Contracture is seen commonly following Distal Radius Fractures (DRF), and surgical management is being used on an increasing number of DRF patients 1 2 . Greater frequency of surgical procedures may come from the desire to help patients restore stability, correct articular malalignment, and regain mobility more expediently 3 4 5 6 7 .

Patient satisfaction through increased joint mobility has been the primary outcome measure in numerous studies that examined the current therapeutic protocols for treating DRF 8 9 10 11 12 13 and protocols supplemented with prolonged durations of therapeutic stretching 14 15 16 17 18 19 . Franco et al conducted a randomized, cross-over, cohort study of 45 asymptomatic patients treated with static splints (which restricts mobility similar to immobilization) 4 . After treatment in a restrictive, static splint, Franco et al concluded that immobilization creates incrementally significant functional limitations.

Prolonged stretching has been shown to have a significant effect on connective tissue in molecular examination 17 and clinical trials 18 19 . Dynamic splinting employs passive, prolonged stretching which has proven responsible for contracture reduction in other joints and pathologies 13 14 15 16 . The purpose of this retrospective study was to evaluate the initial effect of dynamic splinting on wrist extension (active range of motion), in both surgical and non-surgical patients following distal radius fractures.

There was a significant improvement in motion for all patients (P = 0.0001, T = 10.126, df 132; see figure 2). The mean increase was 16° AROM for all patients (SD 2.1). A normal statistical distribution of data was seen in both the initial AROM measurements and the final AROM, and these measurements were highly correlated. There was not a significant difference between patients who received previous surgical treatment or Physical Therapy (PT) plus WED, (74% PT+WED, N = 101, P > 0.05). The results showed no significant difference among gender or in the duration between fracture and WED treatment (Mean 3.9 weeks, Range 3-20 weeks, SD = 3.87, P > 0.05).

This modality was responsible for regaining 62% increased active range of motion which will directly affect function. The efficacy of dynamic splinting for contracture reduction was similar to results from the Carpal Tunnel study by Berner and Willis. The results of that study showed efficacy of dynamic splinting in reducing symptoms from carpal tunnel syndrome 15 . The outcome measured changes in Levine-Katz function/pain survey and nerve conduction, which showed statistically significant differences 15 The benefits of WED in this retrospective cohort study were comparable to results seen in a case report on dynamic splinting for contracture following radial nerve injury 13 . McKee and Nguyen's case described a 76 year old patient who suffered a radial nerve injury following a shoulder replacement. They found that dynamic splinting helped this patient regain motor functions that were previously disabled by the excessive wrist flexion contracture 13 . Molecular analysis has proven prolonged stretching responsible for connective tissue elongation 14 15 16 , as employed in dynamic splinting.

The lack of difference between surgical patients vs. non surgical patients supports the hypothesis that contracture was caused by the combined effect of the distal radius fracture and the associated soft tissue injury. Several manuscripts have recommended studies examine increases in function following treatment for a distal radius fracture 1 2 3 . The duration of WED treatment ranged from 3 to 20 weeks and the mean duration may be skewed because of patients who discontinued using the WED in less than two months, after full ROM was restored.

The physical therapists were not blinded so their methods included the WED as the primary stretching protocol; therefore the therapists spent more time on higher therapeutic protocols for weight bearing, load bearing, and dexterity. Time saved in manual stretching due to the assistance of the dynamic splint was often dedicated to motor dexterity training for handwriting. Since there was not a significant difference with physical therapy, each surgeon should examine the specific needs. In this study the Medicare co-payment for each patient included $20/mo for the WED vs. $200 to $500/mo in co-payments for PT 3/wk. That savings would be substantial for the patients and insurance providers.

The limitations of this study include lack of a control arm. While duration from fracture to contracture was not categorized, all patients were fit with WED within one week from diagnosis of wrist flexion contracture, secondary to DRF. Clinicians often discredit case series manuscripts because such studies lack control group(s) and can have selection bias. However, this study did examine different cohort treatment groups (surgical vs. nonsurgical and physical therapy with dynamic splinting vs. exclusive dynamic splinting) 20 . This study was independent of "measurement bias" because all measurements used in data analysis were taken by clinicians, before initiation of this retrospective investigation.

Kooistra et al wrote a detailed description of the strengths and weaknesses of Case Series studies where they described that such studies can effectively generate a hypothesis for future controlled trials and prove safety of a new protocol 20 . They also described that a retrospective design more clearly reflects what is seen in routine clinical practice because treatment selection was chosen by the surgeon and patient, not by a randomized table. This fact is the cornerstone to their proclamation that retrospective cohort series studies have high external validity 20 .

This retrospective study on WED for contracture reduction, secondary to DRF showed safety as there was only 1 in 133 incidence of skin breakdown and no report of significant adverse events from these treatments. This study was the first investigation of dynamic splinting for contracture reduction following distal radius fractures, and the authors recommend this work be followed by a randomized, controlled trial to measure empirical efficacy of this modality in contracture reduction.

There was no extramural funding for this study. SHB had no conflict or competing interest, and has not received any funds or compensation for his participation in this study. FBW is employed by the parent company of Dynasplint Systems but he has no stock, options, or ownership in either company.

All authors contributed equally to this work. SHB and FBW both participated in the design

of the study and manuscript. FBW was responsible for the literature review and manuscript development. The data analysis was done independently by a biostatistical professor for Texas State University, Dr Ram Shanmugam. All authors read and approved the final manuscript.