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.
The wrist is the most commonly damaged part of the arm and three quarters of wrist injuries consists of radius and ulna fractures. Minor injuries may have just a crack and remain in position and as injuries become more serious they involve larger numbers of fragments and more marked displacement. As the person falls on the hand the results depend to some degree on age: children develop a greenstick fracture (a kink in the bone), adolescents separate the growth plate from the bone and adults fracture the radius and ulna in the last inch near the wrist.
The commonest age groups for colles fractures to occur in are the 6-10 and the 60-69 year olds, with older people more likely to suffer fractures in the forearm away from the joint and younger people, due to the higher violence of the injury, being more likely to get joint involvement in the fracture. Diagnostic features of a radius and ulna fracture are significant pain with increased pain on palpating the area, a "dinner fork" bony deformity, swelling over the area and a marked reluctance to use it.
Management of Colles Fracture
A fracture needs to be maintained as close to the original anatomical alignment as possible while it is healing, for a good functional result. A fracture with little or no displacement may just be plastered in its typical position for successful healing, but a badly displaced fracture may need manipulation and plastering to ensure correct alignment. If the fracture does not stay in the right position then operation such as using a k-wire or performing open reduction and internal fixation (ORIF) will be necessary to stabilise and realign the fracture. After such operations the fracture is plastered to maintain the position.
Physiotherapy after Wrist Fracture
The typical time in plaster is five to six weeks and once it comes off the physiotherapist can assess and rehabilitate the wrist and hand. The condition of the wrist and hand is very variable on coming out of plaster and a skilled assessment of the problems and potential for improvement is vital. The physio will look initially at the colour or swelling of the hand to get an indication of the severity of the problem. Excessive swelling, significant colour change or extreme reported pain might point to Complex Regional Pain Syndrome (CRPS), a severe and important condition which needs prompt treatment.
The shoulder ranges are assessed initially by the physiotherapist as the shoulder can be injured in the fall and suffer loss of movement. Loss of movement at the elbow can occur if the patient holds their arm stiff for the first few weeks but the rotatory forearm movements (supination & pronation) are much more commonly restricted and functionally important. The fracture is close to the lower rotatory forearm joint and restricts this and the wrist ranges of motion. The hand function, finger and thumb movements are also assessed by the physio.
If the assessment shows only a stiff and uncomfortable wrist the physiotherapy exercises will consist of range of movement for the shoulder, elbow, forearm rotation, wrist and hand. To ease the transition out of plaster and enable early functional ability without pain a velcro futura wrist splint can be used for a week or so. Referral to exercise hand class may be necessary and the physios can mobilize the wrist and forearm joints by re-establishing the gliding movements between the joints. As the wrist improves the focus of physio moves to strengthening exercises and the promotion of normal day-to-day activities.