As the winter starts the weather gets cold and frosty mornings make pavements and roads slippery and dangerous, causing an epidemic of falls. A FOOSH, a fall on the outstretched hand, is a typical accident and commonly results in a fracture of the ulna and radius in the forearm, although it is often referred to as a “wrist fracture”. A wrist fracture can be small like an avulsion or a greenstick or major like multiple fractures requiring internal fixation. Physiotherapists assess progress and rehabilitate wrist fractures in physiotherapy departments and fracture clinics.
The wrist is the most commonly damaged part of the arm and three quarters of wrist injuries consists of radius and ulna fractures. Minor injuries may have just a crack and remain in position and as injuries become more serious they involve larger numbers of fragments and more marked displacement. As the person falls on the hand the results depend to some degree on age: children develop a greenstick fracture (a kink in the bone), adolescents separate the growth plate from the bone and adults fracture the radius and ulna in the last inch near the wrist.
Fractures of this type occur mostly in people from 60-69 years old and those from 6 to 10 years old. Fractures can occur without joint involvement (older people) or with fractures extending into the joint (younger people due to higher trauma forces) which complicates the picture. Diagnosis of a fracture is straightforward as the area is often very painful and swollen and the patient resists moving it. It may have a typical postural deformity called a “dinner fork” and feeling over this area will confirm the presence of a fracture.
Medical Treatment of Wrist Fractures
The main principle of treatment is to immobilize the fracture in an anatomically correct position so it heals as closely as possible to the original shape. The fracture is assessed for its severity and whether it is displaced. Displacement can be manipulated and plastered to hold the position but if the displacement is too great or the plaster does not hold the position then operative intervention is pursued. Internal fixation can involve passing narrow wires into the bones to hold position (k wiring) or inserting a plate with screws to immobilize the fracture, after which plaster is again applied.
Physiotherapy after Wrist Fracture
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 assessment shows only a stiff and uncomfortable wrist the physiotherapy exercises will consist of range of movement for the shoulder, elbow, forearm rotation, wrist and hand. To ease the transition out of plaster and enable early functional ability without pain a velcro futura wrist splint can be used for a week or so. Referral to exercise hand class may be necessary and the physios can mobilize the wrist and forearm joints by re-establishing the gliding movements between the joints. As the wrist improves the focus of physio moves to strengthening exercises and the promotion of normal day-to-day activities.
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