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Musculoskeletal Lecture > Fractures (Exam 4) > Flashcards

Fractures (Exam 4) Flashcards

1
Q

Fractures of the UE

A

Ways to classify fx:
* Location in the bone
* Angle of the fracture
* Number of fragments
* Skin closed or open - stable or unstable
geometry: transvers, oblique, spiral
comminuted, vertical
site: base, shaft, neck or head
deformity: rotational, angular or
with shortening

*Very common in winter
Stable - we can do a little bit more, maybe start protective
motion
Unstable - Dr has to go in and make it stable
Comminuted - broken into many pieces
Rotational - if fx rotates it requires surgical correction

  • Shortening of radius is a problem and happens often after distal radial wrist fx

Oblique - clean diagnol
Spiral - it twisted
Angulated - one side is tilted
Impacted - compression force that not only fx bone but
drove the ends together
Distracted - now a gap vs displaced - shifts over
Pathological - cancer or tumor
Comminuted - in multiple pieces

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2
Q

Classifications of Fractures

A

Comminuted Fracture - involves shattering of bone into pieces; usually takes the longest to heal

Compound/Open Fx - bone pierces through skin

  • These take a while to heal and have ossification
    (healing of bone)

Incomplete Fx - greenstick fx, characterized by a small crack and is most commonly found in children
(hairline fx) often w/ athletes in calcaneus in feet
* don’t go all the way across the bone, common in children

Complete Fx - all the way thru the bone
simple fx, transverse, oblique, impacted
can be angulated, displaced, distracted and
pathological
Growth plate fx thru the epiphyseal plate

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3
Q

General Timeline for Fracture Healing

A

Inflammatory Phase: 1-2 wks
hematoma forms on the fx site
tissues come together to begin
bone repair

Regeneration: 2-6 wks
healing takes place - regrowth of bone and
vascular tissue, soft callus turns to hard
callus and direct union

Remodeling Phase: 6 wks to a year
strong bone tissue (ossification) is at
the fx, rigidity of callus dramatically
improves btwn 6-8 wks

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4
Q

Growth Plates

A
  • Kids have growth plates that on an x-ray look like a fx
    these allow growth to occur and is a normal finding in a
    child
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5
Q

Ages of epiphyseal plate closure

A

humerus (proximal/medial end) 10-15 yrs
(distal/lateral) 9-15 yrs
radius - (prox/med) 14-19 yrs
(distal/lateral) 16-22 yrs

  • You can not ultrasound over an epithelialize (epiphyseal)
    plate - it could stunt growth
  • It is important to get fx in child assessed soon and casted
    soon - children heal quick, healing could already start in a
    displaced position
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6
Q

Factors affecting Healing

A

Oblique will take longer then transverse
Compound will take longer than a simple
Blood flow - does bone have poor blood flow in first place
(scaphoid)

Amount of damage
Method of fixation
Association of soft tissue injuries

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7
Q

OT Role in Fracture Management

A
  • Splinting - protection, immobilization, gain ROM
  • Edema control - elevation, massage, ice
  • Pain Control/Modalities - TENS, cryotherapy, hot packs,
    US, NMES
  • Regain ROM - Gentle AROM first
    AAROM
    PROM
    Stretching last

**Edema control and scar tissue are the most important things we can do b/c edema turns into fibrosis and we don’t want stiff thick tissue in addition to fx

** Always start with gentle AROM

Goals:
Regain Function/ADL and Self Care
Regain Sensation
  * Desensitization, Fluidotherapy
  * Neuromuscular re-education
  * Proprioception and kinesthesia
  * Strengthening - when bone healing allows

*** Keep in mind that it is most likely for accidents to occur
in ADLs b/c pts do not transition precautions to
everyday life - so it is important to teach compensatory
techniques with ADLs - nothing heavier than a slice of
bread or a toothbrush

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8
Q

OT Evaluation Acute Stage

A
  • Pain level
  • Edema
  • Associated soft tissue injury
  • ROM in involved or adjacent joints depending on
    precautions
  • Inspect for any deformity/mal-alignment especially in
    MCs

Order:

  • Protect fx - pt education, splinting
  • Edema and soft tissue swelling/inflammation reduction
  • Pain reduction
  • ROM/mobility improvement
  • Strength increased to functional level (LTG)
  • Ability to perform previous occupational tasks (LTG)
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9
Q

Complications Associated with Fractures

A

1) Delayed union or non-union caused by:
- infection
- poor blood supply
- fragments
- movement of parts after fixation, etc

2) Malunion - rotation of spiral fracture or angulation
healing but at unusual angles. Fx healed in
the wrong position

  • Malunion can effect ROM and/or cause pain
    Tx typically involves refracturing or cutting the bones
    realignment, and fixating them with hardware so that
    they heal in the correct position
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10
Q

Choices for Fracture Fixation

A
  • Fractures that are stable will often have closed methods
    of fixation such as a cast or splint
  • Fractures that are displaced or unstable will require
    some form of internal fixation
  • External fixation is used when traction is needed to hold
    a fx out to length. Not seen as much w/ the development
    of the newer plate fixation techniques
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11
Q

Fracture Stabilization Techniques

A
  • Internal fixation
    • screws
    • plates
    • K-wires
    • tension bands
    • wire loop
  • External fixation
    • cast
    • external fixator
  • Combination of fixation
    • splint with ORIF (open reduction internal fixation)
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12
Q

Percutaneous Pinning

A
  • This can be added after reduction to provide additional
    stability
  • Pins for 6-8 wks
  • The superficial radial nerve is affected in up to 25%
    when pins used at distal radius
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13
Q

Complications Associated with Fractures

A

1) Adherence of tendons resulting from edema, surgery or
soft tissue injury over a fracture

2) Joint stiffness and contracture after immobilization

3) Occasionally development of CRPS (complex regional
pain syndrome) especially with distal radius fx

** Secondary to fx - body does not know how to heal layer
by layer, but heals one wound one scar

** Dorsal side of MC are common to having adhesions and
if adhesions in carpal bones it affects flexion

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14
Q

Humeral Fractures

A

Do well unless really compounded
* Start with Codmans pendulums early and AAROM
* Always have exercises with ext rotation (BIG ONE)
* Active assistive with pulleys, they are able to move
sooner

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15
Q

Fracture of the Elbow

A
  • Very difficult to rehab
  • Distal humeral fx - so many parts, doctors use a lot of diff
    terms, but the higher number the more complicated fx
  • Sometimes the tricep muscle is affected and possibly
    could suffer a laceration

The Unforgiving Elbow
* High risk of contractures and motion loss following
fx and dislocation
* Nerve injury often accompanies fractures of the elbow
* High risk of the development of heterotopic ossification
(HO) in brachialis

** Must get them moving quickly
** With olecranon and distal humerus often nerve injury
HO and it likes to scar down to anterior joint capsule
which can lead to muscle loss in both flexion and ext
b/c can’t pull through, so we do not aggressively
stretch elbow - must do soft tissue work

** towel roll behind elbow more affective than 
    aggressive stretching
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16
Q

Brachialis Tone Issues and Adhesions

A
  • The brachialis runs across the anterior joint capsule and
    will adhere to it which will lead to motion loss in both
    flexion and extension
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17
Q

FACTS

A
  • Loss of flexion is more limiting functionally
  • Extension loss is more common (-20)
  • Extension loss is more challenging
  • Radial head fx fairly easy to treat
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18
Q

Tx for Non-displaced Fracture

A
  • Sling for a few days
  • Elbow flexion and extension with forearm in neutral
  • Supination and pronation with elbow flexed at 90

Week 3
* AROM as tolerated
* This is the dangerous week b/c pt starts trying to resume
normal activity - which they should NOT - they can move
in any direction but BREAD RULE

** No resistance for 8-10 wks (with any dx) even with putty
or pinching b/c force is transmitted right up humerus or
radius

** Careful with elderly - cast will throw them off balance
(they already have balance and proprio issues)

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19
Q

Displaced Radial Head Fractures

A
  • Require fixation (usually plates and screws)
  • May or may not have a splint
  • Gentle AROM
  • Management depends on what other structures are
    involved
    Ex: tore the interosseous membrane - have to keep in
    supination
20
Q

Dynamic vs Static Progressive Splints to Restore Flexion and Extension

A

Dynamic splints - rely on the time dependent property of
creep to create joint change or “grow”

Static progressive splints - use the biomechanics principle
of stress relaxation to restore ROM

21
Q

Distal Radius Fracture

A
  • One of the most common fractures in adults and usually
    from a fall on an outstretched hand (FOOSH)
  • Often associated with co-occurring injury
  • Radial fractures can cause shortening of the bone which
    can lead to ulnar abutment syndrome

Colles - dorsal angulation
Smith’s - volar angulation of distal fragment, less common
occur in younger pt and the result of high energy
trauma on the volar flexed wrist

22
Q

Colles Fractures

A
  • Fracture of the distal radius with DORSAL angulation
  • Surgical goal restore radial length and joint alignment to
    avoid ulnar abutment syndrome (compression of TFCC)
  • If fracture crosses the distal radial ulnar joint (DRUJ) or
    has involvement of the ulna then supination, pronation
    and radial/ulnar deviation will be affected

Tx: Closed reduction - no incision made, the fx is manipulated and realigned under X-ray fluoroscopy or just by feeling and a cast is then usually applied

23
Q

Non-Articular and Articular Fractures

A
  • Non-articular fractures:
    • easier to treat
    • can be treated non-operatively w/ immobilization
  • Articular Fractures:
    • involve the joint surface
    • usually require external fixation to re-establish normal
      anatomical surfaces and alignment
    • if the joint surfaces are not preserved this will lead to
      pain, limitations in motion and arthritis from wear and
      tear
24
Q

Ulnar Variance

A
  • If they don’t restore the length of the radius - ulnar
    variance will occur

Normal slope btwn radius and ulna - 22 degrees, allows
room for TFCC that lives there

  • Ulnar negative - does not happen with fx
  • Ulnar positive - (ulnar abutment) radius shortened which
    changes distribution of forces, TFC gets
    pinched
25
Q

Ulnar Abutment Syndrome

A

Presentation:
* Ulnar sided wrist pain
* Pain with supination (ulna migrates distally with sup)
if a positive variance exists then more pressure on
TFCC and carpals
* Pain with weight bearing and power grip secondary to
change in load
* Normally a 22 degree incline btwn ulna and radius.
Weight is distributed approx 80% radius and 20% ulna
* Pain especially with sup combined with grip

** Typically the radius takes 80% of load when we weight
bear and ulna takes other 20% of load in normal
anatomically aligned wrist (80/20) if changed ulna has to
take over load, so if radius is 70% then ulna takes 30%
load and it can’t b/c it is not designed to - so TFCC takes
load and this causes pain

** When we supinate the ulna slides distally - so not only
does the radius length change but now supination adds
even more of compression force to TFCC

26
Q

Kienbock’s Disease: Avascular Necrosis of the Lunate

A

Lunate is also right in an area that takes a lot of pressure

and can develop avascular necrosis of the lunate - when the lunate does not get enough blood

27
Q

Articular Fractures

A

Fx of the articular surface of the radius - to prevent they do volar plate or dorsal plate fixation, put back with a T

Articular surfaces have to be preserved

28
Q

Physician Intervention After Distal Radius Fracture

A

Closed Reduction:
used with fx that have only minor fragments, is usually
non - displaced or easily reduced and the joint surface is
preserved. A cast applied after the fracture is reduced (set)

Surgical Fixation Method:
arthroscopic pinning
volar or dorsal plating and screws
cast applied 2 wks the wrist control splint

29
Q

External Fixation

A

Used on:
* unstable fx
* when the fractures extend proximally up the radius
* radoiocarpal joint too smashed
* open and grossly contaminated fx
* joint space has been compromised (not enough space
or the articular surfaces don’t match up)

30
Q

ORIF - Open Reduction Internal Fixation
Open Reduction = surgeon makes an incision to re-align
the bone
Internal Fixation = bones are held together with hardware
pins, plates, rods, screws

A
  • Volar plate fixation most common procedure but starting
    to see some dorsal
  • Goal to restore close to normal anatomical position and
    joint surfaces
  • Casted 2 wks (immobilized)
  • After 2 wks
    • performing tendon glides
    • AROM of digits
    • edema control
  • Then thermoplastic wrist control splint is fabricated
    • pt is instructed to remove splint to perform gentle
      ROM exercises 3-4 times a day
      wrist control splint is more circumferential than a
      wrist cock-up splint

** Metal plate with screws you have tendons laying right on top and could get tenosynovitis occurring b/c of it and can present a problem for the nerve (anytime you have plates and screws)

31
Q

Management of Carpal Fractures

A
  • Carpal fx are less common than distal radius fx
  • Scaphoid fx are the second most common wrist injury
    and most commonly fractured carpal bone
  • Carpal fractures can be a diagnostic challenge
  • If the fracture is stable, immobilization for 6-8 wks is
    the tx of choice
32
Q

Scaphoid (Most important of carpal bones b/c it bridges the first and second row of carpals)

** Longest healing bone in the body

A
  • 60 - 80% of carpal fx involve this bone
  • Forearm and thumb will have a thumb spica cast with IP
    free for 6-8 wks
  • Wrist immobilization with slight palmar flexion and radial
    deviation
  • Splinting after cast removal is common
  • Men are 10 times more likely to fx than women
  • Mechanism of a scaphoid fx = FOOSH

This fx is missed b/c
* It feels like a sprain
* Unlike the forearm, hand, and finger bones, fx of the
scaphoid rarely show any obvious deformity
* Diagnosis delayed for weeks, months, even yrs
* The fx may occasionally be invisible on the first X-ray
only to show up on an X-ray taken weeks or months
later when bone re-absorption at the fracture site occurs

Common Presentation:

  • Pain in snuffbox ( could have swelling)
  • Limited ROM due to pain (extension/RD)
  • Decreased grip strength
  • Painful grip and pinch

Healing time:

  • Expected time to union for acute fx is 6 - 24 wks
    • distal third = 6 - 8 wks
    • middle third = 8 - 12 wks
    • proximal third = 12 - 24 wks

Scaphoid Fractures:

  • Proximal pole fx
  • Waist fx
  • Tubercle fx

Proximal Pole fractures - do not heal well secondary to
retrograde blood flow. These fx must undergo ORIF of either screw or pinning and might require a bone graft. Doctor has to re-establish blood flow

Therapy for a Scaphoid Fracture:
* A cast or splint is worn during fracture healing (6-8 wks
unless ORIF performed then they can move sooner)

  • Encourage movement of digits and proximal joints, not
    thumb
  • Avoid heavy lifting, gripping, contact sports, and activities
    such as climbing ladders
  • Initially in therapy the goal is to control the pain and
    edema

Complications of Scaphoid Fractures:

  • CTS
  • Radial sensory n. (anatomical snuff box)
  • Edema
  • Pin infections
  • CRPS not near as common
  • Ligament injuries - don’t get caught right away
33
Q

Functional AROM goals for wrist injury

A

Keep the patients focus on realistic goals
* Goal is pain free functional range
* To be independent in most ADLs an individual should
have the following:
- 40 wrist extension
- 40 wrist flexion
- 50 forearm pronation
- 50 forearm supination
- 40 degree arc of ulnar and radial deviation

34
Q

The Importance of Extension

A
  • The most important principle after distal radius fractures
    is to re-establish independent wrist extension
  • Wrist extension required for functional grip strength
    - 35 and 40 degrees
35
Q

Tx While in Cast

A
  • AROM of elbow, shoulder, forearm, digits and thumb
  • Edema management - elevation and ice
  • Mirror therapy
  • Pt education - precautions and activity modification
  • Tendon glides

After casting or immobilization:
* Begin wrist AROM
* Begin static progressive or dynamic splinting if stiff
* Pain control - TENS, ice, E-stim for muscle re-ed
* Functional activities / ADLs
* Ultrasound for tightness or scar tissue - can’t do with
metal plate, will burn them from inside out

36
Q

Joint Stiffness

A
  • Big problem after long term immobilization
  • Joint mobilization (traction and dorsal/volar glide)
  • Soft tissue mobilization
  • PROM
  • Heat and stretch
  • Serial static splint
  • Dynamic/static progressive splints
  • Table top stretch/prayer stretch
  • CPM

*** Occupation based activities are the best
once able to do ADLs have them do these

37
Q

Clinic Activities for Flexibility, ROM and Strengthening

at 8 wks

A
  • Exerstick - hand and wrist exerciser
  • Digiflex - resistance varies

Considerations:
* Important to monitor for paresthesias in hand secondary
to casting
* Monitor for CRPS
* Extrinsic extensor tightness can develop so stress early
on composite fisting
* Encourage shoulder, elbow, and forearm exercises 3-4
times a day to prevent secondary problems
* As ROM exercises are initiated for wrist, be sure pt
exercises while grasping an object. This allows pt to
isolate wrist extensors from the extensor digitorum
communis (EDC)

38
Q

S/S of CRPS

A
  • Intolerable and continuous burning or throbbing pain
  • Extreme sensitivity to touch or cold
  • Swelling
  • Changes and fluctuations in skin temp
  • Changes in skin texture, appearance, hair and nail growth
  • Joint stiffness, muscle spasm, progressing to inability to
    move and function
39
Q

Extrinsic vs Intrinsic Tightness

A
  • Intrinsic Tightness - ( lumbricals, dorsal and volar
    interossei) when PIP flexion is less in the intrinsic
    plus (hook position) and greater in composite fist
  • Extrinsic tightness - (digit flexors and extensors FDP,
    FDS, EDC, EIP and EDM all come from outside of the
    hand and get tight in composite fist
Intrinsic plus (hook position) - MPs hyperextended which
puts the intrinsics on a stretch then flex DIP and PIP (only measure PIP) if you can not get fingers all the way into this position or flexion measurements are greater in composite fist than intrinsic plus = you have intrinsic tightness

Extrinsic tightness - MPs into flexion, which puts intrinsics in a lax position and stretches the extrinsic, then flex DIPs and PIPs if this flexion is less than the intrinsic plus or you can not go into whole fist then you have extrinsic tightness

40
Q

Fractures of the Digits

A

Closed and Non-displaced:

  • Splint or cast
  • Buddy tape
  • Follow closely with X-ray
  • Active motion permitted once pain and swelling resolve

Closed Displaced/angulated:
* Manipulation/reduction of bone and external
immobilization with cast or splint
* Manipulation and percutaneous pinning
* Manipulation and application of an external fixator
* Initiation of active motion will depend on stabilization
technique and rate of fracture healing

Open, displaced, intra-articular, comminuted
* Open tx involves exposure and direct manipulation of fx
* K-wires
* Interosseous wires
* Plate and screws
* External fixation
* Intramedullary device
* Bone grafting
* Tension band technique
* Initiation of motion will depend on stability of fixation
technique and rate of fx healing
* Rigid external fixation such as plate and screws allows for
immediate AROM
* Semi-rigid fixation: Begin motion based on resolution of
pain, swelling and radiographic evidence of healing

41
Q

Fracture Consolidation

A

Varies within each segment of the hand

  • Metacarpal fx: 3-5 wks
  • Proximal phalanx shaft fx: 5-7 wks
  • Middle phalanx fx: 10-14 wks
  • Distal phalanx fx: 3-4 wks
42
Q

Metacarpal Fractures

A

30 - 50% of hand fractures
* Consolidation: 3-5 wks
* Fx site more stable secondary to intrinsic Mm
* Most common fx is the head or neck of the 5th MC
(boxer’s fracture) should have ulnar gutter splint
* Metacarpal fx are characterized by excessive dorsal
edema
* MP joint should be placed in 60-90 degrees of flexion so that collateral ligaments are put on a stretch
* Fracture in dorsal angulation (interossei)
* Fourth and fifth digit can accept some angulation
* Second and third can NOT take beyond 15 degrees of
angulation

Clinical Alignment - fingers should point toward scaphoid

43
Q

Proximal Phalanx Fractures

A
  • Represent 15 - 20% of hand fx
  • Common in thumb and index finger
  • Proximal or mid-shaft area
  • Spiral or oblique
  • Proximal portion takes 3-5 wks
  • Mid-shaft takes 7-8 wks

** Volar angulation of the fx secondary to interossei
attachment on the proximal piece and the central slip
insertin on the distal portion
** Adhesions bad in these fractures

Tx: finger gutter splint
buddy taping

44
Q

Middle Phalanx Fractures

A
  • Represent 8-12% of hand fractures
  • Consolidation 10-14 wks
  • Splinting as needed
  • Buddy strap
45
Q

Distal Phalanx Fractures

A
  • Represent 40-50% of hand fractures
  • Crush injury
  • Quick Healing 3-4 wks
  • Very painful, hypersensitivity
  • Nail matrix injury
  • Tuft fracture is a comminuted fx of the distal phalanx
  • Soft tissue injuries such as Mallet and Jersey are
    avulsion fractures

Musculoskeletal Lecture (14 decks)

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