Accelerated rehabilitation compared with a standard protocol after distal radial fractures treated with volar open reduction and internal fixation: a prospective, randomized, controlled study

Longitudinal recovery following distal radial fractures managed with volar plate fixation

AIMS

To synthesise the literature and perform a meta-analysis detailing the longitudinal recovery in the first two years following a distal radius fracture (DRF) managed with volar plate fixation.

MATERIALS AND METHODS

Three databases were searched to identify relevant articles. Following eligibility screening and quality assessment, data were extracted and outcomes were assimilated at the post-operative time points of interest. A state-of-the-art longitudinal mixed-effects meta-analysis model was employed to analyse the data.

RESULTS

The search identified 5698 articles, of which 46 study reports met the selection criteria. High levels of disability and impairment were reported in the immediate post-operative period with subsequently a rapid initial improvement followed by more gradual improvement for up to one year. The results highlight that the period associated with the greatest physical recovery is in the first three months and suggest that the endpoint of treatment outcomes is best measured at one year post-surgery.

CONCLUSION

Clinically meaningful improvements in outcomes can be expected for 12 months, after which progress plateaus and reaches normal values. This paper adopted a novel approach to meta-analyses in that the research question was of a longitudinal nature, which required a unique method of statistical analysis. Cite this article: Bone Joint J 2017;99-B:1665-76.

Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review

QUESTION

What is the effect of exercise on increasing participation and activity levels and reducing impairment in the rehabilitation of people with upper limb fractures?

DESIGN

Systematic review of controlled trials.

PARTICIPANTS

Adults following an upper limb fracture.

INTERVENTION

Any exercise therapy program, including trials where exercise was delivered to both groups provided that the groups received different amounts of exercise.

OUTCOME MEASURES

Impairments of body structure and function, activity limitations and participation restrictions.

RESULTS

Twenty-two trials were identified that evaluated 1299 participants with an upper limb fracture. There was insufficient evidence from 13 trials to support or refute the effectiveness of home exercise therapy compared with therapist-supervised exercise or therapy that included exercise following distal radius or proximal humeral fractures. There was insufficient evidence from three trials to support or refute the effectiveness of exercise therapy compared with advice/no exercise intervention following distal radius fracture. There was moderate evidence from five trials (one examining distal radius fracture, one radial head fracture, and three proximal humeral fracture) to support commencing exercise early and reducing immobilisation in improving activity during upper limb rehabilitation compared with delayed exercise and mobilisation. There was preliminary evidence from one trial that exercise to the non-injured arm during immobilisation might lead to short-term benefits on increasing grip strength and range of movement following distal radius fracture. Less than 40% of included trials reported adequate exercise program descriptions to allow replication according to the TIDieR checklist.

CONCLUSION

There is emerging evidence that current prescribed exercise regimens may not be effective in reducing impairments and improving activity following an upper limb fracture. Starting exercise early combined with a shorter immobilisation period is more effective than starting exercise after a longer immobilisation period.

REGISTRATION

CRD42016041818. [Bruder AM, Shields N, Dodd KJ, Taylor NF (2017) Prescribed exercise programs may not be effective in reducing impairments and improving activity during upper limb fracture rehabilitation: a systematic review. Journal of Physiotherapy 63: 205-220].

Efecto de las intervenciones fisioterapéuticas en personas con fractura distal de radio

Introducción. La fractura distal de radio (FDR) es muy frecuente y afecta a todos los grupos poblacionales.Objetivo. Realizar una revisión sistemática de la mejor evidencia disponible para determinar el efecto de las intervenciones fisioterapéuticas sobre el dolor, el rango de movimiento, la fuerza muscular y la funcionalidad en personas con fractura distal de radio.Materiales y métodos. Se realizó una búsqueda sistemática de ensayos clínicos controlados en las bases de datos ScienceDirect, PubMed, Medline y Embase.Resultados. Se encontraron 14 estudios que cumplieron los criterios de selección.Conclusión. La evidencia sugiere que intervenciones terapéuticas supervisadas que incluyan modalidades físicas y del ejercicio con una duración entre 6 y 9 semanas, con un promedio de 18 sesiones y realizadas tres veces a la semana mejoran de forma significativa las variables estudiadas en pacientes con FDR. Es necesario que futuros estudios establezcan la relación dosis-respuesta de estas intervenciones.

A structured literature synthesis of wrist outcome measures: An evidence-based approach to determine use among common wrist diagnoses

STUDY DESIGN

Structured literature synthesis.

INTRODUCTION

Hand therapists and researchers have numerous options when selecting outcome measures for patients with wrist pathologies. An evidence-based approach to determining which measures are used most often can inform choices.

PURPOSE OF THE STUDY

To describe how frequently outcome measures are used in recent randomized controlled trials of patients with wrist diagnoses. Identifying assessment design and related International Classification of Functioning, Disability and Health (ICF) domains provides additional consideration for selection.

METHODS

Systematic PubMed and Cumulative Index to Nursing and Allied Health Literature searches for the time frame between January 2005 and March 2015 captured measures used in randomized controlled trials researching wrist-specific fractures, ligament injuries, nerve injuries, arthritis/arthroplasty, or stress injuries/wrist pain.

RESULTS

Three most frequent measures used within each diagnostic category are detailed with assessment design described and ICF domain identified. Across diagnoses, grip/pinch strength and Disabilities of Arm, Shoulder and Hand were the most frequently used physical and patient-reported outcome measures, respectively. The Jebsen-Taylor Hand Function Test was the most frequently used performance measure.

DISCUSSION AND CONCLUSIONS

Consideration of the evidence, ICF domains, wrist diagnoses, and assessment design can help hand therapists select the measure most appropriate for use.

LEVEL OF EVIDENCE

2a.

Early controlled mobilization using dart-throwing motion with a twist for the conservative management of an intra-articular distal radius fracture and scapholunate ligament injury: A case report

This case describes an early controlled mobilization (ECM) approach that uses dart-throwing motion (DTM) with a twist orthoses as an alternative to immobilization for conservative management of a minimally displaced and intra-articular distal radius styloid fracture with an associated scapholunate ligament injury in a 47-year-old female health care administrator (JP). Pain-free active DTM began at day 10 (5 times/d) with a dynamic DTM with a twist orthosis worn during the day from weeks 3 to 6. At 6 weeks, JP had pain-free functional mobility and strength with minimal limitation in household and occupational activities, returning to her normal sporting activities by 3 months. ECM led to rapid return of normal functioning in the short term with no apparent impact on intermediate outcomes at 8 months. This case allows hand therapists to consider a similar ECM approach for the management of similar injuries in their patients.

LEVEL OF EVIDENCE

Level 5 and case report.

Characteristics of secondary arthrofibrosis after intra-articular distal radius fracture

PURPOSE

The purpose of this study was to assess characteristics of radiocarpal arthrofibrosis after intra-articular distal radius fractures (DRF).

PATIENTS AND METHODS

In this study 20 patients who underwent wrist arthroscopy at the time of implant removal after volar plating for intra-articular DRF were included retrospectively. The direction of fibrous tissue formation (FTF) and its rigidity were investigated. The findings were correlated to the course of intraarticular fracture lines seen in the preoperative CT, patient age and AO fracture types.

RESULTS

In all patients FTF spanned the radiocarpal joint. Fibrous tissue formations extended from previous fracture gaps to the scapholunate interosseous ligament and/or capsule. Four basic types of FTF (Type 1-4) and two combination types (Type 1a, 2a) were found. Fibrotic fans with dorsal capsular attachment (Type 1, 30 %) and its combination with dorsal capsule obliteration (Type 1a, 40 %) were the most common findings. Mild rigidity was present in 3 (15 %), moderate in 7 (35 %), and severe rigidity in 10 cases (50 %). Fracture lines crossing the radius extensor compartments or interfacet ridge, cartilage defects and C3 fractures showed the highest risk to develop severely rigid fibrous tissue formations. In older patients and in more comminuted fractures the number of rigid fibrous tissue formations was higher.

CONCLUSIONS

Fracture severity correlates with the development of rigid intra-articular FTF. In case of rigid FTF with restricted wrist motion arthroscopic debridement may be considered at the time of hardware removal.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older people with osteoporosis. There is considerable variation in the management, including rehabilitation, of these fractures. This is an update of a Cochrane review first published in 2002 and last updated in 2006.

OBJECTIVES

To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2014; Issue 12), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, trial registers, conference proceedings and reference lists of articles. We did not apply any language restrictions. The date of the last search was 12 January 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

DATA COLLECTION AND ANALYSIS

The review authors independently screened and selected trials, and reviewed eligible trials. We contacted study authors for additional information. We did not pool data.

MAIN RESULTS

We included 26 trials, involving 1269 mainly female and older patients. With few exceptions, these studies did not include people with serious fracture or treatment-related complications, or older people with comorbidities and poor overall function that would have precluded trial participation or required more intensive treatment. Only four of the 23 comparisons covered by these 26 trials were evaluated by more than one trial. Participants of 15 trials were initially treated conservatively, involving plaster cast immobilisation. Initial treatment was surgery (external fixation or internal fixation) for all participants in five trials. Initial treatment was either surgery or plaster cast alone in six trials. Rehabilitation started during immobilisation in seven trials and after post-immobilisation in the other 19 trials. As well as being small, the majority of the included trials had methodological shortcomings and were at high risk of bias, usually related to lack of blinding, that could affect the validity of their findings. Based on GRADE criteria for assessment quality, we rated the evidence for each of the 23 comparisons as either low or very low quality; both ratings indicate considerable uncertainty in the findings.For interventions started during immobilisation, there was very low quality evidence of improved hand function for hand therapy compared with instructions only at four days after plaster cast removal, with some beneficial effects continuing one month later (one trial, 17 participants). There was very low quality evidence of improved hand function in the short-term, but not in the longer-term (three months), for early occupational therapy (one trial, 40 participants), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial, 96 participants).Four trials separately provided very low quality evidence of clinically marginal benefits of specific interventions applied in addition to standard care (therapist-applied programme of digit mobilisation during external fixation (22 participants); pulsed electromagnetic field (PEMF) during cast immobilisation (60 participants); cyclic pneumatic soft tissue compression using an inflatable cuff placed under the plaster cast (19 participants); and cross-education involving strength training of the non-fractured hand during cast immobilisation with or without surgical repair (39 participants)).For interventions started post-immobilisation, there was very low quality evidence from one study (47 participants) of improved function for a single session of physiotherapy, primarily advice and instructions for a home exercise programme, compared with 'no intervention' after cast removal. There was low quality evidence from four heterogeneous trials (30, 33, 66 and 75 participants) of a lack of clinically important differences in outcome in patients receiving routine physiotherapy or occupational therapy in addition to instructions for home exercises versus instructions for home exercises from a therapist. There was very low quality evidence of better short-term hand function in participants given physiotherapy than in those given either instructions for home exercises by a surgeon (16 participants, one trial) or a progressive home exercise programme (20 participants, one trial). Both trials (46 and 76 participants) comparing physiotherapy or occupational therapy versus a progressive home exercise programme after volar plate fixation provided low quality evidence in favour of a structured programme of home exercises preceded by instructions or coaching. One trial (63 participants) provided very low quality evidence of a short-term, but not persisting, benefit of accelerated compared with usual rehabilitation after volar plate fixation.For trials testing single interventions applied post-immobilisation, there was very low quality evidence of no clinically significant differences in outcome in patients receiving passive mobilisation (69 participants, two trials), ice (83 participants, one trial), PEMF (83 participants, one trial), PEMF plus ice (39 participants, one trial), whirlpool immersion (24 participants, one trial), and dynamic extension splint for patients with wrist contracture (40 participants, one trial), compared with no intervention. This finding applied also to the trial (44 participants) comparing PEMF versus ice, and the trial (29 participants) comparing manual oedema mobilisation versus traditional oedema treatment. There was very low quality evidence from single trials of a short-term benefit of continuous passive motion post-external fixation (seven participants), intermittent pneumatic compression (31 participants) and ultrasound (38 participants).

AUTHORS' CONCLUSIONS

The available evidence from RCTs is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius. Further randomised trials are warranted. However, in order to optimise research effort and engender the large multicentre randomised trials that are required to inform practice, these should be preceded by research that aims to identify priority questions.

Comparing the effect of volar plate fixators and external fixators on outcome of patients with intra-articular distal radius fractures: A clinical trial

BACKGROUND

Distal radius fractures (DRFs) are much more prone to malunion than unstable extra-articular fractures. There is no clear consensus concerning what the proper treatment should be, and the best approach to use for displaced DRFs remains challenging.

OBJECTIVE

To compare the effect of two different therapeutic surgical methods, i.e., volar plate fixators and external fixators, on outcomes of patients with intra-articular distal radius fractures.

METHODS

From May 2010 to November 2014, 76 subjects who had experienced intra-articular fractures of the distal radius were enrolled in this double-blind, randomized, controlled trial in Imam Ali Hospital in Bojnourd, Iran. The patients were divided into two groups, i.e., 1) patients who were treated with internal fixation using the volar plate (group A) and 2) patients who were treated with external fixators (group B). The primary outcome was a composite measure of the patient's quality of life using three different scores, i.e., 1) the MAYO score, 2) Disabilities of the Arm, Shoulder, and Hand (DASH (score, and 3) the Short Form (36) (SF-36) Health Survey score.

RESULTS

A total of 76 patients were allocated randomly to groups A and B. The mean ages for external fixator cases and volar plate cases were 51.7 and 46.3, respectively. No significant age distribution was seen between the two groups (p=0.348). Gender distribution between the two groups was not significantly different (p=0.022). Grip power was significantly different between the two groups, but no significant differences were detected in range of motion (p=0.008, p=0.367, respectively). The MAYO score was significantly higher in the open reduction and internal fixation (ORIF) group, and, according to the SF-36 test, the ORIF group also a higher level of general mental and physical health, social functioning, and personal physical functioning than the other group. However, postoperatively, the mental discomfort and physical discomfort were more prevalent in the external fixator group. The DASH score was not significantly different between the two groups (p=0.124).

CONCLUSIONS

ORIF and its subtitle, volar plate fixation, is a more preferred surgical procedure than the external fixator for the treatment of intra-articular distal radius fractures. This conclusion is important when one considers cost-effectiveness and an earlier return to work.

TRIAL REGISTRATION

The trial is registered at the Thai Clinical Trial Registry (clinicaltrials.in.th) with the TCR identification number TCTR20150609002.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.