A fall on the outstretched hand (FOOSH) is a common occurrence and often results in a Colles' fracture, a fracture of the distal inch of the radius and ulna next to the wrist. Treatment is immobilisation in a splinting material such as Plaster of Paris for five to six weeks to allow healing of the bony fragments, followed by a variable period of rehabilitation depending on the severity of the fracture. The hand is extremely important functionally so the period in plaster is kept to a minimum to allow quick restoration of normal hand use, although a wrist splint can be used for a week or so, particularly in cases where there is significant pain on activity.
Physiotherapy examination starts once the hand has been released from the Plaster of Paris, manually feeling the fracture site which should not be more than minimally uncomfortable, signifying the fracture is well on the way to healing. Hand colour should be normal, the hand should not be swollen much nor have severe muscle wasting. Wrist movements are often restricted in one or two planes but all the movements should not normally be reduced or not significantly. Pain may be present but again should not be severe or occur on all hand movements.
Two hourly range of motion exercises are the first treatment taught to the patient by the physiotherapist and in many cases the wrist movements improve sufficiently for this alone to be required. Elbow and shoulder movement should be reviewed to rule out restrictions before moving on to the rotatory forearm movements of pronation and supination which are important for normal hand use. Further movements assessed are flexion and extension of the wrist, fingers and thumb, along with thumb adduction and abduction. Wrist extension and forearm supination are the most commonly affected movements.
Once the plaster splinting has been removed the wrist may feel it lacks support and the patient may be apprehensive to use it. It is important not to keep the wrist immobilised for too long to prevent complications but early removal means there may be some pain and weakness. A typical forearm wrist brace, often called a futura, is routinely fitted by the physiotherapist to the patient's wrist by Velcro straps, to be worn when doing normal daily activities. The brace is not to be kept on continuously but only for heavier hand work, being taken off the rest of the time and for regular exercise.
Joint mobilisations are used commonly by physiotherapists to improve joint ranges of motion if the exercises do not improve this alone. Physiotherapists perform accessory movements, so called mobilisation techniques, whereby they move the patient's joint passively to re-establish the vital gliding and sliding movements. The midcarpal, radiocarpal (wrist) and lower radio-ulnar joints can be treated this way to increase the ranges, the physiotherapist fixing one part of the joint firmly as they move the other half. This can be done with gentle movements or much more strongly, pushing against the resistance of the stiff joint structures which are preventing full movement.
Returning steadily to normal use of the wrist and hand is the easiest and often the most successful way to regain forearm strength. In some cases more must be done to return the hand to normal if it is very weak or the person needs to return to a heavy manual job or has particular upper limb strength requirements for a sport or hobby. Instruction in practicing all the different hand movements against resistance can be accomplished in a hand class, where patients can use equipment designed to strengthen particular movements such as gripping, pulling, twisting, turning and to improve fine hand function.
If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand.
