Background and Purpose

Distal radius fractures are common injuries associated with falls, comprising of 17% of

all bony related injuries presenting in emergency departments.1 Over $210 million is spent by

Medicare each year in the United States on the treatment of these fractures.2 The mechanism of

injury is often referred to as “falling on an outstretched hand” or FOOSH injury. This occurs

when the individual extends their upper extremities out to break their fall and makes sudden

contact with the ground.3 One of the most well-known FOOSH injuries is termed a Colles’

fracture, with over 640,000 cases reported in a year.4 This involves a transverse fracture of the

distal portion of the radius about 1 in from the radiocarpal joint, often occurring with anterior

displacement of the distal fragment. This may result in visual abnormality known as “dinner fork

deformity.” Additionally, the site of fracture will be painful and edematous, and grip strength

becomes diminished and painful. Colles’ fractures are commonly caused by mechanical events

such as a slipping on ice, tripping over obstacles, or activities that involve forward momentum

such as skating. There is a bimodal distribution in terms of age with the incidence of Colles’

fractures, with pediatric populations and older populations most affected. Colles’ fractures are

most commonly associated with middle-aged women in their 40s and 50s secondary to the onset

of osteoporosis associated with menopause.4 Females are about 5 times more likely to sustain a

Colles’ fracture than males, with the incidence of a fracture almost doubling with every decade

starting from 50 years old.5 However, this injury is also common in children and adolescents,

comprising 25% of fractures,4 secondary to premature skeletal bone density, as well as

involvement with high energy or high speed sports and recreational activities are at risk.4 The

risk of fracture up until the age of 16 years for boys was 42%, while in girls was 27%.4

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 Acute fractures typically require emergency care. X-ray is indicated especially if there is

visual deformity or bony tenderness for suspicion of fractures.3 This will identify skeletal

deformity, whether the fracture is displaced or non-displaced, as well as possible involvement of

the adjacent skeletal structures. Fixation techniques include open reduction internal fixation

(ORIF), and closed reduction external fixation.1 Surgical management is indicated for severely

displaced or unstable fractures. ORIF typically consist of volar plates, screws, and pins, but some

methods may incorporate Kirschner wires, bone grafts, or bone substitutes.6 ORIF has the

benefits of increased biomechanical stability, low malunion rate, earlier wrist mobilization,1 and

increased outcomes with wrist, forearm, and grip strength 6 weeks post-operative.6 ORIF is

associated with increased risk of infection because of its surgical nature, however most infections

are minor.1 External fixation may consist of volar splints or cast immobilization.1,7 Splints are the

temporary and primary method of stabilization for non-severe fractures before progression to

cast immobilization if indicated.8,9 They are faster and easier to apply, and more easily

removable than casts to examine any accompanying wounds present.8,9 Splints benefit over cast

immobilization because the non-circumferential structure of the bandage can allow for a small

amount of edema formation without constricting the joint.8 Additionally, splints have the benefit

of being minimally invasive since surgery is not involved, which may be indicated for elderly

who are too frail to undergo surgery.1 However, external fixation is associated with higher rates

of malunion and total complications,1 such as pressure ulcer formation, wound infection,

compartment syndrome,8 and complex regional pain syndrome.10 An orthopedic specialist may

place non-weight bearing (NWB) precautions to protect the joint, promote proper alignment and

healing, and prevent further injury.

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 Decision making for a patient with a Colles’ fracture for discharge from emergency

services or acute care settings may be complicated by multiple factors. The patient may have

personal or social factors, multiple fractures, or comorbidities and other conditions that

complicate their discharge plan or prognosis. In a study of over 38,000 Medicare beneficiaries

with distal radius fracture, just under 1,700 of these patients were hospitalized.2 Of this group,

95% of patients were discharged to home, but the remaining were discharged to skilled nursing

facilities or inpatient rehabilitation facilities.2 Discharge plans should consider whether the

patient’s home environment will pose architectural barriers to their safe return. This includes

ramps, entryways, stairs, hallways, or other obstructions. Decisions should also reflect the patient

as an individual with their specific conditions or risk factors that increase their likelihood of

injury should they return home prematurely. Additionally, a patient with multiple fracture sites

may be limited in terms of how much weight they are allowed to bear, if any, on each extremity.

This will impact whether they will be able to continue using an assistive device for mobility if

they used one prior to their injury, and impacts what type of device they are permitted to use.

Physical therapists are well known to have roles in the managing patients in the acute

care setting. Typically, physical therapy for Colles’ fractures is more commonly known for its

role in the sub-acute phase for Colles’ fractures2 which may be up to 4-8 weeks post-

immobilization.10 Physical therapy in these settings may consist of soft tissue massage, thermal

modalities, stretching and strengthening, and joint mobilization.11 In the acute care setting,

physical therapists can provide patient education on weight bearing status, functional mobility,

range of motion, precautions or management following surgical or conservative management,

and interventions to reduce fall risk.10 Physical therapists in the acute care setting serve crucial

roles in the management and discharge planning. They are able to make accurate and appropriate

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discharge recommendations with their skills in synthesizing examination information such as

functional mobility assessment, and subjective history taking.12 Physical therapist discharge

recommendations are followed 83% of the time, and patients are 2.9 times more likely to be

readmitted to a hospital when physical therapist recommendations are not followed.12

The purpose of this case report is to describe the physical therapy management and

clinical decision making for an older female patient with legal blindness with bilateral distal

forearm fractures and great toe fracture in an acute care setting. Given her visual impairment, the

fact she had multiple fractures, and with her initial subjective history of living alone, her safety

was called to question, and her discharge was subsequently delayed. The patient had been

transferred from the Emergency Department to the hospital’s Clinical Decision Unit (CDU). This

unit is considered an extension of the Emergency Department responsible for evaluating patients

who are not officially admitted to the hospital, are typically medically stable, but require further

assessment or observation to determine whether they are suitable to return safely home or

whether they need other placement options. Prior to preparing this report, consent was obtained

from the patient to proceed. All information contained in this case report meets the Health

Insurance Portability Accountability Act (HIPAA) requirements of the clinical agency for

disclosure of protected health information. This case report was completed in accordance with

procedures approved by the Institutional Review Board at Central Michigan University.

Case Description

Patient History and Systems Review

A 64-year old Caucasian female with legal blindness presented to the Emergency

Department with injuries sustained in a fall. Her chief complaint was pain in both arms, her foot,

and her back. X-rays taken of the patient’s bilateral wrists and hands were positive for radial and

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ulnar minimally-displaced fractures. X-ray taken of the patient’s right foot was positive for a

non-displaced fracture of the right hallux proximal phalanx. Computed tomography of the

patient’s head, cervical spine, and chest were performed per trauma protocol, but were negative

for acute abnormalities apart from a visible surface contusion on the patient’s back.

The patient was evaluated by orthopedic services and was treated conservatively with

bilateral volar forearm splints and a post-operative right shoe. Pharmacological intervention

included acetaminophen-hydrocodone for pain. The patient had non-weight bearing (NWB)

orders for the bilateral wrists and hands, and weight bearing-as-tolerated (WBAT) orders for her

right lower extremity. The patient was then placed in the CDU for pain management and

observation. The following morning, she was referred to acute care physical therapy (PT)

services, occupational services, and social work services for evaluation and discharge planning.

A brief medical chart review indicated the patient had diabetes, diabetic retinopathy, and

Turner’s Syndrome. During the initial interview, she stated that she had woken up in the middle

of the night last night, must not have been completely awake, and then fell down her flight of 12

stairs on the way to her bathroom. After the fall, she was able to walk. The patient stated she was

legally blind in both eyes, with her left eye being completely blind and with some vision

remaining in her right. The patient was modified independent with a white cane for mobility. She

lived alone with her dog in a 2-story apartment with her bedroom and bathroom on the upstairs

level, and 3 steps to the front entry. The patient states that she was mostly independent with all

activities of daily living and mobility, but occasionally her neighbor, friends, or family members

would assist her for household tasks and driving.

Clinical Impression 1

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 The patient was considered a good candidate for acute care PT services. The patient had

suffered a fall and sustained a number of acute fractures. This warranted a PT evaluation to rule

out any other possible causes of falls, determine needs for any new assistive devices (AD), gait

training for those new devices, patient education on weight bearing orders and the rehabilitation

process, and discharge recommendations. The plan for examination was to determine the

patient’s prior level of function (LOF) and current LOF with bed mobility, transfers, and gait, her

balance, strength, and range of motion, and her education needs and safety awareness with her

weight bearing orders.

Examination

Communication, cognition, and affect. The patient’s communication, cognition, and affect were

all considered to be within normal limits. The patient was alert and oriented to herself, place, and

situation. She was able to follow all commands, answer all questions, and demonstrated

appropriate social behaviors and emotional responses during interactions with the physical

therapist.

Pain. The patient’s pain was measured subjectively using a Numeric Pain Rating Scale (NPRS).

The NPRS has excellent internal consistency for healthy participants aged 25-55 and 65-94.13

The NPRS also had high construct validity for emergency room populations as shown by a

correlation of .88 between the NPRS and Visual Analogue Scale.14 The patient was asked to

“rate your current pain level on a scale of 0 to 10, with 0 being no pain at all to 10 being the

worst possible pain.” The patient rated the pain in her forearms, foot, and back as 8 out of 10,

which indicated severe pain.

Range of motion. Passive range of motion (ROM) of the lower extremities was assessed with the

patient in supine. All joints were assessed in the available planes of motion, except for the

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metatarsophalangeal and interphalangeal joints of the right foot due to the post-operative shoe

protecting the joint and limiting movement. The patient was given instructions such as “bend

your knee as far as you can toward your chest,” and “move your ankle up and down.” The

patient’s passive ROM at all other joints was found to be within functional limits.

Strength. Manual Muscle Testing (MMT) of the lower extremities was performed with the

patient in supine in order to decrease the amount of positional changes required by the patient

secondary to her multiple fractures. Each joint was positioned at the midrange of her available

ROM, and the patient was instructed to hold that position as progressive resistance was applied

in the appropriate directions of joint movement. Strength grades were assigned to each muscle

based on a 5-point numeric scale, with 0 indicating no voluntary contraction and 5 indication

normal strength. Interrater reliability is strong, ranging from .82-.97, and is also high for test-

retest reliability at .96-.98.15 The concurrent validity is good at .768 when compared to a hand-

held dynamometer.15 The patient’s gross strength was rated as 3 to 3+/5 throughout, indicating

fair but limited strength in her hips and knees. The ankle musculature was not tested at this time

secondary to the post-operative shoe.

Balance. The patient’s standing balance was rated using the Kansas University Standing

Balance Scale (KUSBS). The KUSBS was found to have good intra-rater reliability, with a

correlation coefficient of ICC = .893 for inpatient rehabilitation patients.16 The KUSBS consists

of a scale of 10 point scale ranging from 0 to 5, with 0 indicating the patient performed 25% or

less of the standing activity requiring maximum assistance, and 5 indicating the patient moved

and returned their center of gravity in all planes two inches or more. While the patient was able

to use bilateral platform walker, it was deemed necessary to provide minimal assistance for the

patient in standing activities secondary to her WBAT precautions on her right foot as well as her

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visual impairment. As such, the patient’s KUSBS for standing was graded as 1+/5, indicating

that the patient self-supported with both upper extremities, and required minimal assistance from

the therapist, but performed more than 50% of the standing activity.

Outcome Measures. The Functional Reach Test (FRT) was used to further assess the patient’s

standing static balance. The FRT was performed on the first day of treatment following the initial

evaluation due to time constraints. For community dwelling elderly, the FRT has been found to

have excellent inter-observer reliability of ICC = .98.17 The distance the patient could reach

forward without stepping or losing balance was measured twice. The patient was instructed to

stand with her side near the wall, put her arms straight out in front of her, and then reach forward

as far as possible without letting her heels off the ground or losing her balance. The patient was

able to reach forward 8 in on both trials. This indicated she reached below the average distance

compared to the norm for her age group.17

The Timed Up and Go (TUG) was used to further assess the patient’s fall risk during a

functional mobility task. The TUG was performed on the first day of treatment following the

initial evaluation due to time constraints. The TUG demonstrates fair sensitivity as high as 68%

and good specificity as high as 80% in measuring fall risk in acute care settings.18 The TUG

consists of measuring the total time to complete a sit to stand transfer from a chair, walk 3 m,

turn around, walk back to the chair and sit down. Scoring under 20 sec typically indicates

independence with mobility, while greater than 30 sec indicates dependence and assistance

required for mobility tasks, as well as increased likelihood for falls. The patient was able to

complete the task without an AD and was given a verbal cue to indicate the 3 m mark at which to

turn around. The patient’s time was 22 seconds which indicated that further assessment was

required to clarify her level of independence.

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Bed mobility. See Table 1 for the patient’s mobility status for bed mobility. The patient was

given instructions to perform bed mobility. She was able to complete 50-75% of the mobility

tasks, which required moderate assist of the therapist. Verbal guidance was required to reinforce

her NWB status through her hands and wrists, for safety, and for problem solving.

Transfers. See Table 1 for the patient’s mobility status for transfers. The patient was able to

complete tasks 50-75% independently, which required minimal to moderate assist (25-50%

assistance from the therapist) secondary to safety and WBAT for her right foot. This was in

addition to her visual impairment and being in an unfamiliar environment. All transfers were

performed with verbal guidance to reinforce her NWB status for her hands and wrists, for

direction and safety, and problem solving.

Gait and locomotion. The patient used a 2-wheeled walker with bilateral platforms for support to

walk 60 ft on an indoor level surface. The patient required moderate assist (50% assistance from

the therapist) to maintain her balance secondary to her weight bearing precautions, general lower

extremity weakness, pain, and for safety. She also required manual guidance of the walker, and

verbal cues due to her visual impairment.

Gait Analysis. The patient’s gait was observed as she walked in a straight line using two-

wheeled walker with bilateral platforms while wearing a right post-operative shoe. She required

moderate assist to provide manual guidance and verbal cues secondary to her visual impairment.

The patient walked with slow gait velocity and decreased cadence, but had normal step and stride

length, normal base of support, and had slight antalgic gait pattern secondary to pain in her right

foot.

Clinical Impression 2

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 The patient was considered to be a good candidate for physical therapy interventions

given her functional mobility impairments. For basic mobility, she required between minimal to

moderate assist of 1. She required frequent reminders to reinforce her awareness and safety with

NWB through her hands and wrists, as well as verbal and manual guidance of the walker to assist

with transfers and gait secondary to her visual impairment and being in an unfamiliar

environment. As a result, she required gait training with an AD, bed mobility and transfer

training, and education on her weight-bearing status. Additionally, the patient also demonstrated

good cooperation, ability to follow commands, and verbal understanding of all interactions and

education regarding her condition and the rehabilitation process. This made her an agreeable,

appropriate participant for therapeutic activities. Finally the patient’s existing visual impairment,

unsuitable home environment including an entire flight of stairs, and current social status of

living alone without family support warranted the need for further Acute Care PT decision

making in terms of safely discharging the patient.

Interventions.

The patient was seen for 1 evaluation and 1 treatment over the course of 3 days. She

received medications for pain management, an orthopedic surgery consult, a social work consult,

and physical therapy and occupational therapy services.

Bed Mobility and Transfer Training. On the second day that the patient was seen, she was

verbally guided on the best ways to transition from position to position. This included rolling to

her side first and then on to her elbow, and to push off to assume sitting at the edge of the bed,

and to slowly walk her hips forward one at a time to scoot to the edge. The patient was also

instructed to perform transfers slowly with control, such as standing up without using her hands,

and slowly lowering using only her leg strength to sit down in a chair. The patient no longer

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required verbal guidance on her NWB precautions as she demonstrated good safety awareness by

avoiding putting her hands on the bed.

Gait Training. The patient was gait trained 50 ft without use of an AD on indoor level surface

while wearing her left shoe and a right post-operative shoe. She required manual guidance at her

elbow secondary to her visual impairment, which provided guidance for direction as well as

provided a tactile cue in case she needed support.

Splint/Orthotic Care. The patient was educated in proper care for her soft splints on her bilateral

hands and wrists. While she was compliant with NWB through her hands and wrists during the

second day of treatment, she required instruction on keeping the dressings dry, avoiding washing

her hands while the splints were on. She was educated on preventing excessive moisture buildup

on the splints to provide longer, durable protection to her joints to maximize fracture healing.

Additionally, she was educated on proper positioning in bed and in her chair, including keeping

her arms elevated on pillows and occasionally opening and closing her fingers to decrease edema

formation. Finally, she was observed brushing her teeth using her right hand. This warranted

further education on calling for assistance rather than gripping the utensils herself in order to

further promote healing.

Outcomes

The patient’s pain was rated as 3/10 on the second day of treatment and was able to tolerate more

weight on her right foot. As such, her performance with walking had improved to 50 ft without

using an AD, but she still required light contact guard and manual guidance secondary to her

visual impairment. Additionally, the patient’s overall performance with basic functional mobility

had improved as seen in Table 1. The patient had improved to modified independent for some

bed mobility secondary to increased time needed to complete the tasks, but still required standby

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assist for safety at times. For transfers, the patient did require contact guard to minimal assist

secondary to general safety awareness and direction secondary to her visual impairment. The

patient required a decreased level of assistance overall and with less verbal guidance needed for

problem-solving, and she was able to demonstrate good safety and adherence to her weight-

bearing status during mobility.

Discussion

The patient was recommended to continue to receive acute care physical therapy services

during her length of stay in the CDU, which is typically limited to 24 hours. This

recommendation was made secondary to her decreased functional mobility relative to her prior

level of function. Despite this, she was considered medically stable so she did not qualify for

admission to the hospital. Additionally, she did not qualify for inpatient rehabilitation at the

hospital because she was too high level in regard to functional mobility despite her presentation.

However, there were still concerns regarding how safe the patient would be if she were

discharged home. Factors to be considered were the number and nature of her acute fractures and

weight bearing precautions, her visual impairment, the fact that she lived alone and had

architectural barriers that would complicate her discharge, and did not have immediate 24-hour

care assistance at home. Thus, she was recommended to be discharged to an extended care

facility to maximize her gains with functional independence with structured PT until she was

stronger and safe enough to return home independently with stable family and friend support.

Research – acute care physical therapy roles in acute management of distal radius

fractures with gait training, precautions, bed mobility and transfers. Acute care physical therapy

roles in cases that appear to be simple in regard to medical management but may have

complicating factors that prevent a patient from safely being discharged home.

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 Limitations – outcomes were attained on the second day the patient was seen (her first

full treatment), so discharge scores were not able to be attained since the patient was discharged

shortly after.

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