Physiotherapists and a Colles Fracture
A fall on the outstretched hand (FOOSH) is a common occurrence and often results in a Colles fracture, a fracture of the distal inch of the radius and ulna next to the wrist. Treatment is immobilisation in a splinting material such as Plaster of Paris for five to six weeks to allow healing of the bony fragments, followed by a variable period of rehabilitation depending on the severity of the fracture. The hand is extremely important functionally so the period in plaster is kept to a minimum to allow quick restoration of normal hand use, although a wrist splint can be used for a week or so, particularly in cases where there is significant pain on activity. Once the hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand. Initial treatment is to instruct the patient in range of motion exercises to be performed every two hours. For many fractures this is all that is required as the movements are easily restored with a few days exercises, concentrating on the end ranges of movement. The shoulder and elbow are checked to make sure they are not limited as they may have been injured in the initial incident or kept very still by the patient whilst in plaster. The pronation and supination movements of forearm rotation are functionally very important, and the physiotherapist checks wrist extension and flexion and finger and thumb movements. Once the plaster splinting has been removed the wrist may feel it lacks support and the patient may be apprehensive to use it. It is important not to keep the wrist immobilised for too long to prevent complications but early removal means there may be some pain and weakness. A typical forearm wrist brace, often called a futura, is routinely fitted by the physiotherapist to the patients wrist by Velcro straps, to be worn when doing normal daily activities. The brace is not to be kept on continuously but only for heavier hand work, being taken off the rest of the time and for regular exercise. If the progress of the joint is not as expected then the physiotherapist can use joint mobilisation techniques to restore the gliding and sliding movements of the joint. Accessory movements are small movements performed passively on another person and can be done to the midcarpal, radiocarpal and distal radio-ulnar joints. The physiotherapist will hold one side of the joint firmly as they passively move the other side of the joint, either gently and repetitively or more forcefully at the end range of where the joint will allow, pushing against the restriction. The joint can also be placed in the stiff position while the mobilisations are performed. Returning steadily to normal use of the wrist and hand is the easiest and often the most successful way to regain forearm strength. In some cases more must be done to return the hand to normal if it is very weak or the person needs to return to a heavy manual job or has particular upper limb strength requirements for a sport or hobby. Instruction in practicing all the different hand movements against resistance can be accomplished in a hand class, where patients can use equipment designed to strengthen particular movements such as gripping, pulling, twisting, turning and to improve fine hand function. If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand. Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Oxford or elsewhere in the UK.