Lecture 16: UE Fractures Flashcards
What UE fractures have the highest incidence? (Top 3)
- Distal Radius
- Metacarpal
- Finger Phalanx
What are symptoms of an acute presentation for UE fractures?
- 5 diagnostic Ps: Pain, paralysis, parethesia, pallor, pulselessness.
- Mechanism of Injury (Context of the individual age and gender)
- Pt bracing UE against chest/abdomen w/ other arm.
What are the 3 general principles for UE fracture management?
- Early fixation: to promote better outcomes (healing)
- Early mobilization: to avoid the effects of immobilization.
- Early ROM
What is rehabilitation of UE fractures guided by?
- Medical/ surgical management (structures affected and surgeon’s guidelines.
- Functional goals of the pt.
- Detailed functional assessment.
What are the General PT Management procedures for fractures?
- Observe any contraindications or precautions.
- During periods of immobilization prescribe AROM for unaffected joints (especially shoulder if wrist or elbow immobilized)
- Once permitted:
ROM: PROM-AAROM-AROM
Strength: Isom-Concentric-Eccentric-Functional (always pain free)
-Modalities as appropriate and proprioception exercises
Review:
1. What are the advantages of AAROM rather than PROM?
- What are the advantages of AAROM rather than AROM?
- Under what conditions would you opt for PROM exercises rather than AAROM exercises?
- Encourage pt to actively perform movement as much as possible, while providing assistance if their is pain.
- Pt autonomy
- Muscle Activation - Pt can do movement actively but has too much pain.
- When pt has some strength, but not enough to go through the full ROM->add assistance.
- AAROM helps pt do the whole range without pain. - When the pt cannot actively contract their muscle.
- Acute situation when you do not want to involve contractile tissue.
- Muscle attachment near a fracture site for example.
What is the most common mechanism of injury for UE fractures?
Fall on an outstretched hand (FOOSH).
Can result in any time of fracture.
Clavicular Fractures: A) Prevalence B) Main MOI C) Classification D) Medical/Surgical Management E) Main deformity F) PT management
A) 3% all fractures
B) FOOSH or direct blow to the shoulder.
C) Medial Third, Middle Third or Lateral Third
D) Usually managed conservatively w/ immobilization, no reductive. Sling and swathe (4-6 wks) or Figure-of-8 harness (2-3 wks). Rarely surgery: ORIF plate and screw or intramedullary pin.
E) Step in bone: Upward pull sternocleidomastoid (medical 1/3) and downward pull weight of arm.
May affect: ROM, compensations, muscle tightness, impingement, rotator cuff pathology.
F) Starts when # consolidated.
- General PT management
- Goals Restoration of: ROM, strength, scapulo-humeral rhythm (this can be thrown off after #) , function.
With shoulder injuries how do you differentiate between a problem with muscle strength and a problem with the scapula-humeral rhythm?
If you put pt in MMT and they are strong then it is a motor control problem.
If you see problems with motor control and weak MMT then both are a problem.
Scapular Fractures: A) Prevalence B) MOI C) Classification D) Medical and surgical management E) PT management F) What is a common secondary problem with this injury?
A) <0.5% of all #
B) High energy trauma (generally) and direct blow to scapula. Could be FOOSH or avulsion fracture. Glenoid fossa may be # by GH joint dislocation.
C) Classify by location (body, acromion…). Intra or extra-articular for GF.
D) Usually conservative management in a sling (2-3 wks-functional rather than a real joint)
Surgical management: ORIF if displacement of fracture fragments or if glenoid fossa is involved.
E)
p/ 10 days: pendular ex’s (back and forth or side to side, not circular) and PROM gradual progression.
p/ 2-3 wks (radiographic evidence of healing): progressive AAROM
Radiographic evidence of consolidation: Progressive STR ex’s.
F) Cx and Tx spine stiffness
Proximal Humerus Fracture: A) Prevalence B) MOI and Demographics C) Types D) Medical/Surgical management.
A) 6% of all fractures
B) Most common in older women, FOOSH from fall from standing height.
Younger individuals: high energy trauma, forced abduction or a direct blow to shoulder.
C) Location: greater tuberosity, lesser tuberosity, anatomical neck, surgical neck.
# fragments.
Most are non-displaced (85%). Displaced: malalignment of one fracture fragment by >1cm or 45degrees angulation.
D) Medical: Conservative management of non-displaced or minimally-displaced#. Immobilization sling+early ROM.
Surgical: Displaced fractures (especially tuberosities). Internal fixation. Intramedullary nailing- surgical neck fractures. Hemiarthroplasty- excessive bone damage or poor bone quality.
PT management for Proximal Humerus fractures:
A) What muscles insert on the tuberosities?
B) Guidelines for non-displaced fracture
C) Unstable fracture
D) What do you need to watch for during rehab?
A) GT: rotator cuff LT: Subscapularis
B) Start PT 7-14 days.
Flexion: AAROM/AROM and PROM are allowed
IR: AAROM/AROM- yes PROM- caution do not push EOR (stretch tendons on GT)
ER: AAROM/AROM- No for 6 wks PROM- yes
Abduction: AAROM/AROM- No for 6 wks PROM- yes
-Can start gentle isometrics 6-8 weeks, resistive exercises at 12 weeks.
C) Rehab starts at 4 wks, follow guidelines B delay by 4 wks
D) Signs of shoulder stiffness (frozen shoulder: whole capsule is involved: ER>Abduction>IR, capsular pattern of involvement)
Humeral Shaft Fractures: A) Prevalence B) MOI C) What is a possible clinical feature? D) Location and Displacement E) Surgical and Medical Management
A) 1% of all #
B) Most common FOOSH. Direct blow to arm (high-energy trauma).
C) Shortening of the arm
D) Many muscles attach humerus so location of # will affect displacement.
i) Above pec maj: abd prox fragment and add distal frag.
ii) Btwn pec maj and delt tuberosity: add prox and abd distal.
iii) Distal to det tub: abd prx and add distal.
E) 90% conservative. Displacement is acceptable: 20degrees anterior angulation, 30 degrees varus angulation and 3cm overlap fragments.
Conservative: Immobilization. Displaced: coaptation splint, hanging cast. Non-Displaced: Thoracobrachial Immobilization. Stable: functional splint.
Surgical: ORIF, plate and screw preferred to intramedullary rod.
Surgical approach will affect soft tissue:
Anterolateral: brachialis and brachioradialis
Anterior: Biceps and Brachialis
Posterior: Long and lat head triceps.
PT management of Humeral Shaft Fractures
A) Typical
B) Special Considerations
A) No contraindications once MD gives Ok to start PT.
As per general fracture management (progress pain free ROM, STR ex once consolidated)
B) Non-displaced, stable Fx: Sh pendular exercises within 1-2 wks after injury. Prophylaxis against adhesive capsulitis (frozen shoulder).
Distal Humerus Fractures: A) Prevalence B) MOI C) Types D) Medical and Surgical Management
A) 0.5% of all #
B) FOOSH, MVA, sports
C) Named based on anatomical # site (med/lat epicondyle or condyle, capitulum or trochlea)
-Supracondylar
-Transcondylar
-Intercondylar
-Condylar
-Trochlea and capitulum
D) Non-displaced: Splinting-posterior elbow splint w/ 90 degrees elbow flex or posterior long arm splint w/ slight flexion. Casting not preferred.
Displaced or unstable #: ORIF (plate, screws). Total Elbow Arthroplasty if excessive Fx comminution.
