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Physiotherapy Department, Royal North Shore Hospital, 2Rehabilitation Studies Unit, Sydney Medical School/Northern, The University of Sydney,
3
Discipline of Exercise and Sport Science, The University of Sydney
Australia
Question: Do dynamic splints reduce contracture following distal radial fracture? Design: Assessor-blinded, randomised
controlled trial. Participants: Forty outpatients with contracture following distal radial fracture. Intervention: The control
group received routine care consisting of exercises and advice for 8 weeks. In addition to routine care, during the day
the experimental group received a dynamic splint, which stretched the wrist into extension but allowed intermittent
movement. Outcome measures: The primary outcomes were passive wrist extension and the Patient Rated Hand Wrist
Evaluation (PRHWE). The secondary outcomes were active wrist extension, exion, radial deviation, and ulnar deviation,
and the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM). All outcomes
were measured at commencement, at the end of 8 weeks of treatment, and at 12 weeks (ie, 1 month follow-up). Results:
The mean between-group difference for passive wrist extension and PRHWE at 8 weeks were 4 deg (95% CI 4 to 12)
and 2 points (95% CI 8 to 4), respectively. The corresponding values at 12 week follow-up were 6 deg (95% CI 1 to 12)
and 2 points (95% CI 5 to 9). There were no sufciently important between-group differences for any of the secondary
outcome measures at 8 or 12 weeks. Conclusion: It is unclear whether dynamic splints following distal radial fracture have
therapeutic effects on passive wrist extension or PRHWE, but they clearly do not have any therapeutic effects on active
wrist extension, exion, radial or ulnar deviation, or on the performance or satisfaction items of the COPM. The ongoing
use of dynamic splints following distal radial fracture is difcult to justify. Trial registration: ACTRN12608000309381.
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Key words: Distal radius fractures, Wrist injuries, Randomised controlled trials, Splints, Contracture,
Physiotherapy
Introduction
Contracture is characterised by reduced active and passive
range of motion and is a common complication of distal
radial fracture. Various physiotherapy treatments, including
splints in conjunction with advice and exercise, are used
in an attempt to reduce contracture (Handoll et al 2006).
Various types of splints are advocated but dynamic splints
are used widely because they provide a low load and
prolonged stretch whilst also enabling functional movement
of the hand (Figure 1) (Flowers and Michlovitz 1988, Colditz
1983). There is good anecdotal evidence and evidence from
animal studies, retrospective reviews (Berner and Willis
2010), and case series (Lucado et al 2008, Lucado and
Li 2009, McGrath et al 2008) to suggest that splints are
therapeutic for reducing wrist contracture after fracture.
However, the effectiveness of dynamic splints has never
been scrutinised within a randomised controlled trial.
There are at least 30 trials looking at the effectiveness of
stretch administered in various ways to different patient
populations (Katalinic et al 2010). Some of these trials
administered stretch through splints. Collectively, the results
of all 30 trials suggest that stretch is ineffective. However,
most of the studies included in the review involved patients
with neurological conditions, and it is therefore not known
if the results of these trials can be generalised to stretch
administered through dynamic splints for contracture of the
wrist following fracture. Therefore, the research question of
this clinical trial was:
Do dynamic splints reduce contracture following distal
radial fracture over and above usual care?
Method
Design
An assessor-blind randomised controlled trial was
conducted. Patients were recruited as they were referred
to physiotherapy at a Sydney metropolitan hospital (Royal
North Shore Hospital) between June 2009 and December
2011. Patients were referred to physiotherapy by consultant
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012. Open access under CC BY-NC-ND license.173
Research
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012 . Open access under CC BY-NC-ND license.
Randomised
(n = 40)
Exp
(n = 19)
66 (56 to 72)
Con
(n = 21)
58 (52 to 65)
4 (21)
15 (79)
8 (38)
13 (62)
18 (95)
1 (5)
16 (76)
5 (24)
11 (58)
8 (42)
9 (43)
12 (57)
10 (53)
9 (47)
0 (0)
25 (11 to 38)
5 (24)
15 (71)
1 (5)
17 (15 to 42)
76 (72 to 108)
83 (74 to 92)
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012 . Open access under CC BY-NC-ND license. 175
Research
Measured passive torque range of motion, active motion, Patient Rated Hand Wrist
Evaluation and Canadian Occupational Performance Measure
Randomised (n = 40)
Week 0
(n = 19)
Lost to follow-up (n = 2)
t did not attend (n = 1)
t declined follow-up
(n = 1)
Week 8
Control group
t exercise
t advice
Lost to follow-up (n = 2)
t did not attend (n = 1)
t unavailable for
measure at 8 weeks
(n = 1)
Measured passive torque range of motion, active motion, Patient Rated Hand Wrist
Evaluation and Canadian Occupational Performance Measure
(n = 17)
(n = 19)
Lost to follow-up (n = 3)
t did not attend (n = 3)
Week 12
Experimental group
t exercise
t advice
t dynamic splint
(n = 21)
Experimental group
t unsupervised exercise
and advice
Control group
t unsupervised
exercise and
advice
Lost to follow-up (n = 1)
t did not attend (n = 1)
Measured passive torque range of motion, active motion, Patient Rated Hand Wrist
Evaluation and Canadian Occupational Performance Measure
(n = 14)
(n = 18)
Results
Flow of participants through the study
The characteristics of the participants in each group are
detailed in Table 1. The ow of participants through the
trial is shown in Figure 3. Four participants were lost to
post-intervention measures at 8 weeks: two each from the
experimental group and the control group. An additional
four participants were lost to follow-up at 12 weeks: three
from the experimental group, and one from the control
group.
Compliance with trial method
There was one notable violation of the trial protocol. One
participant was randomly allocated to the experimental
group but ended up in the control group within 10 min of
allocation because of an error. It is not clear how this error
occurred because the allocation process required a member
of the research team to ring an independent person for each
participants allocation schedule. The independent person
was then responsible for opening an envelope and reading
its content. The contents of the envelopes were checked
on completion of the trial and were correct. Either the
independent person responsible for opening the participants
envelope wrongly read the contents of the envelope to the
member of the research team, or the member of the research
team misheard the participants allocation. Regardless,
176
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012. Open access under CC BY-NC-ND license.
Discussion
This is the rst randomised controlled trial to investigate
the efcacy of splints for contracture of the wrist following
distal radial fracture. The results indicate uncertainty about
whether 8 weeks of wearing a dynamic splint increases
passive wrist extension at 8 or 12 weeks (the 95% CI spans
the sufciently important treatment effect). That is, it is not
possible to rule out a therapeutic treatment effect on passive
wrist extension. The results are similar for the PRHWE
at 12 weeks. In contrast, the results conclusively show no
effect of dynamic splints on PRHWE at 8 weeks and no
effect of dynamic splints on active wrist extension, exion,
radial deviation, or ulnar deviation, and no effect on the
performance or satisfaction items of the COPM at 8 or 12
weeks.
Dynamic splints are believed to reduce contracture because
of the constant low-force stretch provided through the
splint over prolonged periods of time. No clinical trials
have specically looked at dynamic splints for reducing
wrist contracture but case series suggest that other types
of splints that also apply stretch are effective. In particular,
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012. Open access under CC BY-NC-ND license.177
Groups
Outcome
Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012 . Open access under CC BY-NC-ND license.
Passive wrist
extension (deg)
PRHWEa
(point/100)
Active wrist
extension (deg)
Active wrist
exion (deg)
Active wrist radial
deviation (deg)
Active wrist ulnar
deviation (deg)
COPM
performanceb
(point/10)
COPM
satisfactionb
(points/10)
Week 0
Week 8
Exp
Con
(n = 19) (n = 21)
Exp
Con
(n = 17) (n = 19)
Week 12 follow-up
Exp
(n = 14)
Con
(n = 18)
Week 8 minus
Week 0
Exp
Con
(n = 17) (n = 19)
Week 12 minus
Week 0
Exp
Con
(n = 14) (n = 18)
Week 8 minus
Week 0
Exp minus
Con
Sufciently
important
treatment
Week 12 minus
effect
Week 0
Exp minus Con
57
(14)
35
(18)
54
(7)
38
(8)
18
(6)
20
(7)
5
(2)
55
(12)
34
(17)
55
(8)
37
(12)
17
(5)
17
(7)
4
(2)
67
(20)
16
(11)
55
(12)
45
(10)
21
(7)
23
(9)
8
(2)
61
(11)
17
(9)
59
(7)
46
(11)
17
(4)
21
(6)
7
(2)
66
(14)
14
(11)
63
(8)
49
(8)
22
(8)
21
(6)
8
(2)
61
(11)
12
(9)
65
(8)
48
(12)
20
(5)
24
(9)
8
(2)
9
(13)
21
(14)
1
(11)
5
(10)
3
(6)
4
(8)
3
(2)
6
(11)
16
(17)
3
(5)
9
(11)
1
(5)
4
(6)
3
(2)
10
(8)
24
(17)
8
(5)
10
(8)
4
(7)
1
(6)
3
(2)
3
(9)
21
(20)
8
(7)
10
(9)
3
(5)
6
(7)
4
(2)
4
(4 to 12)
2
(8 to 4)
3
(9 to 3)
3
(9 to 4)
4
(1 to 8)
1
(3 to 6)
0.5
(0.7 to 1.8)
6
(1 to 12)
2
(5 to 9)
0
(5 to 4)
0
(5 to 6)
2
(3 to 6)
4
(8 to 1)
0.0
(1.3 to 1.4)
5
(2)
5
(2)
8
(2)
8
(2)
8
(1)
8
(1)
3
(3)
3
(3)
3
(3)
4
(2)
0.4
(0.8 to 1.6)
0.1
(1.1 to 0.9)
10
5
10
10
10
10
2
Exp = experimental group, Con = control group, PRHWE = Patient Rated Hand Wrist Evaluation, COPM = Canadian Occupational Performance Measure. aOne item in the functional domain was
not scored by a participant in the control group and a participant in the experimental group at baseline. This item was excluded from measures at 8 and 12 weeks. bOne item was not scored by a
participant in the control group at 8 weeks. This item was excluded from measures at 12 weeks, and the Week 0 score recalculated with the omitted item.
Research
178
5BCMF Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups.
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Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012. Open access under CC BY-NC-ND license. 179
Research
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Journal of Physiotherapy 2012 Vol. 58 Australian Physiotherapy Association 2012 . Open access under CC BY-NC-ND license.