Physical Therapy Management Of Colles Fracture

Summary of Colles' Fracture

A Colles’ fracture is a distal radius fracture occurring within 2.5 cm of the wrist with dorsal angulation at the site of the fracture.1 The most common mechanism of injury for sustaining a Colles’ fracture is falling on an outstretched hand (FOOSH) when attempting to break one’s fall. While there is a good prognosis for making a full recovery, the following factors can influence fracture healing and slow recovery: patient age, character of fracture, systemic disorders, bone disease, osteoporosis, and osteopenia.2

Guide to Physical Therapist Practice

Based on the Guide to Physical Therapist Practice3, a patient suffering from a Colles’ fracture can be classified in one or both of the following Practice Patterns depending on if the fracture was treated surgically.

Practice Pattern 4G: impaired joint mobility, muscle performance, and range of motion associated with fracture

Practice Pattern 4I: impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgery

The Guide3 is a helpful tool for physical therapist as it outlines a list of possible interventions that could be performed and the anticipated goals and expected outcomes for each intervention. Each Practice Pattern is associated with a number of pathologies, so it is important to remember that not every intervention, goal, or outcome is applicable for each patient. The other benefit of The Guide is to provide a range of expected visits and a general prognosis.

The previously identified Practice Patterns have the following range of expected visits and prognosis3:


  • Prognosis: 3-6 months postfracture
  • Number of expected visits: 6-18


  • Prognosis: 1-8 months
  • Number of expected visits: 6-70

The following interventions suggested in The Guide are applicable to the management of a Colles’ fracture (these interventions are included in both Practice Patterns):

Therapeutic Exercise

  • Flexibility exercises
    • Stretching, ROM
  • Strength and endurance exercises
    • AAROM, AROM, resistive exercise
  • Balance, coordination, and agility training
    • Neuromuscular education or re-education
    • Task specific performance training

Manual Therapy

  • Massage
  • Mobilization
  • PROM


  • Electrical Stimulation
    • Neuromuscular electrical stimulation (NMES)
    • Transcutaneous electrical nerve stimulation (TENS)
  • Cryotherapy
  • Thermotherapy
  • Ultrasound

The following goals and outcomes should be anticipated or expected for each Practice Pattern based on the previously listed interventions3:

  • Joint swelling, inflammation, or restriction is reduced
  • Pain is decreased
  • Soft tissue swelling, inflammation, or restriction is reduced
  • Joint integrity and mobility are improved
  • ROM is improved
  • Muscle performance is increased
  • Edema is reduced
  • Ability to perform physical actions, tasks, or activities related to self-care, home management, work, community, and leisure is improved

Rehabilitation and Modalities

Many patients present with pain, edema, decreased range of motion, decreased strength, and decreased functional abilities.2 Once a Colles’ fracture has properly healed rehabilitation is recommended in order to restore proper function and strength to the fractured wrist. The focus in the beginning of rehabilitation is to mobilize the wrist, which is indicated approximately 7-8 weeks post fracture. If the fracture is managed using an internal fixation device, early mobilization can begin approximately 1 week after surgery.4 Special attention should be paid to fractures that are treated with an external fixation because the wrist is often held in a pronated position, predisposing the patient to a contracture at the distal radioulnar joint.5 Other soft tissue injuries that can affect progress in rehabilitation include edema, cast impingement, infection, osteomyelitis, adherent scar, intrinsic or extrinsic muscle tightness, joint capsular tightness, neurovascular injury, ligament injury, and post-traumatic arthritis.2

Initial Rehab

One of the first goals in rehab is to regain range of motion (ROM) at the wrist with passive ROM and progressing to active ROM.4^ The first motions emphasized in rehab are wrist flexion and extension working within the patient’s available range. As more motion becomes available and the patient begins regaining strength, passive ROM exercises can progress to active ROM.4^^ The addition of ROM exercises helps to limit that amount of scar tissue and adhesion formation that commonly occur after surgery. It is also important to emphasize motion at the shoulder, elbow, and fingers during all phases of rehab. One of the primary focuses in early rehab is to limit pain and the amount of edema present in the wrist and hand region.

Subacute Rehab

The next phase of rehab in the treatment of Colles’ fracture continues to focus on increasing ROM and beginning strengthening exercises. For surgically treated wrist, the majority of ROM should be regained between 6 to 8 weeks post-op.6 Examples of ROM exercises that can performed include6: wrist flexion/extension, radial/ulnar deviation, pronation/supination, and making a fist and opening. In the sub-acute phase, ROM exercises can progress into strengthening by performing all exercises with a weight in the hand or performing grip squeeze with a foam ball or a towel roll. During strengthening, it is important to address all forearm muscles but also the extrinsic and intrinsic hand muscles progressively building resistance as the individual gets stronger. During this phase, progressive stretching can begin to increase available ROM. The two most common stretches are bringing the wrist into extension or flexion. To perform these stretches the patient can use the uninvolved extremity to gradually and gently pull the wrist into flexion and repeating the stretch into flexion. Each stretch should be held for 30-60 seconds for 3 repetitions. If the patient is unable to tolerate a slow, prolonged stretch, shorter stretches of 10 seconds are performed for 10 repetitions.7

The following outline represent rehabilitation guideline by Pho et al.8

Non-Operative/ Conservative Rehabilitation

Acute Stage (0-8 weeks)

1. Protection with short-arm cast
2. Control pain and edema
3. Maintain range in digits, elbows, shoulder

1. AROM and PROM of digits, elbow, shoulder
2. Elevation of hand and digits to control edema
3. Cast removal between 6-8 weeks

Sub Acute Stage

1. Control pain and edema (TENS, ice)
2. Increase ROM
3. Increase activities of daily living (ADLs)

1. AROM and PROM of digits, elbow, shoulder
2. AROM wrist flexion/ extension, forearm supination/ pronation
3. PROM of low load and prolonged stretch


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Settled Stage

1. Regain full ROM
2. Begin strengthening
3. Return to activity

1. Continue all ROM exercises
2. Progress to strengthening of all joints

Post-Op Rehab for External Fixation

Acute Stage (1-6 weeks)

1. Control pain and edema (TENS, ice)
2. Protect surgical site
3. Maintain ROM of digits, elbow, shoulder

1. Elevation
2. AROM of digits, elbow, shoulder
3. AROM forearm supination/ pronation

Sub Acute (7-10 weeks)

1. Protect fracture site
2. Control pain and edema (TENS, ice)
3. ROM of involved and uninvolved joints

1. AROM and PROM of wrist extension/ flexion, radial deviation, and supination/ pronation

Settled Stage (10-16 weeks)

1. Regain full ROM
2. Begin strengthening
3. Increase tolerance to ADLs

1. ROM of wrist flexion/ extension, radial/ ulnar deviation, forearm supination/ pronation progressing to isometric exercises and resisted exercises using dumbbells or resistive bands
2. PROM of low load and prolonged stretching of wrist motions
3. Grip strengthening
4. ADL training within tolerance

Post-Op Rehab for Open Reduction Internal Fixation

Acute Phase (1-3 weeks)

1. Protect surgical site
2. Control pain and edema
3. Maintain ROM of digits, elbow, shoulder
4. Maintain wrist ROM

1. Elevation
2. Gentle ROM of wrist and forearm
3. AROM of digits, elbow, and shoulder
4. Static splinting in 30 degrees of wrist extension
5. ADLs with less than 2 lbs of lifting

Sub Acute (4-7 weeks)

1. Protection
2. Control pain and edema (TENS, ice, massage)
3. Increase ROM

1. PROM of low load and prolonged stretching of wrist motions
2. Progressively discontinue use of splint
3. Increase ADLs within patient tolerance

Settled Stage (8-12 weeks)

1. Full ROM
2. Begin strengthening

1. AROM of all wrist motions progressing to isometrics and then resistive exercises using dumbbells and elastic bands
2. Grip strengthening
3. Advance ADLs



Two common ways to limiting edema and pain are through the use of cryotherapy and edema massage. Cryotherapy is an effective modality for controlling edema in the acute phase after trauma or during rehab because it helps to decrease blood flow through vasoconstriction limited the amount of fluid escaping from capillaries to the interstitial fluid. Cryotherapy can also be combined with compression and elevation to treat edema as well.9 To control pain using cryotherapy, the modality should be applied to the area for between 10-15 minutes which can result in pain control up to 2 hours post application.9 Precautions for the use of cryotherapy include: over a superficial branch of nerve, over an open wound, poor sensation or mentation, and very young or very old patients.9


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Edema Massage

Another way to control edema is perform an edema massage. Studies have shown it is easier to determine function available in wrist and hand the earlier edema is reduced or minimized.10 In a study by Knygsand-Roenhoej et al.11, edema treatment was performed 3x/week for 4 weeks followed by 2x/week for 2 weeks and all treatments were combined with ROM and strengthening exercises. Edema massage is performed first, starting proximally to clear the lymphatic system in the chosen segment and then progressing to distal to proximal massage toward lymphatic system. In this study, the used of edema massage was effective in reducing edema, pain, and active ROM.11

Electrical Stimulation

The use of transcutaneous electrical nerve stimulation (TENS) can be initiated in any phase of rehab to address pain but is particularly useful for patients that are increasing the level of activity of the wrist. Conventional (high-rate) TENS is useful for disrupting the pain cycle through a prolonged treatment session as great as 24 hours a day.9 Low-rate TENS is another form of electrical stimulation that is successful in diminishing pain by targeting motor or nociceptive A-delta nerves. To target these nerve fibers a frequency between 2 and 10 is needed for proper stimulation. Low-rate TENS has been shown to be effective in pain control for up to 4-5 hours post-treatment.9


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While there is minimal evidence supporting the use of previously discussed therapeutic modalities in the rehabilitation of wrist fractures, one study supports the use of ice and pulsed electromagnetic field (PEMF) treatment for managing pain and swelling. In the study by Cheing et al.12, four groups were compared using ice, PEMF, and sham treatment to determine which treatment methods resulted in the best results. At the conclusion of the study, results showed that the group receiving both ice and PEMF had a higher reduction in mean VAS and increased ROM at the completion of testing. This study also showed the group selected to receive ice only had the smallest effect on reducing pain and swelling.12


1. Blakeney W, Webber L. Emergency department management of colles-type fractures: A prospective cohort study. Emerg Med Australas. 2009;21(4):298-303.

2. Bosch J, Walsh M. Standard of care: Distal upper extremity fractures. The Brigham and Women's Hospital Web site. Accessed March 5 2012.

3. American Physical Therapy Association. Guide to physical therapist practice. 2nd edition. American Physical Therapy Association. Phys Ther. 2001;81(1):9-746.

4. Smith D, Henry M. Volar fixed-angle plating of the distal radius. J Am Acad Orthop Surg. 2005;13:28-36

5. Slutsky DJ, Herman M. Rehabilitation of distal radius fractures: a biomechanical guide. Hand Clin. 2005;21(3):455-468.

6. 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(4):537-544.

7. Kisner CC, LA. Therapeutic exercise. foundations and techniques. 5th ed. Philadelphia: F.A. Davis Company; 2007:928.

8. Pho C, Godges J. Colles' fracture. KPSoCal Ortho PT Residency Web site. Accessed March 5 2012.

9. Cameron M. Physical agents in rehabilitation. from research to practice. 3rd ed. Philadelphia: Saunders Elsevier; 2009:457.

10. Dionyssiotis Y, Dontas IA, Economopoulos D, Lyritis GP. Rehabilitation after falls and fractures. J Musculoskelet Neuronal Interact. 2008;8(3):244-250.

11. Knygsand-Roenhoej KF, Maribo T. A randomized clinical controlled study comparing the effect of modified manual edema mobilization treatment with traditional edema technique in patients with a fracture of the distal radius. J Hand Ther. 2011; 24: 184-94.

12. Cheing GLY, Wan JWH, Lo SK. Ice and pulsed electromagnetic field to reduce pain and swelling after distal radius fractures. J Rehabil Med. 2005; 37:372-377.

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