The patient gazes at me in confusion as I apply a moist heat pack from their right elbow to their fingers. It’s the first therapy visit after initial evaluation and they are eager to get enough wrist motion to brush the hair on the contralateral side of their head with ease. The patient’s diagnosis was distal radius fracture; conservatively-managed the patient had spent 6 weeks in a cast that left digits free to move and forearm able to rotate. It is no secret that stiffness is present after a period of immobilization in a cast or splint. However the strategies for addressing deficits in wrist extension, flexion, radial and ulnar deviation can range from least to most efficacious depending on the clinician’s approach. After a non-comminuted fracture or open reduction with internal fixation (ORIF) the wrist is often immobilized in neutral to 20 degrees of extension. In surgical cases the period of constant lack of motion is a relatively-brief 10 -14 days compared to the 4-6 week course required for non-operative treatment. During this time, all digits, especially the thumb with its extrinsic movers crossing the radius bone itself can stiffen due to inflammation and patient hesitancy to mobilize joints not included in the orthosis or cast. When treating these cases, it is expected that the clinician treats with a micro-lens that is laser-focused on restoring wrist and finger motion by providing home exercise programs that address deficits captured with objective assessment tools at evaluation time. However there is an often-overlooked piece to the joint kinematics puzzle; proximal muscle length and responsiveness to stretch.
What muscles? Any and all muscles that originate on the humerus or forearm and span the wrist, attaching into the carpals or metacarpals should be identified and assessed for tension or tenderness as an exercise course is implemented. Alleviating tension and pain in the flexor carpi ulnaris (FCU) muscle (which has one of three origins at the medial epicondyle) can reduce tenderness at the pisiform while freeing up the distal ulna and triangular fibrocartilage complex (TFCC) so the patient experiences less discomfort during end range supination and ulnar or radial deviation. The supported elbow extension stretch below provides a great stretch of the extrinsic flexors and can be used to target the extrinsic extensors if performed with a pronated forearm. The supported humerus provides an added benefit; enabling the patient to reduce compensatory motion at the shoulder.
Soft tissue mobilization to the mobile wad of Henry (comprised of the brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis) can enable the patient to flex their wrist with greater ease in preparation for activities of daily living (ADLS) such as toileting hygiene and bra-strap donning. This manual therapy course provides a thorough guide to the anatomy and biomechanics of the elbow and how it can affect proximal and distal structures.
The anatomy of the extensor carpi radialis longus (ECRL) muscle with its origin at the lateral epicondyle and insertion on the second metacarpal illustrated above exemplifies how reduced muscle insufficiency after a period of relative stasis can affect the ability to both flex the wrist to lengthen and recruit muscle fibers to contract it into wrist extension for functional grasping. Manual techniques that mobilize the radial head can simultaneously improve end range elbow extension and wrist flexion when tension in the ECRL and ECRB.
Research into the effect of immobilization on skeletal muscle after a few hours shows that motor neuron activity, blood supply and glycogen synthesis are impaired (Uchoa & Santos, 2015). A therapy program that addresses reduced muscle length and contractile efficiency of extrinsic flexor and extensor musculature has tremendous impact on a patient’s ability to increase end range motion. Manual therapy and exercises focused on warming up and engaging skeletal muscle proximal to the wrist and hand can provide immensely positive biofeedback for the patient. This can yield higher compliance levels for in-person therapy visits and greater “buy-in” to the idea that the HEP can maintain and facilitate greater treatment gains and functional outcomes.
This course provides a detailed guide into the assessment and treatment of these fractures: https://www.medbridge.com/course-catalog/details/therapy-and-assessment-following-wrist-fracture-evidence-based-strategies-kristin-valdes-hand-therapy/
References:
Uchoa, S, Santos P M. (2015). Consequences of immobilization and disuse: a short review. 2 (4) (2013) 297-302 Journal of Applied Sciences