Colles’ Fracture Post Operative Rehabilitation Protocol

Distal radius fractures are usually the result of a fall on an outstretched hand. 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.

Some distal radius fractures are managed conservatively, but many will require surgical fixation. 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. It was developed by Australian hand therapists in conjunction with orthopaedic surgeons. Surgical intervention is usually required when volar tilt is greater than 20 degrees, intra articular step is greater than 2mm or ulnar variance is greater than 2mm. If these patients are managed conservatively, function and range of motion may be adversely affected.

If patients are managed conservatively, this programme can be used, but they will begin when cleared by their specialist, usually at 6 weeks post injury.

Goals of the programme

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

NB: Range of motion tends to steadily increase for the first 6 months, but after that progress slows. 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 12 months.

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.

Day 1:

• Take off post op plaster and redress wound.
• Fabricate volar distal orthosis
• Provide compression to control swelling
• Encourage light use of hand
• Review precautions - of particular importance is no weight bearing for 6 weeks and no heavy lifting (usually less than half a cup of tea)
• Splint precautions: wear most of the time, except during exercise, or quiet sitting for the first 3 weeks.
• Start early active range of motion in a patient’s comfort level:
  • Place arm on table in elevation for swelling control
    • Thumb opposition to each finger tip
    • Finger extension/flexion
    • Wrist flexion/extension in tenodesis motion
    • Ulnar/radial deviation
  • Pronation/Supination with elbow by side at 90 degrees elbow flexion

Exercises to be performed 10 times each every 2-3 hourly during the day

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- elbow on table and use non-operated hand to push into flexion
  • Wrist extension using elbow position - unaffected hand is placed on top of operated hand and elbow extending
  • Ulnar deviation in elbow position - push elbow into abduction to achieve ulnar deviation at wrist
  • 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 at this stage and remind patient the patient to keep wearing splint.

2 weeks post op:

Remove sutures and commence 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 - 6 weeks post op:

Continue PROM exercises. At this stage, it is best to see the patient one to two times per week for passive modalities like heat and parabon wax, stretching, mobilising and to review programme and check exercises.

Remind the patient that they now only need to wear their splint for at risk activities (activities with high risk of falling/trauma). These may include being children or pets, or when showering or out in public. They do not need to wear their splint with sleeping or pottering around the house.

6 weeks post op:

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

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.

• Grip strength (with jamar dynamometer)
• ROM - (wrist flexion/extension, ulnar/radial deviation, supination and pronation). Measured with a goniometer. Always measure active range of motion pre treatment
• Quick DASH
• Patient Rated Wrist Evaluation
• Visual Analogue Scale
• X-ray

Complications/Red flags

• Malunion  or non union - these complications are the most common and usually require further surgery
• Hardware failure - these patients usually require further surgery
• Tendon rupture - Extensor Pollicis Longus is the most common tendon to rupture. This complication usually requires further surgery
• Median or radial nerve neuropathy - this will often settle, but sometimes requires investigation
• Ulnar sided wrist pain: may indicate ulnar styloid fracture non union or ulnar impaction syndrome. Surgery is required
• CRPS - suggested when there is significant pain post surgery that cannot be controlled. There may also be swelling that cannot be managed, shiny/blotchy skin, sweating and stiffness
• Infection
• Ongoing pain - which can be caused by related soft tissue injuries or hardware failure
• Stiffness - to combat this hand therapists can fabricate dynamic splints