Fracture

Question 1

What are fractures?

Answer 1

• 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

Question 2

Complete Fractures

Answer 2

• 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

Question 3

Incomplete Fractures

Answer 3

• 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

Question 4

Colle’s - Common Fractures:

Answer 4

• 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

Question 5

Galeazzi

Answer 5

• 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

Question 6

Pott’s

Answer 6

• 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

Question 7

Dupuytren’s

Answer 7

• 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

Question 8

Common Stress Fracture Sites:

Answer 8

Tibia
Metatarsals
Navicular
Femur
Pelvis

Question 9

Causes of a Fracture

Answer 9

•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

Question 10

Stages of Healing

Answer 10

1. 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.

2. 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

3. 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

4. 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

5. 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

Question 11

Medical Treatment of Fractures

Answer 11

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

2. In an open reduction:

The bones or bone fragments are stabilized by devices such as screws, nails, wire, metal plates

Question 12

Early Complications:

Answer 12

• 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

1. 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

2. Nerve Compression:

May be indicated by paresthesia in the tissues under the cast

3. Vascular damage:

Untreated vascular damage may be indicated by an increase in observable distal red, black or blue bruising

4. Bone & soft tissue infection:

Can occur with external fixation or skeletal traction along the pin tract if proper wound care is not observed

5. 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

6. 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

7. 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

8. Loose cast syndrome:

• Occurs when a cast that is to loose rubs on bony prominence, causing skin abrasions

Question 13

Late complications

Answer 13

• 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

1. 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

2. 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

3. 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

4. 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

5. 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

6. Disuse osteoporosis:

• May occur with prolonged immobilization
• It is reversible once full use of the limb is regained

Question 14

Symptom Picture

Answer 14

• 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

1. 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

2. 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

Question 15

Health History Questions

Answer 15

• •

1. What is your general health?
2. When did the fracture occur?
3. Do you know the mechanism of injury?
4. Do you know what type of fracture?
5. What other healthcare practitioners are you seeing for this injury?
6. What type of immobilization was used if any?
7. If there was an open reduction, were implants such as pins, screws, wires or plates used
8. Are you taking any medication?
9. Are you using any supports?
10. What symptoms are you currently experiencing?
11. Are any early complications present?
12. What are your ADL’s?

Question 16

Observations

Answer 16

1. 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

2. 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

Question 17

Palpation

Answer 17

1. 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

2. 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

Question 18

Testing

Answer 18

1. 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

2. 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

3. 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

Question 19

Contraindications

Answer 19

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

2. 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

Question 20

Treatment during immobilization

Answer 20

• 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

Question 21

Treatment immobilization removed

Answer 21

• 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

Question 22

Treatment reduction without casting:

Answer 22

• 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

Question 23

Self care:

Answer 23

1. 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.

2. 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