EARLY ACTIVE MOTION AFTER DISTAL RADIUS FRACTURE: WHY, WHEN AND HOW?

We have to think about before treatment of distal radius fracture.

Despite the high incidence of DRF and the significant time patients with these fractures spend in hand therapy, the types and effectiveness of therapy interventions need to be widely studied in order to identify the practical patterns used in the conservative and post-surgical treatment.

Although not always possible, it is best to initiate therapy while wrist is still immobilized (1). Early therapeutic intervention is especially important in patients with edema that are not resolved quickly. During the proliferative phase scar production is accelerated. As fibrin is deposited, organized adhesion occurs between structures (Joint Capsules, Synovial membranes and fascia layers).

Traditionally, lengthy immobilization has been recommended after surgical intervention in distal radius fracture. Nevertheless, several biomechanical studies offer supporting evidence on carpal kinematics and conclude that there is a minimal implication of the radio-scaphoid and radiolunate during the dart thrower motion. This occurs because the proximal row remains relatively still during midcarpal motion (2) and there is no muscular insertions on proximal row. It is reasonable that early active motion along the dart thrower’s plane of motion can be allowed once a fracture fragment has stabilized, assuming that the ligaments are intact.

Once edema has been controlled at three to five days, hand therapy starts the active dart thrower motion, beginning with a few repetitions several times per day. In order to prevent tendons adherence in zone five, we encourage active patients’ exercises on flexion and extension of MCF, PIF and DIF joints with the wrist in neutral or light extension. 

Therapists must teach the patient to correctly perform exercises avoiding excessively effort of the flexors tendons that will increase the load on fracture site. Patients should be encouraged to undertake these exercises gently. A little ball or similar for encourage handgrip should not be used at this stage.

From a hand therapy point of view, in order to reduce deforming forces on a fresh carpal injury or distal radial fracture, it should be remembered that during the wrist flexion-extension motion, the summed peak wrist extensor forces are significantly less with the wrist in forearm supination than with the forearm in neutral or during active forearm rotation. (3). The extensor carpi radialis longus and flexor carpi ulnaris forces are significantly less in supination than during active forearm motion. During wrist radioulnar deviation motion, extensor carpi ulnaris and flexor carpi radialis force is significantly less with the forearm in supination than in pronation.

In conclusion, as the wrist tendon forces are least in the static forearm supinated position, therefore any hand therapy rehabilitation program should begin with the forearm held in supination.

 

1. Dean W et al. Early Active Rehabilitation for operatively stabilized distal radius fracture. al. J Hand Ther     2004;17:43-49

     2. Moritomo H, Apergis EP, Herzberg G, Werner FW, Wolfe SW, García-Elias M. 2007 IFSSH committee report of wrist biomechanics committee: Biomechanics of the so-called dart-throwing motion of the wrist. J Hand Surg Am. 2007;32:144

    3.   Farr LD, Werner FW, McGrattan ML, Zwerling SR, Harley BJ. Wrist tendon forces with respect to forearm rotation. J Hand Surg Am. 2013 Jan;38(1):35-9