A fall on the outstretched hand (FOOSH) is a common occurrence and often results in a Colles' fracture, a fracture of the distal inch of the radius and ulna next to the wrist. Treatment is immobilisation in a splinting material such as Plaster of Paris for five to six weeks to allow healing of the bony fragments, followed by a variable period of rehabilitation depending on the severity of the fracture. The hand is extremely important functionally so the period in plaster is kept to a minimum to allow quick restoration of normal hand use, although a wrist splint can be used for a week or so, particularly in cases where there is significant pain on activity.
Once the Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.
Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles' fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.
Patients often report that the wrist feels at risk after the plaster has been removed and this may be due to the early removal of the plaster to prevent functional loss from immobilisation. A futura brace, a fabric support stiffened with a metal piece under the wrist, is applied with Velcro straps to give support during normal activities of daily living. The brace should be taken off during rests or light activity and for regular performance of the exercises. Too much further immobilisation at this stage could be harmful so patients should understand the limited use of the splint for comfort during activity.
If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.
Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.
If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand.
Autor: Jonathan Blood-Smyth
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Oxford or elsewhere in the UK.
Added: January 30, 2009
Source: http://ezinearticles.com/
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