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Introduction to fractures management.pdf
- 1. Fractures classification andHealing Mohammad A. Yabroudi, PT, MS, PhD Jordan University of Science and Technology
- 2. What is fracture(#)? • A break in the continuity of a bone or cartilage. • Common causes: – Fall from a height – Car accidents – Direct blow – Repetitive forces – Pathology 2 • Signs and symptoms: – Swelling or tenderness – Pain – Numbness – Bleeding – Broken skin with bone protruding – Limitation or unwillingness to move a limb
- 3. • Closed fracture:A closed fracture is one where the fracture hematoma does not communicate with the outside (skin contact) • Open fracture: This is one where the fracture hematoma communicates with the outside through an open wound • Stress fracture: It is a fracture occurring at a site in the bone subject to repeated minor stresses over a period of time • Birth fracture: It is a fracture in the new born children due to injury during delivery 1. Traumatic Fracture Types (Causes)
- 4. • It isa fracture occurring after a trivial violence in a bone weakened by some pathological lesion. This lesion may be : • Localized disorder: (e.g. secondary malignant deposit) • Generalized disorder : (e.g. osteoporosis). 2. Pathological Fracture Types ( Causes)
- 5. Fractures • A fractureis Identified by: • Site – Diaphyseal, Metaphyseal, epiphyseal, intra- articular • Extent – Complete, incomplete
- 6. Fractures • A fractureis Identified by: • Configuration – Transverse, oblique, spiral or comminuted (two or more fragments) • Relationship of the fragments – Displaced, or undisplaced
- 7. Fractures • A Fractureis Identified by: • Relationship to the environment – Closed (skin is intact), open (fracture penetrated the skin) • Complications – Local or systematic, related to the injury or to the treatment
- 8. Transverse Fracture A fracture in whichthe # line is perpendicular to the long axis of the bone . Oblique Fracture A fracture in which the # line is at oblique angle to the long axis of the bone. Fracture Types (Line of #) Spiral Fracture # plane rotates along the long axis of the bone. These #s occur secondary to rotational force. Longitudinal Fracture A fracture in which the # line runs nearly parallel to the long axis of the bone..
- 9. Comminuted # : The boneis broken into than two fragments. Stellate fracture: This # occurs in the flat bones of the skull and in the patella, where the fracture lines run in various directions from one point. Impacted fracture: This # where a vertical force drives the distal fragment of the fracture into the proximal fragment. # Types (Anatomical Classification)
- 10. # Types (AnatomicalClassification) Depressed fracture: This # occurs in the skull where a segment of bone gets depressed into the cranium. Avulsion fracture: This is one, where a chip of bone is avulsed by the sudden and unexpected contraction of a powerful muscle from its point of insertion.
- 11. Other Terms usedin describing fracture Greenstick: is the fracture in the young bone of children where the break is incomplete, leaving one cortex intact. Displacement: Undisplaced: Bone ends are still in apposition Displaced: Bone ends do not meet and reduction is necessary Stable: Fracture where the bone ends are held firmly
- 12. FRACTURE HEALING Fracture healingis considered as a series of phases which occur in sequence as follows: (I) Inflammatory Phase. (II) Reparative Phase. (III) Remodeling Phase.
- 13. Inflammatory Phase • Bloodvessels are torn at the site of fracture • Resulting in internal bleeding followed by normal clotting • The amount of bleeding depends on the degree of fracture displacement and the amount of soft tissue injury
- 14. Reparative Phase • Theearly stages of healing take place in the hematoma • Osteogenic cells proliferate from the periosteum and endosteum to from a thick callus, enveloping the fracture site (radiolucent on X-ray)
- 15. Reparative Phase • Ascallus start to mature, the osteogenic cells differentiate into osteoblasts and chondroblasts • Chondroblasts form cartilage near fracture site • Osteoblasts form primary woven bone
- 16. Remodeling Phase • Stageof Clinical Union – Fracture site is firm enough that is no longer moves – Clinically united – Occurs when temporary callus consisting of the primary woven bone and cartilage surrounds the fracture site
- 17. Remodeling Phase • Stageof Clinical Union – On Radiographic examination, the fracture line is still apparent , but there is bone in the callus – Usually at this stage, Immobilization is no longer required – Movement of related joints is allowed with caution of avoiding forces at the site of the healing fracture
- 18. Remodeling Phase • Stageof Radiological Union – The bone is considered radiographically healed, when the temporary callus has been replaced by mature lamellar bone – The callus is resorbed and the bone returns to normal
- 19. Union: Partial repairof the bone, when the initialcallus forms around the bone ends so that there is minimal movement Delayed union: The healingprocess is slower than normal. Non-union: The healingstopped before union occurred. Malunion: The fracture healed in unacceptable position. Consolidation: Full repair of the bone, where no movement takes place at the fracture site Terms used in fracture follow-up
- 20. Factors Affecting BoneHealing Enhancing Youth Early Immobilization of fracture fragments Bone fragments contact Adequate blood supply Proper Nutrition Adequate hormones ➢Growth hormone ➢Thyroxin ➢Calcitonin Inhibiting Age (e.g. Average # Femur Healing Time) Infant: 4 weeks Teenager: 12 to 16 weeks Extensive local soft tissue trauma Bone loss due to the severity of the fracture Inadequate immobilization (motion at the fracture site) Infection Avascular Necrosis
- 21. Fracture - Complications Attime of injury (Immediate) – Haemorrhage and resultant adhesions – Damage to important internal structures (brain ,heart..) – Skin loss ,Shock ,Nerve damage Later Complications Local – Delayed/Mal/ Non-union – Shortening – Joint Stiffness – Avascular Necrosis – Autonomic problems – Myositis ossificans – Infection (Osteitis) – Postcallus complications – Osteoarthritis – Muscle weakness General – Deep Vein thrombosis – Pulmonary embolism – Osteoarthritis
- 22. Fractures Management Mohammad A.Yabroudi, PT, MS, PhD Jordan University of Science and Technology
- 23. Principles of Management: Aims: (A)- safe life (B)-save the limb (C)-save the function 1. Efficient First Aid: This relieves the pain and prevents complications. 2. Safe transport: This help to minimize complications in injures to the spine, fracture of the lower limbs, ribs etc (all fractures should be immobilized immediately ) . 3. Assessment of condition of the patients for shock & other injuries. 4. Assessment of local condition of the injured limb regarding complications like vascular injury, nerve involvement and injury to neighboring joints . 5. Resuscitation. If needed 6. Radiography of the part ➢ X-ray before plaster AP & LAT( to determine site and degree of displacement) ➢ Post Reduction films ( wet plaster) for insurance of good alignment ➢ Follow up films to assess healing ➢ Films Before removal of plaster to confirm complete healing 7. Reduction of the fracture(correction of displacement of fragments and done by : ➢closed Manipulation ➢open reduction (surgery)
- 24. 8. Immobilization: Whenreduction achieved→ Bone fragments must be held in space 1) Conservative: External fixation 2) External fixator 3) Internal fixation Principles of Management:
- 25. • Conservative→ non-surgicalmeans • Slings and collar and cuff (c&c) • Triangular bandage or broad arm sling • Relieve the weight on the upper arm • Injuries around the shoulder, humerus and elbow • c&c • Relieve the weight on the forearm • A body bandage • Offers extreme support and used in acute stages 1. Conservative: External fixation
- 26. • Plaster ofParis (POP): ➢ Gypsonia-impergnated bandages ➢ Fully dry→ 24 hours ➢ Advantages: ➢ Cheap and easy to apply ➢ Useful in immobilizing most fracture sites ➢ Can be easily replaced and placed over small wounds ➢ Disadvantages ➢ Potential vascular occlusion ➢ Pressure sores ➢ Undiagnosed infections ➢ Joint stiffness ➢ Heavy weight ➢ Warm and itchy 1. Conservative: External fixation
- 27. • During immobilization: ➢Patient must keep the non-painful joint moving ➢ Contract all muscles isometrically to maintain muscle tone ➢ Notes any changes in sensation ➢ Changes in color ➢ Increase in swelling ➢ Loss of motor function 1. Conservative: External fixation
- 28. • Traction • Itis used temporarily until: • Skin wounds healed • Muscle spasm reduced so that the correct limb length achieved • Other injuries are treated • Patient is fit enough for surgery • Skin traction • Tape or elastic adhesive bandages are placed around the limb distal to the fracture and weight is suspended from the end to apply traction • http://www.aovideo.ch/published/player.2.aspx?id=90091eem0198 1. Conservative: External fixation
- 29. • Traction • Skeletaltraction • Distraction and realignment • Commonly used in treatment of femoral shaft, tibial, and cervical spine # • http://www.aovideo.ch/published/player.2.aspx?id=90092eem0198 1. Conservative: External fixation Thomas Splint Steinmann Pin Denham Pin
- 30. • Bone fragmentsare held by an external scaffold attached to pin • Monofixators • Tibial fracture (most common) • Pelvis • Humerus • Forearm and fingers • Ankle • llizarov device • Infected/ severely injured • Support fractured limb • Lengthening and bone shaping 2. External fixators llizarov device
- 31. • Advantages • Managementof long bone fractures with severe skin loss or infection • Bone # with severe soft tissue or vascular injury • Easily altered for alignment of bone fragment • Disadvantages • Pin track can be infected (osteomyelitis) • Re-fracture • Unpleasant to see for patient and others 2. External fixators
- 32. • ORIF→ OpenReduction Internal Fixation • Indications • Other methods of immobilization failed • # in more than one bone • Blood supply of the limb is jeopardized • Bone ends cannot be reduced without opening the fracture site to remove muscle and soft tissue debris 3. Operative: Internal fixation Intramedullary nail Wires Locking screws Dynamic hip screw: http://www.aovideo.ch/published/player.2.aspx?id=20156e em0198 Or: https://www.youtube.com/watch?v=IdAykU1uvKI
- 33. • Advantage • Betterchances of obtaining a good reduction and union • Early mobilization both generally (whole body) and specifically (the fractured extremity) • Disadvantage • Risk of infection • Additional trauma or surgery both to bone and surrounding tissue • General anesthesia side effects • Notes • Extra support of the callus may be needed to support the callus (e.g. sling for UE, and non-weight bearing for LE) • Pain, swelling, bruising and apprehension presents after internal fixation (10-14 days) 3. Operative: Internal fixation
- 34. Early physiotherapy: forthe preservation of function of the limb (local complication such as ischemia ,nerve damage ,joint stiffness ,infection ..etc may endanger the function of the limb. Rehabilitation: After union of the fracture to restore full muscle power and joint movements and to make the patient fit for his original job. NOTES: • Fractures are treated by reduction (realignment) &immediate immobilization • In most cases, simple fractures heal completely in approximately 6 - 8 weeks • Compound # better to deal with it within 6hrs of injury to avoid infection • The accurate diagnosis of the fracture (site ,lines and displacement ) is made from X- ray examination. • Two projections is required AP or PA +lateral or oblique • Two joints above and below the site of the # should be included in the radiographs
- 35. Fractures Rehabilitation Mohammad A.Yabroudi, PT, MS, PhD Jordan University of Science and Technology
- 36. • Observe forany sign of POP or traction pressure • Keep the limb elevated to control edema • Observe signs of infection ➢ Staining on the POP ➢ Presence of offensive smell • Keep the movement of mobilized joints (passive ROM) • Strengthening of mobilized muscles (e.g. shoulder training every one hour for pt. with radial fracture) • Not to get the POP wet • Not scratch under the POP • Take pain killers Instructions Following Reduction
- 37. Fracture Management • Periodof Immobilization • There is : – Connective tissue weakening – Articular cartilage degeneration – Muscle atrophy – Contracture development – Overall body weakening if confined to bed
- 38. Fracture Management • Planof Care includes – Education of the patient • Teach functional adaptations e.g. teach safe ambulation with or without assistive devices and bed mobility – Decrease effect of inflammation during acute period • Use of ice and elevation
- 39. Fracture Management • Planof Care includes – Decrease effects of immobilization • Use of intermittent muscle setting. Active ROM to joints above and below immobilized region – If patient is confined to bed, maintain strength and ROM in major muscle groups • Use resistive exercises to major muscle groups not immobilized, especially in preparation for future ambulation
- 40. Fracture Management • PostImmobilization Impairments includes – Decreased ROM, Joint play and muscle flexibility – Muscle atrophy with weakness and poor muscle endurance – If there was soft tissue damage at the time of fracture, an inelastic scar tissue restricts the mobility in the region of the scar
- 41. Fracture Management • PostImmobilization Plan of care includes: • Joint mobilization • Effective for regaining joint play without stressing the fracture site • Active stretching techniques • Hold relax agonist contraction • Monitor the intensity of contraction, don’t apply resistive or stretch forces beyond the fracture site until radiological union
- 42. Fracture Management • FunctionalActivities – The patient can resume normal activities with caution – Early post immobilization, important not to traumatize the weaken muscle, cartilage, bone and connective tissues – Partial weight bearing may be continued until full weight bearing is tolerated
- 43. Fracture Management • Muscleperformance: strengthening and endurance – 2-3 weeks of light isometrics following immobilization – Then light resistance through the available ROM • Scar tissue mobilization • Cardiorespiratory fitness – Aerobic exercises are initiated that do not stress the fracture site
- 44. • The aimis not to move the unhealed fracture and to exercise other joints • Joint motion ➢ Assistive active or passive movement?? • Swelling ➢ Active exercise distal and proximal to the fracture ➢ Elevation • Weight bearing ➢ Non-weight bearing (NWB) ➢ Non to Partial weight bearing ➢ Partial weight bearing (PWB) ➢ Partial to full weight bearing ➢ Full weight bearing (FWB) Acute Unstable #
- 45. • Weight bearing ➢PWB started when some callus formation is seen on x- ray ➢ Touch weight bearing is allowed when NWB is difficult ➢ WB started as soon as possible to promote healing and prevent osteoporosis ➢ Use of walking aids ➢ Muscle strengthening and improve ROM will assist in weight bearing ➢ Restoring balance Acute Unstable #
- 46. • Massage, musclecontraction, and hot bath ➢ Improve circulation an nutrition ➢ Sensory feedback • Function ➢ Encourage functional movement ➢ Gentle and gradual functional activities ➢ Ask patient about functional dysfunction! Acute Unstable #
- 47. • Internal fixationshould not be considered similar to healing • Joint motion ➢ ROM distal and proximal to fracture should be started when the # is stabilized ➢ Continuous Passive Machine (CPM) can be used • Strengthening ➢ Do not apply excessive resistance/WB ➢ Increase resistance gradually ➢ Do not suspend weight distal to the # before consolidation ➢ Establish isometric strength then increase endurance Stable United #
- 48. • Weight bearing ➢Read orthopedic surgeon referral ➢ WB increased as the # and muscle strength increased ➢ Gradual decrease level of assistance ➢ Parallel bars ➢ Walker ➢ Crutches ➢ Cane ➢ No assistive device ➢ Load Vs. pain ➢ Normal weight loading (correct load acceptance) ➢ Patient confidence in the limb ➢ Balance ➢ Strength Stable United #