Rehabilitation as part of treatment for adults with a broken wrist

Background and aim

Particularly in older women, a broken wrist (comprising a fracture at the lower end of the radius, one of the two forearm bones) can result from a fall onto an outstretched hand. Treatment usually includes putting the bone fragments back in place, if badly displaced, and immobilising the wrist in a plaster cast. Surgery may be considered for more seriously displaced fractures. Rehabilitation with interventions such as exercises and other physical interventions is used to help prevent complications, such as stiffness and aching, restore function and speed up recovery.

This review set out to evaluate the effects, primarily on wrist function, of different rehabilitation interventions for treating these injuries.

Search results

We searched the scientific literature up to January 2015 and found 26 randomised controlled studies, involving 1269 mainly female and older patients. Only four of the 23 treatment comparisons covered by these 26 studies were tested by more than one study. Participants of 15 studies were initially treated with plaster cast immobilisation. Some or all participants in the other 11 studies were treated with surgery. In seven studies, the rehabilitation intervention being tested started during wrist immobilisation. In the other 19 studies, rehabilitation started when the cast had been removed.

All studies were small and were designed in a way that may affect the reliability of their findings. Most studies did not report on patient-reported outcome measures of function and did not follow up patients for long enough. We judged the quality of the reported evidence as either low or very low and thus we are not confident that the results described below are true.

Key results

Interventions started during immobilisation
Two studies provided very low quality evidence that rehabilitation (hand therapy or task-orientated therapy) improved hand function after the plaster cast was removed, but not in the longer-term. One study provided very low quality evidence that outcome after supervised exercises did not differ from outcome after unsupervised exercises. Four studies provided very low quality evidence of some slight benefits of four different single methods of rehabilitation that were given with standard care.

Interventions started post-immobilisation, mainly after removal of the plaster cast
There was very low quality evidence from one study of improved function for a single session of physiotherapy, primarily advice and instructions for a home exercise programme, compared with 'no intervention' after cast removal. There was low quality evidence from four very different studies of no clinically important differences in outcome in patients receiving routine physiotherapy or occupational therapy in addition to instructions for home exercises versus instructions for home exercises from a therapist. There was very low quality evidence of better short-term hand function in the participants given physiotherapy than in those given either instructions for home exercises by a surgeon (one study) or a progressive home exercise programme (one study). Both studies comparing physiotherapy or occupational therapy versus a progressive home exercise programme after surgery involving plate fixation (a metal plate and screws are used to hold the broken bone in place) found low quality evidence in favour of a structured programme of home exercises preceded by instructions or coaching. One study provided very low quality evidence of a short-term, but not persisting, benefit of accelerated compared with usual rehabilitation after surgery involving plate fixation.

For studies testing single interventions applied post-immobilisation, there was very low quality evidence of no clinically significant differences in outcome in patients receiving passive mobilisation, ice, pulsed electromagnetic field (PEMF), PEMF plus ice, whirlpool immersion, and a dynamic extension splint for patients with a stiff wrist, compared with no intervention. This finding applied also to single studies comparing PEMF versus ice, and a new type of massage treatment for swelling when compared with the traditional approach. There was very low quality evidence from single studies of a short-term benefit of continuous passive motion immediately after removal of external fixation, intermittent pneumatic compression and ultrasound therapy.

Conclusions

We concluded that there was not enough evidence available to determine the best form of rehabilitation for people with wrist fractures. Priority questions need to be identified before further studies are done.

Authors' conclusions: 

The available evidence from RCTs is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius. Further randomised trials are warranted. However, in order to optimise research effort and engender the large multicentre randomised trials that are required to inform practice, these should be preceded by research that aims to identify priority questions.

Read the full abstract...
Background: 

Fracture of the distal radius is a common clinical problem, particularly in older people with osteoporosis. There is considerable variation in the management, including rehabilitation, of these fractures. This is an update of a Cochrane review first published in 2002 and last updated in 2006.

Objectives: 

To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2014; Issue 12), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, trial registers, conference proceedings and reference lists of articles. We did not apply any language restrictions. The date of the last search was 12 January 2015.

Selection criteria: 

Randomised controlled trials (RCTs) or quasi-RCTs evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

Data collection and analysis: 

The review authors independently screened and selected trials, and reviewed eligible trials. We contacted study authors for additional information. We did not pool data.

Main results: 

We included 26 trials, involving 1269 mainly female and older patients. With few exceptions, these studies did not include people with serious fracture or treatment-related complications, or older people with comorbidities and poor overall function that would have precluded trial participation or required more intensive treatment. Only four of the 23 comparisons covered by these 26 trials were evaluated by more than one trial. Participants of 15 trials were initially treated conservatively, involving plaster cast immobilisation. Initial treatment was surgery (external fixation or internal fixation) for all participants in five trials. Initial treatment was either surgery or plaster cast alone in six trials. Rehabilitation started during immobilisation in seven trials and after post-immobilisation in the other 19 trials. As well as being small, the majority of the included trials had methodological shortcomings and were at high risk of bias, usually related to lack of blinding, that could affect the validity of their findings. Based on GRADE criteria for assessment quality, we rated the evidence for each of the 23 comparisons as either low or very low quality; both ratings indicate considerable uncertainty in the findings.

For interventions started during immobilisation, there was very low quality evidence of improved hand function for hand therapy compared with instructions only at four days after plaster cast removal, with some beneficial effects continuing one month later (one trial, 17 participants). There was very low quality evidence of improved hand function in the short-term, but not in the longer-term (three months), for early occupational therapy (one trial, 40 participants), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial, 96 participants).

Four trials separately provided very low quality evidence of clinically marginal benefits of specific interventions applied in addition to standard care (therapist-applied programme of digit mobilisation during external fixation (22 participants); pulsed electromagnetic field (PEMF) during cast immobilisation (60 participants); cyclic pneumatic soft tissue compression using an inflatable cuff placed under the plaster cast (19 participants); and cross-education involving strength training of the non-fractured hand during cast immobilisation with or without surgical repair (39 participants)).

For interventions started post-immobilisation, there was very low quality evidence from one study (47 participants) of improved function for a single session of physiotherapy, primarily advice and instructions for a home exercise programme, compared with 'no intervention' after cast removal. There was low quality evidence from four heterogeneous trials (30, 33, 66 and 75 participants) of a lack of clinically important differences in outcome in patients receiving routine physiotherapy or occupational therapy in addition to instructions for home exercises versus instructions for home exercises from a therapist. There was very low quality evidence of better short-term hand function in participants given physiotherapy than in those given either instructions for home exercises by a surgeon (16 participants, one trial) or a progressive home exercise programme (20 participants, one trial). Both trials (46 and 76 participants) comparing physiotherapy or occupational therapy versus a progressive home exercise programme after volar plate fixation provided low quality evidence in favour of a structured programme of home exercises preceded by instructions or coaching. One trial (63 participants) provided very low quality evidence of a short-term, but not persisting, benefit of accelerated compared with usual rehabilitation after volar plate fixation.

For trials testing single interventions applied post-immobilisation, there was very low quality evidence of no clinically significant differences in outcome in patients receiving passive mobilisation (69 participants, two trials), ice (83 participants, one trial), PEMF (83 participants, one trial), PEMF plus ice (39 participants, one trial), whirlpool immersion (24 participants, one trial), and dynamic extension splint for patients with wrist contracture (40 participants, one trial), compared with no intervention. This finding applied also to the trial (44 participants) comparing PEMF versus ice, and the trial (29 participants) comparing manual oedema mobilisation versus traditional oedema treatment. There was very low quality evidence from single trials of a short-term benefit of continuous passive motion post-external fixation (seven participants), intermittent pneumatic compression (31 participants) and ultrasound (38 participants).

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