Colles' fractures, named after Abraham Colles who first described in 1814 the common fracture of the last inch of the radius and ulna near the wrist, is a very common consequence of a fall on the outstretched hand (FOOSH). Typical treatment is immobilisation in a plaster of Paris or similar material for five to six weeks to allow bony union, followed by a rehabilitation period of a month or more, a short period of which might involve a wrist brace for comfort during activity. Due to the functional importance of the hand, the period of immobilisation is kept to a minimum to prevent dysfunction of the hand and wrist.
Once the Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.
Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles' fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.
Once the plaster splinting has been removed the wrist may feel it lacks support and the patient may be apprehensive to use it. It is important not to keep the wrist immobilised for too long to prevent complications but early removal means there may be some pain and weakness. A typical forearm wrist brace, often called a futura, is routinely fitted by the physiotherapist to the patient's wrist by Velcro straps, to be worn when doing normal daily activities. The brace is not to be kept on continuously but only for heavier hand work, being taken off the rest of the time and for regular exercise.
If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.
Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.
Urgent treatment is indicated if the hand is extremely painful, tightly swollen and has poor movements, before a pain syndrome develops. At this stage medical review is important to make sure there are no complications with the fracture such as poor healing or lack of healing. Analgesia and contrast baths can help with the pain, desensitisation with the hypersensitive areas which can develop and massage and exercise with the swelling. Patient education is vital so they know they have to work hard and through the pain to rehabilitate their hand. - 14130
Once the Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.
Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles' fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.
Once the plaster splinting has been removed the wrist may feel it lacks support and the patient may be apprehensive to use it. It is important not to keep the wrist immobilised for too long to prevent complications but early removal means there may be some pain and weakness. A typical forearm wrist brace, often called a futura, is routinely fitted by the physiotherapist to the patient's wrist by Velcro straps, to be worn when doing normal daily activities. The brace is not to be kept on continuously but only for heavier hand work, being taken off the rest of the time and for regular exercise.
If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.
Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.
Urgent treatment is indicated if the hand is extremely painful, tightly swollen and has poor movements, before a pain syndrome develops. At this stage medical review is important to make sure there are no complications with the fracture such as poor healing or lack of healing. Analgesia and contrast baths can help with the pain, desensitisation with the hypersensitive areas which can develop and massage and exercise with the swelling. Patient education is vital so they know they have to work hard and through the pain to rehabilitate their hand. - 14130
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.
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