Topic 6. Bone Fractures PDF

28/01/2023 Unit 6 Fractures and Physiotherapy 1 FRACTURES Interruption of bone integrity , when a force acts on the bone causing the separation of two or more fragments Classification according to ▪ ▪ ▪ ▪ ▪ Aetiology. Mechanism of production. Soft tissue injuries. Pattern of disruption. Fracture...

28/01/2023 Unit 6 Fractures and Physiotherapy 1 FRACTURES Interruption of bone integrity , when a force acts on the bone causing the separation of two or more fragments Classification according to ▪ ▪ ▪ ▪ ▪ Aetiology. Mechanism of production. Soft tissue injuries. Pattern of disruption. Fracture stability. 2 2 1 28/01/2023 AETIOLOGY CLASSIFICATION Usual: single trauma. Low energy. High energy. Insufficient or pathological: General processes. Local processes. Due to fatigue or stress: In normal bone. In pathological bone. 3 3 MECHANISM CLASSIFICATION • . Direct mechanism: at the site of impact of the force responsible. Indirect mechanism: at some distance from the site of trauma : Traction fractures. Compression fractures. Torsion fractures. Flexion fractures. Shear fractures 4 4 2 28/01/2023 SOFT TISSUE CLASIFICATION Closed Fractures:. The bone breaks but there is not open wound in the skin • Open Fracture: • The bone breaks through the skin • Bad pronostic for sepsis complications . 5 5 PATTERN OF DISRUPTION Incomplete: the fracture line does not affect the full thickness of the bone. Fissures: without separation of the bone fragments. Green stem or inflexion fractures. Complete : the solution of continuity affects the entire thickness of the bone, producing two or more independent bone fragments . 6 6 3 28/01/2023 STABILITY CLASSIFICATION Stable: no tendency to displace after reduction. Fractures with a transverse line or with an obliquity of 45º. Unstable: tend to move after reduction. Obliquity > 45° (except spiroid). 7 7 Fractures Types and pronostic 8 8 4 28/01/2023 Fracture Healing A. Fracture hematoma :24 /72 hrs B. Granulation tissue :3 – 14 days C. Callus formation (minerals deposited in fracture site) : 2- 4 weeks) D. Proliferation/ossification (4 wks – 6 wks). E. Remodeling to original shape, strength > 6 weeks 9 CONSOLIDATION FACTORS 1. Type of bone. 2. Age. 3. Separation of fragments. 4. Interposition of soft tissue. 5. Circulatory disturbances. 6. Foreign body infections. 7. Stability of the fracture site. 10 10 5 28/01/2023 MEDICAL PROCEDURE. 1. Patient stabilisation and damage control.: Xray, etc 2. Reduction: Closed: Manipulation CONSOLIDATION Traction Open. : Stabilization How to do it : 1.Orthopaedic.: plaster cast or orthosis 2. Surgical. Relative: external fixator. Absolute: plates, screws and interlocks. (Internal Fixators) 11 11 Internal Fixators Internal Fixators (IF) Orthopaedic I 12 12 6 28/01/2023 PHYSICAL THERAPY ASSESMENT. 1. What treatment could be performed : ▪ Orthopaédic ( cast , orthesis) ▪ 2. Surgery ( osteoshyntesis) Periods ▪ Inmobilization ▪ Mobilization. 3. General Outcomes ▪ Encourage bone healing ▪ Avoid stiffness. ▪ Prevent muscle atrophy. ▪ Restore limb functionality ▪ Avoid complications. ▪ Train the patient in the use of assistive devices and orthotics if necessary . 13 13 Orthopaedic IF Inmobilization 4 weeks Inmobilization 2/7 days Mobilization 14 14 7 28/01/2023 PHYSICAL THERAPY ASESSMENT ORTHOPAREDIC TREATMENT “4 Weeks” SURGERY “1 Week” INMOBILIZATIÓN PERIOD /MAXIMAL PROTECTION Objective Physic Agent/Intervention Maintain mobility and function of the uninjured structures. Load training “Normal exercise” at non-injured sites + stretching routine Supporting EET if any instablity is caused in fracture Mechanical Pain. Conventional TENS, Dyadinamics. Remove compressive aplications and advice surgeon/Nurse. Neurovascular Pain. Maintain involved muscles trophysm injured site muscles Isometric controlled exercise, painfree Support of EET if any instability is caused in fracture. Reabsorption of hematome –Limb above heart, Prevent loss of motor patterns –Biofeedback, Virtual Reality. Monitoring further complications. –Contact health care profesional. –Nutritional advice. 15 15 PHYSICAL THERAPY ASESSMENT ORTHOPAREDIC TREATMENT “5-8 Weeks” SURGERY “2 Weeks” MOBILIZATIÓN PERIOD/MODERATE PROTECTION Objective Physic Agents/interventien Maintain mobility and function of the uninjured structures. Load training “Normal exercise” at noninjured sites + stretching routine if possible. –Increase load & resistance of exercise. –PNF Pain Analgesia : TENS, IF Thermotherapy, Massage Recover muscles trophism and joint mobility –Isotonic exercise (dynamic) –Manual therapay, active mobilization –Basic PNF activities Recover normal motor patterns (FUNCTION) –Increasing weight bearing/loading → active rest –Basic PNF activities 16 16 8 28/01/2023 PHYSICAL THERAPY ASESSMENT ORTHOPAREDIC TREATMENT MOBILIZATIÓN PERIOD/MINIMAL PROTECTION Objective INCREASE: mobility of the injured structures. INCREASE: Strenght and Endurance INCREASE: Functional patterns Physic Agents/interventien –Any type of active mobilization –Activities adapted to functional requirements – Progression Concentric/ eccentric –Support of electro estimulation if necessary –Walking,running –Sports training 17 17 Advantages for P.T in Surgical reparation ▪ Best quality in reduction and fixation Early mobilization: preventing stiffness. Reduction of Inmobilization period Less further complication ▪ Possibility of active mobilization : the muscle perfomances are maintained Possibility of partial load: promotes bone healing ▪ Weight Bearing Progression : 0-25-50-100% 18 18 9 28/01/2023 FRACTURES AND COMPLICATIONS 19 FRACTURES COMPLICATIONS Joint stiffness. Avascular necrosis. Uncorrect bone consolidation. Compartment Syndrom Complex regional pain syndrome 20 20 10 28/01/2023 JOINT STIFFNESS • Common complication of fracture following excessive immobilization • Common site : knee, elbow, shoulder, small joints of the hand • Causes ➢ Oedema & fibrosis of the capsule, ligaments, muscle around the joint ➢ Adhesion of the soft tissue to each other or to the underlying bone (intra & peri-articular adhesions) ➢ Synovial adhesions d/t haemarthrosis 21 JOINT STIFFNESS • Treatment ➢ Prevention : - Exercise and mobilization ASAP - If joint has to be splinted/casted → Make sure in correct position ➢ Joint stiffness in course : - Intra-articular adhesions → Gentle manipulation under anaesthesia followed by continuous passive motion(CPM) - Adherent or contracted tissues → Released by operation 22 11 28/01/2023 AVASCULAR NECROSIS • Local area of bone necrosis • Common site : • Causes ➢ Femoral head ➢ Femoral condyls ➢ Interruption of the arterial blood flow ➢ Humeral head • Symptoms : ➢ Scaphoid (proximal part) ➢Joint pain, stiffness, swelling ➢Restricted motion ➢ Capitulum of humerus ➢ Talus (body) ➢ Lunate 23 AVASCULAR NECROSIS • General Treatment ➢ Avoid weight bearing on the necrotic bone ➢ Revascularisation (using vascularised bone grafts) ➢ Replacement by prostheses 24 12 28/01/2023 AVASCULAR NECROSIS WARNING SIGNS Pain that increases with movement. Periarticular muscle atrophy. Stiffness of the joint onset. Adoption of antalgic positions. Limitation of functional capacity. Progressive claudication (MI). 25 25 JOINT STIFFNESS / AVASCULAR NECROSIS PROTOCOLE OBJECTIVE THERAPY Increase flexibility of local peripheral tissues – Superficial thermotherapy. – Massage therapy. – Not deep thermotherapy. Obtain normal joint motion –Avoid sudden mobilisation. – Active kinesiotherapy if there is no pain. – Proprioception and PNF. – Orthopedic manual therapy. Avoid further complications –Postural education of the patient. –Therapeutical exercise –Splinting if necessary. 26 26 13 28/01/2023 Consolidation Problems • Fracture takes more than the usual time to consolidate. • Causes ➢ Inadequate blood supply ➢ Severe soft tissue damage ➢ Excessive bone traction ➢ Infection ➢ Insuficient inmobilization • Pseudoarthrosis: the fracture will never consolidate Malunion : the fragments are unsatisfactory position ( angulation, rotation or shortening) 27 CONSOLIDATION PROBLEMS Clinical features Pain at the fracture site Joint stifness GOAL FAVOURING BONE CALLUS CREATION INTERVENTION –Immobilisation monitoring. – TENS and Low Intensity pulsed US. – Magnetotherapy Cochrane Database Systematic Reviews 2011. 28 28 14 28/01/2023 COMPARTMENT SYNDROME A set of signs and symptoms resulting from an increase in interstitial pressure in a closed osteofascial compartment, in which capillary perfusion is reduced below the level necessary for cell viability causes significant morphological and functional sequelae due to tissue necrosis. . Volkman R. Die ischaemischen Muskallahmangen undKontrakturen. Zentralbl Chir. 1881. 29 29 COMPARTMENT SYNDROME • Profilaxis: – Inmovilización adecuada y posición correcta del yeso. – Movilización frecuente de articulaciones libres. – Vigilancia de aparición de los signos y síntomas. Advertencia al paciente. 30 30 15 28/01/2023 COMPARTMENT SYNDROME INITIAL PHASE : GOAL INTERVENTION OEDEME PREVENTION – Elevation of the limb. – Low pressure evacuation massage. – Passive kinesitherapy. MAINTAIN MOBILITY –ACTIVE MOBILIZATION –DAILY MONITORING LIMB –SPLINTING 31 31 COMPARTMENT SYNDROME GOAL SCAR CARE INTERVENTION –Massage –Active mobilization 32 32 16 28/01/2023 COMPLEX REGIONAL PAIN SYNDROME • Previosly known as Sudeck’s atrophy • Post-traumatic reflex sympathetic dystrophy • Chronic pain disorder as result of dysfunction in the central or peripheral nervous system. • Clinical signs ➢ Continuous, burning pain ➢ Early stage : Local swelling, redness, warmth ➢ Later : Atrophy of the skin, muscles ➢ Movement are grossly restricted 33 The International Association for the Study of PainIASP divides CRPS into two types: Type I: Reflex sympathetic dystrophy (Südeck syndrome). There may be previous tissue injury but no nerve injury. Type II: Causalgia. There is chronic nerve damage. Sensitisation of algoreceptors. Permanent vasoconstriction. Capillary stasis: ↓ PO2 and Ph, ↑PCO2. State of acidosis: trophic alterations, . 34 34 17 28/01/2023 35 35 COMPLEX REGIONAL PAIN SYNDROME • Prevention: ▪ ▪ ▪ Immobilization as short as possible and painless. Isometric muscle work during immobilization, if is possible . Mobilization of non- immobilized healthy joints. 36 36 18 28/01/2023 Stage I :Pain > 5 FROZEN PERIOD 37 37 Treatment • Stage II: Pain < 5 . RESOLUTION • Increase mobility specific to involved tissues: neural mobilization soft tissue manipulation • Improve fuctional performance : Strenghth muscles afected Endurance of limb 38 38 19