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 Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.
Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.
After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.
If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.
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.
In some cases a pain syndrome can develop in the hand with tight swelling, poor joint motion, high pain and hypersensitivity, at which time a doctor's opinion is needed to exclude complications with the fracture such as non-union. Painkillers and contrast bathing are treatments for the pain, with self massage used for swelling and desensitising techniques for the abnormal sensibility. The patient should be clear that they have to go through significant pain to get their hand better again. - 16004
Once the Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.
Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.
After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.
If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.
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.
In some cases a pain syndrome can develop in the hand with tight swelling, poor joint motion, high pain and hypersensitivity, at which time a doctor's opinion is needed to exclude complications with the fracture such as non-union. Painkillers and contrast bathing are treatments for the pain, with self massage used for swelling and desensitising techniques for the abnormal sensibility. The patient should be clear that they have to go through significant pain to get their hand better again. - 16004
About the Author:
Jonathan Blood Smyth is a Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. 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 Birmingham.
