Explain how pathological processes influence physiotherapy management for a patient with a fracture of the lower end of radius.
Distal radius fractures (DRF) account for 16% of fractures seen in accident and emergency. (Tosti 2011) They are often caused by a fall on an outstretched hand, and as the risk of falling and osteoporosis increases with age, elderly patients have a higher risk of DRF. DRF are described as Colles’ fractures (with dorsal angulation) or Smiths fractures (with volar angulation), and treatment varies with fracture type, age of patient and presenting symptoms. Many fractures are reduced under anaesthesia and immobilised in a plaster cast from just below the elbow to the proximal crease of the palm (Alsop 2013). During bone healing, immobilisation ensures bone ends remain aligned and reduces the risk of mal-union. Immediately after a fracture, the local bone tissue becomes necrotic, and is resorbed by osteoclasts. A fracture haematoma forms and osteoblasts produce calcium hydroxyapatite crystals which are laid down on the bone matrix, forming callus (Drake 2010). Callus is visible on x-ray at 6 weeks, which is typically when the immobilisation stage ends.
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During immobilisation, patients’ clinical priorities are pain management through medication, swelling reduction and prevention of secondary stiffness and muscle wastage in joints above and below the fracture. To decrease levels of exudate in tissues and aid lymphatic drainage, elevation and compression are the main physiotherapy treatments (Cheing 2005). Stretching exercises for the elbow, shoulder, metacarpal phalangeal joints and inter phalangeal joints on the affected side help maintain range of motion (ROM), and strengthening exercises for muscles of the shoulder, elbow and fingers can reduce muscle atrophy. Physiotherapists’ can provide diet education, explaining that the supplementation of vitamin D, calcium, magnesium and vitamin K will aid bone healing (Price 2012). Vitamin C is shown to improve “mechanical and histological parameters of fracture repair” in a study with rats (Gaston 2007), and to induce osteoblast differentiation, which play an important role in bone healing (Carinci 2005).When the plaster is removed, skin can be flaky, thin and over sensitised. Physiotherapists can explain the importance of gentle washing and moisturising and can perform desensitising treatment if required. Due to their knowledge of fracture pathophysiology, physiotherapists can advise patients on how to protect their wrist, for example, not to lift a full kettle but to continue with functional tasks such as washing dishes.
After immobilisation, an important symptom is pain, affecting the patient’s ability to perform functional activities. Pain or fear of pain can impair treatment, as the patient may be nervous to do their prescribed exercises. Effective pain management in the form of paracetamol and ibuprofen, and explanation that a dull aching pain is demonstrative of bone healing may help reduce patient anxiety. Measuring pain allows physiotherapists’ to provide outcome measures and to tailor treatment to patients’ individual needs. Self-reported measures, such as the visual analogue scale, are the gold standard for measuring pain intensity, location, quality and temporal variation (Jones 2013). Nociception from DRF occurs when the sensory receptors at nerve endings in the periosteum are stimulated by noxious insults that are produced through inflammation (DeLisa 2005). An action potential is carried to the dorsal horn of the spinal cord where the pain signal is sent to the brain.
As pain is transmitted via the dorsal horn, physiotherapists use modalities that use the pain-gate theory to reduce patient’s discomfort. This theory suggests there is a gating mechanism in the dorsal horn, small nociceptors that carry pain facilitate the gate, but larger mechanoreceptor fibres inhibit the gate. When physiotherapists stimulate mechanoreceptors, the gate is inhibited and pain signals transmitted to the brain are reduced (Moayedi 2012). An example of this is accessory mobilisations, where the physiotherapist recreates athrokinematic movements to stimulate mechanoreceptors, inhibiting nociception. In a DRF, all athrokinematic movements can be used at grade one and two to stimulate mechanoreceptors. Massage uses the pain-gate theory, therefore alongside the physiological effects of massage, such as increasing blood flow and lymphatic drainage, massage stimulates the mechanoreceptors that inhibit the gate, inhibiting pain signals.
Stiffness can be caused by a variety of aetiologies. If the fracture involves articular surfaces, blood entering the joint can leave fibrin residue causing fibrous adhesions between the two synovial membranes (Hamblen 2007). This decreases the congruency of the surfaces, therefore decreasing ROM. More commonly, peri-articular adhesions, caused by collections of exudate, reduce the resilience of ligaments and reduces muscles free gliding abilities, causing stiffness. (Hamblen 2007). If the patient has undergone open reduction surgery, scar tissue can cause adhesion of local muscles and tendons, reducing ROM.
Proprioceptive neuromuscular facilitation (PNF) is a modality used to treat decreased ROM. PNF uses the proprioceptive stimulation of muscle groups, using voluntary muscle contractions alongside stretching to reduce the reflexive aspect of muscular contraction (Mahieu 2008). Using maximal muscle contraction enables maximum relaxation, which increases stretch efficacy. By using this technique on physiological movements of the wrist, the adhesions are broken down allowing fluent movement. Simple home stretching exercises can be prescribed, to ensure that soft tissues are stretched frequently to reduce stiffness. As well as treating pain, mobilisations are used to decrease stiffness. For stiffness, both accessory and physiological passive mobilisations can be used to increase ROM. When treating stiffness, grade three and four mobilisations taken to the end of range are used, which break down peri-articular adhesions and allow synovial sweep, creating even lubrication and reducing friction.
After pain, swelling and ROM have been addressed, strengthening excercises are incorporated into treatment to reduce muscle atrophy caused by immobilisation (Powers 2004). Strengthening excercises help to regain muscle mass and strength, by causing neural adaptions, decreasing inhibitory feedback allowing stronger contractions. Stronger contraction is also caused by muscle hypertrophy, where myocytes enlarge, increasing actin and myosin concentration. Excercises should get increasingly more challenging until functional movement is achieved. All excercises should be aimed at functional goals specific to the patient, increasing motivation and also establishing expectations of both the physiotherapist and the patient. Due to NHS cuts, physiotherapists can not see patients as frequently as desired, therefore modalities such as massage and PNF cannot be fully effective. It is therefore important for the physiotherapist to increase motivation for home excercises through explanations of their importance and effects .
As the most common cause of a DRF is falling on an outstretched hand, physiotherapy falls prevention programmes including gait re-education,walking aids and balance exercises, can reduce the risk of DRF. These programmes have been “associated with a significantly lower risk of fractures” (El-Khoury 2013), demonstrating that prevention is the most effective physiotherapy management for both patient and physiotherapist.
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