ORTHOPAEDICS CASE STUDY (CLOSED DISPLACED FRACTURE OF RADIUS )

AZIMAH BINTI HASSAN
940507-02-5320
DIPLOMA IN OCCUPATIONAL THERAPY

A bone has closed displaced fracture when it breaks in two or more pieces and is no longer
correctly aligned but no open wound in the skin.
Typically the cause of the fracture is falling on the outstretched hand or force of impact
against the hand
Ulna and radius located in the forearm, which in most cases of
adult forearm fracture, both bones are broken
It can happen near wrist which is at distal end of the bone, middle of forearm or near the
elbow which is at proximal of end of bone
When radius or ulnar joint fracture occur, it will result in pain, decreased strength, limited
range of motion, and loss of forearm function
(Americans Academy of Orthopedic Surgeons,2011)

Weeks Goals
Early phase: Week 0 - 6 • Reduce swelling
- elevation of hand above level of heart
- frequent active motion
- compressive wrapping/ sleeves of digits
• Minimize stiffness
- active and passive digit ROM
• Support reduced fracture
- removable splint to support stable fracture
or fracture with internal fixation
• Promote ROM
- wrist ROM (plate fixation)
Middle phase : Week 6 - 8 • Increase motion
- ROM (wrist flexion and extension)
(radial-ulnar deviation)
(forearm pronation-supination)
Late phase : Week 8 -12 • Maximize motion
• Promote strength
- digit and grip
- wrist and forearm
- elbow, shoulder and scapula
( Brotzman, 2007 )
DISTAL RADIAL FRACTURE MANAGEMENT FOR THE FIRST TWELVE
WEEKS

DEMOGRAPHIC DATA
Name : Mr A. R
Address : Banting, Selangor
Age : 23 Years Old
Sex : Male
Race : Malay
Religion : Islam
Marital Status : Single
Job : General Customer Service at KLIA
Date of Onset : 29/04/2014 @ 8.30pm
Date of Admission : 29/04/2014 @ 9.17pm
Date of referral : 07/05/2014 @ 4.25 pm
Dominant Hand : Right Hand
Affected Hand : Right Hand
Diagnosis : Closed displaced fracture of distal 1/3 of right radius with ulnar styloid process
and DRUJ disruption
Open comminuted fracture of left midshaft ulna with DRUJ disruption

Alleged MVA at Dengkil on 29/04/2014 @ 8.30pm
Patient was riding a motorbike, helmet fastened
Claimed was going at a moderate speed when all of a sudden a tractor
crossed in front of him
Unable to brake, hit the tractor and was thrown off the bike
Landed on the left side of the body

Works as a general customer service in KLIA
Has worked for 5 years
Shift work from 6.30am to 2.30pm and
1.00pm to 9.00pm.
2 days off on weekend
Go to the workplace by motorcycle

Social smoker
Enjoys spending time playing futsal with his friends
during free time
Always go to the gym during weekend
(lifting dumbbells and bars)

FAMILY HISTORY
 + 
57 y/o 47 y/o
        
26 y/o 25 y/o (pt 23y/o ) 22y/o 20y/o 18y/o 14y/o 9y/o 7y/o
Patient is single
He is the third son of 9 siblings
4 of his siblings has worked meanwhile the others still study
His father is a government officer while his mother is a housewife
No other medical illness

ASSESSMENT
Subjective and objective assessment are based on observation and
interview that was done through observation on 7 May 2014 at OT
department.
SUBJECTIVE ASSESSMENT (7 May 2014)
Patient wore hospital’s cloth
Patient looked neat and tidy
His right hand was bandaged
Patient can co-operate during the session and answer all question asked
Patient had edema at fingers of both hands
Patient complained of pain at right forearm during supination.

Occupational Performance Area Assessments
ADL Modified Barthel Index
Work Role Checklist
Leisure Interest Checklist
Occupational Performance
Component
Assessments
Sensory
• Light touch
• 2 - point discrimination
• Pain
Semmes-Weinstein Monofilaments Test
2 – Point Discriminator
Visual Analog Scale (VAS)
Neuromuscular
• Range of Motion (ROM)
• Muscle strength
Upper Extremity Hand ROM and Wrist Chart
Manual Muscle Testing (MMT)
Psychological Depression Anxiety Stress Scales (DASS)
Psychosocial Interview and observation
OBJECTIVE ASSESSMENT (7 May 2014)

Activity Criteria Initial assessment
Personal hygiene Unable to perform the task (0)
Substantial help required (1)
Moderate help required (3)
Minimal help required (4)
Fully independent (5)
4
Bathing 4
Feeding Unable to perform the task (0)
10
Toilet 10
Stair climbing 10
Dressing 10
Bowel control 10
Bladder control 10
Chair/bed transfer Unable to perform the task (0)
15
Ambulation 15
Total 98/100
Activity of Daily Living (ADL) by using MBI (Modified Barthel Index) on 7 May 2014

Minimal dependency level
Total hours of help required per week is less than 10 hours
In personal hygiene (clipping nails), patient has difficulty to clip and takes a long
time to finish it due to poor pinch strength of right fingers
In bathing, patient has difficulty to rub his back during soaping due to limited
supination of right forearm

ii) . Work (through observation and Role Checklist on 7 May 2014)
Before injury patient works as a general customer service
His jobs are answering call and inserting data entry in which speed typing is
necessary
According to Role Checklist, patient still want continue to work after getting
accident
Role Past Present Future
Student √
Worker √ √ √
Volunteer √
Caregiver √
Home maintainer
Friend √ √ √
Family member √ √ √
Religious participant √
Hobbyist √ √ √
Participant in
organization
√ √

iii) . Leisure (through interview and Interest Checklist on 7 May 2014)
According to Interest Checklist, patient still interested to involve in:
carrying out exercise at gym; he always perform workout by lifting
dumbbells and bars
playing futsal with his friends during free time

Color Monofilament size Force in grams (g) Cutaneous Sensory Perception
Green 2.83 0.07 Normal light touch
Blue 3.61 0.2 Diminished light touch
Purple / pink 4.31 2.0 Diminished protective
sensation
Red 4.56 4.0 Loss of protective sensation
Orange 6.65 200 Untestable
OCCUPATIONAL PERFORMANCE COMPONENT (OPC)

I. SENSORY (7 May 2014)
Light Touch (Assessed by using Semmes-Weinstein Monofilaments Test)
2-Point Discrimination (Assessed by using 2-Point Discriminator Disc)
Right hand : 2 – 6 mm (normal)
Left hand : 2 – 6 mm (normal)
Pain (Assessed by using Visual Analog Numerical Scale (VAS)
- patient marks score 5/10 during rest at right forearm
- patient marks score 8/10 during supination at right forearm
Ulnar nerve Median nerve Radial nerve
Right hand
• Palmar
• Dorsal
2.83
2.83
2.83
3.61
2.83
3.61
Left hand
• Palmar
• Dorsal)
2.83
2.83
2.83
2.83
2.83
2.83

NEUROMUSCULOSKELETAL (7 May 2014)
Range of Motion
Assess by using Upper Extremity Hand ROM and Wrist Chart
Wrist Normal ( 0) Right ( 0) Left ( 0) Right ( 0) Left ( 0)
Flexion 0 – 80 0 – 70 0 - 75 FROM FROM
Extension 0 – 70 0 – 70 0 - 70 FROM FROM
Ulnar
deviation
0 – 30 5 - 25 0 - 25 FROM FROM
Radial
deviation
0 – 20 0 – 20 0 - 20 FROM FROM
Elbow Normal (0) Right ( 0) Left ( 0) Right ( 0) Left ( 0)
Flexion 0 – 150 0 – 140 0 – 145 FROM FROM
AROM PROM
AROM PROM

Finger Normal (0 ) Right ( 0 ) Left ( 0 ) Right ( 0 ) Left ( 0 )
Thumb MCP 0-50 0-40 0-45 FROM FROM
DIP 0-90 0-60 0-90 FROM FROM
Index MCP 0-90 0-60 0-75 FROM FROM
PIP 0-110 0-95 0-110 FROM FROM
DIP 0-80 0-50 0-70 FROM FROM
Middle MCP 0-90 0-35 0-80 FROM FROM
PIP 0-110 0-90 0-100 FROM FROM
DIP 0-80 0-60 0-70 FROM FROM
Ring MCP 0-90 0-30 0-80 FROM FROM
PIP 0-110 0-90 0-105 FROM FROM
DIP 0-80 0-55 0-65 FROM FROM
Little MCP 0-90 0-70 0-80 FROM FROM
PIP 0-110 0-90 0-100 FROM FROM
DIP 0-80 0-60 0-65 FROM FROM
AROM PROM

Has limited supination (35 degrees) at forearm of right UL due to
immobilization and pain.
Has slight ulnar deviation (5 degrees) at wrist of right UL .
Has limited flexion of right fingers.

RIGHT HAND (cm) LEFT HAND (cm)
Palmar crease 20.5 19.5
Thumb MCP 6.5 5.8
Thumb DIP 6.0 5.5
Index MCP 6.2 5.6
Index PIP 5.2 4.5
Middle MCP 6.2 5.4
Middle PIP 5.0 4.7
Ring MCP 6.0 5.2
Ring PIP 4.8 4.5
Little MCP 4.8 4.7
Little PIP 4.0 3.8

Location Flexion Extension
Upper limb Score Score
Elbow 5/5 5/5
Wrist 5/5 4/5
Fingers 4/5 4 /5

PSYCHOLOGICAL FUNCTION (through interview and DASS assessment) on 7 May 2014
INTRA – PERSONAL
Patient is motivated
Patient able to accept his condition and follow all the treatment given for full recovery.
Patient has initiative to continue the treatment.
Patient able to cope with pain.
INTER – PERSONAL
Patient is cooperative.
Patient is able to follow the instruction well.
Marks Interpretation
Stress 1 Normal
Anxiety 0 Normal
Depression 2 Normal

PSYCHOSOCIAL FUNCTION (through interview on 7 May 2014)
Patient has good relationship with family members.
Patient has many friends and always spend time together during weekend.
Patient can cooperate well with colleagues.
Patient able to socialize in the community well.

Patient has good moral support from his family
Patient is compliance and motivated to treatment
Patient does not has financial problem
Patient can follow the instruction well
Patient has good communication skill with others

a) Occupational performance area (OPA)
1. Has difficulty to perform in ADL
In personal hygiene (cutting nails), patient has difficulty to cut nails
and takes a long time to finish it due to poor strength of right fingers
In bathing, patient has difficulty to wash his back during soaping
due to limited supination of right forearm
2. Has difficulty to perform in major work tasks (takes time for typing) due to
poor pinch strength and dexterity of right fingers
3. Unable to perform in previous leisure activity
(lifting dumbbells and bars )
b) Occupational performance component(OPC)
1) Has edema at both hand
2) Has pain at right forearm
3) Has deformity at right hand (slight ulnar deviation)
4) Has limited ROM at all fingers of right hand

Short term goal
To reduce edema at both hand
To reduce pain at right forearm
To improve ROM, strength, dexterity at all fingers of right hand
To correct deformities (ulnar deviation at right hand)
Long term goal
To enable patient to return in ADL independently (personal hygiene, bathing)
To enable patient to return to work independently
(fully participate in company administration and tasks)
To enable patient to return in leisure activity (lifting dumbbells and bars )

Biomechanical FOR
• The approach is focused on addressing basic client factor to
improve occupational performance. Intervention is in the form of
exercises, splinting or orthopedic approach in which the outcome
must reflect engagement in occupation. (Pedretti, 2006)
In this case, biomechanical approach is use to ensure patient get maximum level of
functioning of right upper limb in order to enable patient performing activity daily
living as usual.
Rehabilitation FOR
• The approach is focused on client ability to return the fullest physical, mental,
social, vocational and economic functioning as is possible.
(Pedretti , 2006)
• Treatment are focused on avoiding and reducing impairment of the effected hand by using
adaptation and give purposeful, meaningful activity to the patient.

Problem 1 Edema at both hands
Aim To reduce edema at both hands
Intervention
Technique / Modalities Elevation technique
Method 1. Putting the affected hand above level of heart so
gravity help move interstitial fluid back toward heart.
2. Resting the hand on pillows while sitting or lying down
Duration
• Elevate the injured site for 10 – 15 minutes and
perform it 3 – 4 times per day
• Elevation performs during sleep and daytime
for recovery and rehabilitation process.
(Griffith, 2006)
Grading Continuously until the edema has subsided
Precaution • Prevent sleeping on injured site .
• If sling is used, try not to use for long periods of time
to prevent shoulder stiffness.

Problem 2 Pain at right forearm
Aim To reduce pain at right forearm
Intervention
Technique / Modalities Pain management through deep breathing and
physical agent modality (PAM)
Method
- Deep breathing
1. This treatment must be in a quiet and patient must be in comfortable
position.
2. Ask patient to slowly inhale through nose while counting to 4 seconds.
3. Patient required to hold their breath while counting to 4 seconds.
4. Exhale through mouth while counting to 7 seconds.
5. Repeat the steps until patient feel relax and easy.
- Physical agent modality (Cold therapy)
1. Apply ice at the effected side 10 to 20 minutes, several times per day.
2. Check skin frequently for sensation to prevent tissue damage
3. Stop apply if lose feeling in the skin where you are applying it
Rationale Deep breathing reduces pain by having a direct effect on the
sympathetic nervous system - fibres in the central nervous system
which help to control blood flow and skin temperature.
(Downey and Zun, 2009)
Cold therapy has strong short – term analgesic effect in many painful
condition, particularly those related to the musculoskeletal system.
(Ernst and Fialka, 1994)

Problem 3 Deformity at right hand (slight ulnar deviation at 5 degrees)
Aim To correct deformity at right hand (slight ulnar deviation)
Intervention
Technique / Modalities Splinting
Method 1. Fabricate a resting splint followed by active use.
2. Educate wearing regime and splint care.
3. Splint review for every appointment.
4. Wear it during daytime rest periods and overnight.
5. Put splint for 2 hours then remove it and check the
skin for reddened pressure area
Precaution
• Do not leave splint where it is exposed to temperature above
60 degrees as this will alter its shape
• Remove splint when it causes any problems:
- An area of pressure such as sores, swelling,
excessive stiffness, pain, blisters
Rationale Resting splints help prevent a hand deformity which are needed
until the bone is healed, typically around 4 weeks.
(Aubrey, 2014)
Grading Continuously wear until the deformity has corrected

Problem 4 Has limited ROM, poor strength and endurance of all fingers of right hand
Aim To improve ROM, strength and endurance of all fingers of right hand
Intervention
Technique / Modalities 1) Passive stretching
2) Strengthening activity (theraputty)
Method • Passive stretching
- Each stretch should be held 15 - 30 seconds and
repeated 2 to 4 times
(Wilson ,Hornbuckle and Kim et al. , 2010)
• Strengthening activity (theraputty)
Flexion - Place the putty at the base of the fingers
- Squeeze with fingertips while keeping the palm of the hand open
- After the fingers have pressed into the putty, fold over and repeat
Extension - Roll putty back and forth, being sure to use all fingertips
( Killingworth and Pedretti , 2006)
Rationale In order to improve ROM and strength, forceful exercise is necessary to use which is
there has some type of force that was used to body part when soft tissue is either
near on the available length
(Pendelton & Schultz-Krohn,2006)
Grading Theraputty (from soft to hard texture)

Problem 5 Has difficulty to perform in ADL
• Difficulty in personal hygiene (cutting nails), takes a long
time to finish it due to poor pinch strength of right fingers
• Difficulty in bathing (brushing back of body) during
soaping due to limited supination of right forearm
Aim To enable patient to return in ADL independently
• personal hygiene
(enable to clip nails, maintain hygiene independently)
• bathing
(brushing back of body)
Intervention
Technique / Modalities Compensatory technique by using adaptive equipment
Method • Use long – handled sponge as adaptive bathing aids
to brush back of body during soaping
• Use large grip nail clippers for comfortable handling
Precaution Ensure the equipment is safe to use

Problem 6 Has difficulty to perform in work
(major task; takes time for typing)
Aim To enable patient to return to work independently
(fully participate in company administration and tasks)
Intervention
Technique / Modalities Functional activity (computer typing)
Method Sitting with good posture to stay comfortable and focus on better
typing and speed
Ensure the keyboard is at a comfortable height
Keep the wrist elevated to ensure equal height with the keyboard
Typing with both hands
Precaution Avoid prolonged typing to prevent additional stress on shoulder and
neck
Use arm rest while typing to prevent compression at wrist
Grading Increase total number of words and characters per minute
Increase time

Subjective Assessment
Done on 23 May 2014
Patient come to the department alone with properly attired and neat
Looks more energetic than previous appointment

Activity Criteria Initial assessment
Personal hygiene Unable to perform the task (0)
5
Bathing 5
Feeding Unable to perform the task (0)
10
Toilet 10
Stair climbing 10
Dressing 10
Bowel control 10
Bladder control 10
Chair/bed transfer Unable to perform the task (0)
15
Ambulation 15
Total 100/100
Activity of Daily Living (ADL) by using MBI (Modified Barthel Index) on 23 May 2014

OCCUPATIONAL PERFORMANCE COMPONENT (OPC)
I. SENSORY (23 May 2014)
Light Touch (Reassessed by using Semmes-Weinstein Monofilaments Test)
2-Point Discrimination (Reassessed by using 2-Point Discriminator Disc)
Right hand : 2 – 6 mm (normal)
Left hand : 2 – 6 mm (normal)
Pain (Reassessed by using Visual Analog Numerical Scale (VAS)
- patient marks score 1/10 during rest at right forearm
- patient marks score 4/10 during supination at right forearm
Ulnar nerve Median nerve Radial nerve
Right hand
• Palmar
• Dorsal
2.83
2.83
2.83
2.83
2.83
2.83
Left hand
• Palmar
• Dorsal)
2.83
2.83
2.83
2.83
2.83
2.83

NEUROMUSCULOSKELETAL (23 May 2014)
Range of Motion
Assess by using Upper Extremity Hand ROM and Wrist Chart
Wrist Normal ( 0) Right ( 0) Left ( 0) Right ( 0) Left ( 0)
Flexion 0 – 80 0 - 75 0 - 75 FROM FROM
Extension 0 – 70 0 – 70 0 - 70 FROM FROM
Ulnar
deviation
0 – 30 0 - 30 0 - 25 FROM FROM
Radial
deviation
0 – 20 0 - 20 0 - 20 FROM FROM
Elbow Normal (0) Right ( 0) Left ( 0) Right ( 0) Left ( 0)
Flexion 0 – 150 0 - 140 0 - 140 FROM FROM
AROM PROM
AROM PROM

Finger Normal (0 ) Right ( 0 ) Left ( 0 ) Right ( 0 ) Left ( 0 )
Thumb MCP 0-50 0-50 0-50 FROM FROM
DIP 0-90 0-70 0-90 FROM FROM
Index MCP 0-90 0-70 0-85 FROM FROM
PIP 0-110 0-105 0-110 FROM FROM
DIP 0-80 0-70 0-70 FROM FROM
Middle MCP 0-90 0-85 0-80 FROM FROM
PIP 0-110 0-110 0-110 FROM FROM
DIP 0-80 0-80 0-80 FROM FROM
Ring MCP 0-90 0-90 0-80 FROM FROM
PIP 0-110 0-105 0-105 FROM FROM
DIP 0-80 0-75 0-80 FROM FROM
Little MCP 0-90 0-90 0-85 FROM FROM
PIP 0-110 0-110 0-105 FROM FROM
DIP 0-80 0-80 0-80 FROM FROM
AROM PROM

RIGHT HAND (cm) LEFT HAND (cm)
Palm 19.6 19.3
Thumb MCP 5.9 5.6
Thumb DIP 4.9 5.5
Index MCP 5.5 5.3
Index PIP 4.9 4.5
Middle MCP 5.6 5.2
Middle PIP 5.0 4.6
Ring MCP 5.3 5.2
Ring PIP 4.5 4.5
Little MCP 4.8 4.5
Little PIP 4.0 3.8

Strengthening activity for upper extremity at right hand (wrist and forearm)
Hand function training
Work training (computer typing)

Medical
Base on doctor review, patient prognosis is good where patient condition is not degenerate
Rehabilitation
Base on Occupational Therapy (OT) aspect, patient prognosis is good where:
 Patient shows improvement in ROM and strength at right hand.
 Patient is compliance with the appointment of treatment.
 Patient is motivated to perform passive and active exercise at home.

Downey, L.V. , Zun, L. S. The effects of deep breathing training on pain management in the
emergency department. South Med J. 2009 Jul;102(7):688-92.
Ernst , E. & Fialka, V. (1994). J Pain Symptom Manage, Jan; 9(1): 56 – 9 .
Griffith, H.W. , MD “Complete Guide to Symptoms, Illness & Surgery ” (The Berkeley
Publishing Group, 2006)8
Killingworth, A.D. & Pedretti, L.W. (2006) Chapter 21. Evaluation of muscle strength. In. H.M.
Pendleton & W. Schultz-Krohn (eds). Pedretti’s Occupational therapy: Practice skills for
physical dysfunction (6th ed. pp. 469-512). St. Louis: Mosby, Inc
Manual Muscle Testing (MMT). (2010) PST Exercise in SMA. Retrieved from October 24, 2013
from
https://crcjs.med.utah.edu/sma_fitness/pdfs/manualmuslce_tests_upper_lower_PST.pdf
Pendleton H. M., and Schultz-Krohn W. (2005) Pedreeti’s Occupational Therapy Practice Skills
For Physical Dysfunction 6th Edition. Mosby Elsevier.

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