Distal Radius Fracture | Rehabilitation Evidence-Based

Wrist fractures are a wide range of pathologies that are treated in traumatology and orthopaedic consultants. Among them, fractures of the distal radius are the most frequent of the entire upper limb in adults younger than 75 years old (Kong L et al 2020).

They represent 25% of all fractures that are attended in the Emergency Department, making it one of the traumatic conditions with the highest health and socio-economic costs associated (Bonafede M et al 2013). More importantly, the progressive aging of the population and increased life expectancy may have consequences such as the fact that by 2030, 50% of ALL fractures attended will be distal radius (Maldonado JA et al 2013).

For this reason, correct treatment and multidisciplinary management (Physiotherapy, Occupational Therapy, Surgery, Traumatology, etc.) is key if we want an early return to work to the activities that the patient usually performed before (Bonafede M et al 2013). This, together with an exercise program based on the latest evidence about the Sensorimotor System, involving both the central (Nervous System) and peripheral (the wrist) levels, will allow a faster recovery.

Types of Distal Radius Fractures. Colles, Barton or Smith?

Traditionally, eponyms have been used to represent complex pathological entities and also to give relevance to the person who contributed to determine it (Caldwell RA et al 2018). Specifically in this field of medicine, eponyms continue to be used frequently, such as the following:

A) Colles Fracture:

According to the prestigious book Green’s Operative Hand Surgery consists of ;

A distal radius fracture with dorsal comminution, dorsal angulation, dorsal displacement, radial shortening, and an associated fracture of the ulnar styloid”

This type of fracture causes the famous “dinner fork” or “bayonet” deformity. In this picture you can see in a simple way what this Colles’ fracture consists of:

Colles Fracture according to Green´s Operative Hand Surgery 2010

B) Barton Fracture

In practice it has been used to describe a variety of distal intra-articular radius fractures, with dorsal or volar displacement of the carpus and fracture fragments, which are often unstable. Originally Barton described it as a subluxation of the wrist derived from a fracture at the level of the radial articular surface.

A Volar Barton’s fracture can also be classified as a Smith’s fracture Type II, so we should not be surprised to read it both ways. In the past they did not have the facility to use x-rays, so the authors were guided by the type of displacement that appeared on the wrist.

C) Smith Fracture or Reverse Colles Fracture:

The literature describes it as a fracture of the distal radius with volar (palmar) displacement of the fragment, which may or may not affect the intra-articular level. The main difference with the Colles’ fracture is the displacement of the fracture itself (volar instead of dorsal). As we said before, the Barton volares fractures describe the same case as Smith’s type II.

Depending on the type of displacement we can distribute the Smith fractures as type I, II and III.

Smith and Barton fractures according to Green´s Operative Hand Surgery 2010

D) Chauffeur Fracture:

“Chauffeur” fracture is described in the literature as an avulsion of the radial styloid together with a displacement of the carpus. Its name is now outdated name because of the chauffeur´s propensity to be “struck by the backfire recoil of a starter crank on an early automobile engine”. Those fractures are often associated with intercarpal and extrinsic carpal radiocarpal ligament injuries.

Chauffeur fracture according to Green´s Operative Hand Surgery 2010

E) Die-Punch Fracture

“Die-Punch” fracture represents those in which a depression of the dorsal aspect of the lunate fossa appears. It may be due to the impact of a portion of the articular surface of the lunate in the subchondral bone.

Die-Punch según according to Green´s Operative Hand Surgery 2010

Conservative or Surgical Treatment

Depending on the type of fracture, the surgeon will choose a therapeutic option that maintains the anatomical alignment, where joint congruence is restored, stiffness is avoided and early mobilisation is promoted. In general, unstable and irreducible fractures will be reserve for surgical approach.

Distal Radius Fracture X-ray with Volar Plaque. Obtained from Kong L. et al 2020.

In cases of unstable fractures, the preferred therapeutic management is the Volar Plaque, as it usually allows an early start to rehabilitation and therefore an early return to work. However, this type of surgery can cause various complications such as radiocarpal stiffness, which may produce several functional limitations.

A paper of 2020 (Kong L et al 2020) observed an incidence of radiocarpal stiffness of 35.3% after 6 months from surgery. Among risk factors, improper rehabilitation exercises was demostrated to be associated.

It is essential that we make patients understand the importance of carrying out their post-operative exercise programme.

Did you know that a Feedback-guided home exercise program with ReHand app improved short-term recovery of functional ability and strength? Take a look on our lastest paper publication!!

Exercise programmes for wrist fractures must be prescribed

There is an extensive literature that defends the prescription of early therapeutic exercise as the main treatment for radial fractures.

The studies by Krischak et al G 2009 and Gutierrez-Espinoza H et al 2017 argue that patients under 60 years of age and without complications or comorbidities associated with radial fracture can benefit from a home exercise programs correctly prescribed and individualised to the patient’s situation.

These data have been supported in various international Clinical Practice Guidelines (Gimigliano F et al 2020) and systematic reviews (Handoll HHG & Elliot J 2015), where they recommend prescribing NON-supervised exercise programmes for patients ( assuming no co-morbidities or complications appear), having previously been shown that may produce the same results as face-to-face therapy.

Other studies have shown the need to include these exercise programmes early (Zeckey et al 2020 and Brehmer JL et al 2014) to achieve better effects (up to 3-5 days after surgery), with a progressive increase in difficulty. (Brehmer JL et al 2014). This fact is especially important for older people, since short periods of restricted function can lead to irreversible losses in their capacities (Zeckey et al 2020).

Successful recovery from a distal radius fracture depends on an early and individualised exercise programme

We can conclude that current literature maintains that home exercise programmes produce the same results as face-to-face physiotherapy in people under 60 (Gutierrez-Espinoza H, et al 2017) and without comorbidities (Valdes K et al 2014).

In addition, the importance of adherence to treatment for these patients should be stressed. Lyngcoln A et al’s 2004 work showed that 50% of short-term improvements in patients after a radial fracture depend directly on exercise adherence itself.

Sensorimotor disturbance in distal radius fractures

Christos et al. (2013) described how fractures of the distal radius present functional sensory and motor deficits, which impact on the functional ability of the patient, regardless of the treatment received (Conservative/Surgical or if he received physiotherapy and occupational therapy) and which was maintained for 8 weeks.

According those results, a sensorimotor approach is essential in this type of traumatic injury.

Sensorimotor treatment in wrist fractures

In this regard, touch screens have been proposed in different scientific publications for the sensorimotor approach due to their effect at a central level, also allowing more time to be spent on treatment and individualising the treatment to the patient.

In particular, the work performed by Larsen et al (2016) observed changes in corticospinal conduction after manual dexterity practice on a Tablet with a single 30-minute session!

Picture of a patient working at Sensorimotor level with a tablet. Obtained from Larsen et al. 2016.

ReHand in Sensorimotor treatment of wrist fractures

Therefore, ReHand digital tool allows healthcare professionals to prescribe an individualised therapeutic exercise program to their patients. It includes a range of specific exercises that can be selected according to each patient´s pathology. Thus, patients can rehabilitate their distal radius fracture as a single treatment or as a complement to the face-to-face treatment in the clinic.

Example of a patient with a Wrist fracture working his early rehabilitation exercises program with ReHand on a Tablet.

ReHand takes advantage of the benefits of touch screens for the sensorimotor approach, allowing early patient improvement. Its method of calibration and adaptation to the patient, allows the work to be safe and very frequent, so that we can reduce recovery times.

Finally, ReHand, thanks to the fact that the exercises are carried out on the patient’s Tablet touch screen, allows to obtain data on the adherence to the exercises, motivating and empowering the patient in their therapy.

Distal radius fracture and escafolunar dissociation. Early rehabilitation with ReHand.

References

Bonafede M, Espindle D, Bower AG. The direct and indirect costs of long bone fractures in a working age US population. J Med Econ. 2013;16(1):169–78.

Brehmer JL, Husband JB. Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: A prospective, randomized, controlled study. J Bone Jt Surg – Am Vol. 2014;96(19):1621–30.

Caldwell RA, Shorten PL, Morrell NT. Common Upper Extremity Fracture Eponyms: A Look Into What They Really Mean. J Hand Surg Am [Internet]. 2019;44(4):331–4. Available from: https://doi.org/10.1016/j.jhsa.2018.07.012

Gutiérrez-Espinoza H, Rubio-Oyarzún D, Olguín-Huerta C, Gutiérrez-Monclus R, Pinto-Concha S, Gana-Hervias G. Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study. J Hand Ther [Internet]. 2017;30(3):242–52. Available from: http://dx.doi.org/10.1016/j.jht.2017.02.001

Handoll HHG, Madhok R, Howe TE. Rehabilitation for distal radial fractures in adults. Cochrane Database Syst Rev [Internet]. 2006;(3):CD003324. Available from: http://dx.doi.org/10.1002/14651858.CD003324.pub2

Karagiannopoulos C, Sitler M, Michlovitz S, Tucker C, Tierney R. A descriptive study on wrist and hand sensori-motor impairment and function following distal radius fracture intervention. J Hand Ther [Internet]. 2013;26(3):204–15. Available from: http://dx.doi.org/10.1016/j.jht.2013.03.004

Kong L, Zhai Y, Zhang Z, Lu J, Zhang B, Tian D. Radiocarpal joint stiffness following surgical treatment for distal radius fractures: The incidence and associated factors. J Orthop Surg Res. 2020;15(1):1–7.

Krischak GD, Krasteva A, Schneider F, Gulkin D, Gebhard F, Kramer M. Physiotherapy After Volar Plating of Wrist Fractures Is Effective Using a Home Exercise Program. Arch Phys Med Rehabil. 2009;90(4):537–44.

Larsen LH, Jensen T, Christensen MS, Lundbye‐Jensen J, Langberg H, Nielsen JB. Changes in corticospinal drive to spinal motoneurones following tablet‐based practice of manual dexterity. Physiol Rep [Internet]. 2016;4(2):e12684. Available from: http://physreports.physiology.org/lookup/doi/10.14814/phy2.12684

Lyngcoln A, Hons PT, Taylor N, Pizzari T. The Relationship between Adherence to Hand Therapy and Short-term Outcome after Distal Radius Fracture. 2004; 

Maldonado JA, Baena J, Benavente P. Estudio descriptivo de las fracturas del radio distal del adulto en España. Rev Iberoam Cirugía la Mano. 2013;41(01):005–13.

Valdes K, Naughton N, Algar L. Sensorimotor interventions and assessments for the hand and wrist: A scoping review. J Hand Ther [Internet]. 2014;27(4):272–86. Available from: http://dx.doi.org/10.1016/j.jht.2014.07.002

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green´s Operative Hand Surgery. 6 th. Philapdelphia: Elsevier; 2010.

Zeckey C, Späth A, Kieslich S, Kammerlander C, Böcker W, Weigert M, et al. Early Mobilization Versus Splinting After Surgical Management of Distal Radius Fractures. Dtsch Arztebl Int. 2020;117(26):445–51.

Pablo Rodríguez Sánchez-Laulhé

Physiotherapist and Health Researcher.