Othorpeadics Flashcards
What pathophysiological mechanisms underpin fractures and the associated pain response?
- Fractures result from trauma from twisting or smashing bone
- Nondisplaced fractures = the bone ends retain their normal position.
- Displaced fractures = the bone ends are out of normal alignment.
PAIN
Nociceptive pain is the main pain mechanism from the tissue damage which occurs during a fracture.
Four phases (Heamatoma formation - Bone remodeling)
What is the fracture healing timeline and what physiological proccesses underpin each phase?
- Weeks 0-2 - Hematoma formation: haemorrhaged blood clot forms at fracture site, bone cells deprived of nutrition die, and the tissue at the site becomes swollen, painful, and inflamed.
- Weeks 2-3 - Fibrocartilaginous callus formation: within a few days blood vessels grow into the clot, fibroblasts and chondroblasts invade the fracture site, the fibroblasts produce collagen which connect the broken bone ends, the chondroblasts secrete a cartilaginous matrix which later calcifies forming a fibrocartilaginous callus. This is also called the “soft callus”. (2-3 weeks)
- Weeks 3-6 - Bony callus formation: osteoblasts begin forming spongy bone, within a week osteoblasts begin to lay down trabeculae of new bone around and within the fibrocartilaginous callus. Gradually the fibrocartilaginous callus is replaced by immature bone, converting it to a bony (hard) callus. (3-6 weeks)
- 8 Weeks - 2 years - Bone remodelling : Beginning during bony callus formation and several months after, the bony callus is remodeled. Compact bone is laid down to reconstruct the shaft walls. (8 weeks - 2 years)
What is the fracture healing timeline and what physiological proccesses underpin each phase?
- Weeks 0-2 - Hematoma formation: haemorrhaged blood clot forms at fracture site, bone cells deprived of nutrition die, and the tissue at the site becomes swollen, painful, and inflamed.
- Weeks 2-3 - Fibrocartilaginous callus formation: within a few days blood vessels grow into the clot, fibroblasts and chondroblasts invade the fracture site, the fibroblasts produce collagen which connect the broken bone ends, the chondroblasts secrete a cartilaginous matrix which later calcifies forming a fibrocartilaginous callus. This is also called the “soft callus”. (2-3 weeks)
- Weeks 3-6 - Bony callus formation: osteoblasts begin forming spongy bone, within a week osteoblasts begin to lay down trabeculae of new bone around and within the fibrocartilaginous callus. Gradually the fibrocartilaginous callus is replaced by immature bone, converting it to a bony (hard) callus. (3-6 weeks)
- 8 Weeks - 2 years - Bone remodelling : Beginning during bony callus formation and several months after, the bony callus is remodeled. Compact bone is laid down to reconstruct the shaft walls. (8 weeks - 2 years)
What are the predominant patient-reported dysfunctions for hip fractures?
- Impaired function and mobility
- Disruptions to sleep
- Localised tenderness
What dysfunctions may be found during an objective assessment for hip fracture?
- Limited range of motion and strength in the affected area (particularly in internal rotation)
- Localised swelling around the hip
- External rotation of the hip & appearance of the affected limb being shorter
- Pain in passive and active ROM assessment
- Antalgic gait pattern & stance
- Tenderness to palpation around the inguinal area, over the femoral neck. (do not palpate post operation).
What modifiable and non-modifiable risk factors influence hip fractures?
Non-modifiable
* Falls (Marks, 2009)
* Reduced Bone Density (Anything et al., 2009)
* Gender: postmenopausal women are twice as likely as premenopausal to sustain a hip fracture (Banks et al., 2009)
* Age: Risk of sustaining a hip fracture rises with age, 90% of these fractures occur in the over 70s population
* History of stroke
* Parkinson’s disease
* Osteoporosis
Modifiable
Diet
Medication
Physical Inactivity
Obesity
What is the prognosis for hip fractures?
- 50% of patients over 65 years old die within 6 months of a hip fracture (Anpalahan et al., 2013).
- Mortality rates are reported to be between 18% to 31% within 1 year of sustaining a hip fracture (cheng et al., 2011).
- Only 40% to 60% of patients regain their baseline mobility after a hip fracture, and 20% to 60% of previously independent people require assistance with at least one activity of daily living.
- Sepsis (the body’s extreme response to an infection) is the main cause of death for hip fracture Pts (Anpalahan et al., 2013)
- Many Pts who survive do not recover their baseline independence and function.
- Pre-fracture functional or ambulatory level and age are superior factors which influence the outcome of a patient following hip fracture. Other factors which can influence prognosis include gender, cognitive status, fracture type, corresponding procedures, anaemia, pain in the hip region, muscle strength and postoperative mobility level do appear to influence the prognosis of function, morbidity, and mortality as well.
What are the four classifications for garden fractures and what do they mean?
- Stage 1: Undisplaced, incomplete fracture of the femoral neck where the head has tilted into a valgus position
- Stage 2: Complete but undisplaced fracture across the femoral neck
- Stage 3: Complete fracture that in incompletely displaced (some continuity between the fracture ends)
- Stage 4: Complete fracture that is completely displaced (no continuity between fracture ends)
What are the three types of hip replacement?
- Hemiarthroplasty: The acetabulum is spared whilst the femoral head and neck are replaced.
- Total Hip Arthroplasty (THA): In THAs, both the femoral head and neck, and the acetabulum are replaced
- Resurfacing THA: The femoral head and acetabulum are replaced while the femoral neck is spares
Note: Each of these procedures can be cememted (where by a grout like substance is used to produce an interlocking fit between cancellous bone and the prosthesis) or uncemented (in which textured surfaces that allow new bone to grow into the implant, securing it in place).
What are the primary treatments for hip replacements (with references)?
- Advice on ADLs (NICE Guidlines for Joint Replacements, 2020)
- Home exercise programes (NICE…, 2020 ^; Khan & Scott, 2008)
- Early Mobalisation (NICE… 2020^; NICE guidlines for hip fracture management, 2011; Arshad et al, 2013 (NERP); Khan & Scott, 2008).
What were the key findings of fox et al (2011) regarding the use of hip precautions?
Hip precautions are unnecessary after hemiarthroplasty, cost money both in therapist time and equipment provision and increase the length of hospital stay.
What are the combined key findings of the Norwich Early Rehabilitation Programe (Arshad, 2013) and Khan & Scott (2008).
Early mobilisation promotes bone remodelling through mechanotransduction (Khan & Scott 2008), reduces hospital stays, improves patient’s psychosocial outcomes (NERP - Arshed et al 2013).
What were the key findings of smith et al (2008) regarding bed exercises?
Despite many hospitals administering these, the study been suggested that the addition of bed exercises to a standard gait re-education programme following hip replacement does not significantly improve patient function or QOL through the Iowa level of assistance scale.
What were the key recommendations of the NICE Guidlines for Hip Fracture Management (2011)
- Suggest rehabilitation should start the day after surgery, unless there is a medical/surgical reason not to and should undertake at least one physiotherapy lead session per day.
- Includes support with sitting and standing and keeping an upright posture to improve movement and strength, aiding with long term recovery.
- Patients admitted from care homes should not be excluded from rehabilitation programmes in the community/hospital, or as part of an early supported discharge programme.
What were the key findings of Muir & Abebaw (2009) regarding the effects of cognitive impairment on rehab (with critical appraisal)?
Chronic and acute cognitive impairment are independent risk factors for a poorer outcome after hip fracture.
The behavioural and cognitive impairment can affect an individual’s ability to participate effectively in rehabilitation thereby impacting on the delivery of care.
Critical Appraisal
* Geriatric Physical Therapy (IF = 3.5)
* SR
