The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius

Distal Radius Fracture Therapy Utilization Following Traditional Open Reduction and Internal Fixation and Dorsal Bridge Plate Fixation

Background Many distal radius fractures are treated with a volar locking plate, but a minority undergo dorsal bridge plate fixation. This study's primary purpose was to compare therapy utilization following distal radius fractures treated with traditional open reduction and internal fixation (ORIF) versus dorsal bridge plate fixation. Secondary outcomes were time to first and last therapy visits and therapy costs. Methods Patients over 18 years old who underwent distal radius ORIF between January 2021 and August 2022 at a single regional orthopedic practice were identified. Patients who underwent post-operative hardware removal were retrospectively reviewed to identify dorsal bridge plate fixation patients. This resulted in "traditional ORIF" and "dorsal bridge plate" groups. Therapy visit number, cost, and payor (insurance type including Medicare, private insurance, worker's compensation, automobile policy, and private pay) were collected. Results In total, 1,376 patients met the inclusion criteria. Of these, 713 of the 1,283 (55.6%) patients in the traditional ORIF group and 25 of the 44 patients (56.8%) in the dorsal bridge plate group attended therapy at our institution. Traditional ORIF and dorsal bridge plate patients averaged 12.6(±10) and 24(±18.7) therapy visits in the one-year following ORIF, respectively. Time to last therapy visit was 90.9(±60) and 175.2(±72.1) days in the traditional ORIF and dorsal bridge plate groups, respectively. Total therapy cost was $1,219(±$1,314) and $2,015(±$1,828) in the traditional ORIF and dorsal bridge plate groups with similar out-of-pocket costs. Conclusions Dorsal bridge plate fixation patients attended a greater number of therapy sessions, had a longer time from surgery until therapy end, and had a higher therapy total cost relative to traditional ORIF, but both groups had similar patient out-of-pocket therapy costs.

Patients' preferences for occupational therapy after upper extremity fractures: a discrete choice experiment

OBJECTIVE

Occupational therapy is often prescribed after the acute treatment of upper extremity fractures. However, high out-of-pocket expenses and logistical constraints can reduce access to formal therapy services. We aimed to quantify preferences of patients with upper extremity fracture for attending occupational therapy, when considering possible differences in clinical outcomes.

DESIGN

Discrete choice experiment.

SETTING

Level 1 trauma centre in Baltimore, Maryland, USA.

PARTICIPANTS

134 adult patients with upper extremity fractures.

PRIMARY OUTCOME MEASURES

The scenarios were described with five attributes: cost, duration of therapy session, location of therapy, final range of motion and pain. We report the relative importance of each attribute as a proportion of total importance, and the willingness to pay for benefits of the therapy services.

RESULTS

Of the 134 study participants, the mean age was 47 years and 53% were men. Cost (32%) and range of motion (29%) were the attributes of greatest relative importance. Pain (17%), duration of therapy (13%) and location of therapy (8%) were of lesser importance. Patients were willing to pay $85 more per therapy session for a 40% improvement in their range of motion. Patients were willing to pay $43 more per therapy session to improve from severe pain to mild pain. Patients were indifferent to whether the therapy treatment was home-based or in a clinical environment.

CONCLUSIONS

When deciding on an upper extremity fracture therapy programme, out-of-pocket costs are a paramount consideration of patients. Improvements in range of motion are of greater importance than residual pain, the duration of therapy sessions and the location of service provision. Patients with upper extremity fracture should be prescribed occupational therapy services that align with these patients' preferences.

Defining Outcomes Following Distal Radius Fractures: Correlation of Function, Pain, and Hand Therapy Utilization

Background

Distal radius fractures (DRF) is one of the most common fractures in clinical practice. Our objective was to study the role of early hand therapy and its impact on pain and return to daily activities.

Methods

The charts of patients with DRFs seen between January 2016 and November 2017 in the Hand Center of Mayo Clinic Florida were reviewed retrospectively. Forty-nine patients with DRFs who met inclusion criteria were included in the analysis. The variables collected included: age, gender, side of the fracture, surgery vs non-surgery, time to start hand therapy, number of visits, shortened disabilities of the arm, shoulder, and hand (QuickDASH) initial and discharge scores, and visual analog scale (VAS) initial and discharge.

Results

The patients’ mean age was 67.90 years, (standard deviation (SD) 14.54), 38 (77.6%) were female, 28 (57.1%) had a right DRF, 21 (42.9%) had a left DRF, 38 (77.6%) had no surgery, 11 (22.4%) had surgery. The mean time from fracture to therapy is 32.41, (SD 24.13) days, and the mean total number of visits is 6.20 (SD 3.49). We noticed a statistically significant difference between the initial QuickDASH (59.27, SD 16.93) compared to the discharge QuickDASH (24.08, SD 12.77) (P-value <.001); and initial VAS (3.57, SD 1.71) with a discharge VAS (1.33, SD 0.97) (P-value <.001). 

Conclusion

This retrospective study found a statistically significant reduction in the QuickDASH and VAS scores after six hand therapy visits. The results suggest that early rehabilitation interventions lead to improvements in pain and return to daily activity following DRF.

The Relationship between Hand Therapy and Long-Term Outcomes after Distal Radius Fracture in Older Adults: Evidence from the Randomized Wrist and Radius Injury Surgical Trial

BACKGROUND

Older patients are frequently referred to hand therapy after distal radius fracture. Supervised therapy sessions place a transportation burden on patients and are costly on both the individual and systematic levels. Furthermore, there is little evidence that supervised therapy or home exercises improve long-term outcomes.

METHODS

Data were collected for the Wrist and Radius Injury Surgical Trial, a multicenter, international, pragmatic, randomized trial of distal radius fracture treatment in patients aged 60 years and older. Referral to therapy and therapy protocol were at the discretion of the treating surgeon and therapist. The authors examined outcomes between participants who underwent therapy and those who did not and assessed the duration of therapy. The authors also analyzed the effect of therapy on subgroups at risk for poor outcomes: older participants and those who had more comorbidities or lower baseline activity.

RESULTS

Eighty percent of participants underwent therapy; 70 percent participated in both supervised therapy and home exercises. Participants had a mean 9.2 supervised sessions over 14.2 weeks. There were no differences in patient-reported outcomes between participants who underwent therapy and those who did not. Participants who did not have therapy recovered more grip strength. Participants who engaged in therapy for a shorter time reported greater function, ability to work, and satisfaction. There were no relationships revealed in subgroup analyses.

CONCLUSIONS

Hand therapy after distal radius fracture may not be necessary for older patients. Encouraging participants to resume activities of daily living as soon as possible may be as effective as formal therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A retrospective analysis of the number of therapy visits after distal radius fractures using a new provider-scored clinical severity scale

STUDY DESIGN

Retrospective study.

INTRODUCTION

Fractures of the distal radius are common as is a postfracture referral to occupational therapy (OT). This article examines factors that cause greater morbidity and a greater number of OT visits.

PURPOSE OF THE STUDY

This study aims to analyze which of 5 common sequelae of the distal radius fracture is most significant for increasing the number of therapy visits.

METHODS

Three-hundred Sixty charts were reviewed, and 89 were selected. Multiple regression was used to determine which of our 5 independent variables had the greatest predictive power for the total number of therapy visits.

RESULTS

The regression model demonstrated significance at P ≤ .01. Total active motion (TAM) of the digits (P ≤ .01) and TAM of the forearm (P ≤ .01) were the only complications that demonstrated statistical significance and a positive relationship with the number of therapy visits. In addition to this, TAM of the forearm and digits showed a strong correlation with the number of therapy visits. TAM of the wrist, pain, and edema had a weak correlation. Patients with high total group score on the clinical severity scale also had a moderate correlation.

DISCUSSION

The results of the study illustrate the importance of digital contractures on a patient's morbidity, function, and their need for OT visits.

CONCLUSION

The information from this study is important for the clinician as it identifies patients at risk for increased morbidity and identifies the complications that the clinician may want to stress early in the rehabilitation of that patient.

LEVEL OF EVIDENCE

3.

Early Mobilization and Physiotherapy Vs. Late Mobilization and Home Exercises After ORIF of Distal Radial Fractures: A Randomized Controlled Trial

Volar locking plates have permitted early mobilization, omitting the need for prolonged cast immobilization, after distal radial fractures (DRFs). However, the type of rehabilitation following plate fixation of DRFs remains an unresolved issue. The purpose of this study was to evaluate the effect of physiotherapy after volar plate fixation of DRFs. At a 2-year follow-up, we compared the results of immediate physiotherapy (early mobilization) with those of home exercises following 2 weeks in a dorsal plaster splint (late mobilization).

The New Smartphone Application for Wrist Rehabilitation

BACKGROUND

The rehabilitation after wrist surgery is extremely important. An instructed therapy in hospital is widely practiced. However, a dependent aging society and rush life style in younger generation have precluded patients to access to the frequent formal therapy. With the advancement in telecommunication technology, we have invented an application for smartphone for home-based wrist motion rehabilitation.

METHODS

Twenty participants were included in four-week wrist motion rehabilitation programme after wrist surgery. Participants were instructed to use the application by physical therapist and informed details of home-based wrist rehabilitation. The feasibility of application was evaluated by satisfaction level in various aspects and the adherence to the therapy was monitored by function provided in the application. The degrees of motion were compared at the end of prescribed programme.

RESULTS

Patient satisfaction was consistently high in every aspects. Also, the adherence to the therapy was high (90.42%). Ranges of motion significantly gained in every plane of wrist motion ([Formula: see text]).

CONCLUSIONS

This novel smartphone application seems to be a promising and convenient alternative for patients who need to gain wrist motion without formal rehabilitation in the hospital. Adherence to the therapy is also easily traced with this application.

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.

Does socioeconomic status influence the epidemiology and outcome of distal radial fractures in adults?

PURPOSE

The aim of this study in adult patients with a distal radial fracture was to determine whether socioeconomic status influenced the epidemiology, mechanism of injury, fracture severity, or the outcome according to function, radiographic assessment, and rate of associated complications.

METHODS

We identified 3983 distal radial fractures over a 7-year period. Socioeconomic status was assigned using the Carstairs score, and the population was divided into quintiles depending on deprivation. Patient demographics, mechanism of injury, fracture severity, and radiographic assessment at time of injury were assessed for epidemiological differences according to social quintile. Functional outcome was assessed using grip strength, Moberg pickup test, return to normal use of the hand, and range of movement. Radiographs were assessed at 1 week, 6 weeks, and 1 year. Complications were defined as malunion, carpal tunnel syndrome, complex regional pain syndrome (CRPS), persistent pain, and subjective cosmetic deformity of the wrist.

RESULTS

Socioeconomically deprived patients were significantly younger (p < 0.001) and more likely to be male (p = 0.017); after adjusting for confounding factors, deprived patients were 3.1 (95% CI 1.4-4.7) years younger than the most affluent patients (p < 0.001). Deprived patients were more likely to sustain their fracture by a high-energy mechanism (p = 0.004). There were no significant differences between quintiles in outcome. There was a significantly greater prevalence of CRPS in more affluent patients (p = 0.004).

CONCLUSIONS

Socioeconomically deprived patients sustaining a distal radial fracture are more likely to be younger and male. Outcome is not influenced by socioeconomic status, but the prevalence of CRPS is greater in more affluent patients.

Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

STUDY DESIGN

Randomized clinical study.

INTRODUCTION

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

PURPOSE OF THE STUDY

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

METHODS

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

RESULTS

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

CONCLUSIONS

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

LEVEL OF EVIDENCE

1b.

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.

Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture

PURPOSE

To investigate whether there was a difference in Patient-Rated Wrist Hand Evaluation (PRWHE) scores between patients with and without comorbidities who receive regular supervised therapy provided by a certified hand therapist (CHT) compared with patients who were provided with a home exercise program and were regularly monitored.

METHODS

Fifty patients with a diagnosis of distal radius fractures and volar plate fixation were enrolled in a prospective, randomized clinical trial comparing those who received therapy under the supervision of a CHT with those enrolled in a home exercise program that was instructed and monitored by a CHT. The primary outcome measure (PRWHE) and secondary outcome measures, total arc of motion for wrist flexion and extension, supination and pronation, and grip strength, were assessed at 12 weeks. The primary outcome measure for both groups was also gathered at 6 months.

RESULTS

There were no statistically significant differences between the final scores of the PRWHE, wrist or forearm motion, pain, or grip strength between groups. Effect size calculations revealed that both groups experienced a large effect size for all outcomes.

CONCLUSIONS

Supervised clinic-based therapy is equally beneficial for patients without complications. Clinic-based therapy may be preferable for patients with noteworthy complications after a distal radius fracture with volar plate fixation. Patients with decreased finger motion and various comorbidities may benefit from therapy provided in a clinic under the supervision of a certified hand therapist.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Therapist supervised clinic-based therapy versus instruction in a home program following distal radius fracture: a systematic review

PURPOSE

The primary purpose of this systematic review is to determine the effectiveness of a home program or a structured therapy program for patients following distal radius fracture.

METHODS

A search was performed using terms wrist fracture, supervised therapy, occupational therapy, physical therapy, splint, orthosis, distal radius fracture, exercise, and home program. Studies that met the inclusion criteria were evaluated for research quality using The Structured Effectiveness for Quality Evaluation of Study (SEQES).

RESULTS

Five of the seven trials found no difference between outcomes for their subjects that had uncomplicated distal radius fractures. The population that has complications following distal radius fractures was not represented in the studies reviewed.

CONCLUSION

The available evidence from randomized controlled trials is insufficient to support a home program or therapist supervised clinic-based program as a superior method of treatment for adults following a distal radius fracture without complications or the presence of comorbidities.

Barriers to Adherence with Post-Operative Hand Therapy Following Surgery for Fracture of the Distal Radius

The success of hand surgery relies heavily on post-operative therapy. The ability to identify barriers to patient adherence with therapy may therefore allow for improvement in therapeutic and surgical decisions and results. The purpose of this study was to identify significant barriers to adherence with hand therapy following surgery for distal radius fracture. A questionnaire addressing demographic, social, psychological, occupational and medical factors was administered to 20 subjects undergoing surgery for distal radius fracture. Adherence was evaluated by the therapist and by the number of missed sessions. There were 9 males and 11 females. Average age was 46.2 (19-88). The therapists' evaluation of adherence and number of missed appointments were significantly correlated (R2 = 0.86, p < 0.0001, Spearman's test). Gender, distance from therapy, and driving status were significantly related to adherence. Difficulty in reaching the therapy sessions was negatively related to adherence with hand therapy in our population. Other parameters such as smoking, were borderline significant. Further study is needed to investigate the effect of additional parameters, in a larger population in order to better define barriers to patient postsurgical adherence.

Variation in the Use of Therapy following Distal Radius Fractures in the United States

Background:

Distal radius fractures (DRFs) are one of the most common injuries among the elderly, resulting in significant expense and disability. The specific aims of this study are (1) to examine rates of therapy following DRFs and (2) to identify those factors that influence utilization of therapy and time span between DRF treatment and therapy among a national cohort of elderly patients.

Methods:

We examined national use of physical and occupational therapy among all Medicare beneficiaries who suffered DRFs between January 1, 2007, and October 1, 2007, and assessed the effect of treatment, patient-related, and surgeon-related factors on utilization of therapy.

Results:

Overall, 20.6% of patients received either physical or occupational therapy following DRF. Use of therapy varied by DRF treatment, and patients who underwent open reduction and internal fixation were more likely to receive therapy compared with patients who received closed reduction. Patients who received open reduction and internal fixation were also referred to therapy earlier compared with patients who received external fixation, percutaneous pinning, and closed reduction. Surgeon specialization is associated with greater use of postoperative therapy. Patient predictors of therapy use include younger age, female sex, higher socioeconomic status, and fewer comorbidity conditions.

Conclusion:

Use of therapy following DRF varies significantly by both patient- and surgeon-related factors. Identifying patients who benefit from postinjury therapy can allow for better resource utilization following these common injuries.

The correlation of radiographic outcome to functional outcome following fracture of the distal radius in elderly patients: A literature review

Introduction

Fractures of the distal radius are common in the elderly population. Elderly patients have been considered to be functionally low-demand, but as the population becomes more active, expectations of outcomes may be increasing. The aim of this review was to determine whether there is any correlation between radiographic and functional outcome for elderly patients following fracture of the distal radius.

Methods

Medline, PubMed, CINAHL, Embase and AMED were searched for studies including elderly patients managed conservatively or surgically following distal radius fracture, either alone or in combination with younger patients.

Results

Eleven studies were selected for review. A wide variety of outcome measures and radiological parameters were found to be used. Of the 11 studies, 6 found no correlation between functional outcome and radiological outcome.

Discussion

The literature reviewed suggests functional outcome for elderly patients following distal radius fracture is not dependant on radiological outcome. This may give therapists better insight into potential outcomes for their patients, however further studies may be required to determine the most effective therapeutic management of these patients.

Distal radial fractures in the superelderly: does malunion affect functional outcome?

Purpose. The management of unstable distal radial fractures in the superelderly (≥80 years old) remains controversial. The aim of this study was to compare the functional outcome of super-elderly patients with and without malunion after a distal radial fracture. Methods. We identified 51 superelderly patients living independently with displaced fractures from a prospective database of 4024 patients with distal radial fractures. Activities of daily living, presence of wrist pain, whether the wrist had returned to its normal level function, grip strength and ROM were recorded. The dorsal angulation was measured radiographically. Results. There were 17 (33.3%) patients defined to have a malunion. The outcomes of the independent patients with and without malunion were compared at a mean follow-up of 15 months. No difference was observed in activities of daily living (P = 0.28), wrist pain (P = 0.14), whether the wrist had returned to its normal level function (P = 0.25), grip strength (P = 0.31), or ROM (P = 0.41). An increasing degree of dorsal angulation correlated with diminished ROM (P = 0.038), but did not correlate with activities of daily living (P = 0.10). Conclusions. Malunion of the distal radius does not influence the functional outcome of independent superelderly patients.

Rehabilitative strategies following hand fractures

The importance of rehabilitation in the management of hand fractures cannot be overstated. The breadth of rehabilitative strategies ranges from heat and range-of-motion exercises to more complex splinting and tendon gliding modalities. The goals, however, are clear: control pain; limit soft tissue swelling; provide support for fracture healing; restore motion, strength, and function; and enable the return to work and daily activities.

STATISTICAL ANALYSIS ON FUNCTIONAL AND RADIOGRAPHIC RESULTS AFTER USE OF LOCKED VOLAR PLATE FOR FRACTURES OF THE DISTAL RADIUS

Objectives: To evaluate the functional results from using a fixed-angle locked volar plate for treating fractures of the distal extremity of the radius, using the DASH (disorders of the arm, shoulder and hand) questionnaire and its radiographic correlation with the Lidström classification. Methods: Thirty patients with unstable fractures of the distal extremity of the radius were evaluated after they had undergone a surgical procedure consisting of open reduction and internal fixation using a fixed-angle locked volar plate, at the Military Police Central Hospital of Rio de Janeiro between 2008 and 2009. The results were assessed based on range of motion, DASH protocol scores and radiographies with the Lidström classification. Results: The mean age of the patients in the study was 51 years. The mean DASH score was 11.9 points. It was observed that the radiographic findings did not influence the DASH score. It was found that flexion, pronation, supination and radial deviation correlated with the DASH score. Conclusions: The study showed that subjective functional outcomes using the DASH protocol, obtained from using a locked volar plate to treat fractures of the distal extremity of the radius, are influenced by the range of motion, and especially by the flexion, supination, pronation and radial deviation of the wrist after surgery. There is no correlation between the radiological parameters of either the normal or the operated radius, and the subjective functional outcomes assessed using the DASH protocol.

Recovery after fracture of the distal radius

Stretching exercises are an important part of recovery after sustaining a fracture of the distal radius. However, from the patient's perspective, painful stretching exercises can be counterintuitive after injury. Stretching exercises are straightforward and do not require a significant amount of coaching. It is ultimately the protectiveness, passivity, and sometimes a sense of futility that require coaching. The key for the provider is to empathize with the difficult and counterintuitive nature of the recovery process.

Exercise reduces impairment and improves activity in people after some upper limb fractures: a systematic review

QUESTION

What is the effect of exercise on reducing impairment and increasing activity 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 providing there was an expectation of different amounts of exercise.

OUTCOME MEASURES

Body structure and function, and activity limitations.

RESULTS

13 relevant trials involving 781 participants with an upper limb fracture were identified. 12 of the 13 trials included exercise of different duration and administration in both intervention and comparison groups. In support of the role of exercise there is evidence that: exercise and advice compared to no intervention reduce pain and improve upper limb activity in the short term after distal radius fracture; starting exercise earlier after conservatively managed proximal humeral fractures can reduce pain and improve shoulder activity; and physiotherapy that included supervised exercise and home exercise increased wrist movement after distal radius fracture when compared to home exercise alone. There is contrary evidence from two trials one after distal radius fracture and one after proximal humeral fracture that a home exercise program was superior to a supervised plus home exercise program. Only a single meta-analysis was conducted due to clinical heterogeneity and a lack of common outcome measures among the included trials.

CONCLUSION

There is evidence to support the role of specific exercise regimens in reducing impairments and improving upper limb function following specific upper limb fractures.

The implications of chronic pain models for rehabilitation of distal radius fracture

Distal radius fracture (DRF) is the most common fracture and usually occurs as a result of a fall. Most patients recover following DRF with minimal residual pain or disability; however, a small subset of patients continue to experience pain and disability even one year after the injury. Currently, there are no practice guidelines for early identification and treatment of patients who are potentially at greater risk of developing these adverse outcomes. As a result, hand therapy management of patients following DRF does not incorporate screening of these at-risk patients. The objective of this paper is to apply constructs from learned helplessness and cognitive-behavioural models of chronic pain in assessing the psychosocial risk profile of patients following DRF. We have also integrated key findings derived from studies addressing personal and life-style factors in assessing this risk profile. This framework is proposed as a basis to categorize patients as higher or lower psychosocial risk for developing chronic pain and disability following DRF. We outline a model depicting the RACE approach (Reducing pain, Activating, Cognitive reshaping, Empowering) towards the management of patients following DRF. The model suggests that patients with minimal psychosocial risk factors are managed based on their injury profile and those with higher psychosocial risk are treated with the risk-based RACE approach. Using a biopsychosocial RACE approach to prognosis and treatment, hand therapy intervention can be customized for patients recovering from DRF. In future, researchers can conduct clinical trials to compare the RACE-based treatment approach to routine hand therapy in mitigating the risk of chronic pain and disability in patients with elevated risk profile for adverse outcomes following DRF.

Therapy after injury to the hand

Surgical and nonsurgical management of upper extremity disorders benefits from the collaboration of a therapist, the treating physician, and the patient. Hand therapy plays a role in many aspects of treatment, and patients with upper extremity injuries may spend considerably more time with a therapist than with a surgeon. Hand therapists coordinate edema control; pain management; minimization of joint contractures; maximization of tendon gliding, strengthening, and work hardening; counseling; and ongoing diagnostic evaluation. Modalities used to manage hand injuries include ultrasound, splinting, Fluidotherapy (Chattanooga Group, Chattanooga, TN), cryotherapy, various electrical modalities, phonophoresis, and iontophoresis.

Prediction of outcome after humeral diaphyseal fracture

PURPOSE

The aim of this study is to examine the demographic factors, functional outcome and radiological data to predict the outcome of humeral diaphyseal fractures.

METHODS

We performed a prospective study on a consecutive series of 110 patients of 16 years or over, who had sustained a humeral diaphyseal fracture. There were 42 males and 68 females, with an average age of 59 years (range 16-93 years). A total of 72% sustained low-energy injuries, and 89 patients (81%) were primarily treated non-operatively. Shoulder function was assessed using the Neer's and Constant's scores at 8 weeks, 3 months, 6 months and 1 year after injury. Muscle strength was determined isokinetically using a Biodex System 2 dynamometer. Non-union was defined as a failure to bridge at least three cortices and persistence of tenderness or mobility at the fracture site 16 weeks after fracture.

RESULTS

Sixteen patients (17%) had non-union at 16 weeks, while 80 had achieved union and a further 14 were lost to follow-up. After stepwise multiple linear regression was performed to isolate independent factors affecting outcome, only the presence of a proximal diaphyseal fracture was found to predict non-union along with a poor Neer's score at 8 and 12 weeks. Poor Neer's scores could be predicted at 26 weeks by age (P<0.05), previous stroke (P<0.001) and non-union (P<0.001). At 52 weeks both age (P<0.01) and previous stroke (P<0.01) were independently predictive of poorer Neer's scores. Malunion of any degree had no detectable effect on function.

CONCLUSIONS

Our results indicate that non-union of humeral diaphyseal fractures can be predicted in the presence of a proximal third fracture with a Neer's score of less than 45 by 12 weeks after fracture. Early surgery improves early function, but this is not a lasting effect. Poor shoulder function is predicted by increasing age, proximal third fractures and non-union. We recommend that surgery to promote union be considered at 12 weeks after fracture in fit patients with fractures of the proximal third of the humerus, poor Neer's scores and no radiographic progression to union.

Treatment of distal radius fractures

The clinical practice guideline is based on a systematic review of published studies on the treatment of distal radius fractures in adults. None of the 29 recommendations made by the work group was graded as strong; most are graded as inconclusive or consensus; seven are graded as weak. The remaining five moderate-strength recommendations include surgical fixation, rather than cast fixation, for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees , or intra-articular displacement or step-off >2 mm; use of rigid immobilization rather than removable splints for nonsurgical treatment; making a postreduction true lateral radiograph of the carpus to assess dorsal radial ulnar joint alignment; beginning early wrist motion following stable fixation; and recommending adjuvant treatment with vitamin C to prevent disproportionate pain.

No long-term impact of low-energy distal radius fracture on health-related quality of life and global quality of life: a case-control study

BACKGROUND

Changes in patient-reported outcomes like health related quality of life (HRQOL) and global quality of life (GQOL) in patients with low-energy distal radius fracture might be related to fracture, or be within the normal range of variation in an elderly population. Hence, the present study aims to examine: Whether patients with low-energy distal radius fracture attain their pre-fracture levels in HRQOL and GQOL one year after the fracture and compare these levels with age- and sex-matched controls; and whether objective factors predict changes in HRQOL and GQOL during the same one year period.

METHODS

We examined 160 patients and 169 age- and sex matched controls, respectively (mean +/- SD) 67 +/- 9 and 66 +/- 9 years of age. HRQOL was assessed by the Modified Health Assessment Questionnaire (MHAQ) and the Short-Form 36 (SF-36). The Quality of Life Scale (QOLS) assessed GQOL. Paired sample t-tests and multiple linear regression analyses were applied.

RESULTS

After one year no differences were found in HRQOL (assessed as arm functions, physical health and mental health) compared to pre-fracture level in the patient group. Both patients with distal radius fracture and controls reported a reduced GQOL after one year (p < 0.001). Low-energy distal radius fracture did not predict worsened HRQOL or GQOL one year after inclusion, and few predictors of changes were identified. Worsened arm function was predicted by low BMI (B = -0.20, p = 0.019) at baseline, worsened physical health was predicted by low education (B = 1.37, p = 0.017) at baseline, and living with someone predicted worsened mental health (B = 2.85, p = 0.009)

CONCLUSION

Patients with a distal radius fracture seem to manage well despite the fracture, and distal radius fracture is not an independent predictor of worsened HRQOL and GQOL.

Association between decreased bone mineral density and severity of distal radial fractures

BACKGROUND

The role of osteoporosis and osteopenia in the etiology of fractures of the distal part of the radius is well established, but any link between osteoporosis and the severity of the distal radial fracture has not been extensively investigated. The aim of this study was to investigate the association between the degree of osteoporosis and the severity of distal radial fractures.

METHODS

All patients over fifty-five years of age with a low-energy distal radial fracture were offered dual x-ray absorptiometry scanning of the hip. Data on the 137 consecutive patients were collected prospectively. Plain radiographs of the fractured distal part of the radius were assessed for angulation, metaphyseal and articular comminution, carpal malalignment, ulnar variance, AO/OTA group and subgroup classification, early and late displacement, and malunion. Fracture severity was quantified with use of previously published algorithms for calculating the probability of early and late displacement, late carpal malalignment, and malunion. These severity scores were correlated with the dual x-ray absorptiometry T-scores, which represent the number of standard deviations by which the measured bone density differs from the mean value in healthy controls.

RESULTS

There was a significant linear correlation between increasingly negative T-scores and increasing likelihood of early instability, late carpal malalignment, and malunion. Patients with osteoporosis (a T-score of less than -2.5) had a 43% probability of having early instability, a 39% probability of having late carpal malalignment, and a 66% probability of having malunion. Patients with osteopenia (a T-score of more than -2.5 but less than -1) had a 35% probability of having early instability, a 31% probability of having late carpal malalignment, and a 56% probability of having malunion. This compared with a 28% probability of early instability, a 25% probability of late carpal malalignment, and a 48% probability of malunion in patients with normal bone mineral density (a T-score of more than -1).

CONCLUSIONS

There is a definite correlation between bone mineral density and the severity of distal radial fractures.

Reliability and validity of the German version of "the Patient-rated Wrist Evaluation (PRWE)" as an outcome measure of wrist pain and disability in patients with acute distal radius fractures

The aim was to test the reliability and validity of the German version of the Patient-rated Wrist Evaluation (PRWE) for patients with acute distal radius fractures. To estimate the reliability and construct validity, 44 patients completed a questionnaire booklet containing the German PRWE, the Short Form-36 (SF-36), and the Disability of the Arm, Shoulder, and Hand (DASH) four to six weeks after the fracture, and the PRWE again seven days later. For reliability, the intraclass correlation coefficient (ICC) was 0.94 for the PRWE total score. Its internal consistency was 0.89 (Cronbach's alpha). The PRWE total score showed a moderate correlation with the DASH (0.62) and the SF-36 subscale bodily pain (0.58). Low correlations were found with other scales of the SF-36. Based on our results the German PRWE is a practical, reliable, and valid instrument and can be recommended to measure patient-rated pain and disability in German-speaking patients with acute distal radius fracture.

Reabilitação das fraturas do rádio distal

O objetivo deste estudo foi avaliar a evidência do efeito e eleição da conduta terapêutica nas fraturas do rádio distal. A revisão sistemática utilizou as bases de dados PubMed, Lilacs, Pedro, Cochrane, Scielo, OTseeker, sem restrições de período de publicação, com as seguintes palavras chaves: fraturas do rádio, reabilitação, terapia ocupacional, fisioterapia, incluindo línguas inglesa, espanhola, francesa e portuguesa. Os estudos encontrados foram avaliados independentemente pelos dois autores utilizando critérios da escala PEDro. Estudos não experimentais foram incluídos em busca de esclarecimentos sobre a reabilitação. Foram encontrados 22 estudos, sendo 14 ensaios clínicos controlados randomizados (ECRs). Dentre eles, quatro compararam mobilização precoce com tratamento convencional apresentando evidência moderada a favor da primeira; sete confrontaram tratamento baseado em exercícios domiciliares com tratamento em consultório apontando evidência conflitiva (um deles também comprovou eficácia de mobilização acessória passiva); e três analisaram eficácia de procedimentos terapêuticos: campo eletromagnético pulsado, drenagem linfática, ultra-som, indicando evidências limitadas. Os nove estudos não experimentais encontrados não apresentaram informações suficientes sobre os questionamentos desta pesquisa. Observou-se uma tendência dos autores em utilizar os princípios gerais da reabilitação ao elaborar condutas terapêuticas, mas os procedimentos utilizados não estão bem atestados pela literatura.

Cyclic pneumatic soft-tissue compression enhances recovery following fracture of the distal radius: a randomised controlled trial

QUESTIONS

Does the addition of cyclic pneumatic soft-tissue compression during the 6-week immobilisation period following fracture of the distal radius result in a faster recovery of muscle strength and joint range of motion? Does it result in a larger recovery of muscle strength and joint range of motion immediately after the immobilisation period (at 6 weeks) or four weeks after the immobilisation period (at 10 weeks)?

DESIGN

Randomised controlled trial with concealed allocation and assessor blinding.

PARTICIPANTS

21 patients with fracture of the distal radius.

INTERVENTION

The experimental group received cyclic pneumatic soft-tissue compression during the 6-week immobilisation period whereas the control group received usual care. Both groups were instructed to actively make a fist 100 times per day during the 6-week immobilisation period and were given an exercise program during the 4-week post-immobilisation period.

OUTCOME MEASURES

Function was measured as power grip, pinch grip, key grip, and supination strength using dynamometry from Week 1 to 10 as well as wrist flexion/extension and forearm supination/pronation range of motion using goniometry from Week 6 to 10. The outcome measures are presented as a percentage of the intact side.

RESULTS

The experimental group improved significantly faster than the control group in muscle strength from Week 1 to 10 (p ? 0.001) but not in joint range of motion from Week 6 to 10 (p > 0.05). By Week 6, the experimental group was 12-26% stronger and had 8-14% more range of motion than the control group. By Week 10, the experimental group was 24-29% stronger and had 10-15% more range of motion than the control group.

CONCLUSION

The findings indicate that a larger clinical trial is warranted and should incorporate direct measures of fracture healing.

An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial

QUESTION

Does an advice and exercise program improve outcome for adults following distal radius fracture?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Fifty-six patients whose fracture had been managed with pins and/or cast.

INTERVENTION

The experimental group received a physiotherapist-directed program of advice and exercises. The control group did not receive any physiotherapy intervention.

OUTCOME MEASURES

The primary outcome was wrist extension (measured with a goniometer). Secondary outcomes were the other wrist ranges of motion (measured with a goniometer), grip strength (measured with a dynamometer), pain, and activity limitations (measured with questionnaires). These outcomes were measured initially, then three and six weeks later. Participants also rated their satisfaction with physiotherapy intervention at Week 6.

RESULTS

No difference was found between groups for the primary outcome of wrist extension (mean difference 6 deg, 95% CI -3 to 14), nor for the secondary outcomes of other range of motion data and grip strength. The difference between groups for pain was -16 points out of 100 (95% CI -27 to -5) at Week 3, and -14 points (95% CI -25 to -3) points at Week 6, and for activity was -13 points out of 100 (95% CI -24 to -2) at Week 3; in favour of the experimental group. The experimental group was also more satisfied with the amount of physiotherapy intervention.

CONCLUSION

An advice and exercise program provided some additional benefits over no intervention for adults following distal radius fracture.

Baseline predictors of pain and disability one year following extra-articular distal radius fractures

Distal radius fractures are common injuries; however, identifying which factors are responsible for predicting outcomes remains an area of controversy. The purpose of this study was to define factors predictive of patient-reported pain and disability at 1 year in a prospective cohort of extra-articular distal radius fractures (n = 222). Data were collected at the initial visit and after 3, 6, and 12 months. The primary outcome was the 1-year patient-rated wrist evaluation (PRWE) score. The effect of baseline patient and injury characteristics on the 1-year PRWE score was assessed. Univariate and forward stepwise regression analyses both agreed that the most influential predictor of pain and disability at 1 year was injury compensation. The 1-year PRWE score was significantly higher for subjects involved with third-party claims (35.48) compared to those that were not involved in any claims (14.97), p = 0.006. The regression model found that three baseline factors - injury compensation, education, and other medical comorbidities - explained 16.4% of the variance in PRWE scores at 1 year. No injury characteristic, including the degree of initial fracture displacement, was found to significantly influence the 1-year PRWE score. This study has shown that baseline patient and injury characteristics play a small role in predicting 1-year patient-reported pain and disability in extra-articular distal radius fractures. Conceptual factors outside of this biomedical model should be investigated.

Can radiological results be surrogate markers of functional outcome in distal radial extra-articular fractures?

The purpose of this study was to evaluate the relationship between radiological and functional results in patients with extra-articular fractures of the distal radius. We conducted a prospective study of radiological and functional assessment in 95 consecutively selected extra-articular distal radius fractures. There were two patient groups: more than 60 and less than 60 years of age. The final fracture union radiographs were analysed for their functional outcome using the Michigan Hand Outcomes Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. In patients with acceptable radiological results, 62% (MHQ group) and 72% (DASH group) of patients had satisfactory functional outcome. Analysing patients with satisfactory functional results, 56% (MHQ group) and 59% (DASH group) had satisfactory radiological results. There was a higher proportion of patients with better functional results, despite poor radiological results, in both of the age groups. There was a statistically significant correlation between satisfactory radial tilt and functional outcome in the younger patients. In the older age group, patients with satisfactory radiological results had satisfactory functional outcome (p<0.05). However, in the older age group, satisfactory functional results were achieved, despite unsatisfactory radiological results.

Function Versus Position: A Randomized Controlled Trial of Interfocal Kirschner Wiring of Unstable Distal Radial Fractures

INTRODUCTION

A randomized, prospective study has been carried out to determine if immobilisation in dorsiflexion following K-wire fixation of unstable distal radial fractures improves functional outcome.

METHODS

Sixty patients with unstable fractures of the distal radius were entered into the trial. There were 52 female and 11 male with an average age of 60yrs (17-84). Randomisation was undertaken in theatre using a closed envelope system. The fractures were initially reduced by closed manipulation and interfocal percutaneous K-wires inserted. Patients randomised to group I had their wrists placed in 30 degrees of dorsiflexion and group II had their wrists placed in 30 degrees of palmer flexion. Patients were reviewed with an x-ray at 1, 3, 5, and 17 weeks by a single physician. Dorsal angulation, Radial inclination, Radial length and Radial height were measured. The K-wires were removed in the outpatient clinic at 3 weeks and the plaster at 5 weeks. Blinded functional review was carried out by an Occupational therapist at 5, 8 and 17 weeks post operation. The power and pinch grip was measured using a Jamar dynamometer. Flexion and extension were measured with a goniometer.

RESULTS

There was no statistical difference in radiological or functional outcomes in either group. At 17 weeks the mean dorsal angulation was -0.5 and -1.9 degrees. The mean radial shortening was 1.5mm in both groups. The power grip was 86% and 82% and pinch grip was 99% and 101%. Patients regained 76% and 79% of flexion and 94% and 88% of extension compared to the opposite side.

CONCLUSIONS

Immobilisation in dorsi-flexion following K-wiring for unstable distal radial fractures does not improve functional outcome. The overall functional results were excellent and we believe that Kwiring still as a place in the treatment of distal radial fractures in the previously defined population.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials 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 authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done.

MAIN RESULTS

Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. For interventions started during immobilisation, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilisation (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial).

AUTHORS' CONCLUSIONS

The available evidence from randomised controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Rehabilitation of distal radius fractures: a biomechanical guide

Fracture healing and surgical decision making are not always predictable. The suggested protocols are intended to be flexible rather than rigid to be responsive to patient progress and the fracture site stability. A methodologic approach to the rehabilitation following a distal radius fracture, based on a knowledge of the biology of fracture healing and biomechanics of fixation, may preempt some of the pitfalls associated with distal radius fracture healing.

The relationship between adherence to hand therapy and short-term outcome after distal radius fracture

This study aimed to examine the relationship between adherence to hand therapy and short-term outcome after fracture of the distal radius. Attendance at hand therapy appointments, therapist-rated adherence during appointments, and home-exercise diaries were used to monitor adherence in 15 people undertaking rehabilitation after a wrist fracture. Outcome measures were change in impairment (wrist extension, grip strength, and pain rating) and change in activity (modified Levine questionnaire, Jebsen Test of Hand Function) from initial assessment (after cast removal) to follow-up (six weeks later). Multiple regression analysis found over 50% of variance in wrist extension change, Levine questionnaire change, and change on the simulated feeding item of the Jebsen Test of Hand Function to be predicted by adherence. Home exercise adherence was the most important predictor of the adherence measures. These results highlight the importance of adherence to home exercises prescribed by a hand therapist after fracture of the distal radius.

Effects of circumferential rigid wrist orthoses in rehabilitation of patients with radius fracture at typical site

Background. The use of orthoses is a questionable rehabilitation method for patients with the distal radius fracture at typical site. The aim of this study was to compare the effects of the rehabilitation on patients with radius fracture at the typical site, who wore circumferential static wrist orthoses, with those who did not wear them. Methods. Thirty patients were divided into 3 equal groups, 2 experimental groups, and 1 control group. The patients in the experimental groups were given the rehabilitation program of wearing serially manufactured (off-the-shelf), as well as custom-fit orthoses. Those in the control group did not wear wrist orthoses. Evaluation parameters were pain, edema, the range of the wrist motion, the quality of cylindrical, spherical, and pinch-spherical grasp, the strength of pinch and hand grasp, and patient's assessment of the effects of rehabilitation. Results. No significant difference in the effects of rehabilitation on the patients in experimental groups as opposed to control group was found. Patients in the first experimental group, and in control group were more satisfied with the effects of rehabilitation, as opposed to the patients in the second experimental group (p<0,05). Conclusion. The effects of circumferential static wrist orthoses in the rehabilitation of patients with distal radius fracture at the typical site were not clinically significant. There was no significant difference between the custom and off-the-shelf orthoses.

Therapy interventions for improving joint range of motion: A systematic review

The authors conducted a systematic review of the published evidence on conservative interventions for loss of upper extremity joint range of motion following selected musculoskeletal conditions. Several databases (Medline, CINAHL, PEDRO, PubMed, and Cochrane) were searched for articles that met inclusion criteria. Two reviewers determined abstract selection; two reviews performed critical appraisal of 26 articles. Level of evidence and quality on a 24-item quantitative critical appraisal form were determined for all articles meeting selection criteria. The primary outcome considered was range-of-motion measurement. Overall, the quantity and quality of evidence were moderate to low. Sackett's levels 2b, 3, and 4 evidence has shown that joint mobilization, a supervised exercise program, and splinting can all increase joint range of motion. There were no studies found in the literature that examined techniques of physical agent or electrotherapeutic modalities. Future studies are needed to delineate selection of appropriate candidates for these techniques and effective dosage.

Difficulties associated with wrist disorders--a qualitative study

OBJECTIVE

To explore the range of functional difficulties and compensatory mechanisms reported by individuals with a wrist disorder, to provide a basis for development of a patient-focused outcome instrument.

DESIGN

Descriptive study using a qualitative, interview-based framework.

SETTING/SUBJECTS

A volunteer sample of individuals, who were diagnosed with a unilateral, localized wrist disorder, were recruited from a wide range of health care settings situated in different socio-economic and geographic areas of Adelaide, Australia. Recruitment continued until theoretical saturation of the data occurred.

INTERVENTIONS

Semi-structured, audiotaped interviews were conducted with each individual to elicit information concerning 'how your wrist disorder has affected your ability to perform daily activities'.

MAIN OUTCOME MEASURES

Trends regarding reporting of difficult activities and compensatory mechanisms used.

RESULTS

Forty-two individuals were interviewed. This was the point where theoretical saturation of research information had been reached. A few individuals reported difficulty with functional tasks prior to wrist injury. Following diagnosis, a wide range of difficulties, which included heavy, gross and fine motor activities, was reported. Compensatory mechanisms were used by all individuals, with requesting someone else to do the task, using the other hand, and using other parts of the body to lift or grasp being the most common.

CONCLUSIONS

Current wrist outcome instruments do not contain the full range of difficult activities that were elicited from our sample, which casts doubt on these instruments' ability to fully measure change in capacity. Our results should provide the basis for the development of a relevant, sensitive, patient-focused outcome instrument.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To examine the evidence for effectiveness of rehabilitation intervention(s) for adults with conservatively or surgically treated distal radial fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), the Cochrane Rehabilitation and Related Therapies Field database, MEDLINE (1966 to January 2002), EMBASE (1988 to 2001 Week 50), CINAHL (1982 to December Week 2 2001), Current Controlled Trials (December 2001), AMED, PEDro, conference proceedings and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by skeletally mature patients. 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

All trials meeting the selection criteria were independently assessed by all three reviewers for methodological quality. Data were extracted independently by two reviewers. The trials were grouped into categories relating to the main comparisons, and to when the intervention(s) commenced (for example, during or after plaster cast immobilisation). Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits.

MAIN RESULTS

Twelve trials, involving 601 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 20 patients whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. No trial provided definitive evidence. Only very limited pooling of results from comparable trials was possible. During immobilisation, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial). Post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (3 trials), passive mobilisation (2 trials) or whirlpool immersion (1 trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in patients given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial).

REVIEWER'S CONCLUSIONS

The available evidence from randomised trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.