What is the post-operative management plan for a patient with a comminuted fracture of the distal radius fixated with plates and screws?

Post-Operative Management of Comminuted Distal Radius Fracture After Plate Fixation

For a patient with a comminuted distal radius fracture treated with plate and screw fixation who is developing stiffness in a long arm splint, immediately transition to active finger motion exercises and remove or convert the long arm immobilization to allow wrist mobilization, as early wrist motion is not necessary after stable internal fixation and finger stiffness is the most functionally disabling complication. 1

Immediate Post-Operative Actions

Finger Motion Protocol (Most Critical)

• Initiate active finger motion exercises immediately - this is the single most important intervention to prevent finger stiffness, which is one of the most functionally disabling adverse effects following distal radius fracture 1
• Finger motion does not adversely affect an adequately stabilized distal radius fracture and is an extremely cost-effective intervention with significant impact on patient outcome 1
• Instruct the patient to move fingers regularly through complete range of motion at every encounter, as finger stiffness can be very difficult to treat after fracture healing and may require multiple therapy visits or additional surgical intervention 1

Immobilization Management

• Remove the long arm splint - there is no indication for prolonged rigid immobilization after stable plate fixation 1
• Patients do not need to begin early wrist motion routinely following stable fracture fixation with plates and screws 1
• If any immobilization is used, it should be removable and limited in duration 1

Rehabilitation Protocol

Therapy Approach

• A home exercise program is an appropriate option for patients prescribed therapy after distal radius fracture, as randomized controlled trials show no difference in outcomes compared to supervised therapy in uncomplicated cases 1
• Early wrist motion (within 1 week) shows no significant difference in pain, function (DASH scores), or complications compared to delayed motion after stable internal fixation 1

Radiographic Follow-Up

• Obtain radiographs at approximately 3 weeks post-operatively to assess maintenance of reduction and early healing 2
• Repeat imaging if there are concerns about hardware position or fracture alignment 2

Critical Monitoring Points

Pain Assessment

• Re-evaluate immediately if unremitting pain develops during follow-up, as this may indicate complications such as hardware issues, complex regional pain syndrome, or loss of reduction 1
• Consider vitamin C supplementation (500 mg daily) for prevention of disproportionate pain and complex regional pain syndrome 1

DRUJ Evaluation

• Obtain a true lateral radiograph of the carpus to assess distal radioulnar joint (DRUJ) alignment, as DRUJ instability can lead to poorer outcomes if unrecognized 1
• DRUJ instability identification can be difficult in the presence of distal radius fracture but is important for long-term function 1

Common Pitfalls to Avoid

• Do not keep the patient in prolonged rigid immobilization - this leads to preventable stiffness without improving fracture outcomes after stable plate fixation 1
• Do not delay finger motion exercises - stiffness results from pain, swelling, obstruction by splints, and patient apprehension, all of which worsen with time 1
• Do not ignore unremitting pain - this requires immediate re-evaluation as it may indicate serious complications 1

Expected Outcomes

• With appropriate management, patients typically achieve functional range of motion and grip strength averaging 73-81% of the uninjured side 3, 4
• Most patients return to previous employment within 4 months of injury 3
• Maintenance of reduction should be confirmed radiographically, with acceptable articular step-off of less than 2-3 mm correlating with better functional outcomes 4