Winter Wrist Injuries :: Distal Radius Fracture

Amy Houchens, PT, CHT

The winter season is upon us along with potentially slippery walking surfaces.   Although falling related injuries can happen any time of year, winter tends to create a perfect set of circumstances.   As humans, we have a natural reflex to put our hand out to catch ourselves when we begin to fall.  While this protects our head and torso, it can wreak havoc on our upper extremities.  Obviously, the best option is to prevent this situation from happening in the first place by being aware of our environment and taking proper precaution.   Keeping optimal bone health can also reduce our likelihood of fracture when the undesired spill does occur.

A fall on and outstretched arm (FOOSH) can result in a variety of injuries including fracture and ligament sprains.  The radius is the most commonly fractured bone in the body.  It is one of two bones in your forearm (the other being the ulna) and bears about 80% of the force between your hand and forearm at the wrist joint.  A fracture at the end of the radius near the wrist is often referred to as a distal radial fracture.  These fractures can be further defined by specific location, direction and severity.  A non-displaced fracture has not moved from its normal (anatomical) position.  A Colle’s fracture is a distal radius fracture that is displaced toward the top/back of the forearm and results from a fall on the palm.  A Smith fracture is displaced toward the palm due to a fall on the back of the hand and less common.  Fractures are also defined by whether or not they go through the joint (articular vs. non-articular), if they are in multiple pieces (comminuted), or the bone penetrates through the skin (open).

How a fracture is treated will depend on the type, severity, pt. health, bone status, and patient preference at times.  Non-displaced fractures that do not go through the joint are frequently casted for about 6 weeks.  This time frame may vary depending on how fast the bone heals.  Displaced fractures that can be reduced (set back into place) without surgery (closed reduction) and do not go through the joint may also be casted.  During the casting process, repeat x-rays are taken to determine that the fracture is healing appropriately and has stayed in a good position.  Casts will be replaced periodically as swelling decreases to maintain good immobilization and position. 

If a fracture is unstable, articular (through the joint surface of the bone), or comminuted (more than 2 pieces), closed reduction may not be enough to stabilize and allow healing of the fracture in a good position.   Surgical intervention may be required.   One of the more common forms of surgery involves use of a plate and screws placed on the palm side of the bone to pull fracture fragments together and hold them in place.  This is called open reduction/internal fixation (ORIF).  Other forms of internal fixation such as use of pins and wires may also be used.  Usually, the wrist is immobilized for 1-2 weeks after surgery and the patient is then placed in a removal splint.  This splint will likely be custom fabricated for optional fit.  With the fracture stabilized surgically, earlier hand (physical or occupational) therapy may begin to work on movement.  The fracture still takes around 6 weeks to heal and resistive activity may not be started until 6-8 weeks after surgery.  Often, very heavy activity is to be avoided for 10 weeks post operatively.  It may take 6 months to one year for full recovery of motion and strength and full resolution of all swelling.

Another method of wrist fracture stabilization that is less utilized is external fixation.   This involves placement of and external apparatus that is attached to the bones on either side of the fracture via pins that go through the skin and are screwed into the bone.  This device is worn for about 6 weeks. This time frame may vary and is dependent on fracture healing.  During this time it is important to keep pin insertion sites clean and undisturbed.  Pin tract infection is a possible complication.  Splinting, range of motion, strength activities and return to function proceed after removal of the external fixation device.  Time frames for this are similar to internal fixation and casting.

Hand therapy is an integral part of the rehabilitation process for most people with this type of injury.  Your therapist will work with you on managing swelling and pain, regaining motion and strength, and addressing specific functional goals that you may have for daily self-care, household activity, return to work and resumption of recreational, sport, and leisure activities.

Foot & Ankle Pain 101

Amanda Atwood, SPT; Karen Walz, PT, OCS, FAAOMPT

Plantar fasciitis, often referred to as plantar (bottom of foot) heel pain, is an inflammatory process that can be caused by prolonged standing, direct injury to heel, or excessive foot posturing (high or low arches).  It is more common in active individuals that require push-off power during running and jumping or in folks who have tight calf muscles.  Pain caused by plantar fasciitis can be reduced by elimination of any activity that provokes overstretching of the fascia, wearing shoes that provide good shock absorption at the heel, foot strengthening (towel curls), calf stretching (sometimes including night time splints or braces), and wearing orthotics with supported foot posturing to correct for any foot mechanical deformity. It often takes over a year’s time to resolve these symptoms but physical therapy can help expedite the healing with manual therapy, ASTYM (augmented soft tissue technique that helps to break down scar tissue, restore normal tissue mechanical properties), modalities and education.  
 

Achilles tendonitis is the most common overuse injury of the lower leg caused by the rapid, repetitive movements during running or walking that twists the tendon creating micro tears within the tendon, muscle and possibly surrounding tissues.   If condition lingers, the symptoms can become chronic and the tissue changes associated with it change from an “inflammation” to a “degeneration” of tissue (tendinosis).  Self-management of Achilles pain can include modification of training regime, correct shoe wear, Achilles stretching, eccentric strengthening of calf muscles, and orthotics if deemed necessary. Physical therapy evaluation and techniques can assist in the effective treatment of these conditions.
 

Foot/Ankle Pain- Is Barefoot Running an Answer?
 

There is a rapidly growing community of people who believe barefoot running is better for the body than running in padded shoes.  The theory is running barefoot promotes proper mid-foot strike leading to more efficient body mechanics and less pounding on the heel.  The problem is that it has become so popular, so fast, that many casual runners do not take the time, up to 6 months, to ease into it and can develop an injury.  Assessment of your mechanical foot type, running technique, training targets to prepare for this barefoot running are all recommended. At this time there is little research stating barefoot running is better than running in supportive footwear, however, it is leaning in that direction for some people.  Consider discussion with your physical therapist on this subject if you want to know if it might the best direction for you and your running goals and activities.