Distal Radius Fractures (DRF) Pain Management

Distal Radius Fractures (DRF) Pain ManagementExplain how pathological processes find physiotherapy management for a patient with a fracture of the lower end of radius.Distal radius fractures (DRF) account for 16% of fractures seen in accident and emergency. (Tosti 2011) They argon often caused by a fall on an out carryed hand, and as the chance of falling and osteoporosis increases with age, elderly patients have a higher risk of DRF. DRF are described as Colles fractures (with abaxial angulation) or Smiths fractures (with volar angulation), and treatment varies with fracture type, age of patient and presenting symptoms. Many fractures are reduced under anaesthesia and immobilised in a plaster cast from just below the elbow to the proximal crease of the palm (Alsop 2013). During bone healing, immobilisation go outs bone ends remain aligned and reduces the risk of mal-union. Immediately after a fracture, the local bone interweave becomes necrotic, and is resorbed by osteoclasts. A fracture haematoma forms and osteoblasts produce calcium hydroxyapatite crystals which are l tutelage rarify on the bone matrix, forming callus (Drake 2010). Callus is visible on x-ray at 6 weeks, which is typically when the immobilisation stage ends.During immobilisation, patients clinical priorities are torment management through medication, swelling reduction and pr crimsontion of secondary stiffness and muscle wastage in joints above and below the fracture. To decrease levels of exudate in tissues and aid lymphatic drainage, elevation and compression are the main physiotherapy treatments (Cheing 2005). Stretching exercises for the elbow, shoulder, metacarpal phalangeal joints and inter phalangeal joints on the affected side support maintain range of motion (ROM), and strengthening exercises for muscles of the shoulder, elbow and fingers thunder mug reduce muscle atrophy. Physiotherapists dejection provide diet education, explaining that the supplementation of vitamin D, calcium, magnesium and vitamin K go forth aid bone healing (Price 2012). Vitamin C is shown to improve mechanical and histological parameters of fracture repair in a study with rats (Gaston 2007), and to induce osteoblast differentiation, which bunco an historic role in bone healing (Carinci 2005).When the plaster is removed, skin can be flaky, thin and over sensitised. Physiotherapists can explain the importance of gentle washing and moisturising and can perform desensitising treatment if required. Due to their knowledge of fracture pathophysiology, physical therapists can advise patients on how to protect their wrist, for example, not to lift a full kettle but to continue with functional tasks such as washing dishes.After immobilisation, an important symptom is painful sensation, affecting the patients qualification to perform functional activities. Pain or fear of pain can impair treatment, as the patient may be nervous to do their convinced(p) exercises. Effective pain ma nagement in the form of paracetamol and ibuprofen, and explanation that a dull aching pain is demonstrative of bone healing may armed service reduce patient anxiety. Measuring pain allows physical therapists to provide outcome measures and to tailor treatment to patients individual needs. Self-reported measures, such as the visual analogue scale, are the sumptuous standard for measuring pain intensity, location, quality and temporal variation (Jones 2013). Nociception from DRF occurs when the sensory receptors at nerve endings in the periosteum are stimulated by noxious insults that are produced through inflammation (DeLisa 2005). An action potential is carried to the dorsal horn of the spinal cord where the pain signal is sent to the brain.As pain is transmitted via the dorsal horn, physiotherapists use modalities that use the pain-gate theory to reduce patients discomfort. This theory suggests there is a gating mechanism in the dorsal horn, small nociceptors that carry pain faci litate the gate, but larger mechanoreceptor fibres inhibit the gate. When physiotherapists stimulate mechanoreceptors, the gate is inhibited and pain signals transmitted to the brain are reduced (Moayedi 2012). An example of this is accessory mobilisations, where the physiotherapist recreates athrokinematic movements to stimulate mechanoreceptors, inhibiting nociception. In a DRF, all athrokinematic movements can be used at grade one and two to stimulate mechanoreceptors. Massage uses the pain-gate theory, therefore on base the physiological effects of massage, such as increasing blood flow and lymphatic drainage, massage stimulates the mechanoreceptors that inhibit the gate, inhibiting pain signals.Stiffness can be caused by a variety of aetiologies. If the fracture involves articular surfaces, blood entering the joint can leave fibrin residue ca using fibrous adhesions between the two synovial membranes (Hamblen 2007). This decreases the congruency of the surfaces, therefore decr easing ROM. More commonly, peri-articular adhesions, caused by collections of exudate, reduce the resilience of ligaments and reduces muscles free gliding abilities, causing stiffness. (Hamblen 2007). If the patient has undergone open reduction surgery, scar tissue can cause adhesion of local muscles and tendons, reducing ROM.Proprioceptive neuromuscular facilitation (PNF) is a modality used to treat decreased ROM. PNF uses the proprioceptive stimulation of muscle groups, using voluntary muscle contractions alongside stretching to reduce the reflexive aspect of muscular contraction (Mahieu 2008). Using maximal muscle contraction enables maximum relaxation, which increases stretch efficacy. By using this technique on physiological movements of the wrist, the adhesions are broken down allowing fluent movement. Simple home stretching exercises can be prescribed, to ensure that soft tissues are stretched frequently to reduce stiffness. As well as treating pain, mobilisations are used to decrease stiffness. For stiffness, both accessory and physiological passive mobilisations can be used to increase ROM. When treating stiffness, grade three and four mobilisations taken to the end of range are used, which break down peri-articular adhesions and allow synovial sweep, creating even lubrication and reducing friction.After pain, swelling and ROM have been addressed, strengthening excercises are incorporated into treatment to reduce muscle atrophy caused by immobilisation (Powers 2004). modify excercises help to regain muscle mass and strength, by causing neural adaptions, decreasing inhibitory feedback allowing stronger contractions. Stronger contraction is also caused by muscle hypertrophy, where myocytes enlarge, increasing actin and myosin concentration. Excercises should pull out increasingly more challenging until functional movement is achieved. All excercises should be aimed at functional goals specific to the patient, increasing motivation and also establishin g expectations of both the physiotherapist and the patient. Due to NHS cuts, physiotherapists can not see patients as frequently as desired, therefore modalities such as massage and PNF cannot be fully effective. It is therefore important for the physiotherapist to increase motivation for home excercises through explanations of their importance and effects .As the most common cause of a DRF is falling on an outstretched hand, physiotherapy falls ginmill programmes including gait re-education,walking aids and balance exercises, can reduce the risk of DRF. These programmes have been associated with a significantly lower risk of fractures (El-Khoury 2013), demonstrating that prevention is the most effective physiotherapy management for both patient and physiotherapist.ReferencesAlsop, H. 2013 (2013) Tidys Physiotherapy 15th ed. Saunders ElsevierCarinci, F. Pezzetti, F. Spina, AM. Palmieri, A. (2005) Effect of Vitamin C on pre-osteoblast gene expression. enumeration of Oral Biology. 5 0(5) 481-496Cheing, G. Wan, J. and Lo, S. (2005) Ice and Pulsed Electromagnetic Field to Reduce Pain and Swelling after Distal Radius Fractures. Journal of Rehabilitation treat. 37 372-377Delisa. J, (2005) Physical Medicine and Rehabiliation Principles and Practise 4th ed. Volume 1. Philadelphia Lippincott Williams and WilkinsDrake, R. (2010) Grays Anatomy for Students. 2nd ed. Philadelphia Churchill Livingstone ElsevierEl Khoury, F. (2013) The effect of fall prevention exercise programmes on fall induce injuries in community dwelling older adults systematic review and meta-analysis of randomised controlled trials. British Medical Journal. 347 f6234Gaston, M. Simpson, A. (2007) Inhibition of Fracture Healing. The Bone and Joint Journal. Vol. 89. No. 12. 1553-1560Hamblen, D. (2007) flings Outline of Fractures, Inluding Joint Injuries. 12th ed. Philadelphia Churchill Livingstone ElsevierJones, L. (2013) Tidys Physiotherapy 15th ed. Saunders ElsevierMahieu, N. Cools, A. De Wilde, B. 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