Fracture Flashcards
What are fractures?
- A break in the continuity of a bone
- Fractures are classified into several types according to the nature of the break, its location on the bone and the angle of the broken ends
-If the skin is intact it is termed a closed or simple fracture
- If the ends of the bone have broken through the skin or into one of the body cavities, it is called an open or compound fracture
- Fractures may be complete, where the bone is broken into two or more pieces or incomplete where the bone is bent or cracked and the periosteum remains intact
Complete Fractures
- Transverse-usually stay in place after reduction, but they take longer to heal
- Oblique-difficult to keep in place but they heal more rapidly
- Spiral-difficult to keep in place but they heal more rapidly
- Comminuted-often unstable because it consists of two or more fragments, making healing difficult
- Avulsion-occurs when a ligament pulls the portion of bone that it is attached away from the bone
- Osteochondral-occurs when fragments of articular cartilage are sheared from the joint surface often during a dislocation or sprain
Incomplete Fractures
- Compression-the bone is crushed and usually occur in cancellous bone (vertebral body)
- Greenstick-the bone is bent or partially broken, as when breaking a green twig.
Usually found in children younger than 10 years of age when the bones ar more pliable - Perforation-the result of a missile wound, such as a bullet
- Stress-cracks in bone due to overuse or repetitive actions
Colle’s - Common Fractures:
- Fracture of the wrist where a transverse fracture of theradius just proximal to the wrist allows the fragment to rotate and displace dorsally
- This gives the wrist the classic “dinner fork” deformity before it is reduced
- Most common fracture in older people
*Usual mechanism of injury is a FOOSH
- Can be difficult to reduce successfully
Galeazzi
- Involves a break of the radial shaft and a dislocation of the inferior radioulnar joint
- The mechanism of injury is usually a fall on the hand with some rotational component
Volar Galeazzi Fracture
Pott’s
- Ankle fracture that affects one or both malleoli
- The distal fibula breaks close to the lateral malleolus
- The deltoid ligament may also rupture or avulse the medical malleoli
- The mechanism of injury is usually eversion with some external rotation
Dupuytren’s
- The fibula fractures higher up, the medial malleolus avulses and the talus is pushed superiority between the tibia and fibula
- The mechanism of injury is usually eversion with some external rotation
- Screws or wires are often used to reduce and stabilize the ankle
Common Stress Fracture Sites:
Tibia
Metatarsals
Navicular
Femur
Pelvis
Causes of a Fracture
•A trauma or sudden force which creates more stress than the bone can absorb
+With a direct force, a bone breaks at the point of impact
+ With an indirect force, a bone breaks at a distance from the site of the force
- Overuse or repeated wear which causes cracks in a bone
- Pathologies such as osteoporosis, tumours, local infections or bone cysts
Stages of Healing
- First stage:
- Hematoma forms around the ends of the fractured bone within 72 hours of the initial trauma
- A mesh of fibrin forms around the injury site
-The ends of the bone die back several millimeters.
- Second stage:
• There is an inflammatory reaction and a proliferation of osteoblasts at the periosteum
• These cells create a fibrocartilaginous bridge between the fragment ends
- Third stage:
- A soft callus or point is formed from the mass of proliferating osteoblasts
- Osteoclasts are also present, cleaning up the dead bone and debris
- As the fibrous, immature bone is gradually calcified, movement at the fracture ends gradually decreases
- Union of the fracture ends occurs at about 4 weeks
- Repair is incomplete because the callus is merely calcified and not yet mature bone
- Fourth stage:
• Consolidation occurs as the immature woven bone is changed into mature lamellar bone
• Consolidation is a complete repair because the callus is now ossified
• It may be several months before the bone is capable of bearing normal loads
• No tenderness at the fracture site
- Fifth stage:
• Remodeling of the irregular outer surface and reshaping of the marrow space inside the bone take place through alternating osteoclastic and osteoblastic activity
• This process is governed by Wolff’s Law, where a bone responds to mechanical stress by becoming stronger and thicker the more strenuous its function
Medical Treatment of Fractures
A fracture may be treated by closed or open (surgical) reduction
1. In a closed reduction:
- Manual traction is applied and the bone ends are realigned
- The fracture is held in place until fracture repair
occurs
- In an open reduction:
The bones or bone fragments are stabilized by devices such as screws, nails, wire, metal plates
Early Complications:
- Include torn muscles and tendons, ligament damage, compartment syndromes, nerve injuries, vascular injuries, joint hemarthrosis, bone and soft tissue infections, DVT and problems caused by poorly fitting casts
- Compartment Syndrome:
- Can occur in the forearm or leg following a fracture
- The swelling that accompanies marked edema, hematoma or inflammation increases the pressure within the fascial compartment
- Nerve Compression:
May be indicated by paresthesia in the tissues under the cast
- Vascular damage:
Untreated vascular damage may be indicated by an increase in observable distal red, black or blue bruising
- Bone & soft tissue infection:
Can occur with external fixation or skeletal traction along the pin tract if proper wound care is not observed
- Deep Vein Thrombosis (DVT):
May occur after a lower limb fracture indicated by pain, an increase in swelling local to the calf and a slight increase in temperature
- Pressure or plaster sore:
• Occurs where the cast ischemically compresses the skin over a bony prominence
• Client initially feels a local burning pain under the cast
- Cast dermatitis:
• May result from poor ventilation and hygiene of the skin under the cast
• Allergic reactions to the chemicals present in fibreglass casts are also possible
- Loose cast syndrome:
• Occurs when a cast that is to loose rubs on bony prominence, causing skin abrasions
Late complications
• Include delayed union and non-union of the fracture, malunion, myositis ossificans, nerve compression, nerve entrapment, bone necrosis, Volkmann’s ischemic contracture, joint stiffness and disuse atrophy
- Delayed union:
- Occurs if the bone does not unite within the expected time frame
- May be due to inadequate circulation, insufficient splinting, excessive traction or infection
- Non-union:
- Failure of the bone to heal before the repair process finishes
- May be caused by an overly large gap between the bone ends wither due to bone destruction, boe less, excessive tractioning, inadequate fracture reduction, bone infection or soft tissue
- Malunion:
- Unacceptable joining of the bone ends so that a deformity occurs
- May be due to improper alignment of the bone ends when the fracture was reduced or displacement of the bone ends while the limb was casted
- Myositis ossificans:
- Bone formation within a muscle, which occurs weeks after the initial trauma
- May also result from muscle injury
- Heterotopic ossification is bone formation within soft tissue
- Volkmann’s ischemic contracture:
- May eventually result after a compartment syndrome or injury to an artery causes ischemic contracture of the affected muscle
- While over time the ischemic muscles in the compartment are replaced by inelastic fibrous tissue, the ischemic nerve may be able to recover partial function
- Disuse osteoporosis:
- May occur with prolonged immobilization
- It is reversible once full use of the limb is regained
Symptom Picture
• Immediately after the fracture occurs and before reduction is performed, unnatural mobility and deformity are present at the fracture site
• Shock, pain, bleeding, inflammation, swelling, loss of function, muscle splinting and edema are present
• Soft tissue is also injured
• With stress fractures, the fracture is painful upon compression
- During Immobilization:
• Following closed or open reduction, the limb may be casted or otherwise immobilized
• Pain in present both locally and possibly at a distance from the fracture
• Tissue repair and callus formation are occurring at the fracture site
• Adhesions are developing around the injury
• Due to immobilization reduced circulation, edema, disuse atrophy and CT contracture occur in the tissues under the cast
• HT and TPs are present in compensating structures
• Short-term complications may occur
- Immobilization removed:
• Fracture site is healing and remodelling
• Decreased tissue health in the tissue that has been under the cast
• Adhesions have matured around the injury
• With open reduction, scars will be present
• HT and TPs are present in muscles crossing the fracture site and in compensating structures
• Muscle weakness or disuse atrophy is likely present in muscles crossing the fracture site
• Occasionally, a pocket of chronic edema may remain local to the injury
• Long-term complications may occur
Health History Questions
• •
- What is your general health?
- When did the fracture occur?
- Do you know the mechanism of injury?
- Do you know what type of fracture?
- What other healthcare practitioners are you seeing for this injury?
- What type of immobilization was used if any?
- If there was an open reduction, were implants such as pins, screws, wires or plates used
- Are you taking any medication?
- Are you using any supports?
- What symptoms are you currently experiencing?
- Are any early complications present?
- What are your ADL’s?
Observations
- During Immobilization:
• Antalgic gait if the fracture is in the lower limb
• Affected limb may be casted or an external fixation device may be used
• Client may have crutches, a cane or possibly a walking cast
•Antalgic posture may be present
• Edema is present at the fracture site and distal
• Red, black or purple bruising may be visible at the fracture site or distal to it
• A pained or medicated facial expression
- Immobilization Removed:
• Habituated antalgic gait and posture may be observed
• Chronic edema may remain at the fracture site and distal
• When a cast is initially removed, the skin that was under is likely dry, scaly or flaky
•Disuse atrophy may be visible
• Bruising should resolve to brown, yellow and green and then disappear
• If surgery was performed, scars will be present
Palpation
- During Immobilization:
• Heat and edema are present at the fracture site, although not palpable due to casting
•Pain is present local to the fracture site and refers into the nearby tissue
• Protective muscle spasm is present in muscles crossing the fracture site
• HT and TPs are present in compensating muscles
- Immobilization Removed:
• Health of the tissues that were under the cast is assessed in the first few days following cast removal
• Conditions may include disuse atrophy, dry or flaky skin, local paresthesia, reduced vasomotor control, signs of inflammation or signs of tissue ischemia
• After one week, as tissue health returns, adhesions associated with the fracture site are palpated
• HT and TPs are present in the compensating muscles
Testing
- During Immobilization:
• Testing of muscles and joints directly involved in the fracture is Cl’d
• AFROM of the proximal and distal joints is assessed within pain-free ranges
- Immobilization Removed:
• AF ROM of the proximal and distal joints may be slowly and carefully performed to the onset of pain only
• PR ROM is performed with care
• Overpressure is Cl’d before consolidation has occurred
• AR strength testing is performed, starting submaximally and increasing gradually to the maximum possible pain-free contraction
- Reduction with No casting:
If a fracture has been surgically reduced either by external fixation or by pins or plates and where no casting is present, testing follows the above protocol
Contraindications
1.During immobilization:
- Limb must not be tractioned before union has occurred
- Hot hydrotherapy applications should not be placed distal or immediately proximal to the cast
- If the fracture was at the site of a muscle attachment or if there was laceration or severance of a tendon crossing the fracture site, to avoid further soft tissue damage, AF and AR isometrics should only be performed with the physician’s approval
- With open reduction, on-site work is avoided until the skin has healed
- Local techniques are avoided until the skin is fully healed if the fracture was treated by open reduction and stabilized without a cast
- Immobilization Removed:
• Overpressure testing of the involved joints is CI’d before union has occurred
• Hydrotherapy temperature extremes are avoided on the tissues that were under the cast
• Until tissue health and muscle tone are regained in the muscles that were under the cast, it is Cl’d to use deep longitudinal techniques on these muscles
• If metal implants such as pins or plates have been used to repair the fracture, avoid local hot hydrotherapy applications
Treatment during immobilization
• Do NOT interfere with the healing process
• Refer the client to the physician if complications are
suspected
• Positioning depends on the location of the fracture and the client’s comfort
• The limb is elevated and secured so no stress is placed on the fracture site
• Hydrotherapy is a cold application to the limb, distal to the cast
• Reduce edema proximal to the cast
• Maintain local circulation proximal to the injury
• Maintain ROM with mid-range pain-free PR ROM to the proximal and distal joints
• Vibrations through the cast over the fracture site may help to decrease SNS
• Work distal to the cast is restricted
Treatment immobilization removed
• Positioning is chosen for comfort and accessibility to the structures that are being treated
• Mild contrast hydrotherapy is initially used on the tissues that were under the cast, this helps to normalize circulation and vasomotor tone
• Once tone has returned, deep moist heat can be used to increase the flexibility of the CT contractures and adhesions prior to treatment
• Reduce edema proximally to the injury site
• Reduce HT and TPs in the area proximal to the injury
• In the area that was under the cast, a textured mitten can be used to gently remove any dead, flaky skin and increase local circulation
• Stimulating light techniques are used on the muscles with disuse atrophy
• Maintain ROM with pain-free mid-range passive relaxed and active assisted ROM until tone has improved
• Once consolidation has occurred, careful joint play is indicated to mobilize contractured joints that were under the cast and restore the ROM
• Reduce any chronic edema around the fracture site
• Reduce HT and TPs proximal to the injury site
Reduce adhesions once the muscle tone has improved or if minimal disuse atrophy is present
Treatment reduction without casting:
• With a fracture that was medically treated by open reduction without a cast, or by reduction using an external fixation device, care must be taken to avoid interfering with the healing process until union occurs
• With a stress fracture that is not casted, on-site massage is Cl’d while the fracture site is tender
• Proximally, the limb is treated using the techniques described in the immobilization treatment
• Once any external fixation devices are removed and the pin tracks are healed, work is done to decrease adhesion and scar formation
• After union has occurred, techniques that focus on circulation, drainage and reducing adhesions are indicated
• Once consolidation has occurred, passive forced range and joint play as listed in the immobilization removed section can be used to increase ROM
Self care:
- During Immobilization:
• Educate the client on signs of early complications and hydrotherapy for their presenting symptoms
• Safely maintain ROM and strength in compensating structures
• As soon as the physician permits AF ROM of the Joints distal to the cast can begin
• For strengthening, pain free submaximal isometric contractions of the muscles under the cast are performed.
- Immobilization Removed:
•The client can used a textured cloth to gently exfoliate any dry skin
• The limb should be elevated as often as possible to reduce any remaining edema
• Hydrotherapy applications when the cast is first removed are cool to mild contrast on site. Gradually, increasing the temperature difference to help restore vasomotor controll
• Remedial exercise is continued for compensating structures
• Regain strength with AF ROM for joints that were under the cast
• Increase ROM with stretches
• If necessary, increase proprioception at joints that were under the cast
