A fall on the outstretched hand (FOOSH) is a common occurrence and often results in a Colles’ fracture, a fracture of the distal inch of the radius and ulna next to the wrist. Treatment is immobilisation in a splinting material such as Plaster of Paris for five to six weeks to allow healing of the bony fragments, followed by a variable period of rehabilitation depending on the severity of the fracture. The hand is extremely important functionally so the period in plaster is kept to a minimum to allow quick restoration of normal hand use, although a wrist splint can be used for a week or so, particularly in cases where there is significant pain on activity.

Once the hand is released from the Plaster of Paris the physiotherapist will check the healing process is progressing normally. Palpation of the fractured area firmly should cause no significant tenderness or pain, hand colour should be normal and there should be no excessive swelling of the area. Muscle wasting is common after immobilisation but should not be too great. The ranges of movement of the limb, while restricted in some planes, should not be severely reduced in many planes. Pain should not be severe or widespread nor come on with all movements of the wrist and hand.

Range of movement exercises are the first line of treatment for a physiotherapist, teaching exercise performance every two hours. Many colles’ fractures do very well simply with regular end range exercise practice and do not need more sophisticated treatments. The physiotherapist checks any restrictions in shoulder and elbow movement then records the forearm rotations, supination and pronation, which are important functionally. The physiotherapist will then assess wrist flexion and extension, finger flexion and extension and thumb movements. Most commonly restricted movements are supination and wrist extension.

After the plaster comes off the wrist often feels vulnerable, partly because the plaster is seldom left on until the bone is entirely healed to prevent the onset of complications due to immobilisation. Physiotherapists may give the patient a futura type brace, a fabric brace with Velcro straps and a metal piece for the underside of the wrist to stiffen it. This is not meant to keep the wrist immobilised further but to support the wrist while the patient is performing functional activities and then to be removed for light activities and regular exercise performance.

If the progress of the joint is not as expected then the physiotherapist can use joint mobilisation techniques to restore the gliding and sliding movements of the joint. Accessory movements are small movements performed passively on another person and can be done to the midcarpal, radiocarpal and distal radio-ulnar joints. The physiotherapist will hold one side of the joint firmly as they passively move the other side of the joint, either gently and repetitively or more forcefully at the end range of where the joint will allow, pushing against the restriction. The joint can also be placed in the stiff position while the mobilisations are performed.

Strengthening the wrist occurs with a gradual increase in functional activities but joining a hand class can instruct the patient in practicing the large variety of small movements that the hand can perform and needs to strengthen for optimum hand function. Repetitive work at pieces of apparatus can strengthen and harden the hand to turning, twisting, pulling, grasping and fine work with the thumb and index finger. This can move on to work with weights or functional activities if the person needs to return to manual labour or another job requiring upper limb strength.

In some cases a pain syndrome can develop in the hand with tight swelling, poor joint motion, high pain and hypersensitivity, at which time a doctor’s opinion is needed to exclude complications with the fracture such as non-union. Painkillers and contrast bathing are treatments for the pain, with self massage used for swelling and desensitising techniques for the abnormal sensibility. The patient should be clear that they have to go through significant pain to get their hand better again.