R distal end radius fracture physiotherapy

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Physiotherapy for Distal End Radius (DER) Fractures

Overview

The distal radius is the most commonly fractured bone in adults. Physiotherapy (occupational therapy / hand therapy) plays a central role in restoring wrist range of motion (ROM), grip strength, and function following both conservative and operative management.

Goals of Rehabilitation

Restore wrist, forearm, and finger ROM
Rebuild grip and pinch strength
Reduce oedema and pain
Prevent complications (stiffness, CRPS, tendon adhesions)
Return to activities of daily living (ADLs) and work

Phase 1 — Immobilization Phase (Weeks 0–6)

Conservative (cast/splint) or post-operative:

Finger exercises (active flexion/extension of MCP, PIP, DIP joints) begin immediately to prevent stiffness
Shoulder and elbow ROM maintained throughout immobilization
Oedema control: elevation, retrograde massage
Tendon gliding exercises for the digits
For ORIF with volar plating: ROM may begin earlier (as early as 1–2 weeks post-op) once the construct is stable — surgeon clearance required

Phase 2 — Post-Immobilization / Active Mobilization (Weeks 6–8+)

Once cast is removed:

Exercise Type	Examples
Active ROM	Wrist flexion/extension, radial/ulnar deviation
Forearm rotation	Pronation and supination (often the most restricted)
Passive ROM / stretching	Gentle overpressure at end-range
Tendon gliding	Hook fist, full fist, tabletop position
Grip strengthening	Putty, grip trainer (initiated once bony union confirmed)

Phase 3 — Strengthening & Functional Rehabilitation (Weeks 8–12+)

Progressive resistance exercises for wrist flexors, extensors, pronators, supinators
Functional tasks (writing, lifting, ADLs)
Work-specific rehabilitation if applicable
Return-to-sport protocols for athletes

Home Exercises vs. Formal Therapy

A key clinical debate exists in this area:

An RCT by Souer et al. found that patients who performed independent (home) exercises had better motion and strength than patients who underwent formal occupational therapy, with no difference in DASH scores. The 2015 Cochrane review on rehabilitation for distal radius fractures concludes that there is insufficient evidence to support one therapeutic intervention over another. — Rockwood and Green's Fractures in Adults, 10th ed., p. 1853

Practical implication: A structured home exercise programme is at minimum equivalent to formal therapy; formal therapy may be reserved for patients with complications, poor compliance, or significant functional deficits.

Outcome Measures Used in Practice

DASH / QuickDASH — Disabilities of the Arm, Shoulder and Hand (most widely validated, patient-reported)
PRWE — Patient-Rated Wrist Evaluation
Grip strength dynamometry
Goniometry — wrist and forearm ROM
Mayo Wrist Score / Gartland and Werley score (older, surgeon-based)

Special Considerations

Complex Regional Pain Syndrome (CRPS)

A recognised complication. Vitamin C has been studied as prophylaxis (AAOS 2009 recommended it); however, more recent RCTs showed no benefit. Early, gentle mobilisation is the cornerstone of CRPS prevention and management. — Rockwood and Green's, p. 1853

Elderly / Osteoporotic Patients

Higher rates of malunion; rehabilitation goals may be adjusted toward functional independence rather than anatomical restoration
Bisphosphonate therapy and falls prevention are co-management priorities

Distal Radioulnar Joint (DRUJ) Involvement

Forearm rotation (pronation/supination) must be specifically addressed — DRUJ stiffness is a common sequela
Gradual mobilisation with caution if DRUJ stability is borderline

Expected Outcomes

Most patients achieve satisfactory function by 3–6 months. Grip strength and ROM typically approach 80–90% of the contralateral side. Intra-articular fractures and DRUJ involvement carry a higher risk of residual stiffness and post-traumatic arthritis.

— Rockwood and Green's Fractures in Adults, 10th edition; Miller's Review of Orthopaedics, 9th edition

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