Colles’ Fracture Post Operative Rehabilitation Protocol

Introduction

Distal radius fractures are usually the result of a fall on an outstretched hand. It tends to be more common in paediatric and elderly populations. In children, it occurs more often in males whereas it is more common in females in the older population.[1] In children and young adults, the force required for this sort of fracture is much higher (eg a fall off monkey bars or a car accident) whereas in older adults distal radius fractures tend to occur following a low energy fall from a standing height.[2]

The majority of distal radius fractures are managed conservatively, but the use of internal fixation surgery has increased rapidly.[1] For a fuller description of classification of distal radius fractures and types of surgical management, see Distal Radial Fractures.

Post Operative Rehabilitation Protocol

This protocol is specific to Colles’ fractures fixed with open reduction internal fixation (ORIF) volar lock in plate screws. 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.[3]

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.[3]

Goals of the programme

  • Pain management
  • Restore range of motion of the wrist, fingers and elbow
  • Protect fracture
  • Control swelling
  • Set realistic expectations and goals for patients

NB: Range of motion tends to steadily increase for the first 6 months, but after that progress slows.[3] Usually range of motion of the injured side will match the uninjured side at around 12 months. However, grip strength is usually not equal at this time.[3]

The protocol (0-6 weeks post op)

Successful treatment requires close communication with the relevant orthopaedic surgeon. Physiotherapy treatments are usually 1-2 times per week.[3]

Day 1:

  • Take off post operative plaster and redress wound
  • Fabricate volar distal orthosis
  • Provide compression to control swelling
  • Encourage light use of hand
  • Review precautions - of particular importance, the physiotherapist must remind the patient that they are unable to weight bearing for 6 weeks or do any lifting (usually the patient is advised to lift no more than half a cup of tea)
  • Splint precautions: the patient should wear their splint most of the time, except during exercise or quiet sitting for the first 3 weeks
  • Active range of motion exercises should be started early within a patient’s comfort level:
    • Place arm on table in elevation for swelling control
      • Thumb opposition to each finger tip
      • Finger extension/flexion
      • 1. Flexion tenodesis
        2. Extension tenodesis
        Wrist flexion/extension in tenodesis motion (see image 1 and 2)
      • Ulnar/radial deviation
    • Pronation/Supination with elbow by side at 90 degrees elbow flexion

Exercises should be performed 10 times every 2-3 hours[3]

1 week post op:

  • Commence passive range of motion exercises - gentle forces only to help with bone healing
    • Passive wrist extension - place elbows on table and push hands into wrist extension
    • Passive wrist flexion- place elbow on table and use non-operated hand to push operated wrist into flexion
    • Wrist extension using elbow position - unaffected hand is placed on top of operated hand - extend operated elbow upwards
    • 3. Passive ulnar deviation
      Ulnar deviation in elbow position - push elbow into abduction to achieve ulnar deviation at wrist (see image 3)
    • Wrist extension with hand in fist while resting arm on table
    • Passive supination/pronation - move into position actively and then add stretch with unoperated hand
  • Add in 2 new active ROM exercises
    • Circumduction of  wrist in elevation with arm resting on table
    • Figure of 8s at wrist, with elbow at side

Continue compression and remind your client that they need to keep wearing their splint.[3]

2 weeks post op:

Remove sutures and begin scar management:

  • Scar massage: contact media  on scar such as  silicon and tape
  • Desensitisation - tapping, textures, rubbing, emersion, vibration to reduce scar tissue and sensitivity of scar

Continue PROM and AROM to  minimise internal scarring.[3]

3 - 6 weeks post op:

Continue PROM exercises. At this stage, it is useful to see your client between 1 and 2 times per week for passive modalities like heat and parabon wax, stretching and mobilising. It's also beneficial to review their programme and check their exercises at every appointment.

It is important to remind your patient that they from this point on, they only need to wear their splint for activities with high risk of falling or trauma. These may include being around children or pets, showering or when walking out in public. They do not need to wear their splint when sleeping or if they are just staying at home anymore.[3]

6 weeks post op:

The patient will usually see their surgeon at 6 weeks post op and have follow up x-rays. At this point, they are usually cleared to commence strengthening.[3]

Useful outcome measures

The general consensus in the literature is to repeat outcomes measures at 2 weeks, 6 weeks, 3 months, 6 months and 12 months if possible.[3]

Complications/Red flags

Complications following distal radius fractures varies based on the the treatment received (i.e internal vs external fixation vs non-operative),[4] as well as other patient factors such as smoking[5] or impaired bone quality.[6]

  • Malunion[7]  or non union - these complications usually require further surgery
  • Hardware failure - these patients usually require further surgery[3]
  • Tendon rupture[8] - this complication usually requires further surgery[9]
  • Median or radial nerve neuropathy / compression[4] - this will often resolve, but sometimes requires investigation[2]
  • Ulnar sided wrist pain: may indicate ulnar styloid fracture non union or ulnar impaction syndrome. Surgery is required[3]
  • CRPS[10] - suggested when there is significant pain post-surgery that cannot be controlled. There may also be swelling that cannot be managed, shiny or blotchy skin, perspiration and stiffness[9]
  • Infection[9]
  • Ongoing pain - which can be caused by related soft tissue injuries or hardware failure[3]
  • Stiffness[11] - to address this, hand therapists can fabricate dynamic splints[3]

References

  1. 1.0 1.1 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.
  2. 2.0 2.1 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.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 Thorn, K. Introduction to distal radius fracture [VIMEO]. Queensland: Physiopedia, 2019.
  4. 4.0 4.1 Chung 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.
  5. 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.
  6. 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.
  7. Handoll HHG, Madhok R. Conservative interventions for treating distal radial fractures in adults (Review). The Cochrane Library. 2008;4:1-112.
  8. 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.
  9. 9.0 9.1 9.2 Chung, KC, Mathews, AL. Management of Complications of Distal Radius Fractures. Hand Clin. 2015; 31(2): 205–215.
  10. Ortiz-Romero J, Bermudez-Soto I, Torres-González R, Espinoza-Choque F, Zazueta-Hernandez JA, Perez-Atanasio JM. FACTORS ASSOCIATED WITH COMPLEX REGIONAL PAIN SYNDROME IN SURGICALLY TREATED DISTAL RADIUS FRACTURE. Acta Ortop Bras. 2017;25(5):194-6.
  11. Kleinman WB. Distal radius instability and stiffness; common complications of distal radius fractures. Hand Clin. 2010;26:245-264.