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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.

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 Rehabilitation of Wrist Fractures

Five or six weeks is the normal time for the plaster to remain on, with the physio assessing the state of the wrist and hand as this can be very unpredictable once it’s out. An assessment from a physio skilled in fracture management is important to set the treatment programme and recommend any further treatment. The hand’s swelling and colour is a key indicator of the state of the area and how it should be treated. Strong colour changes, tight swelling and severe pain means the diagnosis of Complex Regional Pain Syndrome (CRPS) should be suspected, a severe pain condition which needs immediate intervention.

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 physiotherapist determines that the wrist is uncomplicated after removal of plaster then they will prescribe mobilizing exercises for the wrist, forearm and hand and perhaps the elbow and shoulder. Coming straight out of plaster is a shock for the wrist and a strap on futura splint can rest the wrist and permit normal activity without too much discomfort. If the wrist is very stiff then attendance at a hand class may be useful and the accessory joint movements can be restored by using joint mobilization techniques on the many wrist joints. The physio will progress to strengthening the wrist as the movements improve and teach the patient to use the hand normally in daily activities.