Stages of Fracture Healing

Fracture Healing

• Primary Healing: occurs when fixation methods provide compression and stability, allowing direct regrowth of bone across the fracture line
• Secondary Healing: occurs when motion is not eliminated across the fracture gap, resulting in a fibrous callus repair phase later converted into bone
• Stages of Fracture Healing:
  • Inflammatory Stage (5-7 days): characterized by hematoma formation, growth factor release, and early stability
  • Repair Stage: hematoma is replaced with a gradually forming soft callus, converted into a hard callus (early bone)
  • Remodelling Stage: angiogenesis, osteogenesis, and remodeling

Primary Healing

• Faster union compared to secondary healing
• Advantages: precise anatomical reduction, avoidance of peripheral callus, and immediate initiation of post-operative motion
• Important note: strengthening or overloading muscletendon structures must be delayed to similar timeframes as per secondary healing

Distal Phalanx Fractures

• Most commonly associated with crush injuries
• Hypersensitivity is a common client complaint
• Do not require immobilization, but often splinted for protection
• Therapeutic considerations: initiate desensitization program as soon as wound healing permits

Metacarpal Fractures

• Represent 30-35% of hand fractures
• More stable than phalangeal fractures
• Usually involve the neck
• Commonly caused by fight or fall
• 4th and 5th metacarpals are most often involved
• Importance of proper splint positioning: MCPJ flexion, MCPJ extension
• Treatment: orthosis/cast (ulnar or radial gutter), MCPJ immobilized in 70 degrees of flexion, IP's within splint to allow full flexion and extension for 3-4 weeks
• Strengthening beginning at 6 weeks

Metacarpal Fractures: Hand Therapy Following ORIF

• Referred to hand therapy within 72 hours
• Orthotic application (volar vs dorsal)
• Wrist in extension, MCPJ's flexed, and the IPJ's extended
• Edema control and AROM
• Intrinsic minus, intrinsic plus, isolated FDS, EDC gliding, and isolated FDP

Proximal Phalanx Fractures

• Represent 15-20% of hand fractures
• Usually proximal or mid-shaft level
• More unstable than metacarpal fractures
• Respond unfavorably to immobilization
• Functional outcome related to severity of injury: open fractures, comminuted fractures, and associated soft tissue injuries
• Treatment considerations: edema draws the PIPJ into a predictable pattern of deformity, ROM initiation, and coban application

P1 Fractures: Complications

• PIPJ extension lag
• PIPJ flexion contracture with pseudoclawing
• FDS and FDP adherence
• Limitations in both flexion and extension
• Treatment priorities: which motion is most functionally limiting, and which motion is most difficult to attain

Middle Phalanx Fractures

• Occur with less frequency (8-12%)
• Main cause: crush injury
• Distal portion mostly common involved
• P2 Fractures: common # - Volar Plate-Avulsion-#
• Avulsion-Fracture Classification: Type 1, Type 2, and Type 3