Management of Lower Limb Fractures PDF

Mona Selim Faggal  OBGECTIVES OF THE LECTURE At the end of this lecture, the student will be able to:  Define the Principles of Fractures management.  Understand How to Handle Fractures.  Know the bone healing process.  Understand the different types of fixation.  Differentiate...

Mona Selim Faggal  OBGECTIVES OF THE LECTURE At the end of this lecture, the student will be able to:  Define the Principles of Fractures management.  Understand How to Handle Fractures.  Know the bone healing process.  Understand the different types of fixation.  Differentiate between different types of internal fixation  Differentiate between different protocols of rehabilitation for lower limb fractures  Complications of the fractures: Infection Avascular necrosis Mal-union (deformity of shortening) Joint disruption Adhesion Injury to large vessels Injury to muscle Injury to nerves Injury to viscera Contracture Union of fractures It depends on the following factors  Type of bone  Classification of fracture  Blood supply  Fixation  Age Delay union – This indicates that healing is taking longer than would normally be expected. Mal union- This indicates that healing is taking with deformity Non-union- This indicates no healing occurs DR. Mona selim DR. Mona selim  In rigid fixation  Very slow  2 weeks from the time of injury.  Intact intramedullary vasculature  New bone grows directly across bone ends  Cannot bridge fracture gabs  No radiographic evidence of a bridging callus  Depends on osteoclastic resorption of bone followed by osteoblastic new bone formation DR. Mona selim  The most common type of bone healing  absence of rigid fixation.  characteristic radiographic appearance of callus formation.  bridging callus adds stability to the fracture site  Greater motion at fracture site greater callus  Occurs with casting, external fixation, & IMN DR. Mona selim The Gustilo-Anderson Classification of Soft Tissue Injury in Open Fractures Type I Wound less than 1 cm long Minimal soft tissue damage, no signs of crush Usually simple transverse or short oblique fracture with little comminution Type II Wound more than 1 cm long Slight-to-moderate crushing injury, no extensive soft tissue damage, flap, or avulsion Moderate fracture comminution and contamination Type III Extensive wound and soft tissue damage, including muscles, skin, and (often) neurovascular structures Greater degree of fracture comminution and instability High degree of contamination  Three stages of fracture management Deal with any open wound Attend to the fracture until it is united Mobilize the joint and rehabilitate the limb DR. Mona selim First aid The patient should not be moved Definitive treatment: 1-Reduction 2-Fixation 3-Rehabilitation Reduction: Closed (Manipulation) Usually with anesthesia Open reduction( when closed is failed) – Allows very accurate reduction – Risk of infection – Usually when internal fixation is needed Methods of fixation: External fixation(plaster casting) Frame fixation(skeletal external fixation) Internal fixation:– Intramedullary nails, compression plates, screws, wire sutures Sustained traction  Skin traction Skeletal traction sites External fixation(plaster casting) Frame fixation (skeletal external Internal Sustained Traction fixation) fixation  The disadvantages of internal fixation are: 1-No casts. 1. The risk of infection at 2- Prevent skin pressure the time of operation. 3- No complications of bed 2. The additional trauma of rest operation. 4-Important for the elderly 5- Early motion 3. A wide exposure is 6- Avoid stiffness needed to apply screws and plates 7-Enhance fracture healing 8-Prevent muscle atrophy mona selim Method of fracture FIXATION determines the mode of bone healing  Stress-sharing devices do not provide rigid fixation.  Stress-sharing devices Permit partial transmission of load across the fracture site.  Micro motion at the fracture site induces 2ry bone healing with callus formation.  E.g. casts, intramedullary nails & external fixators  Shields fracture site from stress by transferring stress to the device.  Fractured ends held under compression and no motion at fracture site.  Stress shielding devices provide rigid fixation result in 1ry bone healing without callus formation.  E.g. compression plating & static locked intramedullary nail.  Because primary bone healing is a slow process, compression plate fixation requires a long period of non-weight bearing (3 months).  Before fracture healing all weight is borne by the plate, which may not withstand early loading.  External Pin, screw, plate rod cast fixator wire biomechanics Stress sharing Stress sharing Stress shielding Stress sharing Stress sharing Type of bone 2ry (callus) 2ry (callus) 1ry 2ry (callus) 2ry healing (no callus) (callus) Rate of bone fast fast slow fast fast healing Weight bearing early delayed late early early mona selim 1. To prevent respiratory complications → breathing exercises. 2. To prevent circulatory complications → -active exercise either by static or isotonic muscle activity- circulatory exercises - changing position every 2 hours - alternating air mattress 3. Maintain joint range where possible To prevent stiffness, weakness & atrophy of the free parts → - ROM exercises - strengthening exercises 4-Reduce edema – to prevent the adhesion formation (bandaging and elevation) 5-Maintain muscle function by active or static contraction 6-To prevent weakness of immobilized parts → static & isometric exercises 7-Maintain as much function as allowed by the particular injury and the fixation 8-Teach the patient how to use special appliances such as crutches, sticks, frames, and how to care for these or any other apparatus Goals: To reduce any swelling To regain full range of joint movement To regain full muscle power To re-educate full function  Is the most commonly used to classify intracapsular femoral neck fractures  Surgery may be indicated depending on the type of fracture. In general:  Type I is an incomplete fracture or valgus impacted fracture.  Type II is a complete fracture without displacement.  Type III is a complete fracture with partial displacement of fracture fragments.  Type IV is a complete fracture with total displacement of fracture fragments  Garden stage I and II are stable fractures and can be treated with internal fixation eg Dynamic hip screw DHS  Garden stage III and IV are unstable fractures and hence treated with hemi or total hip replacement. Garden classification for femoral neck fractures Non-displaced or stable and can bear the full weight minimally displaced immediately after surgery, with no limitations femoral neck fractures: on range of motion (ROM) Early mobilization to prevent morbidities Displaced femoral neck associated with recumbence. fractures Full weight bearing (FWB) is encouraged. WB is not allowed (TDWB) or non-weight bearing (NWB) until fracture Intertrochanteric hip healing is demonstrated. Unstable fractures WB should be delayed until good bony healing Subtrochanteric compression screw device and a static locked fractures intramedullary nail REHABILITATION PRINCIPLES Postoperative rehabilitation of patients with operatively treated fractures depends on the following factors: Open or closed fracture. Open fractures have much higher incidences of delayed union and nonunion and have a poorer prognosis for healing than do closed fractures. Extent of injuries associated with open fracture: this considers the mechanism of injury (high or low energy); the degree of soft tissue damage; the fracture configuration, comminution, and stability; the level of contamination; and concomitant neurovascular injuries. Stability of fracture fixation (strength and type of fixation used) Concomitant fractures of the ipsilateral or contralateral lower extremity. Other fractures may change the rate of rehabilitation and the progression of weight bearing. Overall medical condition of the patient. Some conditions are associated with delayed fracture healing, such as alcoholism, immunocompromise, and systemic diseases. Presence of superficial or deep infection. OTHER CONSIDERATIONS Bone graft by history. If bone loss is more than 50% of cortical surface, early bone grafting is recommended at 6 to 8 weeks after the soft tissue environment has stabilized. Autogenous cancellous iliac bone is preferred. Knee and foot ROM. Active ROM exercises of the knee and foot should be continued whenever possible throughout the rehabilitation protocol to avoid knee flexion contracture or equinus deformity. Early stabilization of fractures in patients with multiple injuries reduces the incidence of pulmonary complications (adult respiratory distress syndrome, fat embolism, and pneumonia), decreases the number of days in the intensive care unit, and shortens the hospital stay. The rate of rehabilitation may be slowed in type III wounds by soft tissue considerations. Anderson found that type III fractures averaged 3 months until soft tissue healing was complete. FRACTURES OF THE LOWER EXTREMITY The goals of successful treatment of lower extremity injuries are (1) restoration of functional ROM (2) rehabilitation of all muscle-tendon units (3) unrestricted weight bearing. GENERAL PRINCIPLES OF REHABILITATION -Phase 1(0 to 6 weeks), mobilization of adjacent joints protected weight bearing -Phase 2 (6 weeks to 3 months), strengthening and endurance exercises progressive weight bearing; -Phase 3 (3 to 6 months), progression to full unsupported weight bearing, agility and endurance training, reentry into work and recreational activities -Phase 4 (more than 6 months), resumption of normal activities. Rehabilitation after ORIF of hip fractures Bed mobility while maintaining proper alignment of the operative limb Lying flat on back for 1 hour/day to avoid hip flexion contractures. Forced hip flexion or rotation avoided for the 1st 7-10 days postoperatively. Semi reclined position is allowed after 24 hours. Patients are assisted into protectively positioned side-lying as soon as possible(2-3 days postoperatively). Side lying position greatly aids in: - toiletry - pulmonary postural drainage - prevention of decubitus (pressure) ulcer. An over head trapeze is essential during the 1st few days postoperatively (using elbows & heels to elevate hips→ 4 times body weight force acts on the hip). [email protected] Gait training with walker or crutches if balance & mobility are good. Over 12-16 weeks gait pattern will evolve into full weight bearing based on: - surgical procedure - area of fracture - radiographic findings - patient comfort Gait training with walker or crutches if balance & mobility are good. Active exercises through a comfortable range Pool exercises to regain strength, proprioceptive sense & mobility. ( there is approximately 75% off-loading with immersion to the level of the xiphoid process and about 50% with immersion to the level of umbilicus. Nb. Tying a shoe with foot on floor requires 124o hip flexion Ascending stairs requires 67o hip flexion Sitting down on a chair requires 104o hip flexion Day 1: Quadriceps sets hamstrings sets gluteal sets ankle pumps Active assisted hip abduction & adduction Supine leg slides for flexion of hip & knee Upper extremity exercise Day 2: Ambulation with TDWB with walker, then PWB with walker Days 3-7 SLR in all directions Thomas stretch of anterior capsule and hip flexors [email protected] Discharge criteria: 1. Get out of bed independently 2. Able to ambulate 50 feet with assistive device 3. In & out of bathroom independently. Standing hip abduction, adduction, flexion, and extension & hip and knee flexion exercises. Progress ambulation from walker to use of a cane Stationary bicycle, pool exercises, and treadmill