Post-ORIF Distal Radius: Stiffness vs. Tendon Risk
A 46-year-old warehouse picker is 9 weeks post volar plate ORIF of a right distal radius fracture. Radiographs show healed bone and a plate at the watershed line. Active wrist flexion is 20 degrees, extension 25 degrees, forearm pronation 45 degrees and supination 30 degrees. Grip strength is 14 kg on the right versus 38 kg on the left. She reports sharp volar wrist pain when she carries totes and a catching sensation with active finger extension. There is mild volar tenderness over the distal plate and a positive but equivocal tenosynovitis provocation. She needs to return to repetitive lifting within 6 weeks. She asks whether aggressive stretching now will speed her recovery.
1. Interpret the assessment findings and decide whether to progress to aggressive end-range mobilisation this session. Justify your decision with the specific findings.
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Do not progress to aggressive end-range mobilisation today.
Key reasoning:
- The sharp volar pain with loaded gripping plus catching with active finger extension over a plate at the watershed line raises concern for flexor tendon irritation/attrition rather than simple capsular stiffness. Aggressive stretching into extension increases tendon tension against the plate edge.
- Strength deficit (14 vs 38 kg) and marked ROM loss are expected at 9 weeks, but the quality of pain (sharp, load-related, localized) is the red flag, not the magnitude of stiffness.
- A equivocal provocation test does not rule out tenosynovitis; combined with catching, it warrants a cautious, tendon-sparing approach and communication with the surgeon.
Plan: avoid forced end-range extension and heavy gripping; use gentle active-assisted ROM within a pain-free range, tendon-gliding exercises in a protected range, and isometric loading. Document findings and flag the catching/volar pain to the referring surgeon before escalating stretch intensity.
2. Design a 6-week progression toward repetitive lifting, specifying how you would titrate load and what objective markers would trigger regression.
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Progression framework (tendon-sparing, load-titrated):
- Weeks 1-2: pain-free active-assisted ROM, tendon glides, light isometric wrist/finger flexion and extension at submaximal effort; avoid end-range extension loading. Target: pain ≤3/10 during and after.
- Weeks 3-4: introduce graded grip and light carry (e.g., start 2-3 kg, progress by ~10-20% per session when symptoms allow); add eccentric wrist extension in a mid-range only.
- Weeks 5-6: task-specific lifting simulation (tote carry, repeated lift cycles) with progressive load toward job demands, monitoring next-day response.
Regression triggers: increase in sharp volar pain, return of catching/clicking with finger extension, next-morning stiffness or pain lasting >1 hour, or grip strength plateau with worsening symptoms. Any of these → reduce load and revert one step, and re-refer if catching persists. Because tendon irritation is suspected, load tolerance-not end-range stretch-is the primary progression variable.