Ortho module chapter 1 content Flashcards
classification of fractures
- skin - open or closed.
- displacement - undisplaced, displaced, impacted and stable.
- shape or line of the fracture - transverse, oblique, spiral, comminated, compression/crush, greenstick.
- anatomical location - left or right, prox/dist/middle.
factors to consider with bone healing
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.
rules for fracture healing
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%.
stage 1 of fracture healing
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.
stage 2 of fracture healing
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.
physio management
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).
stage 3 of fracture healing
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.
physio management in stage 3 healing
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.
stage 4 of fracture healing
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).
physio management of stage 4 healing
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.
stage 5 of fracture healing
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.
general aims of physio management of fractures
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.
complications of fractures - general
Shock
Infection
Respiratory complications
Thrombo-embolic complications
Pressure areas
Falls
Metabolic response to trauma (rhabdomyolysis)
Crush syndrome
Gas gangrene.
shock
- 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.
infection
- 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.
respiratory complications
- 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.
thrombo-embolic complications
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.
pressure areas
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).
falls
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.
metabolic response to trauam
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.
crush syndrome
- 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.
gas gangrene
- 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.
complications of fractures - iatrogenic and preventable.
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).
complications of fractures - local early
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.
