Ortho module chapter 1 content

Question 1

classification of fractures

Answer 1

1. skin - open or closed.
2. displacement - undisplaced, displaced, impacted and stable.
3. shape or line of the fracture - transverse, oblique, spiral, comminated, compression/crush, greenstick.
4. anatomical location - left or right, prox/dist/middle.

Question 2

factors to consider with bone healing

Answer 2

 Age – younger heal faster.
 Site and type of fracture – fractures at a site surrounded by a muscle heal faster, cancellous bone heals faster than cortical bone, oblique and spiral fractures heal faster than transverse, un-displaced fractures heal faster than displaced.
 Blood supply to fragment – scaphoid and head of femur fractures often result in delayed union or sometimes avascular necrosis.
 Mobility of fracture site – excessive mobility slows healing but micro motion and gentle weight bearing speeds healing.
 Separation of bone ends – can be caused by soft tissue interposition, excessive traction, internal and external fixation.
 Infection – slows healing.
 Joint involvement -slows healing.
 Bone pathology, osteoporosis or bony metastases – delays healing.

Question 3

rules for fracture healing

Answer 3

 Rules for fracture healing timeframes:
o Spiral fractures in the upper limb in children take 3 weeks to unite.
o Spiral fractures in the upper limb in adults take 6weeks to unite.
o Spiral fractures in the lower limb take twice as long to unite 12 weeks.
o Transverse fractures take twice as long again.
o For a fractured femur add 25%.

Question 4

stage 1 of fracture healing

Answer 4

Tissue destruction and haematoma
 Haematoma results immediately after fracture – blood vessels are damaged and bleeding occurs between the ends of the fractured bone, and an areas of avascular necrotic bone results.
 The size of the haematoma influences the rate of healing.
 The size of the haematoma depends on:
o The extent of periosteal disruption (the layer that surrounds bone)
o The extent of soft tissue damage.
o The type of fracture:
 Transverse fracture – small haematoma.
 Spiral fracture – larger haematoma.

Question 5

stage 2 of fracture healing

Answer 5

 Within 8 hours of the fracture occurring there is an acute inflammatory reaction with proliferation of osteogenic cells from the endosteum and periosteum.
 Osteoclasts remove the necrotic bone and osteoblasts begin to lay down a matrix of collagen which bridges the fracture site providing a scaffolding on which new bone can be laid and in which new bone formation can take place.
 The clotted haematoma is slowly absorbed, and fine new capillaries grow into the area.

Question 6

physio management

Answer 6

o Promote relative rest and oedema management in the form of the immobilisation, elevation and application of ice.
o To encourage circulo-respiratory and musculoskeletal maintenance exercises where appropriate.
o To instruct patients on the use of appropriate mobility aids once fractures have been immobilised either conservatively or surgically.
o To assess for circulatory or neurological impairment.
o To provide education regarding the patient’s injury and rehab.
o Do no further harm (avoid doing activities that could delay or prevent fracture healing).

Question 7

stage 3 of fracture healing

Answer 7

callus (woven bone) formation (2-4 weeks).
 Callus formation starts at approximately 2 weeks. The main bolus of callus is formed at about 4 weeks by which time the fracture may be said to be ‘united.’
 Thereafter callus does not increase in size, but it does undergo substantial reorganisation and gradually increases in stability.
 In this stage – the proliferating cells potentially form both bone and cartilage given the right circumstances.
 The matrix of collagen formed by the osteoblasts between the periosteal and endosteal surfaces becomes impregnated with calcium salts and develops into woven bone. As it becomes more densely mineralised movement at the fracture site decreases.

Question 8

physio management in stage 3 healing

Answer 8

Role of a physiotherapist in stage 3
 To encourage circulo-respiratory and musculoskeletal maintenance exercises where appropriate.
 To instruct patients on the use of appropriate mobility aids once fractures have been immobilised either surgically or conservatively.
 Do no further harm.

Question 9

stage 4 of fracture healing

Answer 9

Stage 4: Consolidation (8 weeks post fracture)
 Consolidation is the transformation of callus into lamellar bone. In this stage osteoclasts now migrate through the debris at the fracture line and reabsorb the callus. Osteoblasts lay down new bone in the gaps behind them.
 This is a slow process and lasts between four weeks and several months.
 Consolidation occurs in earlier in the upper limb than the lower limb.
 Consolidation is complete when the fracture appears clinically and radiographically united. At this stage there is no tenderness or movement at the fracture site (clinical signs on union) and there is no evidence of a fracture line (radiographic sign on union).

Question 10

physio management of stage 4 healing

Answer 10

To instruct patients on the use of appropriate mobility aids once fractures have been immobilised either surgically or conservatively.
 To progress weight bearing status, gait re-training, balance and strengthening under the guidance of the orthopaedic doctor.
 Increase ROM of effected joints.
 Do no further harm.
 Once there is clinical union – a cast is often removed and movement of previously immobilised joints adjacent to the fracture site can be commenced (active/active assisted). He doctors decision to remove a cast will most often be made after consulting a recent x-ray to confirm radiological union.

Question 11

stage 5 of fracture healing

Answer 11

remodelling (2 months – 2 years post fracture)
 Remodelling is a continuous process of bone reabsorption and formation which occurs at a relatively rapid rate for 1-2 years after a fracture.
 Thicker lamellae are laid down where the stresses are high, unwanted bone is reabsorbed and the medullary canal is reformed as the bone approximated its normal shape.

Question 12

general aims of physio management of fractures

Answer 12

 Doing no further harm to the fracture site.
 Maintaining the integrity of the surrounding musculoskeletal, circulatory, neural and respiratory systems.
 Facilitating safe and independent return to function.

Question 13

complications of fractures - general

Answer 13

 Shock
 Infection
 Respiratory complications
 Thrombo-embolic complications
 Pressure areas
 Falls
 Metabolic response to trauma (rhabdomyolysis)
 Crush syndrome
 Gas gangrene.

Question 14

shock

Answer 14

1. Shock
    Shock is a generalised state of a reduced tissue perfusion; if allowed to persist it will result in damage to vital organs.
    Neurogenic shock may occur as a result of pain from fracture.
    Hypovolemic shock may occur as a result of a blood loss.

Question 15

infection

Answer 15

2. Infection
    Can occur when organism colonises in an area and there is an immune response by the host.
    Infection can reach bones and joints via the bloodstream or by direct invasion from a skin puncture, operation or open fracture.
    Some of the signs of infection for the physiotherapist to routinely look for are pain and tenderness, wound ooze, wound redness and raised temperature and occasionally confusion in the elderly population.

Question 16

respiratory complications

Answer 16

3. Respiratory complications
    Pain from fracture (in thoracic vertebrae/ribs).
    Pneumo or haemothorax associated with rib fractures.
    Pulmonary contusions
    Pre-existing ailment
    General anaesthetic
    Narcotic analgesia.
    Reduced lung volume due to prolonged bed rest.
    Risk of hospital acquired respiratory infection.
    Risk of aspiration and potentially aspiration pneumonia.

Question 17

thrombo-embolic complications

Answer 17

 These occur when blood clot or fat deposit obstructs blood flow.
o Deep vein thrombosis – is a common complication of surgery, trauma (up to 60%) and inactivity. A DVT is a blood clot and most commonly occurs in the deep veins of the calf, thigh and pelvis. A pulmonary embolism (PE) may occur in up to 5% of patients with a DVT.
o PE results when a DVT migrates throughout the circulatory system and becomes lodged in the lung. A PE presents usually after 72 hours as sudden severe shortness of breath, elevated RR and HR and the physiotherapists should be mindful of this when exercising.
o Fat embolism syndrome is the presence of fat globules in the lungs, and other tissues. It occurs in about 3.5% of long bone fractures and about 10% of multi-traumas.

Question 18

pressure areas

Answer 18

 A pressure area occurs when pressure on the skin exceeds capillary pressures for prolonged periods causing cell death and tissue breakdown. These commonly occur on the bony prominences such as the heels, malleoli, fibula head, sacrum, ischial tuberosities, elbows and occiput from either bed rest or casting.
 Methods of pressure areas prevention include:
o Patient education and self-management.
o Physical barriers like – heel wedges, gel pressure pads, sheep skins, pressure relieving mattresses place under bony prominences.
o Early mobilisation
o Regular checks of skin and integrity and regular changes of resting positions (turning regimes).

Question 19

falls

Answer 19

 Of particular importance to the physiotherapists is the risk of a patient falling and further hurting themselves due to impaired mobility after orthopaedic injury.
 A falls risk assessment should be undertaken when mobilising a patient for the first time. It should include assessment of the patient’s cognitive status, previous mobility level, limitations due to the current injury, environment, vital signs and pain, assessment of strength in unaffected limbs.

Question 20

metabolic response to trauam

Answer 20

 The metabolic response to trauma is extremely complex and involves hormonal and cellular mechanism designed to counter the effects of:
o Tissue damage
o Blood loss
o Cardiopulmonary dysfunction
o Inflammatory response.
 The early response is concerned with the body’s defence mechanisms. The second and more prolonged phase is dominated first by tissue breakdown and then by tissue repair.
 The importance of this to the physiotherapist is to recognise that muscle wasting occurs as a result of loss of body protein and when the patient’s condition stabilises it is appropriate to commence a strengthening programme.

Question 21

crush syndrome

Answer 21

8. Crush syndrome
    May occur if a large bulk of muscle is crushed or if a tourniquet has been left on for more than 6 hours. When compression is released, by products of muscle breakdown are released and can block the tubules of the kidneys. Shock is profound. Resultant impaired renal function often necessitates the use of dialysis.

Question 22

gas gangrene

Answer 22

9. Gas gangrene
    This is a clostridial infection where the anaerobic organisms multiple in areas of low oxygen tension such as dirty wound with dead muscle that has been closed without adequate debridement.
    It is a brownish discharge seen within 24 hours in the injury, gas formation is usually not very marked. Intravenous antibiotic therapy is mandatory. It may progress to amputation or death.

Question 23

complications of fractures - iatrogenic and preventable.

Answer 23

 Intra-operative fractures, vascular complications (DVT), respiratory complications (atelectasis), hospital acquired infection, pharmaceutical errors, pressure areas, muscle atrophy, joint stiffness, neurological complications (epidural haematoma and intrinsic/extrinsic).

Question 24

complications of fractures - local early

Answer 24

 Vascular complications – crush syndrome, direct blood vessel damage, compartment syndrome, pressure areas and DVT can occur within first 48hours.
o The 5Ps pain, pallor, pulselessness, paraesthesia and paralysis.

 Neural complications – direct trauma, prolonged pressure, traction injury, compartment syndrome, infection.

 Necrosis – compartment syndrome, gas gangrene, pressure areas.

 Joint complications – hemarthrosis (bleeding into a joint), infection from a wound or surgical incision, dislocation, subluxation, joint stiffness of affected and adjacent joints

 Visceral – fractures of pelvis, spine and thoracic cage are frequently associated with visceral trauma.

Question 25

complications of fractures - local late

Answer 25

 Union
o Delayed union and non-union – late or no union.
 (If radiography does not depict union, then a bone graft or internal fixation may be used to facilitate union)
o Mal-union- occurs when anatomical fracture reduction is not achieved.
o Cross union – occurs when two or more separate fractures heal to each other.
o Growth plate disturbance – disruption of the epiphyseal plate effects the synthesis of new bone and is a special paediatric orthopaedic concern.

 Avascular necrosis (AVN)
o Occurs when blood supply to a bone fragment is disrupted and the fragment dies. Causes unresolving pain. Common in femoral neck fracture, neck fracture or scaphoid fracture.

 Myositis ossificans (MO)
o Ossification of haematoma around a joint seen hereat the knee.
o Aetiology is unknow – perhaps overvigorous passive movement.

 Complex regional pain syndrome
o Aetiology is not known – thought to be associated with abnormal sympathetic nervous system activity. Prevention is thought to be more effective than cure so active maintenance exercises for un-involved joints should be more provided to all patients with limb fractures.
o Independent research on this complex topic advised.
o Joint complications
o Late complications as joints as the result of a nearby fracture or fractures within the joint can manifest as joint instability, joint stability, osteoarthritis and biomechanical changes.

Question 26

fracture management types

Answer 26

o Conservative management
 Auto-fixation
 Traction
 Casting/bracing

o Surgical management
 Open reduction internal fixation (ORIF).
 External fixation.

Question 27

autofixation

Answer 27

occurs when fracture immobilise themselves and require no additional fixation. An impacted fractured neck of humerus may undergo auto fixation and be managed in a sling for comfort. When there is a stable auto fixation early movement should be encouraged. Mal-union is the main complication but is usually or little functional significance.

Question 28

traction

Answer 28

used for cervical spine and lower limb fractures. Traction force maintains the bone fragments in an anatomical alignment while healing occurs. Femoral traction can be applied via weights connected to skin traction or a pin inserted into the tibia or distal femur. The patient’s leg may be suspended in a Thomas splint.

Question 29

casting and bracing

Answer 29

plaster of Paris is a fiberglass cast and thermoplastic and removable orthopaedic splints can be used to immobilise fractures not requiring surgical fixation. The fracture should be anatomically reduced, and the cast should be immobilising the fracture site whilst allowing other joints not related to the fracture site to move freely. Casts can be circumferential, back slabs or bivalve whereby a circumferential cast is split in half to relieve pressure.

Question 30

advantages of ORIF and potential complications

Answer 30

advantages:
- reduced hospital stay
- reduced time resting in bed
- better reduction of avulsion fractures
- anatomical reduction
- early mobilisation

potential complications
- respiratory, circulatory and infection post surgery.
- delayed union or non union.
- fixation failure
- breakdown of overlying skin.

Question 31

Richards pin and dynamic hip screws

Answer 31

sliding mechanism becomes effective when the patient weight bears through the limb, this acts to prevent the screw penetrating the head of the femur.

Question 32

indications of external rotation

Answer 32

o Soft tissue damage associated with some fractures that prevents immobilisation by casting and or ORIF.
o Risk of infection
o Patient not well enough for prolonged surgery required for ORIF.
o Temporary fixation whilst awaiting arrival or metalwork for definitive fixation.
o Provides a level of external adjustability.
o The only device that allows traction to be applied to bone fragments, such as that required for bone transport.

Question 33

complications for external fixation

Answer 33

Complications related to external fixation.
o Infection entering the bone via pin sites and open wounds.
o Post anaesthetic respiratory and circulatory complications.
o Possible pressure areas from the fixator resting on adjacent soft tissues.

Question 34

physio in fracture rehab

Answer 34

 Physiotherapy aims to minimise the impact the fracture has on the person’s function by ensuring appropriate and safe mobilisation, comprehensive circulo-respiratory regimes and progressive musculoskeletal programs for unaffected joints and muscles.
 Physiotherapists do this ensuring they are careful not to compromise fracture healing.
 The patient’s respiratory and circulatory systems should be assessed immediately postoperatively with appropriate exercises initiated until the patient is returning to their previous mobility level.
 Circulation exercises – routine circulation exercises are static gluts, quads, foot and ankle exercises repeated in large volumes initially and reducing as mobility improves.
 Musculoskeletal maintenance exercises for unaffected joints and muscles are issued where appropriate.
 Neurovascular observations include peripheral light touch and capillary refill at the nail bed and should be regularly checked for patients fitted with a cast.
 Rehabilitation commences at the initial assessment and a discharge plan is formulated early so that each treatment sees an outcome achieved.

Question 35

 Discharge planning should commence as soon as possible, even pre-operatively. Careful consideration needs to be given to the patient’s previous functional level and their previous accommodation or level of care. Options for discharge might include:
o The patient’s previous home
o The patient’s previous home with modifications (as recommended by the OT)
o A family members home
o Rehabilitation Unit (only if the patient is likely to improve and facilitate a safe discharge home)
o Residential Accommodation (such as a Nursing Home or Hostel)
o Walking aids and home exercise programs need to be organised in advance.
o Discharge follow up appointments should be organised prior to discharge.
 Coexisting conditions can affect fracture healing as well as a person’s ability to participate actively in a rehabilitation program. This may include conditions such as dementia, metastatic disease, or a neurological impairment.
 A physio needs to be aware of the following factors when planning discharge:
o Patient’s previous functional level
o Patient’s previous living conditions and level of care
o Weight bearing status and appropriate walking aid prescription.
o Co-existing health conditions eg: dementia, neurological impairment
o Independence with walking aid to mobilize safely on flat surfaces +/- stairs.
o Where the patient will be living after discharge eg: home, nursing home etc.