(A PATIENT’S GUIDE)
DEIRDRE HUGHES OTR/L CHT
A distal radius fracture is one of the most common injuries seen by a hand therapist resulting from a fall on an outstretched hand. Depending on the severity of the fracture, surgery is often necessary to achieve stability.
Typically, a plate with screws is attached to the distal radius (side of wrist close to the thumb) in a procedure called ORIF (open reduction internal fixation).
A question that hand therapists usually get asked by patients after surgery is ‘when will the swelling subside?’.
WHAT IS EDEMA?
Edema (swelling) is an accumulation of excess fluid after an injury. It is a normal part of the healing process and is to be expected after surgery. Sometimes, the swelling is confined to the fingers or may exist only at the wrist. Other times, it may be a combination of both.
The extent to which the hand becomes swollen and how long it persists depend on severity of the injury and whether early intervention took place. Additionally, the presence of underlying medical issues may delay healing and contribute to an even further increase in edema.
Unfortunately, many patients experience a lag in the start of care due to insurance issues, transportation, or lack of immediate access to resources. Due to the delay in starting therapy, the patient’s swelling may worsen and become more difficult to manage.
Acute edema is swelling that occurs after the first 24-48 hours of an injury
If you are unable to visit a hand therapist in the first 1-2 wks after surgery, it is essential that you begin to manage the symptoms at home. Possibly, you will be wearing a bulky dressing or partial cast with an ace wrap, and you will only be able to move your fingers.
This first phase of healing is referred to as the inflammatory phase where white blood cells rush to the affected area to clean up any waste products.
The following tips will be helpful in managing your swelling:
1. Elevate hand above heart level with pillow and towels at home immediately after your surgery. Continue with this for the first week.
2. Apply cold pack for 15-20 minutes. Do not apply cold pack directly to skin. Place a protective layer for instance a towel or pillowcase. Remove right away if numbness occurs.
3. Perform light exercises such as towel grasping and tendon glides (refer to diagram), which help to pump fluid out of hand (10 reps every 2-3 hours)
4. To prevent edema while sleeping, elevate your hand using 1-2 pillows next to your side if sleeping on your back. If you are a side sleeper, place 1-2 pillows under your arm and rest the affected hand on top of the pillows.
If you are fearful of rolling over on the affected hand, sandwich the hand between 2 pillows and secure with strap / ace bandage.
Subacute edema is swelling present after the initial inflammatory phase of 3-5 days
Sometimes edema may persist for up to 6 weeks or so lasting well on into the next phase of healing, which begins between 2 and 6 weeks after the surgery. The longer the edema persists, the greater the risk of disability and loss of hand function.
The 2nd phase of healing is referred to as the repair or fibroblastic phase where new collagen is synthesized.
If swelling is uncontrolled at this stage, it can result in increased scarring and development of adhesions.
This will result in further stiffness in the wrist and fingers. At this point, you will be wearing a wrist support or wrist brace. If the swelling continues over 2 weeks, proceed as follows:
1. Continue with finger exercises from phase 1 and increase repetitions and frequency (20 repetitions every 1-2 hours) with arm elevated. Add wrist exercises as follows:
2. Perform retrograde massage which involves massaging from tips of fingers down the hand and along both sides of the forearm for about 5 mins. Apply light pressure.
3. Use compressive garments intermittently including compression gloves, finger sleeves, or coban wrap. (Your hand therapist will assist you in choosing the garment based on your specific needs). The garment should fit snug, not tight.
Diagram: Compression glove (Left), Coban compression wrap (Right) to manage edema in fingers
4. Continue to maintain hand in elevated position intermittently during the day.
5. Continue with cold compresses, but you may initiate use of warm compresses to soften dense tissue and improve circulation.
Chronic edema is swelling that lasts for several months after the injury
In the worse scenario, edema can persist for several months, and tissue will become hard and tight. Pitting maybe present (pressing tissue with finger leaves an indent in the skin).
Venous and arterial insufficiency occurs, and circulation is compromised. The fingers and or wrist become stiff and painful to move and results in loss of hand function.
At this stage, continuous compression is of utmost importance to manage edema. It is also necessary to keep all involved joints moving and compliance with HEP is key.
Kinesiotaping can also be applied to aid in lymphatic flow.
Diagram 2 and 3: Kinesiotape application to aid in lymphatic flow