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Distal  Radius  Fractures  Rehabilita6on  &  Ortho6c  Selec6on  

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Do  you  think  outcomes  will  be  the  same?  

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Therapy  following  DRF  Yes  or  No?   Evidence  for  Therapy  following  DRF  

•  Level  I:    Systema6c  Review  (Handoll,  2006)  – Weak  evidence  to  support  improved  hand  func6on  in  the  short  term.  

– No  significant  difference  in  long  term  follow  up  

•  Level  1b  RCT  Souer  et  al.  2001  JBJS  – Conclusion:  Prescrip6on  of  formal  OT  does  not  improve  average  mo6on  or  disability  score  at  6  months  

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Overall  Complica6ons  with  Distal  Radius  Fractures    

•  TFCC  Injury  •  Distal  Radioulnar  Joint  Instability/Ulnar  Impact  

•  Carpal  Instability  (S-­‐L  or  L-­‐T  ligaments)  •  Complex  Regional  Pain            Syndrome  •  Compartment  Syndrome  •  EPL  rupture  

Richards et al 1997

Therapist  supervised  clinic-­‐based  therapy  versus  instruc6on  in  a  home  

program  following  distal  radius  fracture:  A  systema6c  review  

Valdes  et  al.  2014  Journal  of  Hand  Therapy  

•  Five  of  the  seven  trials  found  no  difference  between  outcomes  for  their  subjects  that  had  uncomplicated  distal  radius  fractures.  The  popula6on  that  has  complica6ons  following  distal  radius  fractures  was  not  represented  in  the  studies  reviewed.  

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Conclusions  

•  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  complica6ons  or  the  presence  of  comorbidi6es.  

•  Accelerated  Rehabilita6on  Compared  with  a  Standard  Protocol  Acer  Distal  Radial  Fractures  Treated  with  Volar  Open  Reduc6on  and  Internal  Fixa6on  

•  Randomized  trial  •  J  Brehmer  &  Husband  J  •  2014:96;1621-­‐1630  

Forces  during  rehabilita6on  at  the  DR  

•  When  designing  a  rehabilita6on  protocol,  one  must  consider  the  forces  during  rehabilita6on  exercises  as  well  as  the  ul6mate  strength  of  the  implants  used    

•  Males  have  an  average  grip  force  of  104  lb  (464  N)  and  that  2.24  lb  (10  N)  of  grip  force    which  translates  into  5.8  lb  (26  N)  of  force  in  the  distal  radial  metaphysis.  

•  During  power  grip,  the  distal  radial  metaphysis  experiences  541.8  lb  (2410  N).  

•  Putnam  et  al.  recommended  that  grip  forces  in  early  rehabilita6on  be  <37.5  lb  (<169  N).    

•  In  the  present  study,  they  used  the  Hand  Innova6ons  DVR  plate  (Biomet,  Warsaw,  Indiana)  which  has  been  reported  to  have  an  ul6mate  strength  of  23  to  230  lb  (102  to  1023  N)  

•  The  accelerated  rehabilita6on  protocol,  mo6on  was  started  three  to  five  days  postopera6vely,  and  strengthening  exercises  were  ini6ated  at  two  weeks  postopera6vely  with  the  goal  of  ajaining  earlier  func6onal  recovery.    

•  Objec6ve  was  to  prospec6vely  compare  early  clinical  outcomes—i.e.,  mo6on,  strength,  and  return  to  func6on—between  tradi6onal  and  accelerated  rehabilita6on  protocols.  

Study  par6cipants  •  2006-­‐2010  •  81  subjects  consented  to  

study  inclusion  •  36  pa6ents  were  

randomized  into  the  accelerated  rehabilita6on  protocol  

•  45  pa6ents  were  randomized  into  the  standard  rehabilita6on  group  

•  The  average  age  at  the  6me  of  surgery  was  55.3  years  for  the  standard  group  and  49.8  years  for  the  accelerated  group  

•  Exclusion  criteria  (1)  a  previous  distal  radial  

fracture  on  the  affected  side  (2)  a  professional  athlete  (3)  bilateral  distal  radial  fracture  (4)  another  concurrent  fracture  (5)  a  distal  radial  fracture  for  which,  in  the  surgeon’s  judgment,  fixa6on  of  fracture  fragments  could  not  be  achieved  to  allow  par6cipa6on  in  the  accelerated  rehabilita6on  protocol  

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3-­‐5  days  

Accelerated  protocol   Standard  Protocol  

•  Finger,  elbow,  shoulder  ac6ve  range  of  mo6on    

Finger,  elbow,  shoulder  ac6ve  range  of  mo6on      

•  Wrist,  forearm  ac6ve  range  of  mo6on     Wrist,  forearm  ac6ve  range  of  mo6on      

•  Edema  control     Edema  control      

•  Custom  splint  (30°  wrist  extension),  removed  for  hygiene,  dressing,  ea6ng,  exercises    

Custom  splint  (30°  wrist  extension),  removed  for  hygiene,  dressing,  ea6ng,  exercises    

Rehabilita6on:    Open  Reduc6on  Internal  Fixa6on  (ORIF)  

•  AROM  to  digits  and  non-­‐involved  joints.  

 •  Passive  ROM  to  s6ff  non-­‐involved  joints.  

 

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No Wiggling

Focus  on  ac2va2ng  wrist  extensors!  

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2  weeks  Accelerated  protocol   Standard  Protocol  •  Wrist,  forearm  passive  range  of  mo6on    

Finger,  elbow,  shoulder  ac6ve  range  of  mo6on      

•  Isometrics     Wrist,  forearm  ac6ve  range  of  mo6on      

•  Light  pujy  strengthening     Edema  control      Custom  splint  (30°  wrist  extension),  removed  for  hygiene,  dressing,  ea6ng,  exercises    

3  weeks  Accelerated  protocol   Standard  Protocol  Weaned  from  the  splint   Finger,  elbow,  shoulder  ac6ve  

range  of  mo6on      Wrist,  forearm  ac6ve  range  of  mo6on      Edema  control      Custom  splint  (30°  wrist  extension),  removed  for  hygiene,  dressing,  ea6ng,  exercises    

4  weeks  Accelerated  protocol   Standard  Protocol  Isotonic  strengthening     Finger,  elbow,  shoulder  ac6ve  

range  of  mo6on      

Medium  pujy  strengthening     Wrist,  forearm  ac6ve  range  of  mo6on      

Discon6nua6on  of  splint  use     Edema  control      Custom  splint  (30°  wrist  extension),  removed  for  hygiene,  dressing,  ea6ng,  exercises    

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6  weeks  Accelerated  protocol   Standard  Protocol  Heavy  pujy  strengthening   Wrist,  forearm  passive  range  of  

mo6on  Light  pujy  strengthening    Weaned  from  splint    Isometrics    

7  weeks  Accelerated  protocol   Standard  Protocol  Heavy  pujy  strengthening   Discon6nua6on  of  splint  use    

Medium  pujy  strengthening  

8  weeks  Accelerated  protocol   Standard  Protocol  Heavy  pujy  strengthening   Heavy  Pujy  strengthening  

Isotonic  strengthening  

12  weeks  and  6  months  Accelerated  protocol   Standard  Protocol  Study  visit  for  measurements     Study  visit  for  measurements    

Results    •  Group  t  test  sta6s6cal  

analysis  was  performed  on  the  data  to  compare  outcomes  between  the  two  groups  at  each  of  the  individual  6me  points  as  opposed  to  assessing  recovery  over  6me.    

•  Significance  was  set  at  p<0.05.  

•  The  minimally  clinically  important  difference  for  the  DASH  score  was  10.1  points.  

DASH  scores  Pre  op  

3-­‐5  days  

2  week  

3  week  

4  week  

6  week  

8  week  

12  week  

6  month  

Standard   66   60   48   39   31   23   15   8   5  Accelerat-­‐ed  

65   55   39   30   21   13   7   5   3  

P  value   0.8   0.3   0.01   0.02   .004   0   .001   .04   0.19  

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What  we  know  and  what  we  don’t  know  

•  All  measurements  and  assessments  were  performed  postopera6vely  at  scheduled  outpa6ent  hand  therapy  appointments  by  the  unblinded  trea6ng  therapist,  which  introduced  a  poten6al  source  of  measurement  bias  

•  We  don’t  know  how  many  visits  pa6ents  were  seen  by  the  hand  therapists  

•  We  don’t  know  if  they  had  a  home  program  

•  Would  they  had  the  same  results  if  treated  by  non-­‐hand  therapist?  

How  to  gain  Wrist  and  Digit  Mo6on  

Dose  of  Ortho6c  Applica6on  

•  Fibroblasts  of  the  connec6ve  6ssue  respond  to  stress  to  alter  the  infra  structure,  resul6ng  in  lengthened  6ssue  if  the  dose  is  adequate.    

•  Further,  the  stress  dose  is  a  combina6on  of  intensity,  frequency,  and  dura6on.    

•  Again,  ortho6c  interven6on  has  the  advantage  of  high  poten6al  dura6on  and  frequency,  and  even  intensity,  if  needed,  by  adding  dynamic  or  sta6c  progressive  forces  

Low-­‐load  prolonged  stress  

•  According  to  Brand  when  living  6ssue  (such  as  skin,  ligament,  joint  capsule,  or  tendon)  is  held  in  a  slightly  lengthened  posi6on,  within  its  elas6c  range  (i.e.,  low  load)  for  a  period  of  hours  or  days  (i.e.,  prolonged),  the  fibroblasts  will  sense  the  tension  and  synthesize  more  collagen,  causing  growth  and  op6mal  remodeling  

Dynamic  splin2ng  in  wrist  extension  following  distal  radius  fractures  

•  Berner  S  &  Willis  FB.  Journal  of  Orthopaedic  Surgery  and  Research  2010,  5:53    Retrospec6ve  study  of  133  DRF  pa6ents  (78  women,  55  men;  mean  age  53  ±  17.6)  who  were  treated  with  dynamic  splin6ng  for  contracture  reduc6on  following  distal  radius  fractures.    Forty-­‐two  of  these  pa6ents  received  this  treatment  following  surgical  management  of  DRF.  

Wearing  schedule  •  Ini6ally  wore  the  WED  for  4-­‐6  con6nuous  hours  at  an  

ini6al  tension  serng  of  #2  (0.1  foot  pounds  of  torque)  •  Then  pa6ents  were  instructed  to  wear  the  WED  system  

at  night  while  sleeping  for  6-­‐8  hours  of  con6nuous  wear  •  Acer  each  pa6ent  was  comfortable  wearing  the  unit  for  

one  week  at  tension  level  #2,  they  were  instructed  to  increase  the  tension  level  to  #3  (0.3  c  lbs.)  and  make  con6nual  increases  every  two  weeks.  

•   If  prolonged  soreness  followed  a  session  (soreness  for  more  than  15  minutes)  the  pa6ent  was  instructed  to  decrease  the  tension  one  half  a  serng  for  two  days  un6l  they  were  comfortable  wearing  it  for  6-­‐8  hours  at  the  new  tension  serng.  The  majority  of  all  pa6ents  reached  level  #5  (0.8  foot  pounds  of  torque)  by  the  end  of  two  months.  

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Results  •  There  was  a  significant  

improvement  in  maximal  ac6ve  range  of  mo6on  (AROM)  for  all  pa6ents  (P  <  0.0001)  acer  a  mean  dura6on  of  3.9  weeks  of  dynamic  splin6ng.  

•   Pa6ents  showed  a  mean  62%  increase  in  ac6ve  extension.  There  was  not  a  significant  difference  between  pa6ents  who  had  received  surgical  treatment  for  the  fracture  vs.  nonsurgical.  

Conclusion  

•  This  dynamic  splin6ng  modality  contributed  138  to  185  hours  of  stretching  at  the  end  range  of  mo6on  for  these  pa6ents  in  their  first  month  following  fracture.  This  unique  regime  is  considered  directly  responsible  for  significant  gains  in  AROM  

   

Lucado, JHT, 2008