Wrist Fracture Rehab: What Physiotherapy Does After a Distal Radius Fracture

The distal radius is the most commonly fractured bone in the arm. It sits just above the wrist joint, and it breaks most often from a fall onto an outstretched hand. The scenario is consistent whether the person is 25 or 75: the hand goes down, the body's weight comes down behind it, and the bone gives way.

The cast period handles the healing. This article is about what happens after the cast comes off, and why the weeks immediately after removal matter as much as the weeks before.

What the distal radius is and why it breaks where it does

The forearm has two bones: the radius and the ulna. The radius is the larger of the two and carries most of the load transferred from the hand to the arm. The distal end, the end closest to the wrist, is where the radius articulates with the eight small carpal bones that form the wrist joint. It is also the point where the bone is widest and most exposed to a fall impact force.

When a person falls and reaches a hand out to break the fall, the impact load travels up through the hand and concentrates at the distal radius. The bone breaks at a predictable location, just above the wrist joint, and the fracture pattern depends on the angle and magnitude of the force.

The two named patterns are the Colles fracture, where the wrist snaps back and the bone fragments displace in a characteristic direction, and the Smith fracture, the reverse pattern where the wrist is in a bent-down position at impact. Both involve the same bone at the same location.

Distal radius fractures are a frequent injury in pickleball players and in older adults with fall risk. Our article on falls and wrist fractures in pickleball covers the prevention side of this specific injury.

What weeks in a cast do to the wrist

The cast immobilises the wrist and typically the thumb side of the hand for four to six weeks while the fracture heals. This is necessary. It is also what creates the rehabilitation problem.

During immobilisation, the wrist joint stiffens. Ligament and capsule tissue tighten without movement. The skin over the wrist and forearm tightens and loses its normal mobility. Grip strength drops. Forearm rotation, particularly supination (turning the palm upward), and wrist extension (bending the hand back) are the two functional motions most consistently restricted.

At the same time, the bone is not fully healed when the cast comes off. The fracture site is consolidated enough to remove the cast, and it is still short of pre-fracture bone strength; remodelling continues for months afterward. This matters for physiotherapy because the early weeks after cast removal are a window for mobility work, and heavy loading waits.

The four phases of recovery

Physiotherapy for a distal radius fracture follows a phase structure tied to what the bone and tissue can handle at each stage. Published protocols such as the one from Brigham and Women's Hospital stage recovery the same way. The timing below is what we typically see in our clinic; your surgeon's protocol takes priority where the two differ.

Phase 1: Cast phase. During this period, the physiotherapist or the treating surgeon's team typically advises keeping the fingers, elbow, and shoulder moving to reduce stiffness and maintain circulation. Finger tendon gliding exercises and shoulder range-of-motion exercises prevent the joint from seizing up while the wrist is immobilised. Some people see a physiotherapist during this phase; many do not until cast removal.

Phase 2: Early mobility after cast removal. This is the most important phase for preventing lasting stiffness. Immediately after cast removal, the wrist is stiff, swollen, and tender. The priority is gentle, pain-guided range-of-motion work: wrist flexion and extension, forearm rotation (pronation and supination), and composite finger flexion (making a full fist, which many people cannot do immediately after cast removal because finger tendon tightness has accumulated).

Scar mobilisation begins here if the person had surgical repair, once the incision has healed enough to be worked, since a scar from a plate incision will tighten and restrict movement if not addressed. Oedema (swelling) management through elevation, compression, and active movement is also part of this phase.

The bone is still consolidating during this phase. Loading is held back, as set by your surgeon's protocol: controlled movement within the pain-free range, without resistance work.

Phase 3: Strength rebuilding. When movement is close to symmetrical with the uninjured side, loading begins. This is where grip strengthening, wrist flexor and extensor resistance work, and forearm rotation with resistance are introduced progressively. Functional tasks (gripping, lifting, turning keys) are practiced as activity-specific loading.

Dynamometer testing is useful here to measure grip strength and pinch strength objectively and compare to the uninjured side. Your physiotherapist sets the symmetry target for advancing to heavier tasks based on the fracture and your goals.

Phase 4: Return to activity. Return to most activities of daily living comes first. Return to sport or demanding physical work is later: racquet sports, heavy manual work, and anything requiring wrist loading under impact require near-full strength symmetry and bone consolidation, and surgical cases usually reach this point later than non-operative ones.

What the physiotherapy session looks like

Initial sessions after cast removal focus on assessment: range of motion in all wrist and forearm directions, grip and pinch strength, skin and scar mobility, and a functional movement screen. The physiotherapist measures where the deficits are and maps a program around them.

Hands-on treatment includes joint mobilisation to restore passive range of motion, soft tissue work on the forearm and wrist, and specific manual techniques to address restrictions in the midcarpal and radiocarpal joints. For surgical cases, incision scar mobilisation is a specific skill and starts once the scar has matured enough to be worked.

Exercise prescription is individualised: what movement is available, what is restricted, and what daily activities matter most to the person. Someone who plays guitar has different priorities from someone who works in construction. The program is built around those priorities.

Timeline expectations

Recovery time depends on the fracture pattern, on whether a plate was needed, on age and bone quality, and on how soon rehab starts. In our clinic, a typical non-operative arc runs from light daily tasks (typing, eating, dressing) in the first weeks after cast removal, through moderate tasks (driving, carrying bags), to most activities within the first few months, with strength continuing to build after that.

For surgical cases, where a plate has been inserted to hold the bone in position, the immobilisation period is sometimes shorter (plates allow earlier movement), and in our clinic the overall recovery to full function usually runs longer than for a non-operative fracture, with strength the last thing to return.

These patterns assume physiotherapy starts promptly after cast removal or after surgical wound healing. In our clinic, people who delay physiotherapy by several months tend to arrive with more residual stiffness and take longer to recover it.

Red flags to report to your surgeon or physiotherapist

Not all wrist fracture recovery follows a predictable path. Contact your treating clinician or surgeon if you experience any of the following:

• Increasing rather than decreasing pain more than six weeks after injury
• Colour or temperature changes in the hand or fingers (blue, purple, or cold hand suggests circulation concerns)
• Burning or electric pain in the hand (possible nerve involvement)
• Swelling that is worsening after six weeks
• Finger flexion that is not returning after two to three weeks of therapy

Complex regional pain syndrome (CRPS) is a rare complication of distal radius fracture where pain and swelling become disproportionate to what the healing timeline would predict. Early recognition and treatment change the outcome.

Booking physiotherapy after a wrist fracture in BC

Physiotherapy for distal radius fracture is direct-access in BC: you do not need a referral to book. Your surgeon may refer you automatically; if not, you can book independently.

Extended health plans generally cover physiotherapy for fracture rehabilitation under the physiotherapy benefit; check your plan for the limit. If the fracture is from a fall at work, WorkSafeBC can cover physiotherapy under an accepted claim. If the fracture was from a motor vehicle accident, ICBC covers physiotherapy as part of the claim. Bring the claim number to your first visit and we handle the billing.

Physiotherapy is available at all five of our Metro Vancouver studios: Lougheed, Coquitlam, Richmond, New Westminster, and North Burnaby.

Frequently asked questions

Can I do physiotherapy while still in a cast?

Yes, but the focus is limited to fingers, elbow, and shoulder during the cast phase. The wrist itself is not worked until after cast removal. Some physiotherapists see patients during the cast phase to prevent unnecessary stiffness from accumulating; others see patients starting at cast removal. Both approaches are reasonable depending on how the early weeks are going.

My wrist still feels weak months after the cast came off. Is that normal?

Grip strength is usually the last thing to come back after a distal radius fracture, and it keeps improving for months. If you did not do formal physiotherapy after cast removal, starting now is still useful. Strength can improve even months after the initial injury, because the limiting factor is often stiffness and unloaded muscle rather than the bone.

Will my wrist ever feel completely normal?

Many people return to full or near-full function. Some residual stiffness or mild aching with sustained gripping or wrist extension is common and often improves over the first year. Older adults with pre-existing wrist changes, and people with complex fracture patterns, are more likely to keep some limitation. The physiotherapy goal is the fullest function your wrist can reach for the tasks that matter to you.

Does it matter if I use my right or left hand?

The dominant hand is typically slower to feel fully recovered because people test it against a higher standard in daily tasks, noticing small deficits in writing or fine motor work sooner. The recovery process itself is the same regardless of which hand was fractured. The physiotherapist will assess both hands to establish the deficit accurately and set expectations from there.

How soon after cast removal should I start physiotherapy?

Soon after the cast comes off, since that is when the wrist responds best to gentle mobility work and when finger stiffness is easiest to reverse. Bring your cast-removal paperwork or the surgeon's note if you have one, so the physiotherapist knows the fracture type and any loading limits. If you are unsure whether the timing still matters for your case, an assessment will tell you where things stand.

Can physiotherapy help if I never had treatment and it has been over a year?

It can still help, though the pattern is different from starting early. Chronic stiffness and residual weakness from an old fracture often respond to a structured mobility and strengthening program, even without the tight timeline of the acute phases described above. A physiotherapist can assess what range and strength are missing now and build a plan around that, rather than the fracture stage itself.

What are the two motions that are hardest to get back after a wrist fracture?

Wrist extension, bending the hand back, and forearm supination, turning the palm upward like accepting a coin, are the two functional motions most consistently restricted by weeks in a cast. Both are also among the most used in daily tasks, from typing to carrying a plate, which is part of why early mobility work after cast removal focuses heavily on restoring them.

What is the difference in recovery between a fracture treated with a cast and one treated with surgery?

A plate inserted surgically to hold the bone in position sometimes allows earlier movement because it stabilises the fracture directly, so the immobilisation period can be shorter. In our clinic the overall recovery to full function for a surgical case usually runs longer than for a non-operative fracture, with strength typically the last thing to return in either case.

This article is general information, not personal medical advice. The phases described apply to typical distal radius fractures and may differ based on fracture type, surgical approach, and individual healing.

Sources

• Brigham and Women's Hospital Distal Radius Fracture Rehabilitation Protocol
• CHCPBC: College of Health and Care Professionals of BC
• Falls and wrist fractures in pickleball