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.
75 percent of wrist fractures involve the radius and ulna, with the wrist the most often injured part of the upper extremity. A fracture can be minor and be undisplaced or very severe with multiple fractures (comminuted) and badly displaced, which may need operation with plates and screws to fix the fracture securely. The type of fracture is related to the age of the sufferer: adolescents have wrist growth plate displacement, children bend their bones in a greenstick fracture and adults present with a fracture of the final inch of the forearm bones above the wrist.
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.
The physio will look at the ranges of movement of the upper limb, checking the shoulder ranges first to make sure the shoulder was not damaged in the fall. The elbow range is usually unaffected except in some cases where the patient has kept their elbow bent in a sling for weeks, making the joint stiff. Supination and pronation are very important movements functionally and often restricted due to the proximity of the inferior radio-ulnar joint to the fracture site. Wrist flexion and extension, finger movement and thumb ranges are all assessed and recorded.
The physio will decide if the patient's hand is normal for coming out of plaster and give range of motion exercises for the elbow, forearm, wrist and hand and perhaps the shoulder. A futura splint, a velcro fastening wrist splint, is useful to reduce the shock of coming out of plaster and allow patients to do functional activities without aggravating the pain too greatly. Attending a hand class for repeated exercise can be useful and physios can use mobilizing techniques to restore the accessory movement between the joints. Once the wrist is settled and moving better the physiotherapist will work on strengthening exercise and encourage functional normality.