Management of Distal Radius Fractures

Georgiann F. Laseter, OTR, FAOTA, CHT

Hand Rehabilitation Services,
Dallas, Texas
Peter R. Carter, MD
Clinical Professor
Division of Orthopaedic Surgery
The University of Texas Health Science Center
Dallas, Texas

he discovery of the x-ray was 80 years

T away when Irish surgeon Abraham Colles
published his paper about fractures of the "distal
extremity of the radius." He had no idea about the
possible intra-articular component of this fracture,
but he knew that the fracture was unstable and fre- Groups 1 and 2
Extra-articular without and with
quently settled back to the deformity that "will distal ulna fracture
remain undiminished through life."l The manage-
ment of this very common fracture and its dys-
functional sequelae2- 13 has remained a challenge to
surgeons and therapists alike. Improved treatment
with better functional results and fewer complica-
tions for unstable, intra-articular, displaced, and
comminuted distal radius fractures has been more
vigorously pursued by modern orthopedic sur- Groups 3 and 4
geons and hand surgeons. Intra-articular involving radiocarpal joint
without and· with distal ulna fracture
The more recent literature tends to support a def-
inite correlation between accurate anatomic position
and a more positive functional outcome. 14 - 26 Height-
ened awareness of risk factors for instability, shorten-
ing, and malunion, coupled with better methods of
fixation, has improved functional results.27-35
The references to therapy following distal ra- Groups 5 and 6 .
dius fraCtures in the literature are mixed. In some Intra-articular involving distal radioulnar joint
without and with distal ulna fracture
sources, there is no mention of therapy.2A,3o,32,36-39
Other sources state that therapy is recommended

only if finger and wrist stiffness persist,8,20,40-42 and
that the need for therapy may actually be consid-
ered to be a poor prognostic sign. More contem-
porary sources stress the importance of therapy and
rehabilitation following fracture management with
external fixation or open reduction and internal fix-
ation (ORIF). Typically, however, these references
are brief and general, and provide few specifics
about the therapeutic management. 14,16,18.26.28.32.33,43,44-49
Most hand surgeons and hand therapists agree that
therapy does play an important role in the treat-
ment of these fractures, and therapist-authored
chapters have outlined treatment techniques. 50,51
However, there is no study to document the effect-
iveness of rehabilitation and what impact therapy
may have on the final outcomes.
The treatment goals for any distal radius frac-
ture are anatomic reduction, restoration of joint
congruency, and upper-extremity function with
maximum pain-free wrist and forearm range of motion
.~
Groups I and 8
Intra-articular involving both radiocarpal and
distal radioulnar joints
without and with distal ulna fracture.
FIGURE 1. Frykman's classification of distal radius frac-
tures. Fractures with higher classifications have worse prog-
noses. Modified with permission from: Frykman G: Fractures
of the distal end of the radius, including sequelae-shoulder,
hand, finger syndrome, disturbance in the distal radioulnar
joint and impairment of nerve function. Acta Orthop Scand
SuppI108:1-155,1967.
(ROM) and full movement of the shoulder, elbow,
fingers, and thumb.
IS IT REALLY A IICOLLES' FRACTURE"?

Correspondence and reprint requests to Georgiann F. Laseter,

Colles' original description was that of a distal
OTR, FAOTA, CHT, Hand Rehabilitation Services, 2731 Lem- radius fracture with dorsal displacement, generally
mon Avenue East, Suite 300, Dallas, TX 75204. caused by a fall on the outstretched hand. 1 This is
114 JOURNAL OF HAND THERAPY
 TYPE I
nAOlo·unrAl. "AOIO,Ult4,l"
ARtiCULAR SUltU,C[$ ARTICULAR sun"AC£$

:=-:,-----
-1
4-PART ARTICULAR FRACTURE
I. SltArr
2. RA()I"l STYLOID
.1 OOnSAl MEDIAL
4 PALMAR MEDIAL Minimal comminution - stable
FIGURE 2. Melone's classification of
intra-articular fractures. The medial
fragments with their strong ligamentous TYP~ II
attachments to the carpus and the ulnar Pos 'erior Displacement'
styloid are termed the "medial complex."
Types I and II are reducible. Type III ne-
cessitates percutaneous pinning or exter-
nal fixation. Type IV necessitates open
reduction. Modified with permission
from: Melone CP: Open treatment for Comminuted - stable
displaced articular fractures of the distal Displacement of medial complex:
radius. Clin Orthop 202:103-111,1986. Posterior: die-punch. Barton Anteriov: Smith

TYPE III TYPE IV

~."~:":::.~"
t1llJ:=:
~~...n"lOl'. '-.
nOIAflOH

Displacement of medial complex as Wide separation or rotation of the

a unit + anterior spike dorsal fragment with palmar fragment
rotation

one of the most common fractures, and many times
is minimally displaced, extra-articular, and stable.
Treatment with cast immobilization for these stable
fractures is usually adequate and effective. 52.53 Re-
sidual deformity is minimal, complications are un-
usual, and full function generally returns. This pa-
tient population, however, is largely unknown by
many hand surgeons and most hand therapists!
While the eponym ''Colles' fracture" may be
appropriate for a stable fracture, a significant per-
centage (up to 25%) do not fit this description. An
increasing number of reports 19•30,32.35,54 and the au-
thors' clinical experience involve treatment of pa-
tients with unstable fractures. Often these fractures
are complex with intra-articular components and
are sustained during "high-energy," often sports-
related, activities by younger patients or a more ac-
tive elderly population. Fractures of the distal ra-
dius are not limited to "little old ladies" anymore!
In higher-impact injuries with the wrist in
extension, there is increased tension on the volar
surface and increased compression on the dorsal
surface, leading to more dorsal comminution.
Sometimes a compression force exerted by the lu-
nate on the distal radius produces a depressed frac-
ture of the lunate fossa-the so-called "die punch"
fracture. 5 More lateral compressive forces exerted
by the scaphoid can cause a scaphoid fossa depres-
sion fracture.
Ulnar styloid fractures occur commonll,4.7,55
with distal radius fractures. The stability of the dis-
tal radioulnar joint cannot be reliably predicted
from the size or location of the ulnar styloid frac-
ture. This is best determined by examination under
anesthesia after stabilizing the radius.
BEYOND COLLES': DISTAL RADIUS
FRACTURE CLASSIFICATION
SYSTEMS
In an attempt to be more definitive and to as-
sist the surgeon in diagnosis and selection of treat-
ment, fracture classification systems have been de-
veloped based on the extent of extra-articular and
intra-articular patterns. No one classification sys-
tem, however, is commonly accepted, since none of
them describes all fracture patterns, accounts for
the varying degrees of comminution, or has consis-
tent prognostic value. 56 By becoming more familiar
with the more commonly used classification sys-
tems, hand therapists may be able to communicate
more effectively with the referring surgeon. An im-
proved understanding of the functional impact of
articular injuries may help better define realistic
goals and treatment plans. Although others have
been developed, the most commonly used are the
Frykman, Melone, and ASIF (or AO) classifications.
April-June 1996 115
 A EXTRAaART1CUlAR: Fractures neither affect the ar·
tlcular surface of the radiocarpal nor the radioulnar
jOints.
A 1 Extra-articular fracture, of the ulna, radius Intact
B SIMPLE ARTICULAR: Fracture affects a portion of Ihe
articular surface. but the continuity of the metaphysiS COMPLEX ARTICULAR: Fracture affects the joint Sl
and epiphysis is intact faclS (radio-ulnar andlor radio-carpal) and It
metaphyseal area

"
B 1 Partial articular fracture, of the radius. sagittal
Cl Complete articular fractura, of the radius.

~ ~ &1
II
II
II
"
II
II
II
II
articular simple. metaphyseal simple
1 , I I
v, -V.l v.l
~I ~" ~"
II
.,. J : .... / { .:.:::./ (
1 styloid process 1 lateral simple .' . J "OJ
, ....
' ,
"'"
I "
2 melaphyseal simple 2 lateral multilragmentary
3 melaphyseal multifragmentary 3 medial
(0' " ...... . 1
(Do', , ~ I e~)
B2 Partial articular Iracture. 01 the radius, 1 postero·medial articular Iragment
A2 Extra-articular fracture, of the radius.
dorsal rim (Barton) 2 sagittal articular fracture line
simpla and Impacted
3 Iron tal articular fracture line

!)I
Il

~
II
I II
I
~' II
--. I I
0'," \
II
, .,4.•,1 .JI C2 Complete articular Iracture. of the radius.
.1
ertlcular simple. metaphyseal multilragmentary
,I.
J

lJJl
II

~
1/ ~'
. II.
~, &J2 I simple
2 with lateral sagittal fracture
•
II
j
II
)
1 without any tilt
2 with dorsal tilt (Pouteau-Colles) 3 with dorsal dislocation of the carpus
COI,],I
3 with volar tilt (Goyran-Smith)
1 sagittal articular fraclure line
2 frontal articular fracture line
83 Partial articular fracture, of the radius, volar rim
3 exlending inlo Ihe diaphysis
A3 Exlra-artlcular Iracture. 01 the radius,
multilragmentary (reverse Barton, Goyrand-Smith II)
C3 Complete articular fracture. 01 the radius,

~
'

tl·
II multi fragmentary

~
II ' II
II
J
~'' -- ~'
.": J I
~,' I ,-J "I'
I'

, It
II

:I.J'
,I
"

~l
II
~ . ,:" I : I

V.I
( . J
~I

I simple. with a small fragment

E!8(J .l CJ(J6'_' _l QSD:-'. )
1 impacted with axial shortening 2 simple. with a large Iragment
2 with a wedge 3 mUllifragmentary 1 metaphyseal simple
3 complex 2 metaphyseal mullifragmentary
3 extending inlo Ihe diaphysis

FIGURE 3_ The AD distal radius fracture classification. Division of the distal radius fracture into three basic types (A, B, C),
each with 9 main groups and 27 subgroups, can, with documentation of ulnar lesions, produce 144 possible combinations of distal
radius fractures. Increased severity, difficulty of management, and a worse prognosis occur in the progression from Al to C3.
Adapted with permission from: Fernandez D, Jupiter J. Fractures of the Distal Radius: A Practical Approach to Management.
New York: Springer-Verlag, 1995, copyright 1995 by Springer-Verlag New York, Inc.

Cited most frequently in the literature is that injury as a separate entity and focuses on fracture
of Frykman/ who established 8 categories empha- patterns (Fig. 2). It defines a 4-part articular fracture
sizing the difference between intra-articular and ex- consisting of the radial shaft, the radial styloid, the
tra-articular fractures and involvement of the ulnar dorsal medial fragment, and the palmar medial
styloid (Fig. 1). Frykman's system does not specify fragment.
the extent of articular displacement or comminu- The Association for Study of Internal Fixation
tion, nor does it take into account deforming forces. (ASIF) classification 5.ystem (also known as the AO
Melone's classification29•36 views intra-articular system)57 differeI1tiates the simple fractures from

I Extra-articular I r--------.------Intra-arlicular - - - - - - . ,

undlsr
aCed
iDiSPlaCed I Undlsplaced Complex Displaced Displaced

I I
(reduced) (unreducible)
I I
Cast immobilization Stable Unstable Cast immobilization Open versus External fixation Open reduction

I I I (percutaneous pins)
I
Arthroscopic versus External fixation
Cast immobilization· Percutaneous pins· I
Closed reduction K-wires

ExternaJ fixation T·plates

• Kapandji and Depalma/Rayhack
Bone graft

I
Supplemental K·wires

I
(intracarpalligament repair)

FIGURE 4. Treatment algorithm for distal radius fractures. Reproduced with permission from: Cooney Wp, Berger RA: Treat-
ment of complex fractures of the distal radius. Hand Clin 9:603-612, 1993.
116 JOURNAL OF HAND THERAPY
those with more increasingly complex articular
fragmentation and metaphyseal comminution as
well as associated ulna fractures (Fig. 3).

IS IT STABLE? OR UNSTABLE?
It is critical very early in treatment to diagnose
patterns of displacement and articular fragmenta-
tion, which may be the markers of instability.17,36
This principle seems obvious, but it is often over-
looked and delays and may compromise ideal
treatment, The algorithm detailed by Cooney and
Berger17 illustrates some of the diagnostic and treat-
ment challenges to be considered with distal radius
fractures (Fig. 4).
Stable fractures generally have minimal com-
minution, have less angulation or displacement,
and usually have no involvement of the radiocarpal
or radioulnar joints. Unstable fractures tend to have
significant volar or dorsal comminution, extension
of the fracture into the radiocarpal joint with a ten-
dency toward lateral displacement of the radial sty-
loid and depression of the lunate fossa fragment. 8
The fracture may involve the radioulnar joint with
OORSAL JIll Of COIlES' fRAClURE
or without fracture of the distal ulna. NORMAL PAlMAR 1111

With unstable fractures, it is usually possible to

achieve fracture reduction, but hard to maintain it. 38
This type of fracture necessitates more aggressive
treatment-pins and plaster, external fixation,· or
internal fixation-and cannot be maintained by
only a cast.58 Displacement and loss of position in
the majority of distal radius fractures usually occur
within the first 2 weeks of immobilization.59,6o One
complication that is rarely associated with cast
treatment of these fractures is a nonunion. 55 If the
fracture is unstable and reduction cannot be main-
c
tained, the fracture settles into its position of in-
herent stability and heals quickly.60 The opportunity
for prompt restoration of exemplary function is FIGURE 5. Restoration of radial angle, palmar tilt, radial
lost. The stage is set for the cascade of complica- length, and joint congruency is important in distal radius frac-
tions well known to the experienced therapist: de- ture functional outcomes. (A) Normal ulnar tilt of the distal
formity; stiffness of the fingers, wrist, forearm, and radius is 23 degrees to a line perpendicular to the long axis of
shoulder; and prolonged loss of functional capabil- the radius. (B) Normal palmar tilt is 11 degrees to a line per-
ities. pendicular to the long axis/of the radius; dorsal angulation
and loss of palmar tilt due to Calles' type distal radius fracture.
(C) Loss of radial articular angle and radial length in Calles'
THE SHAPE AND ALIGNMENT OF fracture. Reprinted with permission from: Frykman G, Kropp
W: Fractures and traumatic conditions of the wrist. In Hunter
THE DISTAL RADIUS REALLY DO I, et al (eds): Rehabilitation of the Hand, 4th Edition. St. Louis,
MATTER Mosby, 1995.

Even though there are reports of some cases of
malunion and residual deformity with surprisingly
good lunction,6,61 careful studies of large groups of
patients have shown that obtaining and maintain-
ing accurate reduction correlate positively with im-
proved outcomes. 22 - 24,29-32 Restoration of the radial
angle, palmar tilt, radial length, and joint congru-
ency definitely impacts final wrist function. Exces-
sive dorsal angulation, radial shortening, and intra-
articular joint incongruency are the major factors in
poor outcomes.
Radial tilt (normal average 23 degrees) (Fig.
SA) has often been found to have less impact on
functional outcome than do some of the other an-
atomic parameters. 12 However, Jenkins and Min-
towt-Czyz13 found a positive correlation between
flattening of the radial angle and a decrease in grip
strength.
When there is a fracture with a loss of palmar
tilt (normal average 11 degrees) (Fig. SB) and a re-
sultant dorsal angulation, the wrist may appear de-
formed 14 and ROM is often limited. 62 Even small
losses of palmar tilt may cause midcarpal instabil-
ityll and shift the hand axis out of alignment with
the forearm. Dorsal angulation ranging from 10 de-
grees up to 45 degrees changes the load on the ulna
April-June 1996 117
 TABLE 1. Demerit Point System Used To Evaluate End Accurate reduction of intra-articular fractures
Results of Healed Colles' Fracture"
is also very important. In a retrospective analysis,
Points Knirk and Jupiter30 found that even very small step-
Residual deformity offs of 1 mm or more result in a high (nearly 65%)
Prominent ulnar styloid 1 rate of traumatic arthritis. Bradway and col-
Residual dorsal tilt 2 leagues31 concur that those wrists with 2 mm or
Radial elevation of hand 2-3 more of intra-articular incongruity are at higher
Point range 0-6
risk for development of posttraumatic arthritis.
Subjective evaluation There is a high incidence of distal radioulnar
Excellent: no pain, disability, or limitation joint injuries associated with unstable, significantly
of motion o displaced distal radius fractures. Results of recent
Good: occasional pain; slight limitation of biomechanical studies65 suggest that ulnar styloid
motion; no disability 2
Fair: occasional pain; limitation of motion; fractures alone change the load in the wrist very
feeling of weakness; activities slightly little. Some studies report that these are not usually
restricted 4 significanf· 12.20 unless associated with instability of
Poor: pain; limitation of motion; disability; the distal radioulnar joint. However, other investi-
activities more or less restricted 6
gators cite poorer overall outcomes associated with
Objective evaluationt ulnar styloid fractures.14.16.22.30
Loss of dorsiflexion 5 Specific parameters have not been established
Loss of ulnar deviation 3 for just how much deformity can result in an ac-
Loss of supination 2 ceptable outcome after the treatment of distal ra-
Loss of pronation 2
Loss of palmar flexion 1 dius fractures. Further biomechanical studies of the
Loss of radial deviation 1 wrist and information derived from clinical studies
Loss of circumduction 1 are helping to answer some of these questions and
Pain in distal radioulnar joint 1 further define treatment guidelines.
Grip strength 60% or less of opposite side 1

Complications
Arthritic change REPORTING OUTCOMES: DISTAL
Minimum
Minimum with pain
1
2
RADIUS FRACTURE OUTCOME
Moderate 3 SCORING SYSTEMS
Moderate with pain 4
Severe 4
Severe with pain 5
As with the fracture classification systems, no
Nerve complications 1-3 one particular outcome scoring system is univer-
Loss of finger motion 1-3 sally accepted. The most commonly used are the
Point range 0-10 Gartland and Werley and the modified Green and
End result point range O'Brien scoring systems. 66
Excellent 0-2
Good 3-8 The rating system of Gartland and WerleY·37 is
Fair 9-20 less stringent in regard to motion and strength re-
Poor 21+ quired to achieve a good or excellent result. Resid-
*Reprinted with permission from: Sarmiento A, Pratt GW, Berry
ual deformity, subjective complaints, and arthritic
NC, Sinclair WF: Colles' fractures-functional bracing in su- changes all factor into the final score (Table 1).
pination. J Bone Joint Surg Am 57:311-317, 1975. The system of Green and O'Brien, as modified
tObjective evaluation is based on range of motion. The mini- by Cooney and coworkers/7 does not take radio-
mum required for normal function: dorsiflexion, 45 degrees; graphic changes into cons~deration, but requires
palmar flexion, 30 degrees; radial deviation, 15 degrees; ulnar higher levels 6f function and better ROM and
deviation, 15 degrees; pronation, 50 degrees; supination, 50 de- strength for an excellent result (Table 2).
grees.

and medial-sided wrist structures from approxi-

mately 20% to more than 65%?
Radial shortening (Fig. 5C) is one of the most
common and disabling deformities associated with
distal radius fractures. lO•25 Even slight shortening of
the radius alters the transmission of axial forces
across the wrist. 64 Steffen et al. 16 reported slight de-
creases in flexion, ulnar deviation, and pronation.
Shortening of 6 mm or more also affects forearm
rotation,s5 but lesser amounts of shortening-3-5
mm-have been demonstrated to be a factor in re-
duced grip strength. In a study with 3-year follow-
up, Villar and Marsh12 reported a 35% decrease in
grip strength for patients who had only 5 mm of
shortening.
118 JOURNAL OF HAND THERAPY
THE STABLE FRACTURE:
CONSIDERATIONS FOR REDUCTION
AND IMMOBILIZATION
Extra-articular, stable, minimally displaced
fractures with no comminution are usually treated
effectively with close reduction and immobiliza-
tion. Care should be taken with cast application to
ensure that the cast is comfortable and well-padded
over the distal ulna, and that full movement of the
metacarpophalangeal (MP) joints is possible. The
x-ray may look fine, but when the patient says that
the cast doesn't feel fine, prompt attention to this
complaint is required. Many of the well-known
complications of finger stiffness, carpal tunnel syn-
drome, and reflex sympathetic dystrophy start with The merits of immobilizing the elbow either in
an improperly applied or too tight cast, particularly pronation or supination, and different types of casts
when the patient's complaints are not promptly ad- and braces, have been the subject of studies.37,4o,7o
dressed. 2,3,lo There is no consensus among orthopedists for any
The usual position of immobilization is with one method. Even the time of immobilization is
the wrist moderately flexed and in ulnar deviation. controversial. Various authors have recommended
Theoretically, the flexed position of the wrist uses from as little as 3 weeks to 8 weeks of immobili-
the dorsal soft tissues and the intact dorsal perios- zation. 40,58,68,70
teum of the radius as a hinge to maintain the re- What is the "bottom line?" The quality and sta-
duction the fracture. Unfortunately, prolonged bility of the reduction would seem to be the most
wrist flexion can have a most deleterious effect on important factor. 71 Immobilization with the wrist in
hand and finger function. 68 Gelberman et al. 69 mea- more than 20 degrees of flexion should be avoided,
sured carpal tunnel pressures in relationship to and problems with casts must be addressed im-
wrist position in patients with Colles'-type frac- mediately and rectified.
tures. They concluded that neutral was the safest
position for the median nerve. Forty degrees of flex-
ion was found to increase the carpal tunnel pres-
sure on the median nerve to dangerous levels. THE UNSTABLE FRACTURE:
The traditional position of immobilization has TREATMENT OPTIONS
been challenged by Gupta,68 who found a lower in-
cidence of loss of anatomic reduction and improved
hand function with the wrist immobilized in 20 de- The unstable fracture necessitates more than
grees of extension. plaster to maintain reduction. Unfortunately, many
surgeons determine fracture stability by loss of re-
duction in the cast. This is frequently insidious and
TABLE 2. Modified Clinical Scoring System* may occur gradually over a period of 10-14 days
Score or later. At 3 weeks, many of these fractures have
Category (Points) Findings slipped to their position of inherent stability and
Pain (25 points) 25 None have begun to heal in a malunion. Stewart et al. 20
20 Mild, occasional identified a means of scoring the fracture prior to
25 Moderate, tolerable treatment to help estimate the risk of collapse in
o Severe or intolerable plaster. These factors include dorsal comminution,
radial shortening, dorsal tilt, and intra-articular dis-
Functional status 25 Returned to regular employment placement. The risk of collapse increases directly in
(25 points) 20 Restricted employment proportion to the number of risk factors present. 72
15 Able to work but unemployed Early recognition of potential instability using the
o Unable to work because of pain pre-reduction x-ray is the key to proper treatment of
these distal radius fractures.
Range of motion Percentage of normal In the 1970s, especially following Green's
(25 points) 25 100 work, pins and plaster were used to provide trac-
15 75-99 tion to augment closed reduction with cast immo-
10 50-74
25-49
bilization; Melone has continued to use and rec-
5
o 0-24 ommend this method. For the most part, the
Dorsiflexion-plantar flexion arc favored technique of the 1980s has been the use of
injured hand only) a wide variety of external fixators. More recently,
25 120° or more improved techniques of ORIF have begun to show
15 91°_119°
10 61°-90° improved outcomes especially in severely commi-
5 31°_60° nuted, displaced, intra-articular distal radius frac-
o 30° or less tures.

Grip strength Percentage of normal Pins and Plaster

(25 points) 25 100
15 75-99
10 50-74
5 25-49 Popularized by Green8 in the 1970s, incorpo-
o 0-24 rating pins into a plaster cast is indicated when an-
atomic reduction can be obtained by traction. How-
Final result
ever, pin tract infections, loosening of the pins,
Excellent 90-100 problems associated with circumferential plaster,
Good 80-89 and lack of adjustability are the disadvantages with
Fair 65-79 this treatment. Restoration of adequate palmar tilt
Poor <65 is often not achieved with this treatment. 8,44,52 The
*Reprinted with permission from Cooney WP, Bussey R, Do- pins are usually removed at 8 weeks postsurgery.
byns JH, Linscheid RL: Difficult wrist fractures. Perilunate frac- Wrist motion is difficult to regain, especially if an
ture-dislocations of the wrist. Clin Orthop 214:136-148, 1987. intra-articular fracture was present.
April-June 1996 119
External Fixation
External fixation of unstable distal radius frac-
tures is the method that has largely superseded
treatment with pins and plaster. The array of exter-
nal fixation devices in use have their own strengths
and weaknesses as well as cost differences. 47,73-76
Like pins and plaster, external fixation is based on
the principle of ligamentotaxis, in which fracture
fragments are brought into alignment by traction
applied across the fracture through the capsuloli-
gamentous structures. 77,78 Rarely does this traction
completely reduce the dorsal angulation of the dis-
tal fragment back to normal volar tilt. 36,79 Often re-
duction and supplemental ~ercutaneous pinning of
this fragment are required. ,80
Treatment of unstable, displaced distal radius
fractures with external fixation has yielded more
satisfactory final radiographs, but also has been as-
sociated with complication rates-as high as 62%
in the studies reviewed. 14,15,27,41,43,80-82 Complications
include a high rate of pin tract infections, iatrogenic
fractures of the metacarpals, and even nonunion of
the distal radius fracture. Other complications en-
countered include: median neuropathies, irritation
of the dorsal sensory branch of the radial nerve,
reflex sympathetic dystrophy, finger stiffness, and
damage to the finger and wrist tendons as well as
the intrinsic muscles of the hand.
Recommendations for periods of immobiliza-
tion with the external fixator average about 8
weeks. If traction is discontinued before this, the
fracture often re-displaces, since healing times are
prolonged with traction. Because many of these
fractures are intra-articular, the wisdom of 8-10
weeks of traction is questionable.
Open Reduction and Internal Fixation
Complex articular fractures in which the frag-
ments are rotated, displaced, or impacted may be
impossible to reduce by traction or other closed
means. 29 - 31 Those fractures with persistent articular
stepoff necessitate ORIF. 17,18,30 In most other areas of
the skeleton, accurate stable reduction of intra-ar-
ticular fractures with bone grafting and rigid fixa-
tion followed by early motion has been shown to
hasten healing and improve functional outcomes.
This has been clinically demonstrated even in
some fractures of the distal radius such as the volar
Barton's anterior lip fracture dislocation. 83 Anterior
plate fixation of these fractures has been the stan-
dard of care for over a decade. Until recently, or-
thopedic surgeons have avoided the dorsally dis-
placed, unstable distal radius fracture. However,
improved techniques and new tools such as low-
profile plate designs and sterile traction operating
tables are making ORIF more predictable. The au-
thors' early experience with these devices suggest
that even severe dorsally displaced fractures of the
Frykman types VII and VIII and the AO types C2
and C3 can be stabilized. The stability achieved in
many cases is adequate to initiate motion of the
120 JOURNAL OF HAND THERAPY
wrist and hand within the first week postopera-
tively.54
The incorporation of early movement of the
wrist in patients undergoing ORIF requires specific
therapeutic management with close communication
between surgeon, therapist, and patient. The pa-
tient's progress and activity level require careful
monitoring and a very specific exercise program. At
first, the wrist is protected in a splint except for
removal for skin care and performance of exercises.
Weaning from the splint begins at approximately
3-6 weeks postsurgery when the first sign of clin-
ical union appears as the clinical tenderness at the
fracture site subsides. Efforts to reduce edema, con-
trol pain, and quickly maximize finger and thumb
ROM are the same as those for fractures treated by
other methods.
REHABILITATION FOLLOWING
DISTAL RADIUS FRACTURES
It is a sign of the times that a discussion about
rehabilitation of distal radius fractures begins not
with therapeutic and anatomic considerations but
instead with factors related to the delivery of hand
therapy services in a "managed care" environment.
The trend in managed care is limitation of the
actual number of treatments (6.7 visits per referral
for upper-extremity problems, according to one
source)85 or the length of treatment time-30-60
days maximum "per condition" in many cases. A
problem arises in the management of distal radius
fractures in that maximum functional improvement
often does not occur for many months. Stable frac-
tures with minimal or no complications usually
reach maximum improvement at about 6 months
postinjury.20,53 Some sources indicate continued
improvement from 1 yeay39.41 to approximately 2
14
years ,30 postfracture. In some cases, benefits for
therapy may expire even before the wrist is ready
to be mobilized!
Therapist, surgeon, and patient are now chal-
lenged with th~ task of completing distal radius
fracture rehabilitation in a time frame not compat-
ible with healing and functional recovery. The is-
sues of patient compliance and the therapist's role
as an educator86 are especially pivotal in the treat-
ment of distal radius fractures. Patient education
and participation in a home program must have
increased focus. Our challenge is to forge a collab-
orative rehabilitation effort with a paradigm shift
from what we can do "to" the patient to what the
patient can do "for" himself or herself to achieve a
satisfactory end result.
Acute Intervention
The optimum situation is to initiate therapy
while the wrist is still immobilized. 51 The goals are
to maintain full shoulder and elbow ROM and to
achieve full finger and thumb ROM by the time the
wrist is ready to be mobilized.
 Early control of edema and pain are of para-
mount importance in eliminating and preventing
joint stiffness and dysfunction, which can quickly
become chronic problems. Active ROM of the
shoulder and elbow needs to be maintained and
full movement of the fingers and thumb must be
re-established as soon as possible. It is important to
encourage functional use of the affected extremity
but always within the limits of pain, swelling, and
tissue reactivity.
Edema Control
Rapid resolution of edema is critical because
swelling decreases mobility, impedes the blood
supply, and can lead to the formation of scar tis-
sue. 87,88 The primary method of combating edema
is elevation. The therapist must insist on it! To be
properly elevated, the hand needs to be above the
elbow and the elbow above the heart regardless of
whether the patient is lying, sitting, or standing. Be
very explicit in these instructions and provide ex-
amples of proper as well as improper elevation.
Commercially available foam positioning devices
make it easier to keep the arm elevated while sleep-
ing.
Shoulder ROM is important not only for pre-
vention of stiffness but for edema reduction as welL
The patient should be instructed to "salute" the
ceiling hourly. Immobility blocks the outflow of the
veins and lymphatic system in the axilla, thus in-
creasing edema in the hand. As the edema in the
hand increases, the motion decreases; a vicious cir-
cle of edema and shoulder and hand stiffness can
occur. Early recognition and prompt treatment of
symptoms of edema, pain, stiffness, and vasomotor
disturbances are needed to alter the dysfunctional
cycle that can result in one of the worst complica-
tions of a distal radius fracture-reflex sympathetic
dystrophy.
The use of a sling should be avoided because
it promotes shoulder and elbow stiffness, does not
properly elevate the hand, and discourages func-
tional use of the upper extremity. The patient
should be allowed to wear a sling only for short
periods when protection is needed in crowded,
public situations.
Prolonged flexion of the elbow in positions of
arm elevation may result in symptoms of ulnar
nerve irritation such as increased pain and tingling
in the small finger. 89 Make the patient aware of this
potential problem and suggest positions of arm ele-
vation that minimize elbow flexion.
Distal-to-proximal massage assists in reduction
of edema and also provides tactile input. 87 If the
edema is not controlled by elevation and massage,
elasticized wraps such as Coban (3M, St. Paul, MN)
or elasticized finger sleeves can be used to help re-
duce digital edema. Massage should be performed
before the application of any compressive wrap and
before exercises.
Range of Motion
Range of motion of the uninvolved joints as-
sists in edema reduction by transporting fluid prox-
imally via the pumping action of the muscles,
prevents tendon adherence, and maintains joint
mobility. Full active flexion and extension of the fin-
gers and the thumb are encouraged and should be
sustained for 10 seconds and repeated 5-10 times
hourly. Nonspecific, fluttering movements aren't
good enough!
The flexed position of the wrist in the cast or
external fixator may prohibit full excursion of the
finger flexor tendons. Full digital flexion may also
be limited by extensor tendon adherence. The pa-
tient should be instructed in individual tendon
gliding exercises for the superficialis and profun-
dus tendons as well as hook fisting for isolation of
the digital extensors and interphalangeal (IP) joint
flexion. Abduction and adduction of the fingers
and isolated movements of the hypothenar and the-
nar muscles should be stressed as well. The intrin-
sic muscles should be stretched because dorsal
edema resulting from a distal radius fracture can
cause intrinsic contracture.
If joint stiffness persists, gentle passive ROM
exercises are initiated. There should be no painful
passive manipulation! The most needed areas of
emphasis are usually MP joint flexion, proximal IP
joint extension, and stretching of the first web
space.
Shoulder ROM should emphasize abduction,
flexion, and external rotation. If the patient is ini-
tially in a long arm cast, elbow exercises with the
focus on reestablishing extension begin when the
immobilization is changed to a short arm cast.
Therapist and patient need to work together to
design a home program taking into consideration
individual needs in relationship to the injury and
lifestyle demands of the patient. 90 The instructions
should contain explicit details regarding number of
repetitions, frequency, and how to alter it if pain
and swelling increase. This serves a dual purpose.
First of all, it helps the pafient accept his or her role
in this rehabilitation partnership.53 Second, it is eas-
ier to exercise clinical judgment about changes
needed in the rehabilitation program if progress ex-
hibited on reevaluation is based on some known
quantity of performance.
Pain Management
The therapist should be a vigilant observer for
the causes of increased pain. For instance, edema
may have increased, the cast may be too tight, or
signs of nerve compression may become evident.
When identified as a factor in the patient's pain, it
needs to be treated promptly.
It is also necessary to watch for signs of in-
creased sympathetic reactivity such as redness over
the dorsum of the joints, a shiny, wax-like character
of the skin, and swelling and stiffness of the fingers
that don't seem to be resolving. Even if the patient's
April-June 1996 121

FIGURE 6. An ulnar gutter-support splint fabricated for
use with an external fixator. The transverse arch is supported,
full motion of the thumb and fingers is allowed, and the length
can vary from short to above the elbow, contingent on the need
to limit forearm rotation.
FIGURE 7. A thermoplastic thumb web-space splint around
an external fixator. Care should be taken to avoid undue stress
on the ulnar collateral ligament of the metacarpophalangeal
joint.
pain does not seem out of proportion to the injury,
these symptoms could signal impending reflex
sympathetic dystrophy. Be alert for descriptive ad-
jectives such as "burning" or comments that the
hand "feels like it's running a fever," because these
can be warning signs of reflex sympathetic dystro-
phy. Treatment of these symptoms in the early
stages results in a better chance to reverse them
and avoid their well-known dysfunctional conse-
quences. 91,92
Pay particular attention to changes in sensibil-
ity and pain related to the median nerve distribu-
tion, which may indicate development of carpal
tunnel syndrome. A baseline sensory evaluation
should be done to measure changes that might oc-
cur early or late in treatment. The Semmes-Wein-
stein monofilaments have demonstrated better re-
liability than 2-point discrimination testing in
assessment of nerve compression syndromes. 93
There are other important subjective and psy-
chological components of pain that physicians and
therapists can't control, but can at least influence
with a positive, supportive approach.94 Pain can be
difficult to assess, measure, and describe. It is im-
PQrtant to acknowledge that the pain is real and to
reassure the patient that it will get beUer. These re-
assurances must be reinforced by instructions in
elevation, massage, and exercises that will empower
the patient to alleviate the pain.
Troubleshooting: Problems Inherent with
Immobilizing Devices
If the wrist is immobilized in a cast, most of
the problems encountered are due to fit problems
122 JOURNAL OF HAND THERAPY
with the cast itself. The cast should allow full
movement of the thumb and MP joints of the fin-
gers, especially on the ulnar half of the hand. There
should be no circumferential constriction or undue
pressure on the distal ulna. Any rough edges that
might irritate the skin should be smoothed.
There is a high rate of complications with ex-
ternal fixators, many of which are related to the
pins. Regardless of the cleansing agents used, the
importance of meticulous pin tract care throughout
immobilization must be reinforced for the patient.
The percutaneous pin fixation of the external fixator
usually transfixes the second and third metacarpals
and the distal radius. This provides distraction of
the fracture and allows visual observation of any
open wounds. Because it is situated along the lon-
gitudinal or fixed arch of the hand, it does not give
support to the mobile transverse arch. To improve
patient comfort and provide support to the trans-
verse arch, a support splint can be helpful (Fig. 6).
It is usually fabricated as an ulnar gutter, closely
conformed in the palm, yet allowing full motion of
the thumb and digits. The length can vary from
short to above the elbow depending on the involve-
ment of the injury or the surgeon's desire to limit
forearm rotation.
The position of many external fixators often
blocks radial abduction and extension of the thumb
and flexion of the index finger. A contracture of the
first web space may not improve adequately with
exercises alone. A thermoplastic web spacer can be
fabricated and fit over the cast or around the exter-
nal fixator (Fig. 7). Care should be taken to avoid
stressing the ulnar collateral ligament of the MP
joint of the thumb. When edema is a bigger prob-
FIGURE 8. If the hand is quite edematous or not tolerant
of hard thermoplastic, a foam web spacer can be used. A piece
of foam 2" X 1" X 6" is tied in the center with length of
Surgitube. Insert into the web and wrap the remaining Sur-
gitube around the wrist in a "figure 8" and tie with a bow.
Reprinted with permission from: Colditz J: Practice forum: Soft
splinting technique for maintaining thumb abduction. J Hand
Ther 4:22, 1991.
lem or the patient has trouble tolerating the hard-
ness of the thermoplastic, a simple splint made
from a piece of foam rubber can help improve
thumb abduction95 (Fig. 8).
When It's Time to Move the Wrist ...
Hopefully, problems with pain, edema, and
ROM of the uninvolved joints have been resolved
by the time the wrist is ready to be mobilized. Pa-
tient education continues to focus on compliance
and the primary role of the patient in rehabilitation.
The anatomy relevant to movement and function of
the wrist and the rationale for the exercise and
splinting programs should be detailed.
Prior to mobilization, the therapist should have
better information about the radiographic status of
the wrist other than "it's healed in pretty good po-
sition." Knowledge of the amount of residual flat-
tening of the radial angle, dorsal angulation, radial
shortening, the presence and amount of any artic-
ular step off, and problems with the distal ulna are
needed to help formulate more realistic expecta-
tions for reestablishment of ROM. Being able to dif-
ferentiate loss-of-motion factors that mechanically
block movement and alter joint spaces from those
that result from soft-tissue restriction helps plan the
course of therapeutic intervention. 96
The severity of the injury and the success of
the reduction are important factors in the final out-
come. At this point in rehabilitation for many of
these fractures, the therapist may need to help
change the patient's focus from achieving "normal"
ROM to a more realistic goal of pain-free move-
ment in a functional range.
Normal wrist ROMs are 140 degrees of flex-
ion/ extension and 150 degrees of supination/ pro-
nation. Palmer and associates97 determined that
most activities of daily living could be performed
with wrist motion of 30 degrees of extension, 5 de-
grees of flexion, 10 degrees of radial deviation, and
15 degrees of ulnar deviation. Ryu et a1. 98 found
that a majority of activities of daily living could be
performed with 40 degrees of extension, 40 degrees
of flexion, and 40 degrees of combined motion of
radial and ulnar deviation. The Gartland and Wer-
lef,37 scoring system to evaluate end results of
healed Colles' fractures requires minimum ROMs
of 45 degrees of extension, 30 degrees of flexion, 15
degrees each of radial and ulnar deviation, and 50
degrees each of supination and pronation.
The "take-home" messages for therapist and
patient alike are that a person can be quite func-
tional wIth less than "normal" wrist ROM and that
functional use of the hand and wrist probably does
little to achieve ROM past certain points. Perfor-
mance of specific active and passive ROM exercises
must be done to regain maximum movement.
If the contralateral wrist is uninjured, the les-
sons begin here. Measure and record the active
ROM of the opposite wrist as well as the active and
passive ROMs of the injured wrist. Point out that
there is usually more movement in ulnar deviation
than in radial deviation. Use a skeletal model to
FIGURE 9. (A) The most important principle in distal ra-
dius fracture rehabilitation is re-establishment of independent
wrist extension. (B) The tendency of the digital extensors-
particularly those of the ring and small fingers-to help ex-
tend the wrist must be overcome.
demonstrate the movement of the radius around
the ulna in forearm rotation. Also, have the patient
feel the movement of the distal radioulnar joint by
placing the uninjured hand on the therapist'S ra-
dius and ulna as supination and pronation are
demonstrated. Seeing and feeling this movement
can help alleviate the apprehension in some pa-
tients that something is "loose" on the ulnar side
of the wrist during forearm rotation. Finally, dem-
onstrate the normal synergistic relationship of wrist
extension/ finger flexion and wrist flexion/ finger
extension. Emphasize the importance of being able
to stabilize the wrist in extension and the impact
this has on power grip.
The most important single principle in distal
radius fracture rehabilitation is reestablishment of
independent wrist extension. The extensor carpi ra-
dialis brevis (ECRB), the extensor carpi radialis lon-
gus (ECRL), and the extensor carpi ulnaris (ECU)
possess different masseS, moment arms, fiber
lengths, and cross-sectional areas, but the "different
anatomic endowments are cerebrally integrated to
balance wrist extension, flexion, and ulnar and ra-
dial deviation."99 The ECRB is the strongest wrist
extensor, and the ECRL helps extend and radially
deviate the wrist. The ECU is more effective as an
ulnar deviator when the forearm is in pronation,
but it becomes a more efficient wrist extensor when
the forearm is supinated. 1°O Because the wrist has
usually been immobilized in some flexion for sev-
eral weeks, a centrally mediated substitution pat-
tern of digital extension to implement wrist exten-
sion occurs. First and foremost in therapy, the
patient must overcome this substitution pattern.
Finger flexion, grip strength, and overall hand func-
tion cannot improve so long as the digital extensors
"fire" when the wrist is extended (Fig. 9).
Splinting of the wrist in slight extension until
independent control of the wrist extensors can be
reestablished is needed while re-training is carried
April-June 1996 123
 FIGURE 10. Most prefabricated wrist splints
don't comfortably fit distal radius fracture pa-
tients and can block full finger and thumb range
of motion.

out. However, the patient should be weaned from sary to reduce the cognitive level of this activity
the splint as rapidly as possible. Prolonged depen- with some light resistance by squeezing something
dency on the wrist splint is counterproductive to such as a sponge and then concentrating only on
redevelopment of wrist ROM and grip strength. extending the wrist. Neuromuscular electrical stim-
Commercially available wrist supports do not ulation isolated to the wrist extensors may be help-
fit most distal radius fracture patients comfortably ful,103 but most patients are able to accomplish the
and can block full finger and thumb ROM (Fig. 10). retraining of independent wrist extension without
Preferable is a custom-made thermoplastic dorsal it.
wrist splint with a slender palmar barlOl (Fig. 11). Wrist flexion should be performed with the fin-
Care should be taken to alleviate pressure over the gers relaxed or extended. Radial and ulnar devia-
ulnar styloid. Since the ulna is more prominent dor- tion of the wrist should be done with the forearm
sally when the forearm is in pronation,102 fabricate pronated and the wrist in neutral position. To pre-
the splint with the patient's forearm pronated. A vent shoulder substitution for movements at the
thin piece of foam padding placed over this area distal radioulnar joint, the patient should be in-
before the splint is molded can then be removed structed to keep the elbow at the side during fore-
and positioned in the splint. The palmar bar should arm supination and pronation. These exercises
be carefully contoured so that it does not interfere should be done for a sustained effort of 10 seconds
with full finger movement. It is difficult to prevent at end range and repeated a certain number of rep-
a volar-based splint from migrating distally and etitions (usually 5-10) several times per day.
blocking finger movement when the wrist is al-
ready stiff in flexion. Compared with its volar-
based alternative, the dorsal splint is cooler, allows
unrestricted finger and thumb ROMs, and, via its
open design, encourages functional use of the hand
while wearing the splint.
An almost totally circumferential splint (Fig.
12) can be fabricated if additional support is needed
because of the distal radioulnar joint or difficulty
in getting the wrist out of its flexed position. Spe-
cial attention in fitting is required to prevent pres-
sure over the ulnar styloid and to ensure full ROMs
of the MP joints (particularly on the ulnar border
of the hand) and the carpometacarpal joint of the
thumb. This splint is cooler to wear if a perforated
th~rmoplastic is used. Both splints can be stripped
of their straps and remolded as needed to coax the
wrist into better position.
Mobilization of the wrist begins with active
ROM exercises first emphasizing wrist extension
with finger flexion. The initial amount of wrist ex-
tension is not important so long as it occurs without
help from the finger extensors. Teach the patient to
monitor that the ring and small finger MP joints do FIGURE 11. A thermoplastic dorsal wrist splint with a
not extend when the wrist is in maximum exten- slender palmar bar allows full finger and thumb movement.
sion; this means that the wrist extensors are work- The open design encourages functional use of the hand while
ing independently! For some patients, it is neces- wearing the splint.
124 JOURNAL OF HAND THERAPY
FIGURE 12. An almost totally cir-
cumferential splint is fabricated if addi-
tional support is needed. Special atten-
tion in fitting is required to prevent
pressure over the ulnar styloid and to
ensure full range of motion of the me-
tacarpophalangeal joints (especially on
the ulnar border of the hand) and the
carpometacarpal joint of the thumb.

The application of heat has been shown to have from the surgeon, the therapist's clinical judgment,
short-term effects on decreasing pain and improv- and the patient's response to treatment.
ing elasticity of tissue. Some patient~ respond. to the
application of cold packs for reduction of pam and
inflammation. The use of these thermal agents103 When the Wrist Won't Move-In Spite of
does seem to help some patients follow their exer~ Our Best Efforts
cise program with less discomfort. These modalities
can be quickly and easily incorporated into a home It has been theorized that joint tightness is im-
program. It should be made clea~ to the patient ~hat proved by controlled physical stress over signifi-
these are adjuncts-not substItutes-for actIve, cant periods rather than by intensity. In other
passive, and resistive exercises. words, low-load, prolonged stretch/ stress (LLPS) is
Passive ROM exercises should be incorporated more effective than high-load, brief stretch-stress
into the patient's program when tolerated. Ea~h (HLBS).96 Therapists' knowledge of the response of
stretch is held for 10 seconds and repeated a certam scar tissue and the biomechanics of the hand and
number of repetitions. The differences between ac- wrist have led to advances in splinting technology.
tive and passive ROMs and their expected thera- Static~progressive splinting applies LLPS to scar
peutic benefits should be expl~ined so that. the pa- tissue through adjustable force application. 104
tient will understand that one IS not a substitute for An articulated splint using the Phoenix wrist
the other. hinge (Human Factors Engineering, Phoenix, AZ)
The concept of joint mobilization is to assist
restoration of normal joint play where ROM is lim-
ited.50•51 Joint mobilization has been used as an ad-
junct in helping relieve pain and stiffness. As well
as being skilled in joint mobilization, therarists us-
ing these techniques need to be aw~re. of ~tra-ar­
ticular or joint congruency contramdicatIons for
treatment.
As pain-free motion improves, the splinting is
decreased, and resistive exercises are added as tol-
erated by the patient. Resistive exercises that can
be carried out easily in a home program should be
emphasized.
The well-known therapeutic techniques of heat
and stretch, cryokinetics, electrical stimulation, and
joint mobilization have been demonstrated to have
short-term mechanical effects on changes in ROM.
Prolonged gentle stress produced by continuous FIGURE 13. Statis-progressive wrist flexion and extension
passive motion, splinting, or serial casting on splint. This articulated splint uses the Pho~nix wris~ hinge and
the Upper Extremity Technology ME~IT [lv!axlmu'!l. En~
tissues altered by scarring is more effective in pro- Range (i) Time] component. ProgressIve wrzst p.osltlOn IS
ducing permanent changes in tis~ue length. H?w- achieved by turning the thumb screw on th~ MERIT ~ompo­
ever, there is no study documentmg the effectn:e- nent. The Phoenix hinge allows the therapIst to achIeve an
ness of these techniques in the treatment of wrIst anatomic axis of motion. Reprinted with permission from:
stiffness caused by distal radius fractures. Thera- King JW: Static-progressive splints. J Hand Ther 5:36-37,
peutic intervention continues to be guided by input 1992.
April-June 1996 125

FIGURE 14. Dynamic su-
pination and pronation splints
of the Colello-Abraham type
(A) or with a commercially
available dynamic supination/
pronation kit (B) can be fabri-
cated and worn to improve
forearm rotation.
and the MERiT component (Upper Extremity Tech-
nology, Glenwood Springs, CO) can be fabricated
for either flexion or extension (Fig. 13). The hinge
allows positioning that approximates the anatomic
axis of motion, and the progressive tension is ad-
justed by turning the thumb screw on the MERiT
component.
Dynamic supination and pronation splints of
the Colello-Abraham type 10S (Fig. 14A) or with a
commercially available dynamic supination/pro-
nation kit (Smith & Nephew Rolyan, Inc., German-
town, WI) (Fig. 14B) can be fabricated and worn to
reduce limitations in forearm rotation.
These splinting approaches can be considered
when the loss of motion is related to soft-tissue
tightness and not bony blockage, and/or the pro-
gress has plateaued before reaching functional lim-
its.
The "Why Weren't You Referred Last
Month?" Dilemma
In therapy utopia, all patients with distal ra-
dius fractures have excellent reductions and are re-
ferred for rehabilitation early to a clinic in which
the therapist and surgeon have excellent commu-
nication. Unfortunately, this is not always the case.
Probably very few therapists reading this arti-
cle have not been faced with the situation of a pa-
tient who is 2-3 months post-distal radius fracture
and arrives in therapy for the very first time with
a definite "failure to thrive" wrist situation. La-
menting the fact that the patient was not referred a
few weeks earlier is not going to be helpful at this
point. Therapist and patient alike must start this
relationship not by thinking "what if" but by fo-
cusing instead on "what now."
Since the diagnosis on the referral is probably
listed as ''Colles' fx," the therapist's first job is to
126 JOURNAL OF HAND THERAPY
seek more information. Is this really a well-healed,
nondisplaced extra-articular fracture? Or is it a dor-
sally displaced distal radius fracture-healed-but
with some intra-articular involvement, displace-
ment, malunion, radial shortening, dorsal angula-
tion, or a combination of these? Assessment of the
residual deformities is the first step in planning re-
alistic goals for wrist ROM and reestablishment of
hand function.
If pain seems to be a bigger problem than stiff-
ness, treatment of the pain is given priority. Try to
evaluate whether pain is related to the restriction
in joint movement, is sympathetically mediated, or
possibly stems from nerve compression problems
such as carpal tunnel syndrome. It will be difficult
to use treatment techniques to overcome stiffness if
pain can't be controlled.
Identify and correct as soon as possible substi-
tution patterns that contribute to stiffness and dys-
function such as using the trapezius to elevate the
shoulder and the digital extensors to extend the
wrist.
Emphasize the importance of patient compli-
ance in improving the functional outcome. Estab-
lish a realistic time frame. Improvement measura-
ble by the therapist and some functional gains
appreciated by the patient should occur by the end
of the first month. If not, it's time to consider the
next step-and that may be discharge from treat-
ment. Clinical judgment includes realization of our
limitations.
OUR CHALLENGE CONTINUES:
BETTER REDUCTIONS, FEWER
COMPLICATIONS, FASTER RETURN
OF FUNCTION ...
The wrist subserves hand function. Most pre-
vious studies have focused on the anatomy of the
distal radius fracture site itself. There has been little
attention given to the overall effects of treatment
on hand function ~uring and following fracture
healing. /
Within this decade, surgeons may be finally
able to apply the established principles of other me-
taphyseal fractures to achieve more predictable
treatment of unstable, intra-articular distal radius
fractures. Accurate ORIF and early motion may im-
prove function with fewer complications within a
few weeks. This approach may make treatment of
these fractures a more pleasant experience instead
of a nightmare for the surgeon, therapist, and pa-
tient alike.
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