Management of Lower Limb Fractures

Management of Lower Limb Fractures

• The objectives of the lecture are to define fracture management principles, explain fracture handling techniques, describe bone healing processes, differentiate internal fixation types, and compare lower limb fracture rehabilitation protocols.

Complications of Fractures

• Potential fracture complications include: infection, avascular necrosis, malunion (deformity from shortening), joint disruption, adhesions, injury to large vessels, muscle, nerves, viscera, and contractures.

Bone Healing

• Fracture union depends on bone type, fracture classification, blood supply, and fixation.
• Age affects healing time; delay union indicates slower-than-normal healing, malunion indicates healing with deformity, and nonunion indicates no healing.

Bone Healing Stages

• Bone healing involves four phases: hematoma formation (0-2 weeks), soft callus formation (2-3 weeks), hard callus formation (3-6 weeks), and bone remodeling (8 weeks-2 years).

Primary Bone Healing

• Involves very slow healing in rigid fixation.
• New bone grows directly across fracture ends, with no bridging callus formation.
• This is dependent upon osteoclast resorption prior to osteoblast formation.

Secondary Bone Healing

• The most common type of bone healing, occurring in the absence of rigid fixation.
• Characterized by bridging callus formation which increases fracture site stability.
• Occurs with casting, external fixation, and intramedullary nails.

Gustilo-Anderson Classification of Soft Tissue Injury in Open Fractures

• Classifies soft tissue injury severity in open fractures.
• Type I: Wound < 1cm, minimal soft tissue damage.
• Type II: Wound > 1cm, slight-moderate soft tissue damage.
• Type III: Extensive soft tissue damage, including muscle, skin, and/or neurovascular structures.

Fracture Management Stages

• Three stages for fracture management: deal with any open wounds, attend to the fracture until united, mobilize the joint and rehabilitate the limb.

Principles of Fracture Management

• First aid: Do not move the patient.
• Definitive treatment steps: reduction, fixation, rehabilitation.

Reduction Techniques

• Closed reduction (manipulation): Usually involves anesthesia.
• Open reduction: Used when closed reduction fails; allows highly accurate reduction with increased risk of infection.

Fixation Methods

• External fixation (plaster casting, frame fixation).
• Internal fixation (intramedullary nails, compression plates, screws, wire sutures).
• Sustained traction

Advantages of Internal Fixation

• No casts.
• Prevents skin pressure complications and bed rest complications.
• Is important for the elderly needing early motion.
• Avoids stiffness.
• Enhances fracture healing.
• Prevents muscle atrophy.

Disadvantages of Internal Fixation

• Increased risk of infection during surgery.
• Additional surgical trauma.
• Need for a wide surgical exposure.

Stress-sharing Devices

• Do not provide rigid fixation and permit partial stress transmission across the fracture site.
• Micro motion at the fracture site induces secondary healing with callus formation.
• Materials include casts, intramedullary nails, and external fixators.

Stress-shielding Devices

• Shield the fracture site, transfer stress to the device, and compress fractured ends with no motion occurring at the site.
• Result in primary bone healing and no callus formation.
• Examples include compression plating and static locked intramedullary nails.

Principles of Fixation Devices Comparison

• The table compares external fixators, pins, screws, plates, rods, and casts in terms of biomechanics, type of bone healing, rate of healing, and weight bearing protocols.

Physical Therapy During Immobilization

• Prevent respiratory complications (breathing exercises).
• Prevent circulatory complications (active exercises, position changes).
• Maintain joint range (ROM exercises).
• Reduce edema (bandaging, elevation).
• Maintain muscle function (active/static contractions).
• Prevents weakness in immobilized limbs (static/isometric exercises.)
• Maintaining function (based on injury and fixation type).
• Teaching patient appliance use and care (as needed).

Physical Therapy After Fixation Removal

• Reducing swelling.
• Regaining joint range of motion.
• Regaining muscle power.
• Re-educating full function

Hip Fractures

• Include intracapsular fractures (neck, subcapital, transcervical, basicervical) and extracapsular fractures (intertrochanteric, subtrochanteric).
• These can be classified by the Garden classification. Garden stage I & II are stable, treatable by internal fixation, III & IV are unstable requiring hemi or total hip replacement.

Rehabilitation After ORIF of Hip Fractures

• Initial immobilization with bed mobility, maintaining proper operative limb alignment.
• Avoiding hip flexion for the first 7-10 days postoperatively.
• Starting semi-reclined positioning 24 hours after surgery.
• Encouraging side-lying positioning for toiletry, pulmonary functions and prevention of pressure ulcers.
• Using over head trapeze.
• Gait training with walker or crutches.

Gait Training

• Begins when balance and mobility are sufficient.
• Over 12-16 weeks gait patterns should evolve into complete weight bearing.
• Surgical procedure, fracture area, and patient comfort are factors in transitioning to full weight bearing.

Active Exercises (e.g., pool therapy)

• Active exercises can be used to regain strength, proprioception, and mobility through immersed exercise.
• Immersion provides 75% off-loading to the xiphoid process or 50% off-loading to the umbilicus.
• Hip flexion exercises, such as tying a shoe, ascending stairs, and sitting on a chair, require varied amounts of hip flexion.

Hospitalization Phase of Upper End of Femur Fractures

• During the hospitalization period, exercises such as quadrucep sets, hamstring sets, gluteal sets, and ankle pumps are routinely performed.
• Active assisted hip abduction and adduction and supine leg slides increase hip and knee flexion.
• Day two includes ambulation with TDWB, with walker.

Discharge Criteria

• Discharge typically occurs one to two weeks after surgery.
• The criteria involves independence of ambulating and going to the bathroom.
• Activities such as standing hip exercises (abduction, flexion), stationary bicycles, pool exercises, and treadmills, are essential components of the rehabilitation process.

General Principles of Rehabilitation

• Phase 1 (0-6 weeks): Joint mobilization, protected weight bearing.
• Phase 2 (6 weeks-3 months): Strength & endurance exercises, progressive weight bearing.
• Phase 3 (3-6 months): Progression to full weight bearing, agility training, and return to activities.
• Phase 4 (>6 months): Resumption of normal activities.