What is the recommended post-operative rehabilitation protocol for an adult patient with a distal end radius fracture fixed with a Joint External Stabilizer (JESS) and no significant comorbidities?

Post-Operative Rehabilitation for Distal Radius Fracture Fixed with JESS

Begin active finger motion exercises immediately following surgery while the JESS fixator is in place, and initiate wrist mobilization at 1-3 weeks post-operatively based on fracture stability and fixation adequacy. 1, 2

Immediate Post-Operative Phase (Day 0-3 weeks)

Finger Motion Protocol

• Start active finger motion exercises on post-operative day 1 to prevent hand stiffness, which is the most functionally disabling complication following distal radius fractures 1, 2, 3
• Instruct patients to move all fingers regularly through complete range of motion multiple times daily 1, 4
• Finger motion does not adversely affect adequately stabilized fractures regarding reduction or healing 2, 3, 4
• This intervention is extremely cost-effective and prevents complications that require multiple therapy visits or surgical intervention if left untreated 2

Wrist Immobilization Considerations

• The JESS external fixator provides rigid stabilization, allowing earlier mobilization compared to cast immobilization 5
• Wrist motion can begin at 1-3 weeks depending on fracture pattern complexity and fixation stability 2, 6
• For highly comminuted or unstable fractures, delay wrist mobilization until 3 weeks 2

Early Mobilization Phase (3-6 weeks)

Wrist Range of Motion

• Begin active wrist flexion, extension, and forearm rotation exercises once adequate fracture stability is confirmed radiographically 6, 7
• A home exercise program is equally effective as supervised physiotherapy for uncomplicated cases 1, 7
• Supervised therapy should be reserved for patients developing complications such as stiffness or complex regional pain syndrome 1

Evidence Quality Note

The evidence supporting routine supervised physiotherapy over home exercises is low quality, with multiple trials showing no clinically important differences between supervised therapy and structured home exercise programs 7. One 2022 study of JESS fixation showed 78.1% acceptable functional outcomes at one year, with significant improvement between 6 months and 12 months 5.

Rehabilitation Algorithm

For uncomplicated JESS fixation:

• Days 0-21: Active finger ROM only + JESS in place
• Weeks 3-6: Add active wrist ROM exercises (flexion/extension/rotation) + continue finger exercises
• Week 6+: Progress to strengthening exercises after JESS removal 6, 5

For complicated cases (stiffness, pain, DRUJ instability):

• Refer to supervised hand therapy immediately 1, 7
• Consider formal occupational therapy for functional training 6

Critical Pitfalls to Avoid

• Never restrict finger motion during the immobilization phase - failure to encourage early finger exercises leads to severe stiffness requiring extensive therapy or surgery 1, 2, 4
• Do not routinely prescribe supervised physiotherapy for all patients, as home exercise programs achieve equivalent outcomes in uncomplicated cases 1, 7
• Reevaluate any patient with unremitting pain during follow-up, as this may indicate complications such as DRUJ instability, malunion, or complex regional pain syndrome 1, 4

Monitoring Requirements

• Obtain radiographs at 10-14 days post-operatively to ensure fracture position is maintained 3
• Assess for pin tract infections (occurs in approximately 9.4% of JESS cases) 5
• Monitor for development of finger stiffness, persistent pain, or loss of reduction 1, 4
• Functional outcomes continue improving significantly between 6 months and 1 year, so extended follow-up is warranted 5

Special Considerations for JESS Fixation

JESS provides excellent stability for displaced distal radius fractures with 96.9% acceptable radiological reductions, allowing earlier mobilization compared to other external fixation methods 5. The rigid stabilization permits confident early finger motion without risk of fracture displacement 2, 5.