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How Physiotherapists Treat Wrist Fractures

 

Every winter the weather gets cold and icy at some time and we realise that the time has come when we are less safe out and about, that season when people start to slip and fall. Falls on an outstretched hand (FOOSH) are a very common injury and often cause a fracture of the end of the forearm bones, a fracture routinely known as a wrist or colles fracture. The fracture can be insignificant or very major requiring screws and plates to realign and fix it in position. Physiotherapists assess and plan rehabilitation of the wrist, hand and forearm.

In the arm the wrist is the most commonly injured area and radius and ulna fractures make up 75% of all wrist fractures. Injuries vary from a single fracture which remains in place without displacement to severe injuries with many fragments (comminuted) and with the bones out of position. The age of the person dictates to some degree the type of fracture experienced: adults suffer radius and ulna fractures in the last inch of the forearm, adolescents displace the wrist growth plate and children suffer from a bend in the cortex of the bone called a greenstick fracture.

Fractures of this type occur mostly in people from 60-69 years old and those from 6 to 10 years old.  Fractures can occur without joint involvement (older people) or with fractures extending into the joint (younger people due to higher trauma forces) which complicates the picture. Diagnosis of a fracture is straightforward as the area is often very painful and swollen and the patient resists moving it. It may have a typical postural deformity called a "dinner fork" and feeling over this area will confirm the presence of a fracture.

Management of Colles Fracture

To allow the fracture to heal correctly a colles fracture needs to be fixed in a position that allows the fracture to be held in as close to the original shape as possible. A simple fracture which is undisplaced can just be plastered and left to heal, while a displaced fracture has to be returned to a better anatomical alignment. Manipulation and plastering might work, but if the fracture does not remain in a good position then operative fixation with k-wires or plates and screws might be required. After the operation plaster is applied to maintain the correction.

Physiotherapy after Wrist Fracture

The plaster is usually in place for 5-6 weeks and then the physiotherapist can get a look at the wrist and hand to see what rehabilitation plan is required. When the hand is removed from plaster its condition varies greatly so a skilled physio needs to assess the situation and recommend appropriate treatment. The swelling and colour of the hand will give the physiotherapist important information about how severe things are. High levels of pain, strong changes in colour and extreme swelling in the hand and wrist could indicate Complex Regional Pain Syndrome (CRPS), a severe pain condition needing vigorous management.

Initially the physio assesses the movements of the shoulder as this can be damaged by a fall on the hand and cause a limitation. It is unusual for the elbow to have restricted movement after colles fracture unless the person has held their arm bent for a few weeks in a sling. The rotatory movements of the forearm (pronation and supination) are key functional movements and often limited as the lower joint between the ulna and the radius is close to the fracture line. The physio records the ranges of wrist flexion, wrist extension, and finger and thumb movements.

If the physiotherapist determines that the wrist is uncomplicated after removal of plaster then they will prescribe mobilizing exercises for the wrist, forearm and hand and perhaps the elbow and shoulder. Coming straight out of plaster is a shock for the wrist and a strap on futura splint can rest the wrist and permit normal activity without too much discomfort. If the wrist is very stiff then attendance at a hand class may be useful and the accessory joint movements can be restored by using joint mobilization techniques on the many wrist joints. The physio will progress to strengthening the wrist as the movements improve and teach the patient to use the hand normally in daily activities.


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