Radius PDF

Treatment2Go
Exploring Hand Therapy

Manual
Slip, Fall, Broken Wrist!

A Fracture Everyone Treats
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Slip, Fall, Broken Wrist! Distal Radius Fractures

A Fracture Everyone Treats • Most common UE fx
– 1 out of 6 fractures seen in ER
– 3rd most common fracture
 Susan Weiss • High morbidity rate. One study
OTR/L CHT found that only 22.9%
9% of Colles’
Colles
fractures had NO permanent
 Contributing author: disability
 Amy E. Turner • Often associated with concomitant
 MHPE, OTR, CHT pathology
– CTS, CRPS, stiff hand, etc.
Statistics of Distal Radius Common Classifications for

Fractures distal radius fractures
• More common in women
• Melone
• Increase with advancing age
• Occur most often from low-energy trauma • Frykman
(f ll ffrom level
(falls l l ground)
d)
• Mayo
• Epidemiologic trends show increase in
more complex, unstable distal radius • A.O.
fractures from high-energy injuries, sports,
and MVAs. • There are over 20 classifications!
Classification Systems Melone Classification

No one system describes all fracture • -describes progressively
worsening comminution
patterns, considers degrees of and displacement
comminution, and is of consistent • -suggests treatment
prognostic value
value. based on classification
• -divides distal radius into
four parts: shaft, radial
Knowing these systems may enhance styloid, dorsal medial,
communication with surgeons and volar medial
1
Mayo Classification
• -underscores specific articular content
Frykman Classification areas
1-8
Higher-classification
Higher classification
fractures have worse • -describes
d ib whether
h th ffracture
t iis di
displaced
l d or
prognoses
nondisplaced, reducible or irreducible, and
stable or unstable
AO Classification
(Comprehensive classification of Patterns of Distal Radius
fractures) Fractures
• Divides into three Colles’
basic types
– A: extra-articular Smith’s
– B:
B Si
Simple
l articular
ti l B t ’
Barton’s
– C: Complex articular
Chauffeur’s
-Each type is subdivided Lunate “die-punch” fracture
into 27 subgroups
-Detailed, descriptive, TIP: Often "Colles' Fracture" is used as
very complex a generic term for all distal radius
fractures
Colles’ fracture Smith’s fracture

 Fx. of the distal radius
 Fx. of the distal radius ("reverse Colles")
with DORSAL angulation  Volar angulation of distal
of distal fragment fragment
 caused by y falling
g onto
 Most commonly caused flexed wrist
by FOOSH (fall on
 Less common than
outstretched hand) Colles' fractures.
 Tx. Goal: restore radial  Immobilized in supination
length and joint congruity (40 degrees) with the
wrist in 30 degrees of
extension
2
A way to remember the fracture

Barton’s
patterns
• Colle's fracture: arm • Barton’s
in fall position makes – Displaced and unstable fracture subluxation
a 'C' shape. of the distal radius with the carpus following
g
the articular fragment
• Smith's fracture: arm – Dorsal and volar types
in fall position makes – Many require ORIF
a 'S' shape
Dorsal Barton’s Volar Barton’s
• Dorsal Barton’s have -Intra-articular volar

a dorsal fragment and fragment
correlate with the -Correlates with
Colles’ fractures Smith’s fracture
Chauffeur’s
Fx. of the radial

styloid (intra-
articular)
Usually managed
with pinning
Can be associated
with S-L injuries
3
Stable vs. Unstable

Lunate “die punch” fracture
What does this mean?
• Intraarticular depression Stable:
of the lunate fossa into – less angulation or displacement
the distal radius
– Minimal comminution
– Do not usuallyy involve radiocarpal joint
j or
• Allows proximal migration
of the lunate and/or
DRUJ
proximal row Unstable:
-displaced, comminuted, may involve DRUJ
• Managed with elevation with or without fracture of distal ulna
and bone grafting - May extend into radiocarpal joint with lateral
displacement of the radial styloid
Physician Management of the

fracture
Closed Reduction Of Distal
Radius Fractures
• Closed reduction
• Percutaneous pinning
• Closed reduction= no/minor comminution with
• External fixation minimal articular components.
• Open reduction with internal fixation (plate • Reduced and placed in appropriate positions
and screws) • Cast is applied (cast must clear the distal palmar
crease to allow full MP motion)
• Depends on comminution, displacement, • Used less commonly due to advances in surgical
procedures
and angulation
Percutaneous Pinning Arthroscopic Assisted Fixation

 Can be added after • Good choice for fractures that don’t
reduction to provide have extensive comminution
additional stability to the • Good to use when suspected
reduced fragments ligament injury exists
 Usually 6-
6 8 weeks • Radial styloid fractures (also have a
 Intrafocal Pinning high incidence of SL injuries that
(Kapandji)- the K-wire is goes along with them)
directed into the fracture • 3 part fractures
site and used as a lever • 4 part fractures (more difficult)
to put the displaced
fragment into alignment • Is becoming more standard for
surgeons to use this technique
4
Role of External Fixation External Fixation

• There are circumstances when a fixator is
still used • Used either alone or in conjunction with
percutaneous pinning as fixator alone can’t
Unstable fractures with significant correct palmar tilt, radial translation or reduce
metaphyseal comminution to correct radial the lunate fossa
length • Principle of all external fixation is based on
When the fracture extends proximally up the “ligamentotaxis” – fragments are aligned by
radius too far for plate to get adequate traction across fracture site.
purchase proximally • Can have complications: median neuropathies,
Open grossly contaminated fractures which irritation of DSBRN, finger stiffness, pin
are being temporarily stabilized infections
1 yr post-op Non-bridging External Fixation

• Allows immediate early motion of the wrist (see photo
next slide)
• An excellent treatment option for extra-articular distal
radius fractures or non-displaced fractures with mild to
moderate comminution
• Contraindicated for severe comminution or
osteoporosis
• Conventional external fixation involves placing the distal
pins into the first metacarpal (pins span the wrist joint)
• Non-bridging fixators do not span the joint but rather
are placed into the distal fracture fragment and do not
cross the wrist
• They are not using ligamentotaxis to treat the fracture
5
ORIF (Open Reduction, Internal

Fixation)
• The benefits of ORIF are
to allow stable fixation of
unstable fractures and to
allow for early
mobilization
• Platingg can be dorsal or
volar
• This technique is more
popular than other
methods
• Very often will go in a
custom-fabricated
orthosis and begin early
ROM after surgery
Volar Plating Done For Distal

Volar vs. Dorsal Plating
• Volar plating
Radius fracture
– Less likely to have dorsal tendon scarring and
subsequent rupture
– Protects blood supply
– Less pain and more motion
– Plating
Pl ti on the
th suboptimal
b ti l sideid off th
the ffracture
t
• Locking technology has helped overcome this problem
• Dorsal plating
– Fixation on the optimal side of dorsally angulated
fractures
• Favored in the absence of locking technology
– Still useful in distal radius malunion correction
Regardless of Method Used for

Normal Inclination and Tilt
reduction…
• The physician must adhere to principles of
adequate reduction and attempt to restore:
– Articular congruency
– Radial length
– Volar tilt
– Radial inclination
– Assess DRUJ instability and treat if necessary
Radial Inclination (22 Palmar Tilt (11

degrees) degrees)
6
Radial Height (length) Normal is Residual deformities to know

12 mm and No Ulnar Variance
• Loss of radial tilt or inclination –normal is 22-33
degrees
– May cause decreased UD and grip strength with a
decrease of 5-10 degrees
– Wrist may appear radial deviated if inclination is
less than 15 degrees
• Loss of palmer tilt - Dorsal angulation – normal
palmar tilt is 11-12 degrees
– Silverfork deformity
Positive Ulnar
variance – Ulnar sided wrist pain due to load shift - TFCC
– Loss of palmar tilt is thought by many to be the
most important aspect of radial malunion
Therapy after Distal Radius

Continued…
• Radial shortening (decreased height) – normal is
Fractures
12 mm
– Decreased grip strength and can affect pronation
– radial shortening may be the most important factor
in the development of symptomatic malunion
– Radial shortening as minimal as 2.5
2 mm can
substantially complicate this dynamic and markedly
increase ulnar loading – TFCC problems
• Distal radioulnar joint involvement
– Increased pain, decreased grip, decreased rotation
• Intra-articular involvement
– Step offs as little as 1-2 mm can increase Requires all of your skills as a therapist for a successful
outcome!
posttraumatic arthritis
What do I need to know from the What do I need to know from the
physician? physician?
1. Type of fracture (Colles’, Smith’s,
Barton’s, etc) and degree (intra-articular, 5. Knowledge of the amount of radial
comminuted, displaced)
shortening, dorsal angulation, the
2. Type
yp of reduction ((closed,, external presence of any articular step-offs
step offs or any
fixation, ORIF (plating)
DRUJ issues (this is paramount)
3. Stability/Integrity of reduction, Bone
quality
4. Additional structures involved (ulnar
styloid, TFCC, ligament injury, etc)
7
What do I need to know from the Therapy Goal for functional

patient? vs normal wrist motion
• DOI/DOS • Normal is 140 flex/ext and 150 sup/pro
• PMH (Diabetes, OI, OA, etc) and general • Functional (varies depending on patient)
health (smoker, etc.) – Palmer et. al: 30 degrees ext., 5 degrees
• Type of work (musician,
(musician heavy laborer,
laborer flexion 10 degrees RD
flexion, RD, 15 degrees UD
secretary, etc) – Ryu et. al: 40 degrees ext,, 40 degrees
• Hobbies (golf, knitting, etc.) flexion, 40 degrees combined rd/UD
• Patient’s goals/expectations – Gartland and Werley: 45 degrees ext., 30
• Family support/living situation (single, degrees flexion, 15 degrees RD, 15 degrees
living alone) UD and 50 degrees of each sup/pro
***Goals vary depending on the patient- ie. Elderly person vs. an athlete
Things to keep in mind with Treatment In A Cast or External

early intervention: Fixator??
 Watch for CRPS/CTS and ill-fitting casts • YES!!
(should allow full MCP flexion and should not – Instruct patient in end range of motion exercises,
be too tight) making sure that the cast clears the DPC
 Avoid slings if at all possible (=tight necks, – Radial abduction and extension of the thumb (web
tight shoulders) spacer)
 Wiggling is worthless (full composite digit – Pin care if in ext. fix.
ROM is necessary)
– Elevation/Edema Control
 Edema control (swelling is the mother of scar)
– Can fabricate dynamic flexion to digits (over cast)
if deficits are severe
– Educate in elbow and shoulder ROM exercises
Treatment following ORIF Benefits of ORIF

• Begin therapy within • Early motion
3-5 days postop
unless complication • Anatomical alignment
prohibits (poor bone • Less pain
quality etc
quality, etc.))
• Fabricate wrist • Less time off, less therapy
immoblization • Patients are happier
orthosis for proper
position and comfort
(to be worn between
exc. and at night)
8
Treatment after casting or

Generalized Treament
immobilization:
• May need splinting
between exercises and • Applies to all types of surgical or
at night nonsurgical interventions or fracture types
• Begin wrist and forearm
ROM exercises
• Add eventual
strengthening exercises
• May require static
progressive or dynamic
splinting to regain ROM.
• Remember that
functional activity is NOT
a replacement for
therapy – they need
ROM to end range
Additional Edema management

Dressings for Edema Control
Considerations
• Best method is elevation
– Hand above the heart at all times
• Overhead pumping
– regularly
• Avoid sling use
– Does not properly elevate and
promotes stiffness
• Distal to proximal massage
– Also provides tactile input
• MEM
• Compressive wraps and
gloves
Essential Exercises It has been said…

• Patient involvement at • That the most important
principle after distal
home is essential radius fractures is to re-
(team effort) establish independent
g about
• Never forget wrist extension
• Avoiding
A idi th the substitution
b tit ti
the shoulder and pattern of using the digital
elbow extensors to perform wrist
extension is critical
• Perform isolated wrist ext.
with the fingers wrapped
down
9
Composite Finger ROM- Do

Tendon Gliding Exercises
close up Demos
a
b
a b
Blocking - FDP
To Avoid EET (Extrinsic Extensor To Avoid EFT (Extrinsic Isolated FDS

Tendon Tightness) Flexor Tendon Tightness)
Important exercises
a
a b
Isolated FPL
Intrinsic Stretches
Composite fisting Lumbrical
exercises
Digital abduction and adduction Isolated wrist extension Wrist flexion
10
a b
Radial deviation Ulnar deviation

Pronation Supination
Scar management Scar massage
• Scar massage (done

by therapist AND
patient))
• Silicone gel sheeting

Gel
• Elastomer
Strengthening and ROM

Clinic Program
programs
• Range can’t be • Exercise regime in the clinic should be
maintained unless the
person has adequate
charted
strength in the • Watch to see when program needs to be
muscles to maintain changed
the available ROM
• Light strengthening • Usually changed at least once a week
should begin after (monitor ROM)
cast, splint or fixator • Don’t get in a rut
removal
11
The following are activities

Hand Exerciser
commonly used in the hand clinic
• These samples are not comprehensive but
will give you some guidelines to rehab.
after distal radius fracture.
Putty Pinch Strengthening
Gripping Intrinsic Strengthening

3-jaw pinch Lateral Pinch
Dowel Exercises Isolated wrist extension
• Putty for wrist

extension with fingers
in flexion to avoid
substitution.
Dowel and putty exercises – sustained

gripping
12
Stretching and Weight Bearing Wrist Curls for Extension & Flexion
Forearm strengthening Clinic Activities
Can be done with a hammer at home (strengthening and

stretching)
Flexbar Exercises for Pronation Flexbar for Supination
13
Work Cube
Powerweb Screwdriver for supination and pronation
Wrist Extension and

Flexion
Large knob on work cube Push/Pull
Work Simulation Floor to Waist
14
Fine motor activities UBE

• Cardiovascular
exercise promotes
healing by increasing
bloodflow
• Promotes generalized
feelings of well-being
• Remember patients
can get depressed or
feel hopeless at times
The Stiff Hand/Wrist

“Fracture Disease”
Why?
• Reasons: • Constellation of symptoms caused by prolonged
– Late referral to therapy immobilization
– Noncompliant patient • Can lead to pain, unresolved edema, muscle
– fear, “wiggling” atrophy, osteoporosis and CRPS
– Tendon adherence • “Late
“L t referral”
f l” patients
ti t often
ft have
h well-
ll
– Joint tightness developed substitution patterns that contribute to
– Other health issues stiffness and dysfunction
(diabetes) (i.e., using digital extensors to extend the wrist)
Can be avoided or prevented with early digital
motion and edema mangagement
Wiggling is Worthless!
Complication: Dynamic Splinting vs. Static-

The Stiff Hand/Wrist Progressive
 Dynamic splinting–
• PROM/Joint “earlier” stiffness –
Mobilization proliferative stage of
• Heat and stretch healing (soft-end feel)
 Static Progressive
• US with a stretch Splinting
p g ((low load,,
• CPM prolonged stretch)
• Serial static splint  more effective when
PROM does not exceed
• Dynamic/static AROM
progressive splints  most effective with hard-
– Can be custom made end feel (worn longer)
or ordered via reps  appropriate through
Dynamic composite flexion
acute, proliferative and splinting (capsular tightness,
chronic stages of healing EET)
15
Dynamic Flexion and Extension
Dinosaur! A real dinosaur!
Static progressive devices Dynasplint for wrist

Extension/
Flexion
JAS
DeRoyal
CPM (Continuous Passive Motion)

JAS for Supination/Pronation
• Designed to reduce
pain, reduce edema
and improve range of
motion
• Can be used at night
to maintain gains
made during the day
• Good when stiff in
both directions and
don’t want to use 2
splints
16
Treatment modalities for pain

Finger CPM and edema associated with the
stiff wrist
• Cold application
• Fluidotherapy (desensitization)
• Moist heat
• Ultrasound
• Interferential
• Compression gloves/sleeves
Complication: What structures could be

Ulnar-Sided Wrist Pain involved?
• Ulnar styloid fracture
• Lets look at the patient who is diagnosed • DRUJ instability
with a distal radius fracture but keeps • TFCC tear
pointing to the ulnar side of the wrist and • Lunatotriquetral joint (carpal instability)
complaining
• Pisotriquetral degenerative joint disease
• Tendinitis – ECU or FCU
• What could be happening?
• Ulnar Nerve Compression
Ulnar head vs. Ulnar styloid Wrist Kinematics

• Ulnar head is rounded • With a 20-degree dorsal tilt of the distal
prominence on ulnar radius, the load across the ulnocarpal joint
side of wrist (easily is increased to upward of 50%
palpated in pronation)
• Ulnar styloid is
• Radius shortening causes the most
localized ulnar and significant kinematic alteration and the
slightly distal to ulnar greatest tension on the TFCC
head • The most problematic deformity for the
DRUJ is dorsal angulation
17
Ulnar variance Ulnar Variance

• When normal articular relationship
between the radius and ulna is disrupted,
loads through the ulnar structures exceed
physiologic limits
• Ulnar variance=the distance that the distal
articular portion of the ulnar head extends
below (negative) or above (positive) the
articular surface of the radius
Positive ulnar variance
Ulnocarpal abutment syndrome

• Also known as impaction, loading, and
impingement
• Sequence of events:
– Wearing of the articular disc of TFCC
– Chondromalacia of ulnar head and ulnar
aspect of lunate
– Disruption of LT ligament
Causes and symptoms of

Treatment
ulnocarpal abutment
Causes: • If radial articular
alignment is satisfactory,
• Malunited radial shortening or angulation ulnocarpal abutment can
• DRUJ ligament injuries be corrected with ulnar
shortening g osteotomy y
Symptoms:
• If radial malalignment is
- Pain localized to dorsal aspect of wrist significant, a corrective
over DRUJ or directly over TFCC region radial osteotomy is
preferred
- Intermittent clicking sensation, activity
related swelling, decreased strength and
motion
18
Corrective Osteotomy
Complication:TFCC
Before After
- Originates from sigmoid
notch and inserts into the
ulnar fovea and the base
of the styloid
– Includes dorsal and volar
radioulnar ligaments,
meniscus homologue,
ulnocarpal ligaments,
ECU tendon sheath,
lunotriquetral
interosseous ligament,
and articular disc (TFC
proper)
TFCC Central vs. Peripheral

- Central Portion consists of chondroid
– Stabilizes the DRUJ and separates it from the fibrocartilage and bears compressive forces
carpus and distal radius between ulnar head and triquetrum (smooth but
mobile gliding surface) – devoid of vasculature
– Primary ulnocarpal ligaments originate from
TFCC, not the distal ulna - Peripheral portion is ligamentous with thick
collagen structure to bear tensile loads (palmar
– The ulna absorbs 20% of axial loading forces
and dorsal limbs)
(as in gripping) through its articulation with
TFCC and ulnar carpus - Primary arterial supply is dorsal branch of
anterior interosseous artery
Central tear=poor blood supply Incidence

Peripheral tear= good blood supply
• Richards found 35% incidence of TFCC
tears in intraarticular fractures and 53% in
extraarticular fractures
• Patients with greater radial shortening and
dorsal angulation were noted to be more
likely to have TFCC tears.
19
Causes and Symptoms TFCC testing

• Injuries usually result from a rotational • Palpate between
injury to the extended wrist head of ulna and the
triquetrum
• Decreased strength and pain at the limits
• Fovea is a g
groove at
of rotation are most common complaints base of ulnar styloid
• Pain primarily with rotation suggests DRUJ that serves as an
involvement. Pain with ulnar deviation attachment for TFCC
suggests TFCC pathology or ulnar (Fovea sign/Sulcus
impaction. Sign) – may also be
ulnar abutment
TFCC Debridement
TFCC testing (central tear)
• TFCC load test – to • Volar wrist splint
detect ulnar abutment or
TFCC tears • AROM 3-5 days postop
• Ulnar deviation and axial • No impact loading
loading of wrist moving
volarly and dorsally or by • Light strengthening at 4-6 weeks
rotating the forearm
• Gradually resume ADL’s and wean from
• Positive with pain,
clicking, crepitus, and splint
reproduction of symptoms
Peripheral repair Complication:

• Week 1 Long arm cast Ulnar Styloid Fractures
• Week 2-4 long arm splint Munster style to avoid • Occur in more than 50% of distal radius
sup/pro
fractures, 25% go on to nonunion
• Week 4-6 short arm splint and begin forearm ROM
• Week 6-10 • TFCC tears or DRUJ instability are
– AROM suspect with radial displacement of the
– Avoid extremes of rotation styloid or fractures at the base.
– Continue use of splint except for bathing and exercise • May require splinting in a long arm
– Light ADL’s orthosis
– Week 10 – begin gentle PROM
– Light strengthening
• 12 weeks continue and upgrade strength program
– Begin dynamic/static progressive splinting
20
Ulnar styloid
f
fracture with
ih
radial
displacement
Complication: DRUJ
DRUJ Instability What is it?
• Prominence of distal • Distal Radioulnar joint
ulnar head is a sign of (includes the TFCC)
– Formed by sigmoid notch
DRUJ instability of radius and ulnar head
– Frykman showed that – Rotates around a
19% of DRFX had longitudinal axis that
problems with the passes through the center
DRUJ of the radial head at the
elbow to the fovea of the
– Some say as many as ulnar head at the level of
30% have at least the wrist
some lasting – Promotes rotation and
complaints related to sliding movements
the DRUJ between radius and ulna
Palpated just radial to

the ulnar head
Piano Key Sign

• Sign – gentle
downward pressure
applied to distal end
DRUJ Testing of ulna with forearm
pronated. Head
moves volarly but
springs back when
pressure is released
• Manuever = “note” of
pain
21
Piano Key Test

(DRUJ instability test)
• Distal ulna is grasped and
moved passively in volar
and dorsal direction at
extremes of pronation
and supination
p
• Done initially in neutral
(up to 5mm may be
noted)
• Pain, tenderness, and
increased mobility relative
to uninjured side
Complication: Malunions result in many

Distal Radius Malunion problems
• The incidence of distal
radius malunion, or • Often overlooked
fracture healing in a non- • As many as 30% of distal radius fracture
anatomic position has patients report complaints at the DRUJ
been estimated to be
23% • Residual dorsal angulation is disruptive of DRUJ
• Symptomatic malunion function
may be less frequent • Radial shortening relative to the ulna causes
• The term "malunion" can higher force transmission across the ulnar
be applied to any fracture carpus, TFCC, and ulnar head which leads to
with a dorsal tilt of 5° or TFCC degeneration and ulnocarpal abutment
greater, a radial syndrome (painful and limited ulnar deviation
inclination of 10° or less,
or a loss of 5 mm or more and decreased grip strength)
of radial height.
Severe dorsal angulation, radial shortening, little/no inclination
22
• Currently, there is no consensus about • Patients with step-offs will likely end up with
which one parameter is the most specific DRUJ arthritis unless it is treated early enough
predictor of symptomatic malunion. – If DRUJ arthritis is NOT present but the patient has
shortening and angulation the physician can perform
• Therefore,, radial length,
g , radial inclination,, a corrective osteotomy y of the distal radius (try
( y to
volar tilt, and articular congruity must all be recreate palmar tilt and radial inclination)
evaluated with each distal radius fracture, – If the radial articular alignment is alright then an ulnar
shortening osteotomy can be used to shorten ulnar
and anatomic reduction must be attempted and decrease ulnar load (Rayhack)
in an effort to restore each parameter to – When arthritis is present the physician can perform
baseline. salvage techniques such as a Darrach, Suave-
Kapandji, or a Bowers
Salvage Procedures
Darrach
Sauve-Kapandji
Bower’s hemi-resection
One bone forearm
Distal ulna arthroplasty
Total wrist fusion
Total wrist arthroplasty
Articular step off
Darrach Sauve-Kapandji
• Distal ulna resection • Fusion of the DRUJ and creation of
a pseudoarthrosis in the distal ulna
• Reserved for the proximal to the fusion
elderly less active or • Rotation then occurs at the
rheumatoid patient pseudoarthrosis
• Ulnar support for the carpus is
• Can have problems preserved, TFCC and ECU remain
with the ulnar stump stabilized
(instability) • Problem with this is instability with
the ulnar stump (more common
when instability is present pre-op)
23
Bowers Salvage procedures continued

• Hemiresection with • Distal ulna implant
interposition arthroplasty arthroplasty may be a
• This is a popular promising option
technique involving
resection only the
articulating portion of the • One bone forearm – will
distal ulna and create one bone to provide
interposing soft tissue to stability and eliminate pain
prevent radio-ulnar
impingement
but sacrifices all rotation
• Does not correct ulnar
(rare)
plus deformity or DRUJ
instability
Scheker DRUJ Prosthesis Pain relieving procedures

• Total wrist fusion/ wrist arthrodesis
– Fusions are reliable and will facilitate stability
and pain free motion
• Total wrist arthroplasties are used with
extreme caution because the long term
results of this procedure are not fantastic
for young active patients
APTIS
Total Wrist Fusion Failed External Fixation
24
Example:
Total wrist fusion
Distal Radius Malunion
25
Quiz Time
1. Describe what you see? Is this intraarticular?

How many parts? Inclination?
2. What has happened?
Intraarticular, 3 part fracture with an articular

step-off, loss of volar tilt
FPL rupture 3. What would you do?

• Wrist ROM
+25/40 (+50/65)
Sup/Pro
40/50 (65/70)
Very unusual complication
26
PROM>AROM 4. Problem Solving

• Could be a strength deficit • Your patient has the following digital ROM
• Good time to begin strengthening program measurements:
in the clinic and at home if cleared by Active Passive
physician 0/50 (0/70)
• Always consider patient’s lifestyle, job 0/80 (0/60)
demands, age, interests, goals! 0/55 (0/40)
What is happening and what do you do?
Very little
MP EET (Extrinsic Extensor Tendon
Is this acceptable? flexion-
50
degrees
Tightness)
• Dynamic composite
flexion splinting
• Digital taping with
heat
• Full composite PROM
EFT (Extrinsic Flexor Tendon

5. What if……
Tightness)
• What if your patient’s digital ROM looked • Dynamics with or
like this: without the wrist
depending on location
Active Passive
g
• Full digital passive
20/80 (0/80) extension is the key
15/100 (0/100)
0/75 (30/75)
27
6. What is being assessed in

Intrinsic Tightness
this position
• This is an Intrinsic
Stretch
• One call also use a
P1 block splint with or
without dynamics
• Also try Digital taping
with heat
• FPL adhesions are

not uncommon (origin
off the radius and
moved during
surgery)
• Include in P1 Block
and vary position to
increase excursion
P1 Block Splint
7. “Stuck in the Muck”

• P1 Block splint (puts
tendons at a mechanical
• Patient presents with normal passive advantage)
flexion of the digits but unable to make a • E-stim to increase muscle
fist actively (following ORIF) – what do you contraction
• Early gentle resistive
do? gripping (nerf ball)
• Sustained gripping
activities
• Address scar adhesions
28
Dig Deep Everyone is different

• Ask questions
• Compare to the • Truly caring for your
unaffected side if patient and treating
possible the “whole” person is
• Don’t assume the difference
anything between being good
and being great
Our role What can we do?

• References to therapy in the literature concerning distal • Know your stuff –
radius fractures vary. educate yourself and
– Some make no mention of therapy communicate well
– Other sources indicate that the need for therapy may • Document outcomes
be a poor prognostic sign and recommend therapy • Publish results
only when finger and wrist stiffness persist.
persist • Set up
– Few studies document the effectiveness of therapy lectures/informational
and the effect on functional outcomes meetings to educate
physicians, case
managers, etc. on what
we do with patients
• Represent your
profession
Show the Way!
Take Risks!
(even if you
might be the
next distal
radius
di
fracture)
• Ask questions, seek answers, and always keep
learning!
• Look at things from a different perspective
• Take a different path
29
• Thank You!!!!!!
30

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Treatment2Go

Exploring Hand Therapy

Slip, Fall, Broken Wrist!

Exploring Hand Therapy, Corporation d/b/a Treatment2Go

Slip, Fall, Broken Wrist! Distal Radius Fractures

Statistics of Distal Radius Common Classifications for

Classification Systems Melone Classification

Colles’ fracture Smith’s fracture

A way to remember the fracture

Dorsal Barton’s Volar Barton’s

• Dorsal Barton’s have -Intra-articular volar

Fx. of the radial

Stable vs. Unstable

Physician Management of the

Percutaneous Pinning Arthroscopic Assisted Fixation

Role of External Fixation External Fixation

1 yr post-op Non-bridging External Fixation

ORIF (Open Reduction, Internal

Volar Plating Done For Distal

Regardless of Method Used for

Radial Inclination (22 Palmar Tilt (11

Radial Height (length) Normal is Residual deformities to know

Therapy after Distal Radius

What do I need to know from the Therapy Goal for functional

Things to keep in mind with Treatment In A Cast or External

Treatment following ORIF Benefits of ORIF

Treatment after casting or

Additional Edema management

Essential Exercises It has been said…

Composite Finger ROM- Do

To Avoid EET (Extrinsic Extensor To Avoid EFT (Extrinsic Isolated FDS

Digital abduction and adduction Isolated wrist extension Wrist flexion

Radial deviation Ulnar deviation

Scar management Scar massage

• Scar massage (done

• Silicone gel sheeting

Strengthening and ROM

The following are activities

Putty Pinch Strengthening

Gripping Intrinsic Strengthening

Dowel Exercises Isolated wrist extension

• Putty for wrist

Dowel and putty exercises – sustained

Forearm strengthening Clinic Activities

Can be done with a hammer at home (strengthening and

Flexbar Exercises for Pronation Flexbar for Supination

Powerweb Screwdriver for supination and pronation

Wrist Extension and

Large knob on work cube Push/Pull

Work Simulation Floor to Waist

Fine motor activities UBE

The Stiff Hand/Wrist

Complication: Dynamic Splinting vs. Static-

Dynamic Flexion and Extension

Dinosaur! A real dinosaur!

Static progressive devices Dynasplint for wrist

CPM (Continuous Passive Motion)

Treatment modalities for pain

Complication: What structures could be

Ulnar head vs. Ulnar styloid Wrist Kinematics

Ulnar variance Ulnar Variance

Positive ulnar variance

Ulnocarpal abutment syndrome