Distal Radius Fractures by Rachel Kelly, OT

The common result after a fall onto an outstretched hand, a distal radius fracture has significant impact on a person’s ability to do basic daily activities as well as return to work and hobbies.

Practitioners of Hand Therapy are regularly involved in the management of distal radius fractures to guide rehabilitation and help a return to function as soon as possible.  Therapy goals are usually to control edema and pain, restore range of motion (ROM), and promote the use of the involved extremity for grip and weight bearing activities.

Phases of hand therapy after distal radius fracture

Distal radius fractures are not all the same, and therefore therapy progression can vary from person to person.  Some considerations to help in clinical reasoning how to progress therapy with a patient include the success of the fracture reduction, complications and obstacles such as pain and edema.  This is a general outline of phases of therapy after distal radius fracture.

Early protective phaseMobilization phasefunction/strength phase
Time frame1-6 weeks depending on fracture fragment stabilityStarts immediately after immobilizationBegins when there is proven healing/bone fixation
Goals and prioritiesProtect fracture   Control swelling and pain   Avoid pin-site infectionsAROM and PROM of digits, elbow, shoulder   AROM of wrist; forearm rotationIncrease ROM to within functional limits; Increase strength to within functional limits for activities of daily living
TechniquesCasting, Orthosis, surgical fixation/stabilization   Elevation, retrograde massage, compression wraps, tendon gliding exercises particularly after ORIF   Regular pin-site cleaning (for percutaneous pinning)AROM of shoulder, elbow, forearm, wrist digits   Gentle PROM of forearm, wrist, digits   Dynamic orthosesIsometric progressing to isotonic exercises   Resisted exercises with putty or grippers
Comments and precautionsDigit ROM should be attained in this phase   Signs of CRPS should be monitored and addressed   Abnormal paresthesias should be recordedAvoid excessive ROM if there are indicators of delayed healing or instability   Wrist extension with digit flexion is a priorityExcessive overload   Irritated tissues   Increased pain after exercises

Based on how the patient progresses in hand therapy, different lengths of immobilization may be used.  In comparison to immobilization for 5 to 6 weeks after distal radius fracture repair, immobilization for 1-3 weeks showed improvements in the patients reported outcomes and functional outcomes (Ghaddaf et al., 2021)

There is also a lack of consensus on when to start vigorous wrist ROM after surgery.  Sorensen et al., 2021 compared an early AROM group (less than 2 weeks of immobilization) to a late AROM group (over 5 weeks of immobilization).

  • The early group had a higher grip power at all follow-up periods, but the difference was only significant at 6-months post-op
  • The early group had more favourable ROM in all direction at 6 weeks, but only in supination at 6 months.
  • The complication rate was not significantly different between the 2 groups.  There was no difference in rates of secondary operation and reduction loss.

Liaison with the treating surgeon is important to help determine how to progress with rehabilitation.

Fracture management technique

There are many different techniques used by surgeons to anatomically reduce and stabilize distal radius fractures.  The surgeon who managed and referred the patient should be contacted to discuss specifics of preferred therapy management.  The most common techniques used are:

  • Closed reduction and cast immobilization
  • External fixation with or without percutaneous pinning
  • Open reduction and internal fixation
    • Volar fixed angle plating
    • Dorsal plating

Common complications after a distal radius fracture

ComplicationWhat to look out for during hand therapy
Complex regional pain syndromeEarly signs may be more pain than expected after injury, vasomotor instability, pain and redness in PIP joints, burning sensation in the hand
Tendinitis, tenosynovitisDuring remobilization may have focal pain at wrist (ulnar sided wrist pain can implicate the ECU tendon)
Tendon adhesions and scarringActive motion lags behind passive motion; examine for scar adherence and observe skin for ‘puckering’
Superficial branch of radial nerve compressionHyperesthesia from wrist to dorsum of thumb, index and middle fingers (to level of PIPJ)
Median nerve compressionAltered sensation in the palmar surfaces of part of the thumb, the index finger, the middle finger, and the lateral half of the ring finger
Ulnar nerve compressionParesthesia in ulnar distribution of hand and/or ulnar innervated intrinsic weakness and atrophy
Distal radioulnar joint problemsFailure to gain forearm rotation can indicate DRUJ incongruity; note pain during forearm rotation
Ruptured EPL/FPL tendonLoss of active extension or flexion at interphalangeal joint.  Symptoms of weakening of thumb extension or flexion can indicate impending rupture.

It is important to be aware of the different complications to look out for during hand therapy sessions, so that when they do happen we can manage them effectively.

Complex regional pain syndrome (CRPS) is relatively a common condition in the distal radius fracture population with the effects resulting in many sufferers experiencing persistent pain and impairment 2 to 6 years after onset.  Prevention is desirable as there is no known proven cure.  In a study (Cowell et al, 2018) the incidence of CRPS was reduced from 25% to 1% in the distal radius fracture population at the study site through a series of practice changes including:

  • Introducing a patient information leaflet
  • A local gold standard for care of distal radius fractures
  • Education for staff regarding risk factors and early warning signs of CRPS

Some interesting resources on hand therapy management of distal radius fractures

Journal article:

  • Complications in the management of distal radius fractures: how do we avoid them? (Seigerman et al., 2019)

Spotify podcast:

  • Trauma – distal radius fractures (the orthobullets podcast)


What to expect after distal radius/wrist fractures – YouTube


Rehabilitation of the hand and upper extremity 6th edition, Chapter 69, Distal radius fractures: classification and management (Robert J. Medoff)

Comparison of immobilization periods following open reduction and internal fixation of distal radius fracture: a systematic review and meta- analysis  (Ghaddaf et al., (2021)

Is early mobilization after volar locking plate fixation in distal radius fractures really beneficial? A meta-analysis of prespective randomized studies (Sorensen et al., 2021)

Complex regional pain syndrome in distal radius fractures: how to implement changes to reduce incidence and facilitate early management (Cowell et al., 2018)

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