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Distal radius fractures (DRF) are the most common upper extremity fracture, with an incidence rate of 100 to 300 per 100,000 person-years.[1] They often result from a fall on an outstretched hand. Risk factors for distal radius fractures include age and sex — they are more common in paediatric and older populations, and women are at higher risk.[2][3] In older adults, osteoporosis is a key contributing factor. Seasonal variations are also observed, with higher fracture rates in countries that experience snowfall.[4]
In children and young adults, the force required for this type of fracture is much higher (e.g., a fall from monkey bars or a car accident), whereas in older adults, distal radius fractures tend to occur after a low-energy fall from standing height.[5]
The majority of distal radius fractures are managed conservatively.[6] However, the use of internal fixation surgery has increased rapidly.[7]
ORIF with Volar Plates for Distal Radius Fracture
Open reduction and internal fixation (ORIF) is frequently required for displaced or unstable distal radius fractures to restore anatomical alignment and function. This surgical approach reduces the risk of long-term complications such as osteoarthritis, limited range of motion, and persistent functional impairment.[8]
Volar plating is a common ORIF technique, often used for palmar angulated fractures. It was historically thought to carry a lower risk of tendon complications due to the plate's position. However, some complications are still associated with volar plating (including extensor tendon rupture, carpal tunnel syndrome, median nerve injury, neurapraxia, and complex regional pain syndrome).[8]
Absolute contraindications for ORIF are rare. Relative contraindications include severe osteoporosis, low functional status in older people, inability to tolerate general anaesthesia, and patient preference.[8]
Post-Operative Rehabilitation Protocol
When ORIF is indicated, a structured rehabilitation programme beginning in the immediate post-operative period is essential to optimise outcomes.
Goals of the Programme
The goals of the post-operative rehabilitation protocol include:
pain management
restoring range of motion of the wrist, fingers and elbow
protecting the fracture
controlling swelling
setting realistic expectations and goals for patients
Range of motion tends to increase steadily over the first 6 months, but after that, progress slows.[9] Usually, the range of motion of the injured side will match the uninjured side at around 12 months. Grip strength is usually not equal at this time. That said, Kumar et al.[10] found that ORIF is associated with greater grip strength recovery compared to conservative management.
Protocol for Colles' Fractures Fixed with ORIF (0-6 Weeks Post-Operative)
This protocol is specific to Colles’ fractures fixed with ORIF using volar-locked plate screws.[11][12] It does not apply to K-wires, external fixators or other surgical approaches and was developed by Australian hand therapists in conjunction with orthopaedic surgeons.[9][13]
If patients with Colles' fractures are managed conservatively, this protocol can be used. However, these patients will only be able to commence exercises when cleared by their specialist. This usually happens at 6 weeks post-injury.[9] Successful treatment requires close communication with the relevant orthopaedic surgeon. Patients are typically seen 1-2 times per week for hand therapy.[9]
No weight-bearing or lifting for 6 weeks (usually the patient is advised to lift no more than half a cup of tea)
The splint is to be worn at all times except during exercises or quiet sitting (e.g., sitting watching TV)
Active range of motion exercises:
These exercises should be performed within the patient's comfort level, aiming for 10 repetitions every 2–3 hours, with the arm placed on the table in elevation for swelling control.[9]
Thumb opposition to each finger tip
Finger extension/flexion
Wrist flexion/extension in tenodesis motion (see images 1 and 2)
Ulnar/radial deviation
Pronation/supination with the elbow by the side at 90 degrees of elbow flexion
1. Flexion tenodesis
2. Extension tenodesis
Week 1 Post-Operative
Commence passive range of motion exercises (gentle forces only to help with bone healing):
Passive wrist extension: place elbows on the table and push hands into wrist extension
Passive wrist flexion: place the elbow on the table and use the non-operated hand to push the operated wrist into flexion
Wrist extension using elbow position: the unaffected hand is placed on top of the operated hand; the patient then extends the operated elbow upwards
3. Passive ulnar deviationUlnar deviation in elbow position: push the elbow into abduction to achieve ulnar deviation at the wrist (see image 3)
Wrist extension with the hand in a fist while resting the arm on the table
Passive supination/pronation: move into the position actively and then add a stretch with the non-operated hand
Additional active range of motion exercises:
Circumduction of the wrist in elevation with the arm resting on the table
Figure of eights at the wrist, with the elbow by the side
Continue compression and remind the patient to keep wearing their splint.[9]
Week 2 Post-Operative
Start scar treatment as soon as the sutures have been removed:
Scar massage: apply contact media to the scar, such as silicone gel sheets and tape
Desensitisation: tapping, textures, rubbing, immersion, or vibration to reduce scar tissue and scar sensitivity
Continue active and passive range of motion to minimise internal scarring.[9]
Weeks 3-6 Post-Operative
Continue passive range of motion exercises. At this stage, it is useful to see the patient 1-2 times per week for passive modalities such as heat, paraffin wax, stretching, and mobilisation. Review their programme and check their exercises at every appointment.
Remind the patient that from this point on, they only need to wear their splint for activities with a high risk of falling or trauma, such as being around children or pets, showering or walking in public. They no longer need to wear their splint when sleeping or staying at home.[9]
Week 6 Post-Operative
The patient will usually see their surgeon at 6 weeks post-operatively and have follow-up x-rays. At this point, they are usually cleared to commence strengthening.[9]
Useful Outcome Measures
The following outcome measures are recommended to monitor patient progress and align with current research protocols. The consensus in the literature is to repeat outcome measures at 2 weeks, 6 weeks, 3 months, 6 months and 12 months if possible.[9]
Grip strength (with dynamometer)
Range of motion (wrist flexion/extension, ulnar/radial deviation, supination/pronation) measured with a goniometer. Note: measure active range of motion before any treatment
Poorer outcomes may be associated with older age, female sex, associated ulnar styloid fracture, workers' compensation status, and lower socioeconomic status.[14][15]
Complications/Red Flags
Complications following distal radius fractures vary based on the treatment received (i.e., internal vs external fixation vs non-operative),[16] as well as other patient factors such as smoking[17] or impaired bone quality.[18]
Malunion,[19] nonunion, hardware failure, and tendon rupture[20][21] usually require further surgery. Median or radial nerve neuropathy/compression often resolves but may require investigation.[16][22] Ulnar-sided wrist pain may indicate ulnar styloid fracture, nonunion, or ulnar impaction syndrome and may require surgery.[9]
Complex regional pain syndrome (CRPS) should be suspected when there is significant, uncontrolled post-operative pain, unmanageable swelling, shiny or blotchy skin, perspiration and stiffness.[23][24] Infection is also reported in up to 2% of patients following ORIF.[25]
Ongoing pain may be caused by related soft tissue injuries or hardware failure.[9] Stiffness can be addressed with dynamic splints, such as supination splints (e.g., Colello splints) and dynamic wrist extension splints using rubber bands and pulleys to maintain an end-range stretch.[9][26] Associated soft tissue injuries, such as triangular fibrocartilage complex (TFCC) tears (resulting in ulnar-sided wrist pain) and scapholunate ligament injuries (resulting in dorsal central wrist pain), are frequently the cause of ongoing pain after the fracture has healed.[27]
Summary
Early mobilisation is key to a faster return to functional range of motion. Clinicians should monitor for red flags and use outcome assessments to track progress. Associated soft tissue injuries and their impact on recovery should also be considered. Above all, the clinician's role is to guide, encourage, and support the patient through their rehabilitation.
References
↑Fahy K, Duffaut CJ. Hand and wrist fractures. Curr Sports Med Rep. 2022 Oct 1;21(10):345-6.
↑Jiang X, Zhang C, Yu B, Wu X, Gong M. Evidence-based guidelines for diagnosis and treatment of adult distal radius fractures (2025). Injury. 2025 Aug 1;56(8).
↑Azad A, Kang HP, Alluri RK, Vakhshori V, Kay HF, Ghiassi A. Epidemiological and Treatment Trends of Distal Radius Fractures across Multiple Age Groups. J Wrist Surg. 2019;8(4):305-11.
↑Doxey SA, Kleinsmith RM, Qian LJ, Husband JB, Bohn DC, Cunningham BP. Generic Volar Locking Plate Use in Distal Radius Fractures: A Prospective Randomized Study to Evaluate Clinical Outcomes and Cost Reduction. Hand. 2026 Jan;21(1):116-23.
↑Lim B, Talbot S, Jassim S, Quinn EP, Shaalan M. Kirschner's Wire versus Casts in Wrist Fractures: A Systematic Review and Meta-analysis. Journal of Wrist Surgery. 2025 Dec;14(06):588-98.
↑MacIntyre NJ, Dewan N. Epidemiology of distal radius fractures and factors predicting risk and prognosis. Journal of Hand Therapy. 2016 Apr 1;29(2):136-45.
↑ 16.016.1Chung KC, Malay S, Shauver MJ, Kim HM; WRIST Group. Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial. JAMA Netw Open. 2019;2(1):e187053.
↑Hess DE, Carstensen SE, Moore S, Dacus AR. Smoking Increases Postoperative Complications After Distal Radius Fracture Fixation: A Review of 417 Patients From a Level 1 Trauma Center. Hand (N Y). 2020;15(5):686-91.
↑Rosenauer R, Pezzei C, Quadlbauer S, Keuchel T, Jurkowitsch J, Hausner T et al. Complications after operatively treated distal radius fractures. Arch Orthop Trauma Surg. 2020;140(5):665-73.
↑Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults (Review). The Cochrane Library. 2008;4:1-112.
↑Yamak K, Karahan HG, Karatan B, Kayalı C, Altay T. Evaluation of Flexor Pollicis Longus Tendon Rupture after Treatment of Distal Radius Fracture with the Volar Plate. J Wrist Surg. 2020;9(3):219-24.
↑Chung, KC, Mathews, AL. Management of Complications of Distal Radius Fractures. Hand Clin. 2015; 31(2): 205–215.
↑Handoll HHG, Huntley JS, Madhok R. External Fixation versus conservative treatment for distal radial fractures in adults (Review). The Cochrane Library. 2008;4:1-78.
↑Ortiz-Romero J, Bermúdez-Soto I, Torres-González R, Espinoza-Choque F, Zazueta-Hernández JA, Pérez-Atanasio JM. FACTORS ASSOCIATED WITH COMPLEX REGIONAL PAIN SYNDROME IN SURGICALLY TREATED DISTAL RADIUS FRACTURE. Acta Ortop Bras. 2017;25(5):194-6.
