537
ORIGINAL ARTICLE
Physiotherapy After Volar Plating of Wrist Fractures Is
Effective Using a Home Exercise Program
Gert D. Krischak, MD, Anna Krasteva, MD, Florian Schneider, Daniel Gulkin, Florian Gebhard, MD,
Michael Kramer, MD
ABSTRACT. Krischak GD, Krasteva A, Schneider F,
Gulkin D, Gebhard F, Kramer M. Physiotherapy after volar
plating of wrist fractures is effective using a home exercise
program. Arch Phys Med Rehabil 2009;90:537-44.
Objective: To determine the effect of 2 different postoper-
ative therapy approaches after operative stabilization of the
wrist fractures: treatment by a physical therapist with 12 ses-
sions and an unassisted home exercise program.
Design: Randomized controlled cohort study.
Setting: Hospital-based care, primary center of orthopedic
surgery.
Participants: Volunteers (N⫽48) with fractures of the distal
radius after internal fixation with locking plates. There were 46
patients available for follow-up after exclusion of 2 participants
due to physiotherapy sessions in excess of the study protocol.
Interventions: Not applicable.
Main Outcome Measures: Evaluation of grip strength us-
ing a Jamar dynamometer, range of motion (ROM), and Patient
Related Wrist Evaluation (PRWE).
Results: After a 6-week period of postoperative treatment,
the patients (n⫽23) performing an independent home exercise
program using a training diary showed a significantly greater
improvement of the functionality of the wrist. Grip strength
reached 54% (P⫽.003), and ROM in extension and flexion
79% (P⬍.001) of the uninjured side. Ulnar and radial abduc-
tion was also higher in this group. In contrast, patients who
were treated by a physical therapist achieved grip strength
equal to 32%, and ROM in extension and flexion of 52% of the
uninjured side. Patients who were performing the home train-
ing after operation recorded an improved wrist function with a
nearly 50% lower value (P⬍.001) in the PRWE score.
Conclusions: In the postoperative rehabilitation of wrist
fractures, instructions in a home exercise program are an ef-
fective alternative to prescribed physical therapy treatment.
Key Words: Fractures; bone; Rehabilitation.
© 2009 by the American Congress of Rehabilitation
Medicine
HE DISTAL RADIAL fracture is the most frequent of all
T 1
fractures in trauma surgery. One of 6 fractures is of the
2,3
distal radius. Assuming that life expectancy continues to
From the Center of Surgery, Clinic for Traumatology, Hand, Plastic, and Recon-
structive Surgery, University of Ulm, Ulm (Krischak, Krasteva, Gulkin, Gebhard,
Kramer); and the School of Physiotherapy, UlmKolleg, Ulm (Schneider), Germany.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Trial registration number: The study was been approved by the local Ethics
Committee (no. 46/06, 12.07.2006).
Reprint requests to Gert D. Krischak, MD, Center of Surgery, Clinic for Trauma-
tology, Hand, Plastic, and Reconstructive Surgery, University of Ulm, Steinhoevel-
strasse 9, 89075 Ulm, Germany, e-mail: gert.krischak@uniklinik-ulm.de.
0003-9993/09/9004-00757$36.00/0
doi:10.1016/j.apmr.2008.09.575
increase in western industrialized nations, the frequency of
fractures to the wrist can be expected to increase by approxi-
mately 50% by the year 2030.4
The treatment of distal radial fractures has changed as a
result of the experience gained through conservative treat-
ments applied over the last 20 years. ORIF has moved to the
forefront in order to maintain reduction and allow early
functional treatment. The usage of locking plates has be-
come the standard process used in the surgical treatment of
distal radial fractures.5
Postoperative rehabilitation is an integral part of the com-
plete concept for radial fractures treated through surgery, be-
cause there is an increased risk of long-term impairment due to
the involvement of the wrist joint.6,7 Functional restoration has
a direct influence on the quality of life, as well as the duration
of sick leave and laborer compensation, and therefore is of
social economic interest. More than half the patients who
sustain this injury are currently employed at the time they
fracture their radius.8 In the median, patients with a distal radial
fracture are off work from 67 days up to 20 weeks.9,10 It is for
this reason that postoperative therapy is critical in restoring
functionality.11 Recommendations from professional organiza-
tions regarding the type, intensity, and duration of postopera-
tive treatment do not exist; neither are there recommendations
supported by studies regarding which patients might possibly
benefit more or less from physical therapy.12 Therefore, it is
incumbent on the treating surgeon to choose a postoperative
treatment on a subjective basis, whereas the primary care
system in Germany results in several doctors participating in
determining and prescribing this treatment.
In this prospectively randomized study, the efficacy of 2
different postoperative rehabilitation approaches after the treat-
ment of distal radial fractures through ORIF with locking plates
was examined. We hypothesized that the treatment given by a
physical therapist within the framework of a conventional
prescription is more effective than an unassisted home exercise
program.
METHODS
Study Design
The study was approved by the local ethics committee (no.
46/06, 12.07.2006). All the patients were informed and con-
firmed their willingness to participate in the study by signature.
Patients receiving surgical treatment of distal radial fractures at
List of Abbreviations
AO Arbeitsgemeinschft für Osteosynthesefragen
AP anteroposterior
ORIF open reduction and internal fixation
PNF proprioceptive neuromuscular facilitation
PRWE Patient Related Wrist Evaluation
ROM range of motion
Arch Phys Med Rehabil Vol 90, April 2009
538 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak

Table 1: Detailed Description of Home Program Exercises on a Weekly Schedule

No. Description Figures Frequency

Week 1
1 Making a fist: Extend fingers before making a fist. 5 ⫻ 10 rep

2 Picking apples: Open your hand above your head 3 ⫻ 15 rep

and close it pulling your arm down.

Week 2
1 Making a fist: Extend fingers before making a fist. 5 ⫻ 10 rep

2 Waving: Hand rests on its edge (side of little 2 ⫻ 20 rep

finger), stabilize wrist. Slow flexion and
extension movement.

3 Windshield wiper: Palm of the hand flat on table. 2 ⫻ 20 rep

Slowly abduct towards radius and ulna.

4 PNF technique: Make a fist while bending your 2 ⫻ 20 rep

arm over head, nose touching elbow. Slowly
bring arm down to side of body, opening hand
and extending elbow.

Week 3
1 Make a fist, squeezing a soft foam ball for a few 3 ⫻ 10 rep
seconds.

2 Hand at edge of table: Slowly move hand 2 ⫻ 10 rep

towards you: (1) flexion, (2) extension, and (3)
thumb pointing towards you.

3 Brushing teeth: Brush teeth as usual with injured — 2 ⫻ 2 min

arm.
Week 4
1 Making a fist, squeezing a soft foam ball for a 3 ⫻ 10 rep.
few seconds.

2 Waving: Hand rests on its edge (side of little 2 ⫻ 20 rep.

finger), stabilize wrist. Slow flexion and
extension movement.

3 Windshield wiper: Palm of the hand flat on table. 2 ⫻ 20 rep.

Slowly abduct towards radius and ulna.

Arch Phys Med Rehabil Vol 90, April 2009

 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak
Table 1 (Cont’d): Detailed Description of Home Program Exercises on a Weekly Schedule
No. Description
4 Pressure and counter pressure: (1) Push with
healthy hand against palm of injured hand, and
(2) vice versa.
5 Movement as above but without pressure, and
fully flex and extend hand.
Week 5
All exercises of week 4 (1–5).
6 Water bottle: Same as in exercise 2 during week
3, while holding a bottle in your hand.
Week 6
1 Making a fist, squeezing a soft foam ball for a
few seconds.
2 Water bottle: Same as in exercise 2 during week
3, while holding a bottle in your hand.
3 Stretching: Stretch injured hand towards total
flexion and extension.
4 Making a fist, squeezing a tennis ball for a few
seconds.
NOTE. Exercises were performed twice daily with a 10-second break between exercises.
Abbreviations: rep, repetitions; , direction of active movement; , direction of passive pressure; R, healthy side.
the center of surgery between July 2006 and November 2007
were candidates for the study. All the fractures were stabilized
using a volar locking platea after open reduction.
Patients were excluded from the study if they were younger
than 18 years, were uncooperative, lacked the cognitive capac-
ity to participate in the study, lacked self-sufficiency in man-
aging the requirements of daily life (eg, home care needed),
had a psychiatric illness, had a bone disease responsible for the
treated fracture (ie, bone metastasis, osteolysis), had a previous
fracture near the wrist or carpal tunnel syndrome on the injured
side, had inflammatory joint disease (ie, rheumatoid arthritis,
gout), or had reflex sympathetic dystrophy.
One week after surgery, patients underwent their first exam-
ination (follow-up 1). A randomized selection process based on
age was used to sort each patient into 1 of 2 postoperative
programs. The randomized selection process based on age was
done through block randomization. Each patient was placed in
1 of 3 blocks (age 18 – 44, 45– 64, and ⬎64y) before the
539
Figures Frequency
2 ⫻ 10 rep.
2 ⫻ 10 rep.
2 ⫻ 10 rep.
3 ⫻ 10 rep.
2 ⫻ 10 rep.
3 ⫻ 1 min.
3 ⫻ 10 rep.
randomization procedure. The study was not blinded. All mea-
surements were done by the authors (G.D.K. and A.K.). Group
A (home exercises) followed a regimen of exercises in home
training; group B (therapist) received treatment by prescription
in the practice of a physical therapist. Each patient was put in
a splint after surgery for 2 weeks in order to ensure proper
wound healing. The splint was removed for the therapy and put
back on after the treatment.
After 6 weeks of rehabilitative treatment, a second follow-up
examination (follow-up 2) was performed to determine the
success of the respective postoperative therapies.
Types of Postoperative Therapy
Patients in group B received a prescription for a total of 12
sessions lasting 20 to 30 minutes each, over a 6-week period.
All patients were free to choose their own therapist. The
therapists were free to choose the type of therapy based on their
own evaluation. As is general practice, the therapists were
Arch Phys Med Rehabil Vol 90, April 2009
540 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak
instructed to implement exercises that could be executed by the
patients unassisted at home.
Patients in group A (home exercises) received detailed in-
structions and demonstrations in the home exercise program
after the follow-up 1 examination. Patients were instructed in
home exercises by the authors (G.D.K. and A.K), and received
an exercise guidance booklet. The contents instructed the pa-
tients about the type of exercises, repetitions, intensity, train-
ing, and rest phases, as well as including a diary-type weekly
plan (table 1). The details grouped 3 to 5 exercises in units
requiring approximately 20 minutes. Each day called for 2
training units, to be performed once in the morning and once in
the evening. Detailed descriptions and photographic illustra-
tions were included for each of the exercises. The patients
maintained a regular protocol of each exercise they performed,
which was used to record information about compliance.
The exercises were grouped by week in accordance with the
phases of wound and fracture healing. For the first 2 weeks,
priority was given to pain reduction and reduction of postop-
erative edema.11 After the second week, passive exercises were
introduced to stretch soft tissue. In addition, early active move-
ments were added, without resistance, to increase muscle ac-
tivity, including stretching and spreading fingers, making a fist,
forearm stretching, and bending and stretching the elbow, as
well as abduction/adduction and external/internal rotation of
the arm.11,13 Starting after the second week, exercises from the
PNF technique were introduced. PNF activates motor function
through stimulated proprioception induced by adequate facili-
tation.13 Stimulus is provided primarily by pull and pushing
techniques. In the fifth week, dynamic muscle exercises against
light resistance were increased.
Follow-up
During the postoperative examinations, general data and
data concerning accompanying illnesses of the patients were
collected. The fractures were grouped according to AO classi-
fication.14 The postoperative position of the joint was docu-
mented using standard radiographs (lateral and AP view): joint
alignment (lateral view), radial inclination angle (AP view),
and length of the radius (AP view).
Impairment was measured at both follow-up examinations
(follow-up 1 and 2). The PRWE score was determined for each
patient. The PRWE determines a subjective scoring of the
functionality of the hand. The PRWE is a 15-item question-
naire that equally rates wrist-related pain and disability in
functional activities. Scoring is performed on an 11-point scale
(0, no issues or pain; 10, unable to perform or pain). Five
questions require the patient to estimate pain at rest or during
activities such as repeated motion or lifting. Functional items
are divided into 2 categories: specific activities and activities of
daily life. There are 6 specific tasks, such as turning a door-
knob, cutting meat, and closing a button, and 4 categories of
daily-life activities (self-care, work, household duties, recre-
ation). The pain score is the sum of 5 items, with a worst score
of 50. The disability score is the sum of 10 items, divided by
2. Thus, the total function on the PRWE scale ranges from 0
(normal wrist) to 150 (worst possible score). The PRWE is
described in more detail elsewhere.15,16 At the time of the
follow-up 1 examination, the patients were requested to de-
scribe their PRWE status preceding the injury. At the time of
the follow-up 2 examination, their current status was deter-
mined.
Grip strength was measured during both the follow-up 1 and
2 examinations by using a hydraulic hand strength measuring
instrument.b The measurements were made in accordance with
the recommendations of the American Society of Hand Ther-
Arch Phys Med Rehabil Vol 90, April 2009
apists17: sitting in an upright position, feet flat on the ground,
shoulders in neutral position, elbows flexed at 90°, forearm
rotation neutral, and wrist extension between 0° and 30°. Three
tests of maximum grip strength were performed, alternating
between the injury-free and the injured hand, with a maximum
of 4 seconds maintaining maximum grip force and 30 seconds
of rest between the individual attempts. The injury-free hand
was tested first and alternated thereafter. If the third value was
the highest measured, a fourth measurement was made and, if
necessary, additional measurements were made until the last
measurement was not the highest.18,19 The mean was taken of
the 3 valid measures and recorded as the grip strength for the
day of the examination.
Earlier studies recommended a correcting adjustment of 10%
for the dominant hand regardless of right- or left-side domi-
nance.20 Subsequent research determined that while the normal
grip strength of the dominant hand in right-handed people is
higher, the same is not true for left-handed people, who have
equal strength in both hands.21,22 Therefore, as recommended
by the latter authors, a 10% adjustment was only made for the
right hand in patients with right-hand dominance. The results
of the injury-free hand served as the base value for both
examination days, while the measurement of the injured hand
was drawn as a percentage indexed value of the mean for the
healthy hand.
ROM was documented for both the healthy and the injured
hand using a commercially available goniometer23; extension
and flexion of the wrist, ulnar and radial abduction of the wrist,
and pronation and supination were measured. ROM was cal-
culated from the values of the opposing directions. Because
there are interindividual differences in mobility, the ROM of
the healthy hand was defined as the initial value and set
empirically with a value of 100%. Then, a relative degree of
mobility, in percentage terms, was calculated for the injured
hand. As the values of the opposing side were measured in
each of the postoperative examinations (follow-up 1 and 2),
the mean was calculated as the ROM for the healthy ex-
tremity.
Statistics
Analysis was done using the Software StatView.c The data
were first structured descriptively: for constant interval-scaled
variables by mean, SD, frequency, maximum, and minimum;
for nominal- and ordinal-scaled variables by absolute and rel-
ative frequency.
Differences between the semistatistical scores were analyzed
using the nonparametric Mann-Whitney U test. Correlation
analysis was done using a regression analysis, followed by a
Fisher transformation determining the P value. Because of the
low-frequency level, the Fisher exact test was used, which
delivers the results as a conditional probability. The level of
significance for every comparison was set below .05 (P⬍.05).
The measure for effect size was Cohen d, which is a measure
of standardized differences between means, expressed in terms
of SD units.24 Cohen24 roughly defined an effect size of 0.2 as
small, that of 0.5 as medium, and that above 0.8 as large.
Box-plot diagrams are not uniformly defined and therefore
require a more exact description. StatView defines the upper
and lower borders of the box as the first and third quartile,
respectively. Therefore, 50% of the data points lie within the
box. The lower and upper whiskers represent the tenth and
ninetieth percentile, respectively. The dots above and below the
whiskers show the maximum and minimum values.
For the evaluation of grip strength and ROM, the results of
both examinations of the healthy hand were taken in average
and set empirically at 100% as the reference value. The results
 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak 541

Table 2: Distribution of the Injured Side in Relation to the Table 4: Distribution of the Observed Frequency of the Class of
Dominant Hand Fractures According to AO
Side AO Classification Group A Group B
No. Dominant Side
Group Total Injured Right Left A2 2 (9) 4 (17)
A (Home program) 23 8 (35) 9 14 A3 6 (26) 2 (9)
B (Physiotherapist) 23 11 (48) 11 12 B1 0 0
B2 0 1 (4)
NOTE. Values are number (percentage). B3 1 (4) 2 (9)
C1 2 (9) 8 (35)
C2 9 (39) 4 (17)
of the measurements of the injured hand from each postoper- C3 3 (13) 2 (9)
ative examination (follow-up 1 and 2) were then calculated in
NOTE. Values are number (percentage).
relation to this value.
RESULTS
than group B. The difference was significant (P⬍.001) and
Patient Data corresponded to a large effect size (Cohen d⫽1.18).
A total of 48 patients with distal radial fractures were in- Grip strength relative to the opposing healthy side is shown
cluded in the study. Two participants (1 of each group) had to in figure 1. Both groups showed a distinctly lower level at the
be excluded because they received additional physiotherapy postoperative examination (follow-up 1). After 6 weeks, pa-
sessions. Thus, the randomized groups each consisted of 23 tients in group A showed a mean grip strength that was 54% of
patients. Patients in group A (8 men, 15 women) had a mean the starting base value, while those in group B only recorded a
age of 53.7⫾17.9 (18 –76) years, while patients in group B (8 grip strength that was 32% of the starting base value. This
men, 15 women) were 56.0⫾11.1 (26 –73) years. There were difference was significant (P⫽.003), and a large effect size
no significant differences in age or sex between the 2 groups. difference was calculated (Cohen d⫽1.14).
The distribution between the injured and dominant hands is The ROM in the healthy hand showed no notable difference
shown in table 2. The results of the Fisher exact test showed no between the 2 groups. The mobility of all patients at the time of
significant differences in the distribution on the side injured or the first follow-up (follow-up 1) was markedly reduced. The
on the dominant side injured. results of the ROM of extension and flexion are shown in figure 2.
The distribution of the accompanying illnesses is shown in After an interval of 6 weeks from treatment, group A achieved
table 3. There were no significant differences between the a ROM that was 79% of the uninjured side, while group B only
randomized groups with respect to the severity of the fractures achieved 52%. The difference was significant (P⬍.001), cor-
by AO classification (table 4). The percentage of C fractures responding to a large difference in effect size (Cohen d⫽1.35).
was identical in both groups (61%). One B fracture was treated The results recorded for ulnar and radial abduction are shown
in group A, while there were 3 B fractures in group B. The in figure 3. At the time of the follow-up 2 examination, group
remainders of the fractures were grade A according to the AO A reached a ROM that was 70% of the healthy side, while
classification. Radiographically, there were no significant dif- group B showed a significantly lower ROM of 59% of the
ferences in the postoperative alignment of the joints (table 5). healthy side (P⫽.013), corresponding to a medium difference
Twenty patients in group A documented their compliance in effect size (Cohen d⫽0.71). The results recorded for prona-
with the exercise guidance booklet; 97% of exercises were tion and supination are shown in figure 4. Both groups
documented as “done.” Three patients did not return their achieved a high level of motion after the postoperative treat-
booklet to the examiners. All patients in group B received 12 ment, without a significant difference between the 2 groups.
documented sessions of physical therapy.
DISCUSSION
The PRWE scores of both groups showed a virtually iden-
tical starting value before the fracture (table 6). A large differ- This prospectively randomized study investigated the effect
ence was recorded in the functional scores after the postoper- of 2 different postoperative therapy concepts after the surgical
ative treatment. Group A showed a nearly 50% lower value treatment of distal radial fractures. After a 6-week period of
postoperative treatment, the patients performing an indepen-
dent home exercise program using a training diary showed a
Table 3: Descriptive Listing of the Recorded significantly greater improvement of the functionality of the
Accompanying Illnesses wrists (PRWE, grip strength, ROM extension and flexion, ulnar
Accompanying Illness Group A Group B
and radial abduction).
The postoperative treatment of fractures receiving surgical
None 7 (30) 6 (26) therapy generally targets the avoidance of complications and
Musculoskeletal disease 14 (61) 9 (39)
Heart disease 1 (4) 2 (9)
Pulmonary disease 1 (4) 2 (9) Table 5: Position of the Joints in the First Radiographs of the
Diabetes mellitus 0 5 (22) Wrists in Both Planes: Radial Inclination, Alignment, and Length
Prosthesis 0 0 of the Radius
Vascular disease 9 (39) 2 (9) Postoperative Radiograph Group A Group B
Neurologic disease 5 (22) 2 (9)
Carcinoma 1 (4) 2 (9) Radial inclination, AP (°) 16.7⫾6.0 (3–28) 17.3⫾7.8 (5–33)
Others 10 (43) 9 (39) Alignment, lateral (°) 0.4⫾8.2 (⫺12–22) 2.9⫾8.7 (⫺8–22)
Radial length, AP (mm) 0.9⫾1.8 (⫺3–4) 0.2⫾1.7 (⫺2–4)
NOTE. Multiple incidences per patient were possible. Values are
number (percentage). NOTE. Values are average ⫾ SD (range).

Arch Phys Med Rehabil Vol 90, April 2009

542 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak
Table 6: PRWE Scores Before the Accident (Data Gained During
Follow-up 1) and at Follow-Up 2
Before Accident After Accident (FU2)
PRWE (Ascertained FU1)
A (Home program) 1.1⫾5.2 (0–25) 18.5⫾15.9 (2.5–56)
B (Physiotherapist) 0.5⫾2.3 (0–11) 36.1⫾13.9 (10.5–61)
NOTE. Values are mean ⫾ SD (range).
Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
the optimal possible recovery of functionality and the perfor-
mance of daily tasks.25 The starting point for beginning phys-
ical therapy after surgical treatment was investigated by Gron-
lund et al.26 They found that for 17 patients, as opposed to 23
others, who received postoperative physical therapy directly,
there was a significantly better functioning of the hand and
recommended, based on their results, an early start to postop-
erative treatment.
Study Limitations
When comparing our results with the data in the literature, it
should be noted that follow-up in our investigation was only
short-term (6 weeks), and long-term results are not available,
which we consider a limitation of our study. Randomized
studies examining the effect of physical therapy on surgically
treated distal radial fractures have not been published. Several
studies have been published on this subject following conser-
vatively treated distal radial fractures. Watt et al27 showed that
patients with distal radial fractures who completed a 6-week
home exercise program after removal of their casts, had a poorer
ROM and grip strength than patients receiving treatment from a
therapist. After a 6-month period, Wakefield and McQueen28
were able to document a better range of mobility in extension
and flexion after treatment by physical therapists, beyond
which there were no other significant differences between the
2 groups. After a period of 3 months (6 months after surgery),
the authors found that there were no significant differences
between the groups. The ROM did not correlate to the func-
tionality score, leading the authors to conclude that extension
and flexion do not influence hand functionality.
Other studies were not able to prove that there was an
advantage to after-treatment given in a physical therapy prac-
tice. Maciel et al29 were unable to detect any significant effect
of a postoperative physical therapy treatment on the function-
ality of the hand, pain, or the PRWE score after periods of 6
Fig 1. Recorded grip strength, using the Jamar dynamometer, as a
percentage of the healthy side (empirically 100%) as measured in
both follow-up examinations, follow-up 1 and follow-up 2 (box
plots: upper and lower borders of box, first and third quartile,
respectively; horizontal line inside box, median; lower and upper
whiskers, tenth and ninetieth percentile, respectively; dots above
and below whiskers, maximum and minimum values, respectively).
Abbreviations: FU1, follow-up 1; FU2, follow-up 2.
Arch Phys Med Rehabil Vol 90, April 2009
Fig 2. ROM of wrist extension and flexion as a percentage of the
healthy side (empirically 100%) as measured in both follow-up ex-
aminations, follow-up 1 and follow-up 2 (box plots: upper and lower
borders of box, first and third quartile, respectively; horizontal line
inside box, median; lower and upper whiskers, tenth and ninetieth
percentile, respectively; dots above and below whiskers, maximum
and minimum values, respectively). Abbreviations: FU1, follow-up
1; FU2, follow-up 2.
and 24 weeks. The PRWE was originally described by Mac-
Dermid et al16 as a tool for quantifying wrist pain and disability
in patients with distal radial fractures. The PRWE has been
identified as the most responsive measurement for evaluating
outcomes of patients with distal radial fractures when com-
pared with other measurements (including Disabilities of the
Arm, Shoulder and Hand score, Brigham and Women’s carpal
tunnel questionnaire, and the Gartley and Werley score).30 The
authors confirmed a good reliability and responsiveness of the
PRWE, and a fair validity.30
In a prospective study, Taylor and Bennell31 investigated the
effect of passive exercise treatment on conservatively treated
distal radial fractures, which after a median of 4.5 weeks
showed no significant improvement beyond that from active
motion therapy. Other authors found no difference in the func-
tional results between patients doing exercises without direc-
tion and those receiving professional after-treatment from ther-
apists.32
A remarkable finding in all the studies in which a directed
home exercise program and professional treatment from a
physiotherapist were researched, is the low frequency of treat-
ment in the visits to the therapist. The median number of
therapy sessions in the study by Pasila and Sundholm33 was 4
units (minimum 1, maximum 12); by Bache et al,34 3 units
(minimum 1, maximum 16); by Wakefield and McQueen,28 3
units (minimum 1, maximum 22); by Watt et al,27 5 units; and
Fig 3. ROM of ulnar and radial abduction as a percentage of the
healthy side (empirically 100%) as measured in both follow-up ex-
aminations, follow-up 1 and follow-up 2 (box plots: upper and lower
borders of box, first and third quartile, respectively; horizontal line
inside box, median; lower and upper whiskers, tenth and ninetieth
percentile, respectively; dots above and below whiskers, maximum
and minimum values, respectively). Abbreviations: FU1, follow-up
1; FU2, follow-up 2.
 PHYSIOTHERAPY OF WRIST FRACTURES, Krischak
Fig 4. ROM of pronation and supination as a percentage of the
healthy side (empirically 100%) as measured in both follow-up ex-
aminations, follow-up 1 and follow-up 2 (box plots: upper and lower
borders of box, first and third quartile, respectively; horizontal line
inside box, median; lower and upper whiskers, tenth and ninetieth
percentile, respectively; dots above and below whiskers, maximum
and minimum values, respectively). Abbreviations: FU1, follow-up
1; FU2, follow-up 2.
by Maciel et al,29 4.4 units. Therefore, the number of treat-
ments received by the patients in all available studies was far
below the level achieved in the patients participating in this
study, each of whom was examined after 12 treatment sessions
by a physical therapist.
A fracture of the wrist is an injury that results in the loss of
function for the entire affected extremity. Patients frequently
have a tendency to disassociate the injured extremity from their
body (make the best of it, doctor).35 Therefore, the call for
taking responsibility for the after-treatment is an alternative
medical concept, in order to engage the patient directly in the
medical treatment and postoperative therapy. The informed
patient realizes that success and failure depend on the patient’s
own motivation and reliability, and neither the surgeon nor
therapist can be solely responsible for the results. A presuppo-
sition here is that the patient is to be informed during a
comprehensive consultation about the rationale for, and details
of, the home exercise program, clarifying that (1) the self-
directed treatment can only succeed when one can be assured
that the patient performs it concomitant with the treating phy-
sician’s intentions, and (2) the establishment of a basis of trust
is primary to following through with an alternative treatment
concept, without which it cannot be successful.
Lyngcoln et al36 studied patients with distal radial fractures
to determine the effect of patient reliability on the performance
of physical therapy. They were able to show that of all the
exercises, those diligently performed and documented in the
study using an exercise diary, were the most important factor in
regaining functionality of the hand. In order to ensure that this
study was correctly executed, in addition to a comprehensive
consultation, each of the exercises was demonstrated, and the
patients received a home exercise diary with instructions and
commented exercises as well as pictorials.
It is known that educational status and cognitive level influ-
ence the commitment towards participation in research stud-
ies.37-40 Patients in group B (physiotherapy, self-reliant)
were only required to make and attend the appointments
with a therapist. Taking personal responsibility was there-
fore of little importance. By contrast, the home exercise
program of group A required an understanding of the ur-
gency of the after-treatment, as well as motivation and
endurance in performing the exercises.
While regaining functionality of the hand is primarily of
personal and medical interests, it also has economic implica-
tions. Within the framework of an outpatient physical therapy,
patients incur costs resulting from the product of the treatment
543
fee and the number of treatments. In general, a physiotherapist
practice charges approximately 18 € for a 20- to 30-minute
session. Therefore, the expense of a prescription for 6 sessions
of therapeutic exercises alone is 108 €. Furthermore, the cost
for transportation may not be insignificant, depending on the
distance involved. Independent of the expense, there is a bur-
den placed on the patient as a result of the postoperative
treatment at a physical therapist’s practice. Each session re-
quires travel to and from the practice, to which there may well
be waiting room time added. Wittemann et al10 enumerated the
sum of the costs of injury during the time of disablement for
patients with small hand injuries, to which the authors included
distal radial fractures, to be 7700 €.
A possibly important factor for the better outcomes of pa-
tients in group A could be the higher level of exercise intensity.
If one calculates the intensity in terms of hours trained per
week, the physiotherapy group had 1 hour per week of training
versus 4.6 hours per week for the home exercise group, assum-
ing that the training book instructions were followed. For
economic reasons, a similarly high level of exercise intensity in
an outpatient physical therapy practice, considering the good
clinical results of the patients in group A, is not justified.
The individual constitution of the patient, possible clinical com-
plications and fracture type, accompanying illnesses, and other
circumstances can make it unfeasible to have the patient respon-
sible for carrying out a home exercise program. For example,
patients with dementia, depression, or lack of motivation, as well
as those with amblyopia or cognitive impairment, are not candi-
dates for a home exercise program.
CONCLUSIONS
The hypothesis that patients performing postoperative reha-
bilitation therapy after surgical treatment of wrist fractures
would have poorer development of hand functionality after 6
weeks has to be rejected. We conclude that instructions in a
home exercise program using a booklet with guidance is a valid
alternative to prescribed physical therapy.
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Suppliers
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b. Jamar Dynamometer; Sammons Preston, 1000 Remington Blvd,
Ste 210, Bolingbrook, IL.
c. Abacus Concepts Inc, 1918 Bonita Ave, Berkeley, CA.