PT Management for Colles Fracture with RSD: Case Report

Abstract:

Background and purpose: Colles' fracture is one of the most common types of forearm fractures that usually result in form falling in an outstretched hand. Females are susceptible more than males for this type of injury due to history of osteoporosis. Stable fractures are usually managed with cast. The purpose of this study is to emphasize on the key role of physiotherapy and describe a comprehensive rehabilitation program for colles fracture following cast removal. Case description: 61 years old female referred to physiotherapy department after colles fracture cast removal, presented with persistent pain, swelling and lack of power and mobility of hand and wrist. An intervention program is presented to restore her pre-accident activities. Outcomes: After 5 weeks of physiotherapy, significant improvement was documented. Discussion: During physiotherapy, the program patient started gradually to resume her hand function with contrast bath, mobilization and sustained stretching.

Keywords: Colles fracture, physical therapy

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Introduction:

Colles fracture is defined as extra articular fracture of the distal end of radius with posterior distal fragment ant results in radial shift of wrist carpal bones that usually result from falling on an outstretched hand. It is extremely common in osteoporosis conditions and it is more frequently in female than male.

Closed reduction and immobilization in long arm cast is one of the conservative management that is used to treat stable fractures. Reflex Sympathetic dystrophy (Sudeck’s osteodystrophy) is very common complication after colles fracture. Reflex Sympathetic dystrophy is a painful debilitating condition that is characterized by pain, allodynia, hyperalgesia, hypersensitivity and trophic changes with reduced use of the affected limb.it is also associated with abnormalities in skin, bone, and autonomic. Sensory and motor nerves. 1

The goal of physiotherapy is to assist the patient to gradually progress in the acute phase by relieving pain and starting early gradual movement of the affected limb. However, many evidence-based articles support the key role of physiotherapy in reflex sympathetic dystrophy. Standard treatment includes desensitization, contrast baths (ice-cold vs hot-warm water immersion), hydrotherapy, graded exercise/strengthening, gradual increase in weight loading of the limb (by using weights or pushing down on a set of bathroom scales), sensory re-education/exposure therapy (placing limb in sand, use of tactile gloves and texture boxes) and edema control (compressive garments). The patient must move, exercise and reintegrate the limb into normal everyday activity.3

Methodology:

Patient History:

This case study was conducted on Mrs. W. M. in September 2019. The patient came to a physiotherapy clinic in Sharjah social affairs referred from a Specialist orthopedic as a case of post-healed-colles fracture ( Date of fracture incidence: 21st august 2019) after being in case for 4 weeks . Mrs. W.M. is 61 years old woman working as a housemaid, she reported that she slipped on a wet floor and fell over her outstretched hand and had colles fracture. Closed reduction under local anesthesia and long arm cast was applied for 4 weeks.

Chief Complain: Mrs. W.M. complained of constant pain at left forearm, with a burning sensation at wrist joint level and radiated to fingers. She complained as well about limited mobility and lack of power in the left side accompanied by moderate effusion at wrist and hand. She stated that she would like to be able to work in the kitchen as a cook as soon as possible.

Pain Assessment:

• Duration: continuous since august 2019
• Site and side: Left side around the wrist and radiating to her hand
• Pain rate: 6/10 Numeric pain rate scale
• Aggravating factors: any minimal movement of the affected limb
• Easing factors: Resting elbow in supination and slight bending and medication.
• Other Medical History: osteoporosis

Clinical impression 1:

As Mrs. W. M. medical diagnosis has been confirmed with imaging, a differential diagnosis was not listed. Further objective measurements for range of motion, muscle power, reflexes integrity, and dermatomal assessment were planned to determine the treatment plan and progression of symptoms over the course of treatment.

Mrs. W. M. was a good candidate for the case report based on the data collection, as she is post-healed colles fracture with reflex sympathetic dystrophy, which created a high-complexity case.

Objective Evaluation:

Local observation: Integumentary system: patients affected hand was swollen, peeling, warm temperature.

Swelling Assessment (using a measuring tape)

-Non-pitting edema, starting from the distal forearm extending to the distal parts of the fingers. The most swollen part was in the middle of the hand with a 4.5 cm difference in circumference from the non-affected limb. Measurements were taken using a measuring tape with the wrist joint as the landmark

Position of measurement

Right limb (nonaffected)

Left limb (injured)

Distal radioulnar joint (2cm above)

4 cm

6 cm

Wrist ( radiocarpal joint)

4.5 cm

6.5 cm

2cm lower (carpometacarpal joints)

16.5 cm

21 cm

2cm lower

18 cm

20 cm

-Palpation evaluation:

moderate atrophy at the left wrist extensor muscles with severe tenderness to mild pressure.

- Musculoskeletal Assessment:

Goniometric evaluation of the left elbow, wrist and metacarpophalangeal joints were done in compare to the non-affected side as well. Active Range of motion for the Right (unaffected) upper limb joints were fully and pain free. For the affected side, The range of motion assessment revealed full range of motion of elbow flexion and extension and full range of motion at distal radioulnar joint supination and pronation. The range of motion assessment for wrist in the left side revealed a limitation of Active Range of motion in flexion by 20 degrees, in extension by 25 degrees, in radial deviation by 5 degrees and by 10 degrees for ulnar deviation. Active Range of motion testing for metacarpophalangeal joints revealed limitation by 10 degrees in flexion. Empty end feel while assessing passive range of motion in left wrist and metacarpophalangeal joints. Manual muscle testing for Upper extremity were graded 5/5 while it revealed lack of strength in elbow flexors (grade 3/5), elbow extensors (grade 4/5), (grade 2+/5) for wrist flexors and extensors. Dynamometer testing revealed a grip strength of 8 Ibs in the left upper extremity while 35 Ibs in the right upper extremity.

Neurological Assessment:

Biceps, triceps, and brachioradialis were tested using reflex hammer for both sides and revealed normal reflexes.

-Dermatome: superficial sensation tested using the brush of Buck and comparing between both limbs, she had normal sensation in C5, C6, C7, T1, but in the dermatome of C8 she had diminished sensation towards the light touch of the brush especially on the tips if the 5th phalange.

-deep sensation tested using the needle of Buck and Babinski hammer: comparing between both limbs, she had normal sensation in C5, C6, C7, T1, but in the dermatome of C8 she had diminished feeling towards the needle prick (all over the lateral aspect of the hand).

Clinical impression 2:

Mrs. W.M. presented with signs and symptoms consistent with her medical diagnosis and her problem list includes Soft tissue swelling in the wrist and hand, Pain with hand and elbow movements rated 6 on numeric scale, Muscle weakness of wrist flexors, extensors, and phalangeal flexors and extensors and decreased power in dynamometer grip and marked Limitation in range of motion of all wrist movements and hand function which impaired her ability to manage ADLs especially kitchen work. She continued to be an excellent candidate for a case report to emphasis of the key role of physiotherapy in rehabilitation after colles fractures with reflex sympathetic dystrophy as a complication.

Mrs.W.M. prognosis was determined to be good due to the early referral for physiotherapy, the patient medical health status is good, and she is cooperative. However, full recovery from Reflex sympathetic dystrophy is not anticipated but the return of normal hand functions and subsiding of the pain is possible by regular therapy and the cooperation of patient to do the given home programs. 4

Mrs. W. M. was scheduled initially to receive 3 sessions per week for 5 weeks, Re-evaluation of pain, range of motion, muscle strength and dynamometer grip were planned to be assessed every 2 weeks.

Short term and long-term goals are listed in table 1

Intervention:

Planned physiotherapy intervention involved a multi-model approach to treat all listed problems that she had. Initial treatment consisted of the application of ice and ultrasound to reduce swelling followed by gentle passive range of motion exercise to patient tolerance and grade 2 peripheral joint mobilization. Once swelling had abated, contrast bath was introduced to increase circulation and mobility. After this point the physiotherapy program focused on increasing mobility, power of the affected side, and regain normal hand function.

Detailed treatment plan is listed in table 2

Procedural intervention:

Mrs. W. M. attended all physiotherapy scheduled sessions and was compliant with the prescribed home exercise program.

Outcomes:

At week 5, Mrs W. M. reported decrease in pain intensity, the severity of the pain has considerably reduced to 3 using the 10 points numeric pain scale. swelling of the wrist and hand decreased considerably and goniometric assessment of the active range of motion had improved to be 60 degrees for left wrist flexion and 55 degrees for extension and by 5 degrees in both radial and ulnar deviation. Dynamometer grip strength has increased from 8 Ibs to 20 Ibs.

Table 1:

Short-term goals for 5 weeks :

1. reduce swelling in wrist and hand
2. reduce pain in wrist and elbow (with movement) from rate 6 to rate 2 NPRS.
3. increase muscle power of wrist flexors from 2+ to 4 within.
4. increase muscle power of wrist extensors from 2+ to 4.
5. increase muscle power of phalangeal flexors from 2+ to 4.
6. increase muscle power of phalangeal extensors from 2+ to 4.
7. gradually increase active range of motion of wrist flexion by 40 degrees to reach up to 60 degrees of flexion.
8. partially increase active range of motion of wrist extension by 30 degrees to reach up to 55 degrees of extension.
9. partially increase ROM of phalangeal flexion up to the limit of being able to grab bottle of water. Almost increasing it by 50 degrees.
10. 10-partially increase ROM of phalangeal extensors to reach up to full range of extension.

long term goals:

1. Regain normal hand functions and return to her kitchen work painfree

Table 2:

Intervention plan

· For reducing swelling

1. Ice packs for 15 mins on forearm, wrist and hand
2. Ultrasound over wrist joint ( 1MHZ, 2.3 intensity, intermittent duty cycle, 5 minutes)

• active range of motion for wrist and hand
• Peripheral joint Mobilization for wrist and metacarpophalangeal joints grade 2.
• Once swelling is abated:
• Contrast bath: (alternate the affected side between hot water ( 40 degrees C) and cold water( 7-21 degrees C) for 3 to4 mins in the hot water and 1 minute in the cold water, for 20 minutes . start and end with hot water.
• Isometric exercise for wrist flexors, extensors, ulnar and radial deviators
• Active stretch to elbow flexor and extensors
• Assisted stretching exercise for forearm flexors and extensors and radial and ulnar deviation muscles
• · Weight bearing for wrist extension exercise (nonaffected hand to the affected hand with gentle push as tolerated or hand on a table with the patient leaning forward on his affected side)
• Intrinsic hand muscle exercise (towel ringing exercise, theraputty, theraweb, opposition of thumb using rubber ball)
• Strengthening exercise (using dumbbells or thera band) for elbow flexor, extensor, wrist flexor, extensor, radial and ulnar deviator)
• Functional activities (resume previous activities like cooking as tolerated)

-Home Program:

• Patient is advised to persistently elevate the hand above the shoulder level while carrying out the active ROM pumping exercises at least 3 times a day to reduce edema.
• Patient is advised to carry out strengthening exercises at home using a bottle of water in which she can use to strengthen her wrist flexors and increase the amount of resistance gradually by increasing the amount of water inside the bottle.
• Patient should carry out the stretching exercises given for fingers and wrist.
• Patient should avoid sleeping on that limb to avoid blocking the circulation to the limb.
• Patient should use cold packs for maximum 20 minutes per day, at least 3 times a week on the injured arm to reduce swelling and pain.

Discussion:

Bac et al. mentioned that therapeutic procedure of colles fractures is divided into 3 basic stages. The first two are repositioning and immobilization while third one consists of phsyiotherpay treatment to speed up healing process, prevent complications and restore wrist mobility, strength and function as possible.5 Barbosa et al., assessed the evidence regarding the adoption and effectiveness of therapeutic procedures employed for rehabilitation of distal radius fractures. Literature shows a trend from authors to use general principles of rehabilitation when designing therapeutic approaches, but the procedures usually employed are not well documented and evidenced, turning the evidence-based practice difficult for professionals trying to recover patients with the condition6 . Dias at al. reported that early mobilization of wrist resulted is rapid recovery of both strength and movement 7. kaufman et al. reported significant recovery from unique regimen employing manipulation of the intercarpal and radiocarpal joints in flexion and extension8. McAuliffe et al. reported that early mobilization demonstrated distinct improvement in strength and pain9. This case study has outlined the physiotherapy intervention plan that was applied to subside pain and swelling and improve range of motion, hand grip power after colles fracture cast removal using variety of different techniques. After 5 weeks, the patient was reassessed to monitor the improvement which revealed a progression in mobility and strength. She started to resume her functional activities that involve wrist and hand such as cooking. A limitation to this study was lack of available evidence regarding contrast bath effectiveness in colles fracture and Reflex sympathetic dystrophy.

References:

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