A patient with distal transverse radial fracture has plaster Accident had occured 17 days ago Plan physiotherapeutic rehabilitation prtocol
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distal radius fracture rehabilitation physiotherapy immobilization exercises guideline 2024
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distal radius fracture AND rehabilitation
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PMID: 39213418
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https://www.worcsacute.nhs.uk/leaflets/wrist-fracture
Physiotherapy rehabilitation protocol: distal transverse radius fracture, plastered, day 17
Assumptions: the fracture has been reduced/managed conservatively, the plaster is intact, and the orthopaedic clinician has confirmed that alignment is stable. At day 17, the fracture is still in the protection phase. Do not mobilize the wrist or load the injured hand until the treating orthopaedic clinician permits it.
Typical distal radius rehabilitation starts with movement of joints not immobilized, then begins wrist and forearm mobility only after cast removal or explicit clearance. This is consistent with the 2024 distal radius rehabilitation guideline and an NHS rehabilitation guide.
Goals at day 17
- Protect reduction and promote union.
- Control pain, swelling, and stiffness.
- Maintain finger, thumb, elbow, and shoulder mobility.
- Maintain general function without loading the injured wrist.
- Educate the patient on cast care and warning signs.
Phase 1: While in plaster, from now until cast removal
Usually this is approximately until 4-6 weeks after injury, but the exact date depends on fracture pattern, radiographic healing, age, and orthopaedic review.
Treatment frequency
- Physiotherapy: 1 visit per week, or every 1-2 weeks if uncomplicated.
- Home programme: 3-5 short sessions daily.
A. Education and protection
- Keep the arm elevated above heart level when resting, especially if swelling is present.
- Keep the cast dry and do not insert objects into it.
- Use sling only for comfort outdoors or briefly, not continuously, unless specifically prescribed. Prolonged sling use may cause shoulder stiffness.
- Avoid lifting, pushing, pulling, gripping strongly, weight-bearing through the palm, or using the injured arm to rise from a chair.
- Encourage normal light use of the fingers for tasks that do not cause wrist pain or cast movement.
B. Swelling and pain management
- Elevation: 10-15 minutes, 3-5 times/day.
- Active finger motion acts as a muscle pump.
- Cold pack may be placed over the exposed proximal forearm or around the shoulder, wrapped in cloth. Do not soak or wet the plaster.
- Gentle soft-tissue massage of accessible fingers and hand can be used only if there is no marked pain, altered sensation, or concern for vascular compromise.
C. Exercises while in plaster
Perform within comfort. Mild stretching discomfort is acceptable, but sharp pain at the fracture site is not.
| Exercise | Dose | Key instruction |
|---|---|---|
| Finger full flexion and extension | 10-15 repetitions, 4-5 times/day | Make a full fist if the cast allows, then straighten fingers fully. |
| Tendon gliding | 5-10 repetitions, 3-5 times/day | Sequence: straight hand, hook fist, full fist, tabletop, straight fist. |
| Thumb opposition | 10 repetitions, 3-5 times/day | Touch thumb tip to each fingertip. |
| Thumb flexion/extension and abduction | 10 repetitions, 3-5 times/day | Keep wrist still inside cast. |
| Elbow flexion/extension | 10-15 repetitions, 3-5 times/day | Move fully unless the cast blocks it. |
| Shoulder flexion | 10 repetitions, 2-3 times/day | Raise arm forward as comfortable. No weight. |
| Shoulder abduction | 10 repetitions, 2-3 times/day | Lift arm sideways as comfortable. |
| Scapular setting | 10 repetitions, 3 times/day | Gently draw shoulder blades back and down, hold 3-5 seconds. |
| Cervical active ROM | 5-10 repetitions, 2-3 times/day | Gentle neck movements if sling posture causes stiffness. |
Do not perform during plaster phase unless specifically cleared:
- Wrist flexion, extension, radial/ulnar deviation.
- Forearm pronation/supination if it causes movement or pain at the fracture site.
- Grip strengthening with ball/putty.
- Resistance-band wrist exercises.
- Weight-bearing through hand or forearm.
- Joint mobilization of the wrist/distal radioulnar joint.
Review at approximately 4-6 weeks
The orthopaedic clinician should review symptoms and radiographs before cast removal or progression. Confirm:
- Fracture alignment/union is satisfactory.
- No new pain, deformity, or neurovascular issue.
- Permission to start wrist and forearm range-of-motion exercise.
- Whether a removable wrist splint is required.
Phase 2: After cast removal or when cleared for wrist movement
Goals
- Restore wrist and forearm movement.
- Reduce edema and pain.
- Recover functional hand use.
- Avoid excessive loading while bone healing continues.
A. Active range-of-motion exercises
Start gently, ideally 3-5 times/day, 10 repetitions each:
- Wrist flexion and extension.
- Forearm pronation and supination with elbow tucked at side.
- Radial and ulnar deviation.
- Finger and thumb range of motion.
- Gentle grip using a soft sponge only if comfortable and cleared.
Use pain as a guide. Aim for mild discomfort only, with symptoms settling by the next day.
B. Functional retraining
- Light activities: dressing, feeding, keyboard use, holding light objects.
- Avoid kettle lifting, heavy pans, forceful twisting, opening tight jars, heavy doors, and pushing up from a chair initially.
- Continue edema control and scar management if surgery was performed.
Phase 3: Around 6-8 weeks, only after evidence of healing and clearance
Begin progressive strengthening if pain is low and radiographs/clinical assessment support healing.
- Light grip strengthening: sponge, putty, or hand gripper.
- Wrist flexion/extension with 0.5-1 kg or light resistance band.
- Pronation/supination using a hammer handle or light dumbbell, starting close to the hand to reduce torque.
- Radial/ulnar deviation with light resistance.
- Increase repetitions before increasing load.
Suggested dose: 2-3 sets of 8-12 repetitions, every other day.
The NHS guide similarly advises active wrist/forearm mobility after cast removal, with strengthening commonly introduced from about 8 weeks as symptoms and healing allow.
Phase 4: Around 10-12+ weeks
Progress toward normal work, domestic, and recreational activity if union is confirmed.
- Gradual carrying, pushing, pulling, and weight-bearing through the hand.
- Closed-chain exercises: wall press-up, then table press-up, then floor-based loading as tolerated.
- Task-specific training for occupation, sport, or household demands.
- Compare grip strength, wrist ROM, pain, and functional use with the unaffected side.
Some stiffness, weakness, and intermittent ache can persist for months. Recovery of maximal motion and strength may take up to a year.
Assess at every physiotherapy visit
- Pain score and analgesic use.
- Finger swelling and active range of movement.
- Sensation, capillary refill, skin color, and temperature of fingers.
- Elbow and shoulder ROM.
- Cast fit and skin symptoms around cast edges.
- After removal: wrist ROM, forearm rotation, grip strength, functional score such as QuickDASH/PRWE.
Urgent orthopaedic review if any of the following occur
- Increasing severe pain or pain not relieved by elevation/analgesia.
- Numbness, tingling, burning pain, weak finger movement, blue/pale/cold fingers.
- Marked increasing swelling or inability to move fingers.
- Cast becomes too tight, loose, cracked, wet, foul-smelling, or causes skin burning/pressure pain.
- Fever, discharge, new deformity, or a fall/new injury.
- Disproportionate pain, hypersensitivity, sweating/color change, or rapidly worsening stiffness, which may suggest complex regional pain syndrome.
This plan should be individualized after confirming the patient’s age, dominant hand, exact fracture alignment, whether reduction or surgery was done, cast type, and the orthopaedic follow-up radiograph findings.
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