Distal radius fracture fixation — volar locking plate

Before starting, establish the fracture pattern, fixation stability, distal radioulnar joint status, associated injuries and prescribed restrictions. Record pain, swelling, sensation, finger and thumb movement and — when permitted — wrist and forearm range of motion. The Patient-Rated Wrist Evaluation (PRWE) questionnaire may be used to monitor function. Defer maximal grip-strength testing until loading is permitted. Record the dominant limb, work demands, independence and fall risk. Include a bone-health assessment after a low-energy fracture. The orthopaedic surgeon plans radiographic review; deterioration requires earlier assessment. [1–3]

Use a wrist orthosis for protection as instructed by the surgeon; establish when it may be removed for exercises and when its use may be reduced. Do not impose rigid immobilisation for 6 weeks on everyone after stable plating, but do not independently abandon prescribed protection. After triangular fibrocartilage complex (TFCC) or ligament repair, or with distal radioulnar joint instability, rotation and loading may require longer protection. New ulnar-sided wrist pain, clicking or a sense of instability require clarification before progression. This programme does not define rehabilitation for those additional repairs. [1,2]

01 · Protection and finger movement

From the first postoperative days

Goal: Control swelling, maintain finger movement and preserve movement of the other joints of the limb.

Actions: Support the limb at rest. Avoid prolonged dependent positioning of the hand; change position and gently move the fingers. Use prescribed pain treatment. Check that wrist protection does not cause pressure.

Exercises: With the forearm supported and wrist neutral, slowly straighten the fingers, then bend them into a loose fist with the thumb outside. Add gentle thumb-to-fingertip touches. Start with 5–10 repetitions in 3–5 short daily sessions. Maintain permitted elbow and shoulder movement without loading the operated wrist.

Protection: No forceful gripping, carrying shopping, opening jars or supporting body weight through the hand. Finger movement should not increase pain or forcibly tension tissues.

Progression and review: No deterioration in sensation or circulation, swelling controlled and finger movement improving. Wrist movement requires confirmation of the permitted range by the treating team.

02 · Active wrist movement

Usually within the first 0–2 weeks — after movement is permitted

Goal: Begin recovering mobility without overloading the fixation or soft tissues.

Actions: After stable fixation, early movement may be allowed in the first days. Postoperative instructions determine the precise start, not the calendar alone. Use the orthosis outside exercise as instructed. [1,2]

Exercises: Rest the forearm on a table with the hand beyond the edge. Slowly raise and lower the hand at the wrist within the permitted, comfortable range, keeping the forearm still. Do not pull with the other hand. For example, 5–10 repetitions in 3–5 short daily sessions; the angular range is selected individually.

Protection: Movement without external resistance. No weights, weight bearing through the hand or forceful stretching. Do not independently remove immobilisation if movement has not been permitted.

Progression and review: Correct technique without a marked increase in pain or swelling after the session or the next day. Deterioration calls for dose reduction and reassessment if symptoms persist.

Approximately weeks 2–6; rotation may be permitted earlier

Goal: Gradually improve wrist and forearm movement and light daily activities.

Actions: Develop permitted movement and light self-care. Gentle assisted movement or manual treatment is introduced by the physiotherapist after assessing stability and tissues. In selected uncomplicated cases, light resisted grip may be considered from about week 2, with stable fixation, satisfactory radius–ulna alignment, no ulnar-sided pain and treating-team approval. [1]

Exercises: Sit with the upper arm beside the trunk and the elbow bent to about 90° and supported. Rotate the forearm, turning the palm up and then down. Keep the wrist straight; do not substitute moving the elbow outwards for forearm rotation. Start with 5–10 slow repetitions without a weight. Only exercise after rotation is permitted.

Protection: Do not force end range or use a hammer or weight for rotation. Light grip does not authorise heavy lifting. Ulnar-sided pain or instability rules out automatic progression.

Progression and review: Improved range and self-care without a sustained pain or swelling response. Increasing resistance depends on healing assessment and surgical review, not simply reaching 6 weeks.

Often around weeks 6–12 — after healing assessment and clearance for resistance

Goal: Rebuild grip tolerance, wrist strength and use of the limb under increasing load.

Actions: Update restrictions after examination and imaging review when indicated. Start with low resistance and short sets. Earlier light grip training in stage 03 does not replace this assessment.

Exercises: With the forearm supported and wrist straight, gently squeeze a soft sponge and release the grip fully. Example: 1 set of 5–10 repetitions followed by rest; 2–3 strengthening sessions per week. If tolerated, increase repetitions before resistance. Introduce wrist exercises with a weight, such as 0.5 kg, only after individual clearance for that load.

Protection: No maximal squeezing or sudden load increases. Introduce weight bearing through the hand separately, progressively increasing the weight transferred; push-ups and pushing off a chair with the operated hand are not starting exercises.

Progression and review: Good movement control and tolerance of the current resistance without next-day deterioration. Stop resistance and seek review for pain over the plate, tendon friction or loss of movement.

From approximately week 12 or later — depending on union and function

Goal: Perform specific tasks safely, build endurance and reduce the risk of another injury.

Actions: Practise tasks relevant to work and recreation: low resistance and short duration first, then difficulty and duration. Desk work and heavy manual work do not require the same level of function.

Exercises: Select 2–3 relevant activities, such as handling light objects, carrying an authorised load close to the body and controlled tool grip. Practise in short sets with breaks. Record the load and next-day response; do not increase weight, speed and duration simultaneously.

Protection: Contact sport, fall risk, heavy work and high-load weight bearing through the hand require clearance based on union and functional assessment. Driving requires safe grip, control and emergency responses, without the effects of medicines that impair performance.

Progression and review: Healing confirmed as sufficient for the intended task, functional range, adequate strength and task tolerance without increasing pain or swelling. Full symmetry need not be achieved at week 12; persistent deficits require further rehabilitation.