Lectures 13-14-15: all fractures Flashcards
What would be the main goals for medical management of a fx (3)?
Rehab is guided by (3)?
Goal
- early fixation of the fracture
- early mobilization of the patien
- adapted WB as needed
- Avoid Prof.Gilderoy Lockhart
Rehab:
Medical / surgical management
Structures affected
Surgeon’s guidelines
Functional goals
Detailed functional assessment
What is considered a “conservative management” of a fx
- closed reduction: traction, manipulation
- immobilisaton: slings, casts, braces, traction
Define OREF
OREF (Open reduction, external fixation)
With what tool can we do an internal fixation?
Tension band fixation
– Less bulky than plates
– Induces compression at the fx site
Intramedullary nail or rod
– For fixation of long bones
What are the advantages for internal fixation (3)?
• Precise restoration of anatomy / alignment
• Early mobilization
– Includes WB (partial or full)
• Generally more comfortable
With what are external fixations used primarily?
What are the characteristics of it?
• Used primarily with extensive soft tissues injury
– Closed or Open Fx
– Has ability to neutralize deforming forces
– Often replaced once soft tissue injury is healed
What is the lizarov technique?
External fixation that can be used to
grow bone at a
fracture site
What are the general guideline in PT management? (what to “know”)
• Know the surgical procedure
• Know the structures involved
• Know your anatomy
– Which muscles/tendons will impact on the Fx site?
• Know & respect the stages of tissue healing
– How long before the Fx is stable enough such that
stressing the fracture site will not impede healing?
• Know the case-related contraindications
• Apply principles of rehabilitation
What’s a fracture comminution
High energy fractures are more often associated with multiple fracture fragments, known as
fracture comminution.
Explain an important complication of all open fractures
Risk of infection
What are the five clinical presentation signs of an acute fracture
- Pain – often severe
- Paralysis - partial to full loss of ability to move the affected limb / adjacent joints.
- Paresthesia – subjective loss of sensation associated with tingling (pins and
needles, or ‘fourmillement/picotements’ in French). An objective loss of
sensation may indicate associated nerve damage. - Pallor – the affected limb may appear drained of colour (pale, cyanotic)
- Pulselessness - absence of distal pulse, which may indicate associated arterial
damage
T/F Primary bone healing: 1- involve a callus 2- rely on osteoclast action 3. incude angiogenesis
- T
- F on osteoblast actions to lay down new bone
- F that’s in the secondary bone healing
T/F Secondary bone healing include the development of - new blood vessels - fibrous tissue - cartilage - x-ray visible fracture callus
All T
What factors can influence the rate of fracture healing (6)?
The severity of the Fx (degree of comminution, etc.)
The severity and extent of associated soft-tissue damage
The location of the Fx, and which bone is involved
The management of the Fx (e.g. method of immobilization)
The age and health status of the individual
The individual’s compliance with management
Union, clinical union, consolidation or remodelling?
- fracture considered fully healed
- 3-10 days post-injury
- Stabel fx site
- This step takes twice as long as consolid.
- initial callus formation
- Return to pre-fx state
- Visible fracture line on x-ray
- poor biomechanical properties
- No line on x-rays (radiological union)
- No WB
- Immobilzation terminated
- This step take twice as long as fx union
- Callus with calcification
- Fx stable, no mvt
- PT become involved
Union (U), clinical union (CU), consolidation (C) or remodelling (R)
- fracture considered fully healed - C
- 3-10 days post-injury - U
- Stabel fx site - CU
- This step takes twice as long as consolid. - R
- initial callus formation - U
- Return to pre-fx state - R
- Visible fracture line on x-ray - U, ±CU
- poor biomechanical properties - U
- No line on x-rays (radiological union) - C
- No WB - U
- Immobilzation terminated - CU
- This step take twice as long as fx union - C
- Callus with calcification - CU
- Fx stable, no mvt - C
- PT become involved - CU
Name some complications that can happen with fx
- MSK related: 11 tot
- Non MSK: 5 tot
MSK: infections fix. failure neurovasc compromise malunion delayed union - non-union post-trauma arthritis stiffness/loss of rom osteonecrosis heterotopic ossification complex regional pain synd (CPRS) acute compartment syndrome
Non-MSK atelectasis pneumonia pressure sores urinary tract infection thromboembolic event (DVT, PE, CVA, stroke)
(More info: p8 document on fx, lect 13)
patients presenting with a thigh or groin pain (old and younger) should be r/o for what type of fx?
femoral neck stress fx
How does a femoral neck stress fx present?
- thigh groin pain
- slight (referred) pain along medial side of the knee
- walk with a limp
- no obvious deformity
- discomort hip AROM/PROM
- ms spasm EOR
- gr.troch percussion is painful
Femoral diaphysis fx: what the post-op rehab will focus on (3)?
– Quadriceps and hamstrings exercises
– Unrestricted ROM of hip and knee
– Weight bearing: Generally FWB / WBAT -> Depends on associated injuries, etc.
Femoral diaphysis fx: what complication can happen (3)?
Knee Stiffness, Knee Pain, and Hip Pain
– Limited knee flexion
• ant. scarring of quadriceps (esp. Vast. Intermedius)
• Treatment - aggressive rehab. incl. active knee flexion
– Knee pain → retrograde nails
– Hip pain → antegrade nails
What is the criterias in the ottawa knee rule (5)
Knee radiograph following acute knee-injury if one
or more of:
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex to 90 degrees
Inability to WB 4 steps: immediately and in ED
What is the indication for non operative tx for the patella?
And the general tx?
– Non-displaced # with intact extensor mechanism
Tx: splint 4-6we
PWB/WBAT + crutches
Quads sets, SLR
What is the indication for patellectomy?
highly comminuted & displaced #
What is a complication of patellar fx? And the tx?
• Loss of knee flexion – options, in order, are:
aggressive PT for at least 6-8 weeks
manipulation under anesthesia
arthroscopic lysis of adhesions
indwelling epidural anesthesia, CPM & intensive
physical therapy
– quadricepsplasty may be considered with failure to
progress after 8 to 12 months
What are the ottawa ankle rule for the ankle x-ray
• Ankle X-Ray following acute injury if:
Pain in malleolar zone and any of the following:
– Bone tenderness at post edge or tip of lat malleolus, or
– Bone tenderness at post edge or tip of medial mallolus, or
– Inability to weight bear immediately and in ED
What are the ottawa foot rule for the ankle x-ray
Foot X-Ray following acute injury if:
Pain in midfoot and any of the following:
– Bone tenderness at base of 5th MT, or
– Bone tenderness at Navicular, or
– Inability to weight bear immediately and in ED
why is ankle fx important to be splinted in a neutral position
to avoid equinus contracture
Name a key management component for calcaneal fx
Ankle (talocrural & subtalar) ROM exercises to
prevent hindfoot stiffness
• During wear of fracture boot, for non-operative
management
• Once fracture site is deemed stable for operative
management
What is common MOI for femoral neck and inter-trochanteric?
Fall from standing height
When can clavicular fx be seen in physio?
When fx consolidated
What complication (stiffness) can happen to a humerus - greater tuberosity fx
Frozen shoulder, whatch out for shld stifness throughout rehab
When shoud PT start for
- scaphoid fx?
- other carpals?
- Scaphoid: once there is evidence of consolidation
- carpal fx: once clinically healed
what is Essex-Lopresti lesion
Essex-Lopresti lesion is a specific injury involving a longitudinal disruption of the interosseous ligament of the F/A, usually accompanied by a radial head Fx and/or dislocation, and an injury of the distal R/U joint.
What is a nighstick fx
common name for ulna fx → direct blow to the medial forearm
What is a montegia fx
proximal ⅓ ulna+ dislocation of radial head
What is a galeazzi fx
radius + dislocation of distal radio-ulnar joint
What is a clavicular middle 1/3 fx can be due to
the pull of the muscles and the arm: primarily the upward pull of the sternocleidomastoid muscle on the medial 1/3 of the bone, combined with the downward pull of the weight of the arm.
colle’s fx is whaat?
FOOSH with extended wrist
fracture of the radius, usually within 3cm of the radiocarpal joint, with dorsal angulation and displacement of the distal radius
What is the “deformity associated with colle’s fx?
The “dinner fork” deformity (gives the pronated wrist and hand the appearance of a fork, with tines pointed down).
What’s a smith fx
FOOSH with flexed wrist
volar angulation/displacement of the distal end of the radius
What is the deformity associated with smith’s fx?
garden spade deformity
What is a Barton’s fx?
intra-articular fracture of the distal radius, with dislocation (or subluxation) of the radiocarpal joint.
Palmar (volar) displacement of the carpals (and fracture fragment) is most common , but dorsal displacement may also occur.
What often happen with scaphoid fx?
high incidence of non-union and avascular necrosis, due to the poor blood supply to this bone
What gives an clinical imprssion of a scpahoid fx?
1) Pain in the region of the anatomical snuff box (delineated by the tendons of extensor pollicis longus and brevis, and the radial styloid process).
2) Tenderness to palpation in the anatomical snuff box (slight ulnar deviation of the wrist will make the scaphoid prominent)
3) Pain with axial compression of the 1st metacarpal, while immobilizing the radius
4) While holding the patient’s hand (handshake position), pain in the region of the anatomical snuff box with resisted forearm supination>pronation.
What is a bennet fx?
base of the 1st MC, in which the fracture line separates the major part of the MC from volar lip fragment, producing a disruption of the 1st CMC (1st MC is pulled proximally by the abductor pollicis longus).
What is a mallet finger?
disruption of the extensor tendon (not only associated with Fx) causing an inability to extend the distal IP joint
