Therapy following DRF Yes or No?

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1 Distal Radius Fractures Rehabilita6on & Ortho6c Selec6on Do you think outcomes will be the same? 1 2 Therapy following DRF Yes or No? Evidence for Therapy following DRF Level I: Systema6c Review (Handoll, 2006) Weak evidence to support improved hand func6on in the short term. No significant difference in long term follow up Level 1b RCT Souer et al JBJS Conclusion: Prescrip6on of formal OT does not improve average or disability score at 6 months 4 Overall Complica6ons with Distal Radius Fractures TFCC Injury Distal Radioulnar Joint Instability/Ulnar Impact Carpal Instability (S- L or L- T ligaments) Complex Regional Pain Syndrome Compartment Syndrome EPL rupture Richards et al Therapist supervised clinic- based therapy versus instruc6on in a home program following distal radius fracture: A systema6c review Valdes et al Journal of Hand Therapy Five of the seven trials found no difference between outcomes for their subjects that had uncomplicated distal radius fractures. The popula6on that has complica6ons following distal radius fractures was not represented in the studies reviewed. 1

2 Conclusions The available evidence from randomized controlled trials is insufficient to support a home program or therapist supervised clinic- based program as a superior method of treatment for adults following a distal radius fracture without complica6ons or the presence of comorbidi6es. Accelerated Rehabilita6on Compared with a Acer Distal Radial Fractures Treated with Volar Open Reduc6on and Internal Fixa6on Randomized trial J Brehmer & Husband J 2014:96; Forces during rehabilita6on at the DR When designing a rehabilita6on protocol, one must consider the forces during rehabilita6on as well as the ul6mate strength of the implants used Males have an average grip force of 104 lb (464 N) and that 2.24 lb (10 N) of grip force which translates into 5.8 lb (26 N) of force in the distal radial metaphysis. During power grip, the distal radial metaphysis experiences lb (2410 N). Putnam et al. recommended that grip forces in early rehabilita6on be <37.5 lb (<169 N). In the present study, they used the Hand Innova6ons DVR plate (Biomet, Warsaw, Indiana) which has been reported to have an ul6mate strength of 23 to 230 lb (102 to 1023 N) The accelerated rehabilita6on protocol, was started three to five days postopera6vely, and strengthening were ini6ated at two s postopera6vely with the goal of ajaining earlier func6onal recovery. Objec6ve was to prospec6vely compare early clinical outcomes i.e.,, strength, and return to func6on between tradi6onal and accelerated rehabilita6on protocols subjects consented to study inclusion 36 pa6ents were randomized into the accelerated rehabilita6on protocol 45 pa6ents were randomized into the standard rehabilita6on group The average age at the 6me of surgery was 55.3 years for the standard group and 49.8 years for the accelerated group Study par6cipants Exclusion criteria (1) a previous distal radial fracture on the affected side (2) a professional athlete (3) bilateral distal radial fracture (4) another concurrent fracture (5) a distal radial fracture for which, in the surgeon s judgment, fixa6on of fracture fragments could not be achieved to allow par6cipa6on in the accelerated rehabilita6on protocol 2

3 3-5 days Rehabilita6on: Open Reduc6on Internal Fixa6on (ORIF) Finger, elbow, shoulder ac6ve range of Wrist, forearm ac6ve range of Finger, elbow, shoulder ac6ve range of Wrist, forearm ac6ve range of AROM to digits and non- involved joints. Passive ROM to s6ff non- involved joints. No Wiggling Custom splint (30 wrist extension), removed for hygiene, dressing, ea6ng, Custom splint (30 wrist extension), removed for hygiene, dressing, ea6ng, 14 Wrist, forearm passive range of 2 s Finger, elbow, shoulder ac6ve range of Isometrics Light pujy strengthening Wrist, forearm ac6ve range of Focus on ac2va2ng wrist extensors! Custom splint (30 wrist extension), removed for hygiene, dressing, ea6ng, 15 Weaned from the splint 3 s Finger, elbow, shoulder ac6ve range of Wrist, forearm ac6ve range of Custom splint (30 wrist extension), removed for hygiene, dressing, ea6ng, Isotonic strengthening Medium pujy strengthening Discon6nua6on of splint use 4 s Finger, elbow, shoulder ac6ve range of Wrist, forearm ac6ve range of Custom splint (30 wrist extension), removed for hygiene, dressing, ea6ng, 3

4 Heavy pujy strengthening Heavy pujy strengthening 6 s 7 s Wrist, forearm passive range of Light pujy strengthening Weaned from splint Isometrics Discon6nua6on of splint use Medium pujy strengthening 8 s Heavy pujy strengthening Heavy Pujy strengthening Isotonic strengthening 12 s and 6 months Study visit for measurements Study visit for measurements Group t test sta6s6cal analysis was performed on the data to compare outcomes between the two groups at each of the individual 6me points as opposed to assessing recovery over 6me. Significance was set at p<0.05. The minimally clinically important difference for the DASH score was 10.1 points. Results Pre op 3-5 day s DASH scores Standard Accelerat- ed mont h P value

5 What we know and what we don t know All measurements and assessments were performed postopera6vely at scheduled outpa6ent hand therapy appointments by the unblinded trea6ng therapist, which introduced a poten6al source of measurement bias We don t know how many visits pa6ents were seen by the hand therapists We don t know if they had a home program Would they had the same results if treated by non- hand therapist? How to gain Wrist and Digit Mo6on Dose of Ortho6c Applica6on Fibroblasts of the connec6ve 6ssue respond to stress to alter the infra structure, resul6ng in lengthened 6ssue if the dose is adequate. Further, the stress dose is a combina6on of intensity, frequency, and dura6on. Again, ortho6c interven6on has the advantage of high poten6al dura6on and frequency, and even intensity, if needed, by adding dynamic or sta6c progressive forces Low- load prolonged stress According to Brand when living 6ssue (such as skin, ligament, joint capsule, or tendon) is held in a slightly lengthened posi6on, within its elas6c range (i.e., low load) for a period of hours or days (i.e., prolonged), the fibroblasts will sense the tension and synthesize more collagen, causing growth and op6mal remodeling Dynamic splin2ng in wrist extension following distal radius fractures Berner S & Willis FB. Journal of Orthopaedic Surgery and Research 2010, 5:53 Retrospec6ve study of 133 DRF pa6ents (78 women, 55 men; mean age 53 ± 17.6) who were treated with dynamic splin6ng for contracture reduc6on following distal radius fractures. Forty- two of these pa6ents received this treatment following surgical management of DRF. Wearing schedule Ini6ally wore the WED for 4-6 con6nuous hours at an ini6al tension serng of #2 (0.1 foot pounds of torque) Then pa6ents were instructed to wear the WED system at night while sleeping for 6-8 hours of con6nuous wear Acer each pa6ent was comfortable wearing the unit for one at tension level #2, they were instructed to increase the tension level to #3 (0.3 c lbs.) and make con6nual increases every two s. If prolonged soreness followed a session (soreness for more than 15 minutes) the pa6ent was instructed to decrease the tension one half a serng for two days un6l they were comfortable wearing it for 6-8 hours at the new tension serng. The majority of all pa6ents reached level #5 (0.8 foot pounds of torque) by the end of two months. 5

6 There was a significant improvement in maximal ac6ve range of (AROM) for all pa6ents (P < ) acer a mean dura6on of 3.9 s of dynamic splin6ng. Pa6ents showed a mean 62% increase in ac6ve extension. There was not a significant difference between pa6ents who had received surgical treatment for the fracture vs. nonsurgical. Results Conclusion This dynamic splin6ng modality contributed 138 to 185 hours of stretching at the end range of for these pa6ents in their first month following fracture. This unique regime is considered directly responsible for significant gains in AROM Lucado, JHT,