Distal Radius Fracture:

Early-Stage Rehabilitation
Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT

Not for reproduction or redistribution

Disclosures

• Financial
– None
• Nonfinancial
– Instructor for International Academy of Orthopedic
Medicine–US

Not for reproduction or redistribution

Learning Objectives

1. Identify structural bony changes that can occur

following distal radius fracture (DRF) and can impact
recovery of range of motion
2. Detect potential complications that can negatively
affect the patient’s recovery
3. Determine which tests and measures are appropriate
to perform on the initial therapy visit
4. Implement a treatment plan that addresses
impairments including finger and wrist stiffness,
dexterity, and proprioceptive deficits

Not for reproduction or redistribution

 Chapter 1
Structural Changes and Potential Complications
Following Distal Radius Fracture

Not for reproduction or redistribution

Structural Changes

• What bony changes can occur as a result of a distal

radius fracture (DRF)?
– Loss of volar tilt (i.e., increased dorsal tilt)
– Loss of radial height (i.e., positive ulnar variance)
– Coronal shift/ulnar styloid base fracture

Not for reproduction or redistribution

Structural Changes: Loss of Volar Tilt

• Clinical implications
– Increased wrist
extension with limited
flexion (arc of motion
biased into extension)
– May have limitations
with forearm rotation
due to malalignment of
the DRUJ

Not for reproduction or redistribution

Structural Changes: Loss of Volar Tilt (cont.)

• Evaluated 109 patients with distal radius fracture over

four years
– At follow-up, 40 patients had persistent ulnar wrist pain
• The most important factor for predicting ulnar pain
was final dorsal angulation of the radius
• The authors suggest that ulnar wrist pain following
Colles fracture is caused by incongruity of the distal
radioulnar joint

Tsukazaki & Iwasaki, 1993

Not for reproduction or redistribution
Structural Changes: Loss of Radial Height
(Change in Ulnar Variance)
• Clinical implications
– Ulnar impaction syndrome,
which can lead to
• Limited wrist ulnar
deviation
• Painful and/or limited
forearm pronation
– Cadaver study by Trehan et
al. (2019) showed loss of
radial height did not affect
DRUJ stability

Trehan et al., 2019

Not for reproduction or redistribution
Structural Changes: Coronal Shift/Ulnar
Styloid Base Fracture
• Distal radius fractures with
associated basilar ulnar styloid
and coronal shift of the proximal
fracture fragment result in
increased distal oblique bundle
(DOB) laxity and decreased
resting tension
• As a result, DRUJ stability is
compromised
– Tension and DRUJ stability is
restored upon coronal shift
reduction

1. Dy et al., 2014 2. Trehan et al., 2019

Not for reproduction or redistribution
Structural Changes: Coronal Shift/Ulnar
Styloid Base Fracture (cont.)

• Clinical implications
– DRUJ instability, due to loss of integrity of the volar and
dorsal deep radioulnar ligaments if the fracture involves
the fovea
– Painful and/or limited forearm rotation (due to
malalignment)
– Painful grip and resisted forearm rotation

Pidgeon et al., 2018

Not for reproduction or redistribution
Structural Changes: What Determines
Whether or Not a Patient Needs Surgery?

• Retrospective cohort study, N = 326

• Purpose
– To identify what patient and fracture characteristics
may influence the decision to pursue surgical vs.
nonsurgical treatment in patients over 65 years of age
with distal radius fracture (DRF)
• Factors associated with operative treatment were
largely related to the severity of the injury (increased
dorsal tilt)

Walsh et al., 2022

Not for reproduction or redistribution
Other Potential Complications: Tendon
Rupture

• Extensor pollicis longus (EPL)

– EPL tendonitis is classically seen in the setting of a
nondisplaced DRF that often progresses to tendon
rupture1
– What to look for2
• Pain and difficulty extending the IP joint of the thumb

1. Diep & Adams, 2016 2. Roth et al., 2012

Not for reproduction or redistribution
Other Potential Complications: Tendon
Rupture (cont.)

• Extensor pollicis longus (EPL)

– Incidence1
• EPL ruptures in nondisplaced distal radius fractures
(N = 61) was 5%
• This occurred an average of 6.6 weeks after the fracture
– Following volar locking plate2 found that the incidence of
extensor tendon rupture varies from 0%–12.5% (relatively
uncommonly), with EPL involved most
• Several risk factors include dorsal screw prominence and
fracture fragments

1. Roth et al., 2012 2. Kunes et al., 2022

Not for reproduction or redistribution
Other Potential Complications: Flexor
Tendon Rupture
• Poor bone stock or multiple
bone fragments can cause
loosening of the plate or
nonlocking screws, which
can irritate the flexor tendons
• Screws or the distal edge of
the plate can cause potential
rupture of the
– FCR (flexor carpi radialis)
– FPL (flexor pollicis longus)
– FDS (flexor digitorum
superficialis) or FDP (flexor
digitorum profundus) of the
index or middle fingers

Adham et al., 2009

Not for reproduction or redistribution
Other Potential Complications: Triangular
Fibrocartilage Complex (TFCC) Injury
• The incidence of TFCC
injury associated with
distal radius fractures
ranges from 35% to 78%
• Clinical implications
include
– Ulnar-sided wrist pain
– Decreased grip strength
– Decreased ROM
– DRUJ instability

Kasapinova & Kamiloski, 2020

Not for reproduction or redistribution
Other Potential Complications: Triangular
Fibrocartilage Complex (TFCC) Injury (cont.)

• In a study of 70 patients with DRF with arthroscopic

exam, the TFCC was injured in 45 patients (64%)
– These patients demonstrated greater pain and disability
at 3 and 12 months post injury

Kasapinova & Kamiloski, 2020

Not for reproduction or redistribution
Other Potential Complications: Triangular
Fibrocartilage Complex (TFCC) Injury (cont.)

• Yan and colleagues took MRIs of 57 patients with DRF

– 55 were diagnosed with TFCC injuries
– There was no significant relationship between the TFCC
injury pattern and the type of distal radius fracture, DRUJ
instability, or ulnar styloid fracture
– Conclusion
• High prevalence of TFCC injuries in patients with distal
radius fractures

Yan et al., 2019

Not for reproduction or redistribution
Other Potential Complications:
Scapholunate (SL) Injury

• How common is SL injury

with DRF?
– Incidence: between 5%–64%
of all distal radius fractures
demonstrate SL diastasis

Lans et al., 2018

Not for reproduction or redistribution
Other Potential Complications:
Scapholunate (SL) Injury (cont.)
• Retrospective review of 42 patients
with SL diastasis of over 3 mm
• Divided into three groups
– 23 had SL repair within 21 days
of injury
– 8 had SL repair after 21 days
– 11 did not have a repair
• Outcomes
– 6 months to 12 years showed no
difference between the three
groups

Duethman et al., 2021

Not for reproduction or redistribution
Other Potential Complications: Carpal
Tunnel Syndrome

• Carpal tunnel syndrome (CTS) after DRF can present in

three forms: acute, transient, and delayed
– Acute
• Requires an emergent carpal tunnel release
– Transient
• Typically resolves following distal radius repair
– Delayed
• Monitor for symptoms of this in your patient

1. Pope & Tang, 2018 2. McEntee et al., 2022

Not for reproduction or redistribution
Other Potential Complications: Carpal
Tunnel Syndrome (cont.)

• Retrospective review of 4,487 patients with DRF

– 68 were identified to have an ipsilateral carpal tunnel
release within six months of the distal radius fracture
• Results
– CTS was more likely to develop in older
patients (62.9 years vs. 57.4 years)
– Sex, body mass index, and smoking history were not
found to be different between the groups

McEntee et al., 2022

Not for reproduction or redistribution
Other Potential Complications: Complex
Regional Pain Syndrome (CRPS)

• An array of painful conditions characterized by a

continuing (spontaneous or evoked) regional pain that
is seemingly disproportionate in time or degree to the
usual course of any known trauma
• The pain is regional and does not follow a specific
dermatome or nerve distribution and usually has a
distal predominance of abnormal sensory, motor,
sudomotor, vasomotor, and/or trophic findings
• Shows variable progression over time

Harden, 2010
Not for reproduction or redistribution
Other Potential Complications: Complex
Regional Pain Syndrome (CRPS) (cont.)

• Distal radius fractures

– CRPS 1
• No evidence of nerve injury (analogous to former “RSD”)
– CRPS 2
• Evidence of nerve injury (formerly “causalgia”)
– Postfracture and postsurgical CRPS are almost always
classified as CRPS 1

1. Cleland & McCrae, 2002 2. Marinus et al., 2011

Not for reproduction or redistribution
Other Potential Complications: Complex
Regional Pain Syndrome (CRPS) (cont.)
• What are the factors associated with CPRS in patients
recovering from DRF?
– Identified 59,765 patients treated for a DRF between 2012 and
2014
– 114 (0.19%) were diagnosed with CRPS
– Older age, female sex, open fracture, and comorbid
fibromyalgia were independently associated with diagnosis of
CRPS
• What to watch for
– History of multiple cast changes
– Significant stiffness in the wrist and digits

Crijns et al., 2018

Not for reproduction or redistribution
Other Potential Complications: Is the
Patient a Fall Risk?

• Distal radius fractures (both in women and men) can be

the start of a cascade of declining mobility and
impairments in balance, strength, and physical activity,
which can place the patient at further risk for future
falls
• Questions to ask
– Was the fall an isolated event, or has the patient had a
history of previous falls?
– Ask both the patient and family members

Dewan et al., 2019

Not for reproduction or redistribution
Chapter 2
Evaluation

Not for reproduction or redistribution

Evaluation

• Equipment you will need

– Functional outcome measure: Patient-Rated Wrist
Evaluation (PRWE)
– 360° goniometer: for wrist
– 180° goniometer: for thumb CMC and forearm, fingertip
to distal palmar crease (DPC)
– Tape measure

Not for reproduction or redistribution

Evaluation (cont.)
• Subjective
– Pain levels at rest and with activity?
– Was the fall an isolated event, or has the patient had a history
of previous falls?
– Does the patient have shoulder pain?
• In a qualitative study, Doerrer and colleagues evaluated the
impact of shoulder pathology on individuals with DRF1
– Of the 45 participants, 35.6% presented with shoulder
pathology: 6 initially due to a fall and 10 who developed
shoulder issues due to compensation or disuse
– Average number of days to develop shoulder pathology was 43

1. Doerrer et al., 2023

Not for reproduction or redistribution
Evaluation: Fall Risk Assessment
• Cross-sectional survey of 156 hand therapists by
Dewan and colleagues showed a gap in current practice
patterns with fall screening and referral1
• Systematic review by Lusardi and colleagues found the
three most evidence-supported functional measures to
determine risk of future falls2
– Berg Balance Scale (more than 50 points)
– Timed Up and Go Test (less than 12 seconds)
– 5-Times Sit-to-Stand Test (less than 12 seconds)

1. Dewan et al., 2019 2. Lusardi et al., 2017

Not for reproduction or redistribution
Evaluation: Functional Outcome Measure
• Patient-Rated Wrist Evaluation (PRWE)
– Originally published in the Journal of Hand Therapy in 1996
• Has been shown to have strong measurement properties and
has been translated into multiple languages
– This outcome measure considers the patient’s pain with
selected activities to evaluate various wrist functions
• Fastening buttons (dexterity)
• Cutting food (grip with ulnar deviation)
• Turning a doorknob (forearm rotation)
• Pushing up from a chair (wrist extension)
• Carrying a heavy object (strength)
• Using bathroom tissue (wrist flexion)

MacDermid, 2019
Not for reproduction or redistribution
Monitor for Potential Complications
• Watch for signs of CRPS
– If patient begins to develop
this, alert the surgeon
immediately
• Monitor function of the EPL
– Can the patient perform
hyperextension of the thumb
IP joint?
– If the patient suddenly starts
complaining of discomfort in
the front in the thumb from the
cast or wrist-hand orthosis
(WHO) rubbing, check to make
sure the patient’s EPL is
functioning

Not for reproduction or redistribution

Evaluation Objective: Edema
(Figure-Eight Method)

1. Pellecchia, 2003 2. Leard et al., 2004

Not for reproduction or redistribution
Evaluation Objective: Edema
(Circumferential Method)

At the wrist flexion At the level of the At the level of the

crease metacarpophalangeal proximal phalanges (if
(MCP) joints needed)

Not for reproduction or redistribution

Evaluation Objective

• If post surgery
– Assess incision/scar
– Measure the length of
the incision/scar
• If there’s still an incision
– Any drainage present?
– If so, what type?
• Serous (clear)
• Serosanguinous
• Sanguineous

Not for reproduction or redistribution

Evaluation Objective (cont.)

• Observation
– Monitor for signs of CRPS
• What to watch for
– History of multiple cast changes
– Significant stiffness in the wrist and digits
– Pain out of proportion
– Complaints of burning
– Excessive hair growth
– Sudomotor changes

Crijns et al., 2018

Not for reproduction or redistribution
Evaluation Objective (cont.)
• Sensibility test: Ten Test
– Used to assess the sensibility of the hand via moving
light touch
– Graded by the patient on a scale of 1–10
– 10 represents normal sensation
– The higher the score, the less sensory loss
– To assess the median nerve, compare the moving light
touch at the thumb tip, index fingertip, and middle
fingertip
– To assess the radial nerve, compare the dorsal aspect of
the second metacarpal

1. Strauch et al., 1997 2. Karagiannopoulos et al., 2013

Not for reproduction or redistribution
Evaluation Objective (cont.)

• Sensibility test: Ten Test

– To assess the median nerve,
compare the moving light
touch at the thumb tip, index
fingertip, and middle fingertip

1. Strauch et al., 1997 2. Karagiannopoulos et al., 2013

Not for reproduction or redistribution
Evaluation Objective (cont.)

• Sensibility test: Ten Test

– To assess the radial nerve,
compare the dorsal aspect of
the second metacarpal

1. Strauch et al., 1997 2. Karagiannopoulos et al., 2013

Not for reproduction or redistribution
Evaluation Objective
• Active range of motion (AROM)
– Fingers
• Composite flexion and extension
– Thumb
• Radial abduction and palmar abduction and opposition
– Wrist
• Straight plane and dart thrower’s motion
– Forearm
• Pronation and supination
– Shoulder screen
• Forward flexion, abduction, external rotation (with arm at side),
and internal rotation with reaching behind back

Not for reproduction or redistribution

Evaluation Objective: Active Range of
Motion (AROM)

Fingers: composite finger extension and flexion (deficit

of fingertip to distal palmar crease [DPC])

Not for reproduction or redistribution

Evaluation Objective: Active Range of
Motion (AROM) (cont.)
• Thumb
– Radial abduction and palmar abduction
• Using the intermetacarpal distance (IMD)
– From the dorsal midpoint from the second metacarpal to the
first metacarpal
• McGee and colleagues found the IMD distance has excellent
interrater reliability and acceptable-to-excellent precision when
measuring palmar and radial abduction in subjects with suspected
thumb CMC OA
• It is the most reliable tool for measuring thumb radial abduction

McGee et al., 2022

Not for reproduction or redistribution
Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Thumb: radial abduction and palmar abduction

McGee et al., 2022

Not for reproduction or redistribution
Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Thumb: opposition

Not for reproduction or redistribution

Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Wrist: straight-plane motion

Flexion Extension

Not for reproduction or redistribution

Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Wrist: straight-plane motion

Radial deviation Ulnar deviation

Not for reproduction or redistribution

Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Wrist: dart thrower’s motion

Radial extension Ulnar flexion

Bergner et al., 2023

Not for reproduction or redistribution
Evaluation Objective: Active Range of
Motion (AROM) (cont.)

Forearm
Pronation Supination

Not for reproduction or redistribution

Evaluation Objective: Shoulder Screen
Forward flexion External rotation
(with arm at side)

Abduction Internal rotation

(reaching behind
back)

Doerrer et al., 2023

Not for reproduction or redistribution
Evaluation Objective: Proprioception

• Consists of joint position sense (JPS), kinesthesia, and

force sense
– This information originates from sensory nerve endings
in skin, joint capsules/ligaments, Golgi tendon organs,
and muscle spindles
• Disturbed proprioception can have adverse effects on
motor control and the regulation of muscle stiffness

1. Röijezon et al., 2015 2. Muurling et al., 2021

Not for reproduction or redistribution
Proprioceptive Training

Hagert, 2010
Not for reproduction or redistribution
Evaluation: Proprioception
Proprioceptive Training (Conscious Sense)

Sensorimotor control

Conscious sense Unconscious sense

Sence
Sense of Joint position Neuromuscular
kinesthesia sense sense

Perception of Perception of Muscle and ligament

joint motion joint position receptors

Muscle and Volutional

Volitional Muscle and
cutaneous muscle cutaneous
receptors contraction receptors

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
 Evaluation: Proprioception (cont.)

• Conscious sense
– Produces willful perceptions of joint motion (i.e.,
kinesthesia) and position (i.e., joint position sense)
• Unconscious sense
– Controls the body’s reflexive neuromuscular mechanisms
toward postural stability and equilibrium

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
Evaluation Objective

• Sensorimotor control: joint position sense

– Cross-sectional case control study found patients with a
history of distal radius fracture demonstrated disturbed
processing of sensory feedback of the sensorimotor
system, especially the joint position sense (JPS)
– This leads to an impairment in detecting a changed
environment and adapting to it
– Impaired JPS should be considered during rehab of
patients with distal radius fracture

Muurling et al., 2021

Not for reproduction or redistribution
Evaluation Objective (cont.)
• Sensorimotor control: joint position sense (JPS)
– Assesses conscious proprioception
– JPS: the ability to accurately reproduce a specific joint angle while
vision is blocked
• Procedure for performing the active JPS test
– Patient is asked to close their eyes
– Start with the patient’s wrist and forearm in neutral with fingers
relaxed
– With a goniometer on the volar aspect of the patient’s wrist in 20°–30°
of extension, ask the patient to hold this position for 3 seconds
– The patient then moves the wrist into full flexion and tries to
replicate the angle
– The final score is the angular difference between the referenced angle
and the reproduced angle (normal: 3° difference)
• JPS deficit of near 3° is considered normal among healthy adults

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
Evaluation Objective (cont.)

Sensorimotor control: active JPS test

Hold for 3 seconds

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
 Evaluation: Dexterity Assessment
• 242 patients with DRF (45 males and 197 females) with
a mean age of 60.2 years had their dexterity tested
using the NK hand dexterity test at 3, 6, and 12 months
after fracture
• Statistical differences in hand dexterity were found
between the injured and uninjured hands across all
time frames
• At no point did dexterity equal the uninjured side
• Conclusion
– Greater attention to assessing and treating dexterity may
be needed to provide a complete recovery following DRF
Bobos et al., 2018
Not for reproduction or redistribution
Evaluation Objective: Dexterity
Assessment

• 9-Hole Peg Test or

Jebsen-Taylor Hand
Function Test can be
used to obtain an
objective dexterity
assessment within the
first several visits

1. Liu et al., 2017 2. Carvalho de Almeida Lima et al., 2017

Not for reproduction or redistribution
 Chapter 3
Treatment for the First 4–6 Weeks

Not for reproduction or redistribution

What Are the Benefits of Therapy?
• RCT to comparing improvements in pain and functional status
between a supervised therapy program and an unsupervised HEP in
DRF patients over 60 years old
• 74 patients
– One group (37 patients) received 12 sessions of supervised PT, and the
other group (also 37 patients) received a home exercise program
• Three evals were performed at the beginning of treatment, six weeks,
and six months
• Results
– The supervised group showed clinically significant differences in the
PRWE score with function and pain at both six weeks and six months
• Conclusion
– Supervised PT program is more effective for improving function in the
short- and medium-term when compared with HEP in adults over 60 with
DRF without complications

Gutiérrez-Espinoza et al., 2017

Not for reproduction or redistribution
Treatment

• Addressing patient impairments

– Protection
• What are the patient’s precautions or restrictions?
– Edema
– Scar (if postoperative)
– ROM deficits and loss of neuromuscular control
– Proprioceptive deficits
– Dexterity

Not for reproduction or redistribution

Protection

• Use of a prefabricated or
custom WHO
– Patients are typically placed
in a prefabricated or custom
wrist-hand orthosis (WHO)
initially, then remove it to
exercise 4–5 times per day
– The WHO is discontinued
during the later stages of
rehab when they are cleared
for strengthening

Not for reproduction or redistribution

Edema Management

• Avoid dependent
positioning
• Instruction in full
composite flexion and
extension, avoiding
just wiggling the
fingers
• Manual edema
mobilization

Not for reproduction or redistribution

Scar and Soft-Tissue Management
• Once the incision is closed
(wait at least two days after
stitches are removed), scar
tissue mobilization can begin
– Begin with using fingers to
gently move the closed
incision
• Can work up to using shelf
liner or Dycem to further
improve the mobility
• Address soft-tissue
restrictions manually or with
tools (instrument-assisted
soft-tissue mobilization)

Not for reproduction or redistribution

Addressing Finger Stiffness
• Addressing finger stiffness
in the early stages of rehab
is very important
• In older patients with
asymptomatic finger
osteoarthritis (OA), the
trauma of the distal radius
fracture can sometimes
cause an “activated
arthrosis”
• Patients can present with
increased pain and
stiffness in their fingers

Not for reproduction or redistribution

Addressing Finger Stiffness:
Tendon Glides
Straight Hook Full composite Tabletop Straight fist
fist

Return to the straight position each time to optimize the tendon glide

Sheereen et al., 2022

Not for reproduction or redistribution
Addressing Finger Stiffness:
Intrinsic Tightness

• Interosseous stretch
– Combined passive MP
hyperextension with
PIP flexion

Not for reproduction or redistribution

Addressing Finger Stiffness:
Intrinsic Tightness (cont.)

• Lumbrical stretch
– Passive MP
hyperextension
orthosis with active PIP
flexion
– A pen can be used to
support the MP joint if
needed

Not for reproduction or redistribution

Addressing Finger Stiffness:
Intrinsic Tightness (cont.)

• Finger abduction and

adduction
– Promotes mobilization
of the opposite
interosseous muscles
to further improve
mobility

Not for reproduction or redistribution

Dexterity Training: Improving Fine Motor
Control
Picking up coins, Manipulating tennis Manipulating nuts
paper clips, or ball to touch the and bolts
marbles numbers

Bobos et al., 2018

Not for reproduction or redistribution
Mental Practice and Mirror Therapy
• What if your patient’s wrist is
immobilized and they cannot begin
wrist motion?
– RCT investigated the effects of
mental practice and mirror therapy
on wrist function after DRF
– N = 31
– Patient performed six weeks of
mental practice or mirror therapy,
performing the following home
program
• Wrist flexion, extension
• Radial deviation
• Ulnar deviation
• Forearm supination, pronation
• Squeezing

Korbus & Schott, 2022

Not for reproduction or redistribution
Mental Practice and Mirror Therapy (cont.)
• (cont.)
– Participants were encouraged to
associate their wrist movements
with activities of daily life
– Assessed subjective function
(PRWE and QuickDASH), wrist
ROM, grip strength, and health-
related quality of life (EQ-5D)
– Both experimental groups (mental
practice and mirror therapy)
showed higher improvements
across the intervention period
compared to the control
• Conclusion
– Mental practice and mirror
therapy are promising therapy
supplements
Korbus & Schott, 2022
Not for reproduction or redistribution
Neuromuscular Reeducation

• Early active motion leads to better outcomes; add

when the patient is cleared for active range of motion
(AROM)
– Neuromuscular reeducation is safe to start early

Roll & Hardison, 2017

Not for reproduction or redistribution
Neuromuscular Reeducation (cont.)
• When should wrist AROM begin following volar plating?
– Systematic review and meta-analysis was to determine the
effectiveness of early vs. delayed motion for functional
outcomes in patients older than 18 years with DRFs treated
with volar locking plate
– Early motion
• AROM initiated 3–5 days following open reduction and internal
fixation (ORIF) with volar plate
• Strengthening allowed at two weeks post surgery
– Delayed motion
• 4–6 weeks of post-op immobilization following ORIF
– All differences favored early motion

Gutiérrez-Espinoza et al., 2021

Not for reproduction or redistribution
Neuromuscular Reeducation (cont.)

• When should wrist AROM begin following volar

plating?
– At three months, only the DASH, pain on VAS, and grip
strength showed significant differences in favor of early
motion
– At one year of follow-up, none of the variables were
different between groups

Gutiérrez-Espinoza et al., 2021

Not for reproduction or redistribution
Neuromuscular Reeducation (cont.)
• Range of motion (ROM) vs. purposeful activities
– Purpose
• Following surgical repair of a DRF, evaluated wrist movement
during purposeful activities (household chores and food
preparation) compared with a set of AROM exercises
• Does similar or better movement occur with purposeful
activity?
– N = 35; randomized crossover design
– ROM exercises produced higher volumes of sustained joint
position; however, purposeful activities produced more
repetition
– This study challenges therapists to consider the rehabilitative
potential of movement produced by activity
Collis, Mayland, Wright-St Clair, Rashid, et al., 2022
Not for reproduction or redistribution
Neuromuscular Reeducation (cont.)

• Technique
– Light touch
• “Gentle persuasion” to guide the normal arthrokinematic
motion (not joint mobilization)
– Goal is to promote joint proprioceptive feedback to
facilitate the patient’s ability to move into the newly
gained range

Not for reproduction or redistribution

Neuromuscular Reeducation:
Arthrokinematics of the Wrist
• Radiocarpal joint (RCJ)
– The relatively mobile
proximal row
(scaphoid, lunate, and
triquetrum) moves on a
fixed distal radius and
ulna
– The convex proximal
row rolls and glides in
straight planes of
motion
• Flexion/extension,
radial/ulnar deviation

1. Foumani et al., 2009 2. Neumann et al., 2017

Not for reproduction or redistribution
Neuromuscular Reeducation: Arthrokinematics
of the Radiocarpal Joint (RCJ)

• Radiocarpal joint (RCJ)

– Opposite
arthrokinematics
• The proximal row will roll
in one direction and glide
in the opposite
– When facilitating motion,
we want to follow the
joint’s normal
arthrokinematics pattern
by promoting the glide

1. Foumani et al., 2009 2. Neumann et al., 2017

Not for reproduction or redistribution
Neuromuscular Reeducation: Arthrokinematics
of the Radiocarpal Joint (RCJ) (cont.)

Extension Flexion

1. Foumani et al., 2009 2. Neumann et al., 2017

Not for reproduction or redistribution
Neuromuscular Reeducation: Facilitating
Wrist Extension (RCJ)
• Technique • Perform slow,
– Ulnar side of the rhythmic motion
patient’s wrist
– Using the ulnar aspect
of your hand and small
finger, provide a “gentle
persuasion” to the
proximal row in a volar
direction as your roll
your hand and forearm
into supination (i.e.,
“scooping motion”)

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Wrist Extension (RCJ) (cont.)

• Technique • Perform slow,

– Perform the following rhythmic motion
• Passive ROM
• Active assisted ROM
• Active ROM

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Wrist Flexion (RCJ)
• Technique • Perform slow,
– Ulnar side of the rhythmic motion
patient’s wrist
– Using the ulnar aspect
of your hand and small
finger, provide a “gentle
persuasion” to the
proximal row in a
dorsal direction as your
roll your hand and
forearm into supination
(“scooping motion”)

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Wrist Flexion (RCJ) (cont.)

• Technique • Perform slow,

– Perform the following rhythmic motion
• Passive ROM
• Active assisted ROM
• Active ROM

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Straight Plane Wrist Flexion and Extension

• Activities
– Using a 2-pound
weighted ball on the
tabletop (lightly rolling
the ball, avoiding
weight-bearing)

Not for reproduction or redistribution

Home Program: Straight-Plane Wrist
Flexion and Extension

• Keep fingers relaxed to

promote recruitment of
the wrist flexors and
extensors (active
tenodesis)
• Repeat for 10
repetitions, 4–5 times
per day

Not for reproduction or redistribution

Neuromuscular Reeducation:
Arthrokinematics of the Wrist

• Midcarpal joint (MCJ)

– The trapezium,
trapezoid, and capitate
articulate with the
distal pole of the
scaphoid
– The distal row moves in
a 45-degree angle in
relation to the dorsum
of the wrist

Moritomo et al., 2014

Not for reproduction or redistribution
Neuromuscular Reeducation:
Arthrokinematics of the Wrist (cont.)

• Midcarpal joint (MCJ)

– This is referred to as
the dart thrower’s
motion (DTM)
– Used to designate one
of the most frequently
used planes of motion

Moritomo et al., 2014

Not for reproduction or redistribution
Neuromuscular Reeducation: Arthrokinematics
of the Midcarpal Joint (MCJ)

Radial extension Ulnar flexion

Moritomo et al., 2014

Not for reproduction or redistribution
Neuromuscular Reeducation: Facilitating Radial
Extension and Ulnar Flexion (DTM)

• Technique • Perform slow,

– Perform the following rhythmic motion
• Passive ROM
• Active assisted ROM
• Active ROM

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating Radial
Extension and Ulnar Flexion (DTM) (cont.)

• Activities
– Placing cones from
radial wrist extension
to ulnar flexion

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating Radial
Extension and Ulnar Flexion (DTM) (cont.)

• Activities
– Wrist maze

Not for reproduction or redistribution

Home Program: Circumduction (Circles)

Repeat for 10 repetitions, 4–5 times per day

Not for reproduction or redistribution

Home Program: Active Dart Thrower’s
Motion

Repeat for 10 repetitions, 4–5 times per day

Not for reproduction or redistribution

Neuromuscular Reeducation:
Arthrokinematics of Forearm Pronation
• Proximal radioulnar joint
Neutral Pronation
(PRUJ)
– Opposite
arthrokinematics
• The radial head rolls in a
volar-medial direction
and glides dorsal-lateral
• When facilitating
pronation, we want to
follow the joint’s normal
arthrokinematics pattern
by promoting the glide in
a dorsal-lateral direction

1. Orbay & Cambo, 2020 2. Neumann et al., 2017

Not for reproduction or redistribution
Neuromuscular Reeducation:
Arthrokinematics of Forearm Supination
• Proximal radioulnar joint
Neutral Supination
(PRUJ)
– Opposite
arthrokinematics
• The radial head rolls in a
dorsal-lateral direction
and glides volar-medial
• When facilitating
supination, we want to
follow the joint’s normal
arthrokinematics pattern
by promoting the glide in
a volar-medial direction

1. Orbay & Cambo, 2020 2. Neumann et al., 2017

Not for reproduction or redistribution
Neuromuscular Reeducation:
Facilitating Forearm Supination (cont.)

• Technique • Perform slow,

– Dorsal aspect of
rhythmic motion
patient’s forearm
– Provide a “gentle
persuasion” to the
radial head in a
volar-medial direction
as you bring the
patient’s forearm into
supination

Not for reproduction or redistribution

Neuromuscular Reeducation:
Facilitating Forearm Supination (cont.)

• Technique • Perform slow,

– Perform the following
rhythmic motion
• Passive ROM
• Active assisted ROM
• Active ROM

Not for reproduction or redistribution

Home Program: Facilitating Forearm
Supination

• Technique
– Gently pull the radial
head in a volar-medial
direction with active
forearm supination
• Slow, rhythmic motion
– Repeat for 8–10
repetitions, 4–5 times
per day

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Forearm Pronation

• Technique • Perform slow,

– Volar aspect of
rhythmic motion
patient’s forearm
– Provide a “gentle
persuasion” to the
radial head in a
dorsal-lateral direction
as you bring the
patient’s forearm into
pronation

Not for reproduction or redistribution

Neuromuscular Reeducation: Facilitating
Forearm Pronation (cont.)

• Technique • Perform slow,

– Perform the following
rhythmic motion
• Passive ROM
• Active assisted ROM
• Active ROM

Not for reproduction or redistribution

Home Program: Facilitating Forearm
Pronation

• Technique
– Gently push the radial
head in a dorsal-lateral
direction with active
forearm pronation
• Slow, rhythmic motion
– Repeat for 8–10
repetitions, 4–5 times
per day

Not for reproduction or redistribution

Home Program: Preventing a Frozen
Shoulder
Forward flexion External rotation (with arm at side)

Abduction Internal rotation (reaching behind back)

Doerrer et al., 2023

Not for reproduction or redistribution
Proprioceptive Training
Proprioceptive Training (Conscious Sense)
Focus on conscious sense: kinesthesia and joint position sense

Sensorimotor control

Conscious sense Unconscious sense

Sence
Sense of Joint position Neuromuscular
kinesthesia sense sense

Perception of Perception of Muscle and ligament

joint motion joint position receptors

Muscle and Volutional

Volitional Muscle and
cutaneous muscle cutaneous
receptors contraction receptors

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
Proprioceptive Training

• Early conscious proprioception training is considered a

precursor for establishing long-term unconscious
neuromuscular joint control toward meeting daily
functional demands

1. Karagiannopoulos & Michlovitz, 2016 2. Hagert, 2010

Not for reproduction or redistribution
Proprioceptive Training: Kinesthesia
• Vibration (tuning forks)
and tactile stimulation
– Can enhance human
kinesthetic perception
• Closed-chain wrist
AROM
– Can reduce pain and
enhance functional
joint motion via
controlled stress
loading

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
Proprioceptive Training: Joint Position
Sense

• Mirror therapy
– Improves pain and
enhances sensory
representation of the
injured side
– Conscious sense in
joint position and
motion improve,
leading to gains in
functional active range
of motion
Karagiannopoulos & Michlovitz, 2016
Not for reproduction or redistribution
Proprioceptive Training

Reproduction of wrist angle without visual cues

Karagiannopoulos & Michlovitz, 2016

Not for reproduction or redistribution
Home Program: What to Include
• Edema techniques (refer to • Forearm
Vivian Dim’s courses) – Guiding radial head in a
• Scar tissue mobilization/ volar-medial direction with
soft-tissue mobilization to the supination (and pronation,
wrist and hand if needed)
• Fingers • Shoulder
– Tendon glides and dexterity – Active shoulder flexion,
activity abduction, external rotation
with arm at side, reaching
• Thumb behind back
– Active radial abduction, • Proprioception
palmar abduction and
opposition – JPS training and kinesthesia
(conscious sense)
• Wrist
– AROM in straight plane (RCJ),
circumduction, and dart
thrower’s motion (MCJ)

Not for reproduction or redistribution

What’s Next?

• Consider the follow-up to this course

– Distal Radius Fracture: Late-Stage Rehabilitation

Not for reproduction or redistribution

 Bibliography

MedBridge
Distal Radius Fracture: Early-Stage Rehabilitation
Ann Porretto-Loehrke, PT, DPT, CHT, COMT, CMTPT

Adham, M. N., Porembski, M., & Adham, C. (2009). Flexor tendon problems after volar plate
fixation of distal radius fractures. Hand, 4(4), 406–409.
https://doi.org/10.1007/s11552-009-9180-0
Bergner, J. L., Farrar, J. Q., Master, H., & Coronado, R. A. (2023). Clinical measurement of
functional dart thrower’s motion in patients with unilateral wrist conditions
undergoing nonoperative or postoperative hand therapy. Journal of Hand Therapy.
Advance online publication. https://doi.org/10.1016/j.jht.2022.10.012
Bobos, P., Lalone, E. A., Grewal, R., & MacDermid, J. C. (2018). Recovery, age, and gender
effects on hand dexterity after a distal radius fracture. A 1-year prospective cohort
study. Journal of Hand Therapy, 31(4), 465–471.
https://doi.org/10.1016/j.jht.2017.08.002
Carvalho de Almeida Lima, K., da Silva Borges, L., Hatanaka, E., Clemente Rolim, L., &
Barbosa de Freitas, P. (2017). Grip force control and hand dexterity are impaired in
individuals with diabetic peripheral neuropathy. Neuroscience Letters, 659, 54–59.
https://doi.org/10.1016/j.neulet.2017.08.071
Cleland, J., & McRae, M. (2002). Complex regional pain syndrome I: Management through
the use of vertebral and sympathetic trunk mobilization. Journal of Manual &
Manipulative Therapy, 10(4), 188–199.
https://doi.org/10.1179/106698102790819067
Collis, J.M., Mayland, E.C., Wright-St Clair, V., Rashid, U., Kayes, N., Signal, N. (2022). An
evaluation of wrist and forearm movement during purposeful activities and range of
movement exercises after surgical repair of a distal radius fracture: A randomized
crossover study. Journal of Hand Therapy, S0894-1130(22)00082-5. Advance online
publication. https://doi.org/10.1016/j.jht.2022.07.009
Collis, J. M., Mayland, E. C., Wright-St Clair, V., & Signal, N. (2022). “The more I do, the more
I can do”: Perspectives on how performing daily activities and occupations
influences recovery after surgical repair of a distal radius fracture. Disability and
Rehabilitation, 44(19), 5440–5449.
https://doi.org/10.1080/09638288.2021.1936219
Crijns, T. J., van der Gronde, B. A. T. D., Ring, D., & Leung, N. (2018). Complex regional pain
syndrome after distal radius fracture is uncommon and is often associated with
fibromyalgia. Clinical Orthopaedics and Related Research, 476(4), 744–750.
https://doi.org/10.1007/s11999.0000000000000070

1
Dewan, N., MacDermid, J. C., MacIntyre, N. J., & Grewal, R. (2019). Therapist’s practice
patterns for subsequent fall/osteoporotic fracture prevention for patients with a
distal radius fracture. Journal of Hand Therapy, 32(4), 497–506.
https://doi.org/10.1016/j.jht.2018.03.001
Diep, G. K., & Adams, J. E. (2016). The prodrome of extensor pollicis longus tendonitis and
rupture: Rupture may be preventable. Orthopedics, 39(5), 318–322.
https://doi.org/10.3928/01477447-20160623-12
Doerrer, S. B., Walter, J. R., Priganc, V., Winston, K., Barth, R. W., & Moss, D. P. (2023). The
impact of shoulder pathology on individuals with distal radius fracture. Journal of
Hand Therapy, 36(1), 33–44. https://doi.org/10.1016/j.jht.2021.09.002
Duethman, N. C., Aibinder, W. R., Robinson, N. L., Moran, S. L., & Kakar, S. (2021). Early
outcomes of scapholunate injuries with concomitant distal radius
fractures. Hand, 16(5), 650–656. https://doi.org/10.1177/1558944719890037
Dy, C. J., Jang, E., Taylor, S. A., Meyers, K. N., & Wolfe, S. W. (2014). The impact of coronal
alignment on distal radioulnar joint stability following distal radius fracture. The
Journal of Hand Surgery, 39(7), 1264–1272.
https://doi.org/10.1016/j.jhsa.2014.03.041
Foumani, M., Strackee, S. D., Jonges, R., Blankevoort, L., Zwinderman, A. H., Carelsen, B., &
Streekstra, G. J. (2009). In-vivo three-dimensional carpal bone kinematics during
flexion-extension and radio-ulnar deviation of the wrist: Dynamic motion versus step-
wise static wrist positions. Journal of Biomechanics, 42(16), 2664–2671.
https://doi.org/10.1016/j.jbiomech.2009.08.016
Ghaddaf, A. A., Abdulhamid, A. S., Alomari, M. S., Alquhaibi, M. S., Alshehri, A. A., & Alshehri,
M. S. (2023). Comparison of immobilization periods following open reduction and
internal fixation of distal radius fracture: A systematic review and meta-
analysis. Journal of Hand Therapy, 36(1), 23–32.
https://doi.org/10.1016/j.jht.2021.06.004
Gutiérrez-Espinoza, H., Araya-Quintanilla, F., Olguín-Huerta, C., Gutiérrez-Monclus, R.,
Jorquera-Aguilera, R., & Mathoulin, C. (2021). Effectiveness of early versus delayed
motion in patients with distal radius fracture treated with volar locking plate: A
systematic review and meta-analysis. Hand Surgery and Rehabilitation, 40(1), 6–16.
https://doi.org/10.1016/j.hansur.2020.10.007
Gutiérrez-Espinoza, H., Rubio-Oyarzún, D., Olguín-Huerta, C., Gutiérrez-Monclus, R., Pinto-
Concha, S., & Gana-Hervias, G. (2017). Supervised physical therapy vs home exercise
program for patients with distal radius fracture: A single-blind randomized clinical
study. Journal of Hand Therapy, 30(3), 242–252.
https://doi.org/10.1016/j.jht.2017.02.001
Hagert, E. (2010). Proprioception of the wrist joint: A review of current concepts and
possible implications on the rehabilitation of the wrist. Journal of Hand
Therapy, 23(1), 2–17. https://doi.org/10.1016/j.jht.2009.09.008
Harden, R. N. (2010). Objectification of the diagnostic criteria for CRPS. Pain
Medicine, 11(8), 1212–1215. https://doi.org/10.1111/j.1526-4637.2010.00909.x
Karagiannopoulos, C., & Michlovitz, S. (2016). Rehabilitation strategies for wrist
sensorimotor control impairment: From theory to practice. Journal of Hand
Therapy, 29(2), 154–165. https://doi.org/10.1016/j.jht.2015.12.003

2
Karagiannopoulos, C., Sitler, M., Michlovitz, S., & Tierney, R. (2013). A descriptive study on
wrist and hand sensori-motor impairment and function following distal radius
fracture intervention. Journal of Hand Therapy, 26(3), 204–215.
https://doi.org/10.1016/j.jht.2013.03.004
Kasapinova, K., & Kamiloski, V. (2020). Outcomes of surgically treated distal radius
fractures associated with triangular fibrocartilage complex injury. Journal of Hand
Therapy, 33(3), 339–345. https://doi.org/10.1016/j.jht.2017.09.012
Korbus, H., & Schott, N. (2022). Does mental practice or mirror therapy help prevent
functional loss after distal radius fracture? A randomized controlled trial. Journal of
Hand Therapy, 35(1), 86–96. https://doi.org/10.1016/j.jht.2020.10.017
Kunes, J. A., Hong, D. Y., Hellwinkel, J. E., Tedesco, L. J., & Strauch, R. J. (2022). Extensor
tendon injury after volar locking plating for distal radius fractures: A systematic
review. Hand, 17(1_suppl), 87S–94S. https://doi.org/10.1177/15589447211068186
Lans, J., Lasa, A., Chen, N. C., & Jupiter, J. B. (2018). Incidence and functional outcomes of
scapholunate diastases associated distal radius fractures: A 2-year follow-up
scapholunate dissociation. The Open Orthopaedics Journal, 12, 33–40.
https://doi.org/10.2174/1874325001812010033
Leard, J. S., Breglio, L., Fraga, L., Ellrod, N., Nadler, L., Yasso, M., Fay, E., Ryan, K., &
Pellecchia, G. L. (2004). Reliability and concurrent validity of the figure-of-eight
method of measuring hand size in patients with hand pathology. The Journal of
Orthopaedic and Sports Physical Therapy, 34(6), 335–340.
https://doi.org/10.2519/jospt.2004.34.6.335
Lima, K. C. A., Borges, L. D. S., Hatanaka, E., Rolim, L. C., & de Freitas, P. B. (2017). Grip
force control and hand dexterity are impaired in individuals with diabetic peripheral
neuropathy. Neuroscience Letters, 659, 54–59.
https://doi.org/10.1016/j.neulet.2017.08.071
Liu, C. J., Marie, D., Fredrick, A., Bertram, J., Utley, K., & Fess, E. E. (2017). Predicting hand
function in older adults: Evaluations of grip strength, arm curl strength, and manual
dexterity. Aging Clinical and Experimental Research, 29(4), 753–760.
https://doi.org/10.1007/s40520-016-0628-0
Lusardi, M. M., Fritz, S., Middleton, A., Allison, L., Wingood, M., Phillips, E., Criss, M., Verma,
S., Osborne, J., & Chui, K. K. (2017). Determining risk of falls in community dwelling
older adults: A systematic review and meta-analysis using posttest
probability. Journal of Geriatric Physical Therapy, 40(1), 1–36.
https://doi.org/10.1519/JPT.0000000000000099
MacDermid, J. C. (2019). The PRWE/PRWHE update. Journal of Hand Therapy, 32(2), 292–
294. https://doi.org/10.1016/j.jht.2019.01.001
Marinus, J., Moseley, G. L., Birklein, F., Baron, R., Maihöfner, C., Kingery, W. S., & van Hilten,
J. J. (2011). Clinical features and pathophysiology of complex regional pain
syndrome. The Lancet Neurology, 10(7), 637–648. https://doi.org/10.1016/S1474-
4422(11)70106-5
McEntee, R. M., Tulipan, J., & Beredjiklian, P. K. (2022). Risk factors and outcomes in carpal
tunnel syndrome following distal radius open reduction internal fixation. The Journal
of Hand Surgery. Advance online publication.
https://doi.org/10.1016/j.jhsa.2022.03.016

3
McGee, C., O’Brien, V., Johnson, J., & Wall, K. (2022). Thumb carpometacarpal palmar and
radial abduction in adults with thumb carpometacarpal joint pain: Inter-rater
reliability and precision of the inter-metacarpal distance method. Journal of Hand
Therapy, 35(3), 454–460. https://doi.org/10.1016/j.jht.2021.03.001
Moritomo, H., Apergis, E. P., Garcia-Elias, M., Werner, F. W., & Wolfe, S. W. (2014).
International Federation of Societies for Surgery of the Hand 2013 Committee’s
report on wrist dart-throwing motion. The Journal of Hand Surgery, 39(7), 1433–
1439. https://doi.org/10.1016/j.jhsa.2014.02.035
Muurling, M., Lötters, F. J. B., Geelen, J. E., Schouten, A. C., & Mugge, W. (2021). A long-term
effect of distal radius fracture on the sensorimotor control of the wrist joint in older
adults. Journal of Hand Therapy, 34(4), 567–576.
https://doi.org/10.1016/j.jht.2020.07.002
Neumann, D. A., Kelly, E. R., Kiefer, C. L., Martens, K., & Grosz, C. M. (2017). Kinesiology of
the musculoskeletal system: Foundations for rehabilitation. Elsevier.
Orbay, J. L., & Cambo, R. A. (2020). Biomechanical factors in stability of the forearm. Hand
Clinics, 36(4), 407–415. https://doi.org/10.1016/j.hcl.2020.06.001
Pellecchia, G. L. (2003). Figure-of-eight method of measuring hand size: Reliability and
concurrent validity. Journal of Hand Therapy, 16(4), 300–304.
https://doi.org/10.1197/s0894-1130(03)00154-6
Pidgeon, T. S., Crisco, J. J., Waryasz, G. R., Moore, D. C., & DaSilva, M. F. (2018). Ulnar
styloid base fractures cause distal radioulnar joint instability in a cadaveric
model. Hand, 13(1), 65–73. https://doi.org/10.1177/1558944716685830
Polat, O., & Toy, S. (2022). Comparison of the clinical and radiographic outcomes of plate
fixation versus new-generation locked intramedullary nail in the management of
adult forearm diaphyseal fractures. Acta Orthopaedica et Traumatologica
Turcica, 56(5), 321–326. https://doi.org/10.5152/j.aott.2022.21190
Pope, D., & Tang, P. (2018). Carpal tunnel syndrome and distal radius fractures. Hand
Clinics, 34(1), 27–32. https://doi.org/10.1016/j.hcl.2017.09.003
Röijezon, U., Clark, N. C., & Treleaven, J. (2015). Proprioception in musculoskeletal
rehabilitation. Part 1: Basic science and principles of assessment and clinical
interventions. Manual Therapy, 20(3), 368–377.
https://doi.org/10.1016/j.math.2015.01.008
Roll, S. C., & Hardison, M. E. (2017). Effectiveness of occupational therapy interventions for
adults with musculoskeletal conditions of the forearm, wrist, and hand: A systematic
review. The American Journal of Occupational Therapy, 71(1), 7101180010p1–
7101180010p12. https://doi.org/10.5014/ajot.2017.023234
Roth, K. M., Blazar, P. E., Earp, B. E., Han, R., & Leung, A. (2012). Incidence of extensor
pollicis longus tendon rupture after nondisplaced distal radius fractures. The Journal
of Hand Surgery, 37(5), 942–947. https://doi.org/10.1016/j.jhsa.2012.02.006
Sheereen, F. J., Sarkar, B., Sahay, P., Shaphe, M. A., Alghadir, A. H., Iqbal, A., Ali, T., & Ahmad,
F. (2022). Comparison of two manual therapy programs, including tendon gliding
exercises as a common adjunct, while managing the participants with chronic carpal
tunnel syndrome. Pain Research & Management, 2022, 1975803.
https://doi.org/10.1155/2022/1975803

4
Strauch, B., Lang, A., Ferder, M., Keyes-Ford, M., Freeman, K., & Newstein, D. (1997). The ten
test. Plastic and Reconstructive Surgery, 99(4), 1074–1078.
https://doi.org/10.1097/00006534-199704000-00023
Trehan, S. K., Gould, H. P., Meyers, K. N., & Wolfe, S. W. (2019). The effect of distal radius
fracture location on distal radioulnar joint stability: A cadaveric study. The Journal of
Hand Surgery, 44(6), 473–479. https://doi.org/10.1016/j.jhsa.2019.01.002
Tsukazaki, T., & Iwasaki, K. (1993). Ulnar wrist pain after Colles’ fracture: 109 fractures
followed for 4 years. Acta Orthopaedica Scandinavica, 64(4), 462–464.
https://doi.org/10.3109/17453679308993668
Walsh, A., Merchan, N., Bernstein, D. N., Ingalls, B., Harper, C. M., & Rozental, T. D. (2022).
Predictors of management of distal radius fractures in patients aged >65
years. Hand, 17(1_suppl), 25S–30S. https://doi.org/10.1177/15589447211017217
Yan, B., Xu, Z., Chen, Y., & Yin, W. (2019). Prevalence of triangular fibrocartilage complex
injuries in patients with distal radius fractures: A 3.0T magnetic resonance imaging
study. The Journal of International Medical Research, 47(8), 3648–3655.
https://doi.org/10.1177/0300060519856157