervised therapy. Extended supervised therapy does not appear to impact outcomes and a single instruction session with a home-based program produces similar results. Although we feel that formal structured therapy may have a role in select high-risk patients, the literature remains unclear on which patients would benefit most from formal supervised therapy.

A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention

STUDY DESIGN

Descriptive cross-sectional design.

INTRODUCTION

Wrist and hand sensori-motor impairment have been observed after distal radius fracture (DRF) treatment. This impairment and its relationship to function lack research.

PURPOSE OF THE STUDY

The primary aim of this exploratory study was to determine the magnitude of wrist and hand sensori-motor impairment following surgical and non-surgical treatment among older patients following DRF. Secondary aims were to determine the relationship between wrist and hand sensori-motor impairment with function and pain as well as the relationships among wrist and hand sensori-motor impairment and function and age following DRF.

METHODS

Ten Test (TT), active joint position sense (JPS), electromyography (EMG), computerized hand-grip dynamometer (CHD), and the Patient-Rated Wrist Evaluation (PRWE) were used to assess twenty-four female participants 8 weeks following DRF treatment and their 24 matched-control healthy counterparts on wrist and hand sensibility, proprioception, muscle recruitment, grip force, muscle fatigue, and functional status.

RESULTS

Participants following DRF demonstrated significantly (p < .05) greater sensory (i.e., JPS, TT), and motor (i.e., EMG, CHD) deficits than their control counterparts. A significantly higher functional deficit (i.e., PRWE) also existed among participants following DRF than the control group. Participants following surgical and non-surgical DRF treatment were found to be statistically different only on total grip force. Group differences on JPS and total grip force revealed the strongest effect size with the highest correlations to PRWE. EMG and muscle fatigue ratio group differences revealed a weaker effect size with a fair degree of correlation to PRWE. Pain significantly correlated with sensori-motor function. Age did not correlate with any measured variable.

CONCLUSIONS

Significant wrist and hand sensori-motor impairment and functional deficits among older females 8 weeks following DRF surgical and non-surgical interventions were revealed. JPS and total grip force were the most clinically meaningful tests for assessing the sensori-motor status as well as explaining functional disability and pain levels for these patients.

LEVEL OF EVIDENCE

2c.

An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial

QUESTION

Does an advice and exercise program improve outcome for adults following distal radius fracture?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Fifty-six patients whose fracture had been managed with pins and/or cast.

INTERVENTION

The experimental group received a physiotherapist-directed program of advice and exercises. The control group did not receive any physiotherapy intervention.

OUTCOME MEASURES

The primary outcome was wrist extension (measured with a goniometer). Secondary outcomes were the other wrist ranges of motion (measured with a goniometer), grip strength (measured with a dynamometer), pain, and activity limitations (measured with questionnaires). These outcomes were measured initially, then three and six weeks later. Participants also rated their satisfaction with physiotherapy intervention at Week 6.

RESULTS

No difference was found between groups for the primary outcome of wrist extension (mean difference 6 deg, 95% CI -3 to 14), nor for the secondary outcomes of other range of motion data and grip strength. The difference between groups for pain was -16 points out of 100 (95% CI -27 to -5) at Week 3, and -14 points (95% CI -25 to -3) points at Week 6, and for activity was -13 points out of 100 (95% CI -24 to -2) at Week 3; in favour of the experimental group. The experimental group was also more satisfied with the amount of physiotherapy intervention.

CONCLUSION

An advice and exercise program provided some additional benefits over no intervention for adults following distal radius fracture.

Retrospective comparison of percutaneous fixation and volar internal fixation of distal radius fractures

A change in the practice of a single surgeon provided an opportunity for retrospective comparison of comparable cohorts treated with percutaneous fixation (17 patients) or a volar plate and screws (23 patients) an average of 30 months after surgery. The final evaluation was performed according to the Gartland and Werley and Mayo rating systems and the DASH questionnaire. There were no significant differences on the average scores for the percutaneous and volar plating groups, respectively: Gartland and Werley, 4 vs 5; Mayo, 82 vs 83; and DASH score 13 for both cohorts. Motion, grip, and radiographical parameters were likewise comparable. Volar internal plate and screw fixation can achieve results comparable to percutaneous fixation techniques in the treatment of fractures of the distal radius.

The Effectiveness of Origami on Overall Hand Function After Injury: A Pilot Controlled Trial

This pilot study measured the effectiveness of using origami to improve the overall hand function of outpatients attending an NHS hand injury unit. The initiative came from one of the authors who had used origami informally in the clinical setting and observed beneficial effects. These observed effects were tested experimentally. The design was a pilot non-randomised controlled trial with 13 participants. Allocation of the seven control group members was based on patient preference. The experimental group members attended a weekly hour of origami for six weeks, in addition to their conventional rehabilitation. Hand function of all participants was measured using the Jebsen-Taylor Hand Function Test before and after the six-week period, and additional qualitative data were gathered in the form of written evaluations from patients. The quantitative data were analysed using the Mann Whitney U test or Fisher's exact test. Themes were highlighted from the qualitative data.

The results show that there was a greater difference in the total score of the experimental group using the impaired hand between pre- and post-intervention of 11.8 seconds, compared with 4.3 seconds in the control group, but this was not statistically significant at the 5% level (p=0.06). Additionally, differences in the sub-test scores show a markedly larger improvement in the experimental group. Qualitative data indicate that the experimental group experienced the origami sessions as being enjoyable and beneficial. Further research with a larger sample and randomised group allocation is recommended to verify and expand these preliminary findings.

Hand therapy management of intra-articular fractures with open reduction and pi plate fixation: a therapist's perspective

Open reduction enhances the opportunity for patients to benefit from early rehabilitation following complex distal radius fractures. In the early phase of rehabilitation, therapists focus on motion, edema management, early identification of complications, and assist patients to understand and deal appropriately with their injury. Frequent and gentle exercise in elevation is key to restoring movement without adverse impacts on pain or edema. After six weeks, the focus of rehabilitation should be on ameliorating any residual physical impairments and moving patients towards normal activity. Strengthening, mobilization splinting, and reintegration into work activities may be required. Both physical impairment (volume, motion, strength, sensibility, dexterity) and self-report (pain and disability) measures may be required at different stages to provide a comprehensive view of recovery.

The International Classification of Functioning as an explanatory model of health after distal radius fracture: a cohort study

Background

Distal radius fractures are common injuries that have an increasing impact on health across the lifespan. The purpose of this study was to identify health impacts in body structure/function, activity, and participation at baseline and follow-up, to determine whether they support the ICF model of health.

Methods

This is a prospective cohort study of 790 individuals who were assessed at 1 week, 3 months, and 1 year post injury. The Patient Rated Wrist Evaluation (PRWE), The Wrist Outcome Measure (WOM), and the Medical Outcome Survey Short-Form (SF-36) were used to measure impairment, activity, participation, and health. Multiple regression was used to develop explanatory models of health outcome.

Results

Regression analysis showed that the PRWE explained between 13% (one week) and 33% (three months) of the SF-36 Physical Component Summary Scores with pain, activities and participation subscales showing dominant effects at different stages of recovery. PRWE scores were less related to Mental Component Summary Scores, 10% (three months) and 8% (one year). Wrist impairment scores were less powerful predictors of health status than the PRWE.

Conclusion

The ICF is an informative model for examining distal radius fracture. Difficulty in the domains of activity and participation were able to explain a significant portion of physical health. Post-fracture rehabilitation and outcome assessments should extend beyond physical impairment to insure comprehensive treatment to individuals with distal radius fracture.

A randomised clinical trial of activity-focussed physiotherapy on patients with distal radius fractures

INTRODUCTION

Physiotherapy is considered by some authorities to be an important aspect of management in patients following distal radius fractures. There is evidence of improvement in impairment with physiotherapy; however, there is no evidence to support early return of functional activity. Traditional physiotherapy management has focussed on improving impairment; however, there are no trials with emphasis on skill acquisition via motor re-learning principles.

MATERIALS AND METHODS

Forty-one participants with conservatively managed distal radius fractures were studied in a randomised, single-blinded, prospective trial. Two treatment options were compared: exercise and advice versus activity-focussed physiotherapy with measurement periods of 6 weeks after removal of cast and follow-up at 24 weeks.

RESULTS

Participants allocated to the exercise and advice group consulted a physiotherapist an average of 0.9 (SD 0.4) times, while the participants allocated to the more intensive activity-focussed group consulted with physiotherapy a mean of 4.4 (SD 2.3) times. At both 6 and 24 weeks there were no significant differences between the groups for change in impairment (as measured by grip strength, range of motion of wrist flexion and extension and pain intensity), activity limitation and participation restriction, as measured by the Patient-Rated Wrist Evaluation (PRWE). Exercise and advice given by a physiotherapist were equally as effective as activity-focussed physiotherapy in recovery both at 6 and 24 weeks.

CONCLUSION

The results suggest that after removal of cast from fracture of distal radius, patients may routinely require no more than a single session of advice and exercise provided by a physiotherapist.

Early active rehabilitation for operatively stabilized distal radius fractures

From the young to the elderly, distal radius fractures are very common. Extensive literature has been written regarding surgical management of distal radius fractures, but the same degree of attention has not been given to the critical rehabilitation that follows. Successful functional outcomes for distal radius fractures are a result of appropriate surgical treatment as well as timely and specific rehabilitation. Surgical treatment strategies available for unstable distal radius fractures include percutaneous pinning, external fixation, dorsal plating, and volar fixed-angle plating. Arthroscopically assisted as well as other minimally invasive techniques are now gaining acceptance. The ideal surgical treatment would provide stable fixed-angle fragment-specific support with minimal soft tissue disturbance and allow safe, early active wrist rehabilitation. This article reviews the normal anatomy of the region, the pathoanatomy created by the different stabilization strategies, and specific therapy techniques, including static and static progressive splints, that correlate with each of the surgical procedures.

A supination splint worn distal to the elbow: a radiographic, electromyographic, and retrospective report

The purposes of this study were to 1) describe a dynamic supination splint that does not cross the humeroulnar and humeroradial joints, allowing flexion and extension of the elbow; 2) provide retrospective data on effectiveness of this splint in patients with limited supination; and 3) provide data from radiography and electromyography (EMG) that document this splint's ability to provide a passive supination force. Eleven subjects treated for various elbow and/or wrist fractures leading to losses of forearm supination significantly increased their passive range of motion (PROM) from 34.0 degrees at the initial visit to 82.3 degrees at discharge and active range of motion (AROM) from 27.0 degrees to 72.3 degrees. Radiographic images of the radius and ulna were identical in maximal voluntary supination and resting in the splint. Surface EMG was used to measure supinator muscle activity at rest, passively supinated while wearing the splint, and during a maximal isometric supination effort (without splint). Average supinator EMG activity was 7.9 mV at rest, 7.8 mV in the splint, and 68.0 mV with maximal isometric contraction. Results indicate the supination splint is clinically effective in increasing supination PROM. EMG data and radiographs indicate that the splint passively positions the forearm in supination even though the proximal margin of the splint does not cross the elbow.

Correlation of impairment and activity limitation after wrist fracture

BACKGROUND AND PURPOSE

During physiotherapy rehabilitation, judgements about activity limitation are often based on measurements of impairment. The present paper reports an investigation into the relationship between measurements of impairment and activity limitation in people with a fracture of the distal radius.

METHOD

Twenty people with a fracture of the distal radius were referred to physiotherapy after conservative management of their fractures. Measurements of impairment (grip strength and range of wrist extension) and activity limitation (Jebsen Test of Hand Function) were taken at the second physiotherapy appointment after cast removal. The scores between these measurements were correlated.

RESULTS

There were strong and significant correlations (-0.51 < rs < -0.76) between grip strength and the tasks of the Jebsen Test of Hand Function. The relationship between range of wrist extension and the Jebsen Test of Hand Function was weaker (-0.17 < rs < -0.55). However, subgroup analysis of those subjects with a Colles' type fracture of the distal radius demonstrated significant relationships between wrist extension and three of the seven activity tasks (-0.74 < rs < -0.84).

CONCLUSIONS

Preliminary evidence was found to support the physiotherapy practice of use of measurement of impairment to monitor progress in a person with a fracture of the distal radius.

Distal radius fractures: therapy practice patterns

Identifying practice patterns for therapy interventions following distal radius fractures (DRFs) is necessary to define the most frequently used examination and intervention techniques. The purpose of this study was to identify preferred practice patterns and physical and functional outcome measures used during DRF management. Two hundred forty-two therapists (PTs, OTs, and CHTs) were surveyed by questionnaire at an annual hand therapy meeting. A descriptive analysis of data was performed. Preferred practice patterns during the immobilization and the post-immobilization periods were identified. More than 75% of the surveyed therapists used upper extremity range-of-motion exercises and compressive wrap with retrograde massage during the immobilization phase. More than 90% of therapists included range-of-motion exercises and heat/cold modalities in the post-immobilization treatment plans. Physical impairment measures of outcome were used much more frequently than functional outcome questionnaires in assessing progress during treatment. This study advances the evidence-based practice of therapy by establishing a foundation for future research.

Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures

A study of acute, dorsally displaced, unstable (high-energy) fractures of the distal radius was conducted to determine the safety and efficacy of a new low-profile plate for unstable distal radius fractures. Thirteen surgeons in 11 US cities participated in the study. A minimum follow-up period of 1 year was required to be included in the study. Seventy-three fractures in 71 patients met this criterion. Each fracture was treated according to a prospective protocol. An autogenous bone graft was used in 64 fractures. All procedures were completed using a radiolucent sterile traction table. No external fixators were used either during or after the operation. After bone grafting and while in traction, a fracture reduction clamp with a template preshaped to the normal contour of the dorsal radial metaphysis molded the fracture into reduction and then allowed precision drilling of the holes for the plate. Active wrist motion began at an average of 14 days. Satisfactory open reduction was obtained in 93% of the fractures and maintained in 88%. Ninety-five percent of the fractures demonstrated good or excellent outcomes using a standardized evaluation. Eighty-one percent of the outcomes were rated as excellent. This initial report demonstrates that the method is a safe and effective treatment for acute, unstable, dorsally displaced fractures of the distal radius.

Fractures of the distal radius: what are the expectations of therapy? A two-year retrospective study

This retrospective study addressed two basic questions important to hand therapists: what are the expectations of therapy vis-a-vis range of motion and strength among patients with distal radius fractures, and do patients treated by different therapists within a center experience substantially similar or dissimilar outcomes? Differences between patient groups were tested using ANOVA, and changes in performance were tested using the Student's t-test; significant differences between patient groups treated by different therapists were lacking and patients demonstrated significant changes in active motion and strength. Data were used to derive regression equations that yielded good estimates of active motion at discharge from therapy. Patients were treated an average of ten times; at discharge, they demonstrated active wrist and forearm motion compatible with the performance of activities of daily living.