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 hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand.
Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.
After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.
If the progress of the joint is not as expected then the physiotherapist can use joint mobilisation techniques to restore the gliding and sliding movements of the joint. Accessory movements are small movements performed passively on another person and can be done to the midcarpal, radiocarpal and distal radio-ulnar joints. The physiotherapist will hold one side of the joint firmly as they passively move the other side of the joint, either gently and repetitively or more forcefully at the end range of where the joint will allow, pushing against the restriction. The joint can also be placed in the stiff position while the mobilisations are performed.
Wrist strengthening is usually accomplished by general use of the arm gradually more in normal daily life but there are occasions where this is not enough and more needs to be done. There are wrists which don't strengthen up and those who need more strength to perform manual jobs or heavy activities. A hand class can provide guidance to practice the many individual hand movements which must be worked to strengthen up the hand. Working at specially designed pieces of apparatus can work harden or strengthen the muscles involved in grasping, gripping, twisting, pulling, turning and fine hand function.
If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand.
Once the hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand.
Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.
After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.
If the progress of the joint is not as expected then the physiotherapist can use joint mobilisation techniques to restore the gliding and sliding movements of the joint. Accessory movements are small movements performed passively on another person and can be done to the midcarpal, radiocarpal and distal radio-ulnar joints. The physiotherapist will hold one side of the joint firmly as they passively move the other side of the joint, either gently and repetitively or more forcefully at the end range of where the joint will allow, pushing against the restriction. The joint can also be placed in the stiff position while the mobilisations are performed.
Wrist strengthening is usually accomplished by general use of the arm gradually more in normal daily life but there are occasions where this is not enough and more needs to be done. There are wrists which don't strengthen up and those who need more strength to perform manual jobs or heavy activities. A hand class can provide guidance to practice the many individual hand movements which must be worked to strengthen up the hand. Working at specially designed pieces of apparatus can work harden or strengthen the muscles involved in grasping, gripping, twisting, pulling, turning and fine hand function.
If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand.
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 Manchester.
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