B(Hons.

) Physiotherapy
UiTM Puncak Alam

Colless Fracture
Presented by : Safwan Idham b Ramlan 2010652676

Wrist anatomy

Colless Fracture

Also called poutteaus fracture Described by Abraham Coles in 1814 It is not just fracture lower end of radius but fracture dislocation of the inferior ulnar joint Occur about 2.5cm above carpal extremity of the radius
(Ebnezar J. ,2011)

Mechanism of injury

The common mode of injury is fall on outstretched hand with dorsiflexion ranging from 40 90 degree

Clinical Features

Patient complain pain,swelling and deformity Tenderness over distal end of the radius Dinner fork deformity Styloid process at the same level

(McRae R.,2006)

Doctor management

Operative method

Closed reduction and percutaneous fixation K wires or ORIF with plate and screws Rarely required External fixator for communited fracture Closed reduction under GA or LA the immobilized by below elbow cast Plaster cast remove after 6 to 8 weeks

Conservative method

(Ebnezar J. ,2011)

Complication
Persistent deformity & malunion Complex regional pain syndrome Delayed rupture of extensor pollicis longus Carpal tunnel syndrome Persisting stiffness

(McRae R.,2006)

Case studies

Case history: 38-year-old Malay man A 38-year-old right-handed male motorcyclist that attempted to take a curve at a high speed and overturned and hit over road divider 3 month ago. On presentation at the hospital, he was conscious and complained of right forearm pain. He can see lateral side of his wrist is dislocated. Doctor management : closed reduction and plaster of paris for 3 month

Patients complain
Week 1
1. Right wrist pain at distal volar and dorsal aspect 2. Unable to perform full grip 3. Unable to do all wrist motion 4. Swelling at the right wrist during prolong walking 5. Right shoulder pain due to restricted motion 6. Opposition until index finger 7. During immobilize, the finger joint is not free to move

History

Past medical history experience right thumb had been chopped during 4th grade. Family history have a wife and 2 children Social history lives with family, 2 children, working as SYABAS driver, smokes 5 cigarettes per day, takes no exercise, partial mobile (immobile right arm) and unable to complete all ADLs such as driving,writing and eating

Pain assessment
Week 1 VAS 5/10

AREA
TYPE OF PAIN DEPTH & QUALITY

ACTIVITY LIMTATION

Distal Volar and dorsal aspect of wrist Throbbing pain Deep & superficial Eating ,driving, wearing cloth

Observation
Week 1 GENERAL Lack of confident, walking into department with wearing sling and put the affected arm at the chest level ,long nail, keep hanging hand. Dinner fork deformity seen Right hand swelling,tremor and wasting of brachioradialis

LOCAL

PALPATION

Right biceps flaccid & flabby, pain on palpation of affected wrist. Warm and tenderness

Muscle Bulk (cm)

Week 1 Left BRACHIORADIALIS BICEPS 23.9 25.6 Right 22 28.3

Interpretation : slightly wasting of brachioradialis due to immobilize for prolong time. Biceps also wasting but the large diameter is due to soft tissue.

Special test
Apley scratch : IR + extension = +ve, pain on movement ER + flexion = +ve, pain on movement Interpretation : there are shoulder rotator cuff involvement

Sensation test
Hot and cold sensation intact Pin prick sensation intact Light touch sensation intact

Range of motion (Degree)

LEFT WRIST Flexion Extension Ulnar Dev.
0-70 0-55 0-35

RIGHT PROM AROM

0 0 0 0 0 0

AROM
0-72 0-57 0-35

PROM

Radial Dev.

0-16

0-16

Interpretation : patient cannot perform radial and ulnar deviation due to restriction of movement . Thus, he cannot perform pronation and supination. The wrist motion slightly increase week after week.

Range of motion (Degree)

LEFT ELBOW Flexion Extension Supination Pronation
0-90 90-0 0-80 0-82

RIGHT PROM AROM

0-80 80-0 0-82 82-0 -

AROM
0-90 90-0 0-82 0-82

PROM

Interpretation : patient cannot perform full grip. Thus, supination & pronation is cannot be performed.

Range of motion (Degree)

LEFT
SHOULDE R Flexion AROM
0-178 0-50 0-75 0-80

RIGHT
PROM AROM
0-110 0-46 0-30 0-20

PROM
0-110 0-46 0-30 0-21

0-180 0-52 0-76 0-81

Extension
Int. rot Ext. rot

Interpretation : due to prolong immobilization, patient prone to get frozen shoulder.

Muscle strength (All 3 weeks)

Muscle
Wrist extensor Wrist flexor Ulnar deviator Radial deviator Elbow flexion Elbow extension Pronator Supinator Shoulder flexor Shoulder extensor

Left
5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5

Right
3/5 3/5 1/5 1/5 3/5 4/5 1/5 1/5 3/5 3/5

Abductor
Int. rotator Ext. rotator

5/5
5/5 5/5

3/5
2/5 2/5

Interpretation : patient cannot tolerate with resistance due to pain

Impression

All joint stiffness due to prolong immobilization Muscle wasting due to prolong disuse Swelling because of poor blood circulation and lack of muscle pumping Shortening of the finger flexor and extensor tendon due to immobilization Shoulder symptoms may explained frozen shoulder due to patient fear of fracture displacement. Pronator & supinator contracture

Goal
Short term - Improve confidence level - Reduce wrist pain - Reduce hand swelling - Improve ROM of wrist, digit, elbow and shoulder - Improve muscle strength of the wrist,thumb,digit flexor and extensor,hypothenar,thenar, lumbricals and interossei muscle - Reduce joint stiffness Long term - Allow patient to participate in ADL

Treatment plan
Treatment Plan
Reduce pain

Intervention
Paraffin wax therapy -6 layer -20 minute TENS -Apply to wrist, elbow & shoulder -6.5 mA -Continuous -20 minute Hot pack -apply to shoulder -20 minute

Evidence based
TENS was effective in reducing analgesic agent-related side effects and in reducing analgesic consumption. In addition, TENS also decreased activity related pain (Kara B ,Baskurt F. ,2011)

Reduce joint stiffness & improve ROM

The addition of deep heating to stretching exercises produced a greater improvement in pain relief, and resulted in better performance in the activities of daily living and in range of motion than did superficial heating. (Leung MSF, Cheing GLY,2007) Low-intensity ultrasound exposure results in stronger and stiffer callus formation and in acceleration of the endochondral ossification process (Rubin, C., Bolander, M., Ryaby, J. P. & Hadjiargyrou, M. 2001)

Ultrasound -apply to shoulder & wrist -frequency 1mHz -intensity 1.2 W/cm2 - Mode continous

Treatment plan
Treatment Plan
Prevent further atrophy

Intervention
Isometric contraction exercise -Hold 6 sec -20 x - brachioradialis & biceps

Evidence based
Isometric exercise prevent or minimize muscle atrophy when joint movement is not possible owing to external immobilization (casts, splints, skeletal traction) and to activate muscles (facilitate muscle firing) to begin tore-establish neuromuscular control but protect healing tissues when joint movement is not advisable after soft tissue injury or surgery. (Kisner C, Colby LA , 2002)

Improve ROM

AROM/PROM -digits -wrist Opposition exercise Theraputty exercise Hand cycling Education - Elevation of arm above heart level - Elevate on the pillow during sleep

Reduce wrist swelling

Review

For the first treatment,doesnt have enough time to give all treatment. Only give the most important treatment Next treatment plan Joint mobilization of wrist and shoulder Pendular exercise to overcome shoulder problem Ultrasound to the shoulder

FOLLOW UP

Patients complain
1st follow up 1. Right wrist pain at distal volar aspect 2. Swelling at the right wrist during prolong walking 3. Only able to do a little bit wrist extension & flexion 4. Unable to perform full grip 5. Right shoulder pain due to restricted motion 6. Opposition until middle finger 2nd follow up 1. Only able to do a little bit wrist extension & flexion 2. Unable to perform full grip 3. Right shoulder pain due to restricted motion 4. Opposition until middle finger

Doctors Note : osteopenia formation at fracture site and MCP during 2nd follow up

Interpretation : there are some improvement of the wrist and finger

2nd Follow up

Figure 1 : patient still unable to perform full grip

Figure 2 : patient still unable to perform wrist extension

Pain assessment
1st follow up VAS AREA TYPE OF PAIN DEPTH & QUALITY ACTIVITY LIMTATION 2/10 Distal Volar aspect of wrist Throbbing but less than week 1 superficial Eating ,driving, wearing cloth 0/10 Eating ,driving, wearing cloth 2nd follow up

Interpretation : Pain decreasing in week 3

Observation
1st follow up GENERAL
walking into department without wearing sling . Dinner fork deformity Right hand swelling, atrophy of brachioradialis Right biceps flaccid

2nd follow up
walking into department without wearing sling with more confident Dinner fork deformity

LOCAL

PALPATION

Right biceps flaccid

Interpretation : swelling is reduced. Right biceps flaccid due to disuse

Muscle bulk (cm)

1st follow up Left BRACHIORADIALIS BICEPS 24 26.5 Right 23 27.5 Left 23.9 26.5 2nd follow up Right 23.4 27.5

Interpretation : slightly improvement of brachioradialis. Biceps still wasting but the large diameter is due to soft tissue.

Range of motion (Degree)

LEFT
WRIST Follow up Flexion Extension Ulnar Dev. Radial Dev. 1st
0-70 0-57 0-35

RIGHT
PROM AROM 1st
0-23 0-7 0

AROM 2nd
0-70 0-57 0-36

PROM 1st
0-24 0-7 0

1st
0-73 0-59 0-35

2nd
0-72 0-58 0-37

2nd
0-30 0-20 0

2nd
0-32 0-21 0

0-16

0-18

0-16

0-19

Interpretation : until 2nd follow up,patient still cannot perform radial and ulnar deviation. Thus, he cannot perform pronation and supination. The wrist motion slightly increase week after week.

Range of motion (Degree)

LEFT ELBOW Follow up Flexion Extension Supinatio n 1st
0-90 90-0 0-80

RIGHT PROM AROM 1st

0-95 95-0 -

AROM 2nd
0-90 90-0 0-80

PROM 1st
0-95 95-0 -

1st
0-90 90-0 0-81

2nd
0-90 90-0 0-82

2nd
0-110 110-0 -

2nd
0-111 111-0 -

Pronation

0-81

0-81

0-82

0-81

Interpretation : until 2ng follow up,patient still cannot perform full grip. Thus, supination & pronation is still cannot be performed.

Range of motion (Degree)

LEFT SHOULDE R Follow up Flexion Extension 1st
0-178 0-50 0-75

RIGHT PROM AROM 1st

0-117 0-46 0-32

AROM 2nd
0-179 0-50 0-77

PROM 1st
0-117 0-46 0-33

1st
0-180 0-52 0-75

2nd
0-180 0-51 0-77

2nd
0-120 0-47 0-40

2nd
0-120 0-47 0-40

Int. rot Ext. rot

0-81

0-80

0-81

0-82

0-20

0-20

0-20

0-20

Interpretation : due to prolong immobilization, patient prone to get fozen shoulder.

Treatment plan(1ST follow up)

Treatment Plan
Reduce pain

Intervention
Paraffin wax therapy -6 layer -20 minute TENS -apply to wrist, elbow & shoulder -6.5 mA -Continuous -20 minute AROM/PROM Joint mobilization -shoulder & wrist -Oscillatory grade 2 -traction, PA & AP glide Hot pack -apply to shoulder -20 minute Ultrasound -apply to shoulder -frequency 1mHz -intensity 1.2 W/cm2 - Mode continous

Evidence

Reduce joint stiffness & improve ROM

A combination of thermal ultrasound and joint mobilizations was effective in restoring AROM to wrists lacking ROM after injury or surgery (draper D ,2010) Specific joint mobilization techniques are believed to selectively stress certain parts of the joint capsule and improve glenohumeral joint in frozen shoulder (Kelley MJ, McClure PW, &Leggin BG,2009)

Treatment plan(1ST follow up)

Treatment Plan Intervention
Pendulum exercise -To treat frozen shoulder -3 minute -2 lb weight Isometric contraction exercise - brachioradialis & biceps Improve ROM Opposition exercise Theraputty exercise Hand cycling

Evidence

Treatment plan(2nd follow up)

Treatment Plan
Reduce pain

Intervention
Paraffin wax therapy -6 layer -20 minute TENS -apply to wrist, elbow & shoulder -6.5 mA -Continuous -20 minute AROM/PROM Joint mobilization -shoulder & wrist -Oscillatory grade 2 -traction, PA & AP glide Hot pack -apply to shoulder -20 minute Ultrasound -apply to shoulder -frequency 1mHz -intensity 1.2 W/cm2 - Mode continous

Evidence

Reduce joint stiffness & improve ROM

Treatment plan(2nd follow up)

Treatment Plan Intervention
Pendulum exercise -To treat frozen shoulder Isometric contraction exercise - brachioradialis & biceps Improve ROM Opposition exercise Theraputty exercise Arm supinator and pronator Hand cycling

Evidence

conclusion

Short term goal is achieved

Patient achieve reduction of pain to 0/10 in in 3 week Swelling is reduced in week 3 Patient achieve slightly increase in wrist ROM only in extension and flexion in 3 week. Ulnar and radial deviation is still no improvement. Supinator and pronator is still no improvement

Patient education is also important to improve confidence. Joint mobilization is effective to reduce stiffness

with heat therapy plus stretching is proven improve shoulder ROM

AROM/PROM are also important to improve ROM and prevent further stiffness

Reference

Draper, D.. (2010). Ultrasound and Joint Mobilizations for Achieving Normal Wrist Range of Motion After Injury or Surgery: A Case Series. Journal of Athletic Training, 45(5), 486-491

Bunker, T. (2009) Time For a New Name for Frozen Shoulder Contracture of the Shoulder. Shoulder and Elbow, 1, 4-9.
Kelly, M.J., Mcclure, P.W., Leggin, B.G., (2009) Frozen Shoulder Evidence and a Proposed Model Guiding Rehabilitation. Journal of Orthopedic and Sports Therapy,39(2), 135-148. Kara B, Baskurt F, Acar S, Karadibak D, ifti L, Erbayraktar R, Gkmen A (2011)The Effect of TENS on Pain, Function, Depression, and Analgesic Consumption in the Early Postoperative Period with Spinal Surgery Patients. Turkish Neurosurgery, 21(4):618-624. Leung MSF, Cheing GLY (2008). Effects of deep and superficial heating in the management of frozen shoulder, Journal of Rehabilitation Medicine, 40, 145150