Distal Radius Fracture
Case Study: You have just received a referral and OT order to evaluate and treat a patient in the outpatient setting with a distal radius fracture post-op, approximately 4 weeks post-surgery. What are the essential elements to include in the evaluation, treatment, and home exercise plan?
Evaluation
Subjective
– Pain levels at rest and with activity?
– Was the fall an isolated event, or has the patient had a history of previous falls?
Consider administering a fall risk assessment: 5 Times Sit-To-Stand Test
– Does the patient have shoulder pain?
Functional Outcome Measure
Patient-Rated Wrist Evaluation (PRWE): Has been shown to have strong measurement properties and has been translated into multiple languages.
This outcome measure considers the patient’s pain with selected activities to evaluate various wrist functions (E.g., Fastening buttons (dexterity), Cutting food (grip with ulnar deviation), Turning a doorknob (forearm rotation), Pushing up from a chair (wrist extension), Carrying a heavy object (strength), Using bathroom tissue (wrist flexion)
Range of Motion
360° goniometer: for wrist
180° goniometer: for thumb CMC and forearm, fingertip to distal palmar crease (DPC)
Finger flexion (deficit of fingertip to distal palmar crease)
Finger extension
Radial abduction
Palmar abduction
Opposition
Wrist straight plane
Forearm pronation/ supination
Shoulder forward flexion
Shoulder abduction
Shoulder external rotation
Shoulder internal rotation (reaching behind back)
Edema
Figure-Eight method using tape measure
At the wrist flexion crease
At the level of the MCP joints
At the level of the proximal phalanges
Coordination
Nine Hole Peg Test
If Post-Operative
Measure length of the incision/scar
Any drainage present? (Serous (clear), Serosanguinous, Sanguineous)
Sensibility Test: Ten Test
– Used to assess the sensibility of the hand via moving light touch
– Graded by the patient on a scale of 1–10
– 10 represents normal sensation
– The higher the score, the less sensory loss
– To assess the median nerve, compare the moving light touch at the thumb tip, index fingertip, and middle fingertip
– To assess the radial nerve, compare the dorsal aspect of the second metacarpal
Treatment for the first 4-6 weeks
• Addressing patient impairments
– Protection
• What are the patient’s precautions or restrictions?
Prefabricated or custom wrist hand orthosis (WHO), remove to exercise 4-5 times per day. WHO is discontinued during the later stages of rehab when they are cleared for strengthening.
– Edema
-Avoid dependent positioning
Instruction in full composite flexion
– Scar (if postoperative) and soft-tissue management
Once the incision is closed (wait at least two days after stitches are removed), scar tissue mobilization can begin – Begin with using fingers to gently move the closed incision
Can work up to using shelf liner or Dycem to further improve the mobility
Address soft-tissue restrictions manually or with tools (instrument-assisted soft-tissue mobilization)
– Range of Motion & Exercise
Tendon glides: straight, hook, full composite fist, tabletop, and straight fist
Interosseous stretch: combined passive MP hyperextension with PIP flexion
Lumbrical stretch: passive MP hyperextension orthosis with active PIP flexion
Finger abduction and adduction
Dexterity training: improving fine motor control
Picking up coins, paper clips, or marbles
Manipulating tennis ball to touch the numbers
Manipulating nuts and bolts
Mirror therapy
Wrist flexion/ extension
Radial deviation
Ulnar deviation
Forearm supination, pronation
Neuromuscular reeducation: facilitating radial extension and ulnar flexion: activities – placing cones from radial wrist extension to ulnar flexion
Home Exercise Plan
AROM wrist in straight plane
AROM Circumduction (circles) repeat 10 repetitions, 4-5 times per day
AROM dart throwers motion
Scar tissue mobilization
Tendon glides
Active radial abduction
Palmar abduction
Thumb opposition
Forward shoulder flexion
Forward abduction
Shoulder external rotation with arm at side
Shoulder internal rotation reaching behind back
Forearm pronation and supination