Colles' Fracture Post Operative Rehabilitation Programme from Week 6

Introduction

Distal radius fractures are usually the result of a fall on an outstretched hand. In children and young adults, the force required for this sort of fracture is much higher (eg a fall off monkey bars or a car accident) whereas in older adults distal radius fractures tend to occur following a low energy fall from a standing height.[1]

Some distal radius fractures are managed conservatively, but many will require surgical fixation. For a fuller description of classification of distal radius fractures and types of surgical management, see Distal Radial Fractures.

The Protocol

This protocol is specific to Colles’ fractures fixed with open reduction internal fixation (ORIF) volar lock in plate screws. It was developed by Australian hand therapists in conjunction with orthopaedic surgeons.[2] The early post operative protocol is described here.

By 8 weeks post surgery, most Colles’ fractures will be clinically and radiographically healed and it is at this point that patients can usually begin strengthening exercises.[2]

This page describes the rehabilitation protocol from this point on. Please note that the patient must first be cleared by their surgeon to begin strengthening exercises before starting any of these exercises.[2]

Strengthening exercises are key at this stage if a client is to achieve a full return to function.[2] It’s important to note that at 12 months post fracture, patients with distal radius fracture fixed by ORIF will not have achieved full strength when compared to the non-fractured side.[2] It has been shown that an exercise programme based on sensorimotor principles (including proprioception, isometric control, dynamic level and unconscious dynamic level) can have a beneficial outcome on strength and function in chronic wrist pain.[3]

When beginning strengthening exercises, remember to “start slow” and carefully manage progressions.[2] As patients have been doing very little apart from range of motion exercises for six to eight weeks, they need to gradually increase load and weight bearing in order to allow tissues to adapt and strengthen safely - otherwise, they may be at risk of overload injuries.[2]

Initially, it’s recommended that you see your client for one session per week. This can be reduced to one session per fortnight over time. It’s important to have this contact, so that you can regularly review your client and ensure that you update or modify their treatment as needed and detect any complications.[2]

Week 8 Post ORIF

Begin strengthening exercises.

With theraputty:

    1. Full fist
    2. Hook - which works on intrinsics
    3. Table Top (or Duck Beak)
    4. Pincer - repeat with each finger
    5. Lateral pinch
    6. Gentle weight bearing with putty - begin on table and start to push down into the putty with an extended wrist. Variations include bilateral table top push on wrists, wall press up, with a progression to a regular push up
1. Full fist
2. Hook
3. Table Top (Duck Beak)
4. Pincer
5. Lateral pinch
6. Weight bearing on theraputty

Also add in light weights - approximately 1kg (or 0.5kg)

Place arm on table top and perform:

    1. Eccentric movement into wrist flexion and concentric movement into wrist extension.
    2. Repeat in opposite direction - eccentric movement into wrist extension to concentric movement into wrist flexion.
    3. Radial and ulnar deviation.
    4. Dart throwing motion -  wrist extension with radial deviation and wrist flexion with ulnar deviation.
1. Eccentric wrist flexion/concentric extension
2. Eccentric wrist extension/concentric wrist flexion
3. Radial and ulnar deviation
4. Dart throwing motion

Aim for 2 x 12 repetitions 2 x per day.[2]

Progressions (usually from approximately 9 weeks)

Start theraband exercises

  1. Wrist extension
  2. Wrist flexion
  3. Supination - with elbow by side at 90 degrees using ring band
  4. Pronation - elbow by side at 90 degrees using a single band[2]
1. Theraband wrist extension
2. Theraband wrist flexion
3. Theraband supination
4. Theraband pronation

Dynamic strengthening exercises

Weighted ball (1.5kg)

Throw ball side to side, up down, dart throwing motion. When the patient can tolerate it, you can start throwing them the ball for them to catch and return.[2]

Twist and bend exercises
  1. From a supinated position bend Twist and Bend into a U shape
  2. From a pronated position bend it into an N shape
  3. Wobble Twist and Bend forward/back, side to side, round and round in operated hand. These exercises are useful to train proprioception and stability of the wrist if there are ligament issues (eg scapho-lunate or TFCC)[2]
1. Twist and bend supination
2. Twist and bend pronation
Hammer
  1. Move hammer down into pronation. Use the weighted end of hammer to help the action
  2. Move hammer down into supination
  3. Dart motion with hammer[2]
1. Pronation with hammer
2. Supination with hammer
3. Dart motion with hammer
Power web for grip strengthening
  1. Flex hand
  2. Pull to side (for intrinsics)
  3. Weight bear on an extended wrist on the web[2]
2. Power web - flex hand
2. Pull power web to side
3. Weight bear onto power web
Soft pipe

These exercises are beneficial for training proprioception. This is a home made tool which is easy to make - take a plumbing pipe and fill with water and then seal ends.

  1. Patient holds the pipe out in front of them with elbow extended, at 90 degrees of shoulder flexion. Aim for stable grasp in pronation. The goal of the exercises is to prevent the water from tipping. If this is too difficult, the same exercise can be performed in elbow flexion.
  2. This exercise can be repeated in supination with elbow extended or flexed.[2]
Tennis racquet

These exercises are also beneficial for training proprioception.

  1. Patient holds the racquet in a supinated position. Place ball in racquet and trace around the edge of the racquet clockwise and anticlockwise
  2. Trace the letter on the racquet with the ball[2]
Body blade (if available in clinic)
  1. Place elbow at side at 90 degrees flexion. Wobble the blade up and down in a vertical position
  2. Repeat in horizontal position
  3. Can progress to above head[2]

Referral

Once you have completed the above programme, it is important to refer clients who are going to need higher function, including athletes or young people returning to sports, on to exercise physiologists. These exercise professionals will be able to implement a bridging programme and continued strengthening to ensure they reach an adequate level to return to their former level of play.[2]

Complications

Soft tissue injuries to be aware of include:

Scapho-lunate injury

This injury presents as radial sided wrist pain, localised to the area over the scaphoid and lunate bones.[4] Complaints may include clicking that causes pain, a report of “giving way,” and decreased grip strength.[4] If there is evidence of a scapho-lunate injury, it’s important to avoid very strong gripping as this can create gapping between the scaphoid and the lunate. It may also be painful for the patient to weight bear and extend their wrist.[2]

Triangular Fibrocartilage Complex (TFCC) injury

This injury presents as ulnar sided wrist pain, often with clicking/grinding and weakness.[5] It is important to avoid forced pronation and twisting while weight bearing, as well as too much ulnar deviation when treating patients who present with this complication.[2]

Key warning signs

  1. Pain - particularly sharp pain - you need to stop your client exercising and review them
  2. Painful clicking/snapping
  3. Severe pain after exercise that lingers more than 48 hours. This usually indicates that your client has done too much too soon. They may need a week off their exercises to let the pain settle and then, when rested, re-start with a more gradual approach
  4. Excessive swelling - often occurs the day after starting exercises. It is important to address the swelling, then review their programme and monitor progress more closely.[2]

References

  1. Handoll HHG, Huntley JS, Madhok R. External Fixation versus conservative treatment for distal radial fractures in adults (Review). The Cochrane Library. 2008;4:1-78
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 Thorn, K. Introduction to distal radius fracture [VIMEO]. Queensland: Physiopedia, 2019.
  3. Lotters F, Schreuders T, Videler A. SMoc-Wrist: a sensorimotor control-based exercise program for patients with chronic wrist pain. Journal of Hand Therapy (online). 2019.
  4. 4.0 4.1 Lau S, Swarna SS and Tamvakopoulos GS. Scapholunate dissociation: an overview of the clinical entity and current treatment options. Eur J of Ortho Surgery & Trauma. 2009 Mar;19(6):377-385.
  5. UK Orthopaedic Surgery & Sports Medicine. Health in Sports Report-Issue 6: Triangular Fibrocartilage Complex (TFCC) Injury. http://ukhealthcare.uky.edu/sportsmedicine/health_in_sports/issue6.asp (accessed 25 June 2009).