Lower limb fractures
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Transcript of Lower limb fractures
IRENE TOHPRINCIPAL PHYSIOTHERAPIST
PHYSIOTHERAPY DEPARTMENTSINGAPORE GENERAL HOSPTIAL
Post op management of lower limb fractures
Learning objectives• Awareness of classification of various lower limb fractures• Understand the general medical/surgical management of fracture and
rehabilitation• To understand the management of the following conditions• Hip fractures• Patella fractures• Femur/Tibia fractures• Ankle fractures
Classification of fractures
https://www2.aofoundation.org/wps/portal/surgery
General Medical/Surgical Management• Reduce fragments • Prevent further injuries eg vascular injuries, avascular necrosis, soft tissue
damage• Prevent deformities• allow early mobilisation (esp in elderly)
• Immobilise fractures• Prevent displacement / angulation of fragments• Prevent movements that will affect union• Reduce pain
Methods of immobilisation1) Plaster of Paris (POP) or external splint / brace / backslab
2) Continuous traction
Methods of immobilisation3) External Fixation
4) Internal Fixation / ORIF
Test of union• Clinical and radiological tests are used to ensure that the fracture is
UNITED.• Clinical
• Absence of mobility.• Absence of tenderness.• Absence of pain (?)
• Radiological-X-ray criteria.1) visible callus bridging both fragment.2) contiunity of bone trabeculae across the fracture
Bone healingPhase Cells Time frame
Inflammatory phase Haemorrhage, necrotic cells, haematoma and fibrin clot formed to bridge gap
Immediately
Soft callus phase Fibrous and cartilaginous tissue formed between the fracture ends, increase in vascularity and ingrowth of capillaries into the fracture callus; increase in cellular proliferation, osteoclasts remove dead bone fragments
1-6 weeks
Hard callus phase Calcification of fibrocartilage into woven bone, osteoclasts and osteoblasts
4-6 weeks, up to 3 months
Remodeling phase Woven bone changes to lamellar bone, medullary canal reconstituted; fracture diameter deceases to orginal width
6 weeks to months or years
Rehabilitation Goals1) Early phase – control swelling and pain2) Preserve function while the fracture is uniting3) Restore function to normal when the fracture is united
Duration of rehab dependent on many factors – intrinsic and extrinsic. May take months to years.
Rehabilitation• Active use of other joints without compromising the healing of the
fracture – preserve joint mobility• eg Colles fracture, active shoulder/elbow AROM must be done to prevent
joint contractures
• Gradual active use of injured part without risk• Eg compression fracture – trunk extension and posture
• Active exercise of muscles and joints to prevent atrophy• Static muscle contractions• Once splint removed – start gentle joint mobilisation • Progressive resistive exercise when fracture united
Rehabilitation• Ambulate (most Internal fixated fractures are allowed
to begin TTWB or PWB) – dependent on surgeon’s order.• If only on external fixation – usually NWB• Maintain cardiovascular fitness
Proximal Hip Fractures• Garden’s classification of neck of femur fractures
Operative Management
Dynamic hip screw / Cancellous screwPhase 1 (Acute inpatient to 3 weeks)
Impairments ?
Phase 1 (Post op day 1 to Week 3)Goal?
1. Reduce pain2. Reduce swelling3. Promote bed mobility and transfers4. Improve hip range of motion as tolerated5. Gait training with walking aids as appropriate
Phase 1
What exercises would you prescribe to patient?
Phase 2 (Week 4 – 7)• Impairments?
Phase 2Goals?
1. Increase hip range of motion2. Increase lower limb strength3. Progress gait – may increase weight bearing status depending on
surgeon.
Phase 2
What exercises would you prescribe to patient?
Phase 3 (week 8-12)Impairments• Poor lower limb strength• Decrease balance• Reduce endurance
Goals?1. Increase lower limb strength2. Increase balance and stability3. Increase walking endurance
Phase 3
What exercises would you prescribe to patient?
Phase 4 (week 12-20 or longer)• Goals• Progression of phase 3
Proximal Tibial Fractures
http://orthoinfo.aaos.org/topic.cfm?topic=A00393
Fracture does not extend not the knee joint (extra-articular) – rod and screw.
Fracture extends into the joint (partial/complete articular) – plate and screws needed
https://www2.aofoundation.org/wps/portal/surgery
Proximal Tibial Fractures Rehab• What do you think will be affected?
• How would your plan your rehabilitation process?• Consider the phases of bone healing• Consider extend of fracture/soft tissue injuries• Consider fixation stability• Consider intrinsic and extrinsic factors• Any other things??
Tibial/Femur shaft fractures rehab• What do you think will be affected?• Joints?• Muscles?• Circulation?
• How would your plan your rehabilitation process?
Ankle Fracture
Ankle fracture Rehab• What do you think will be affected?• Joints?• Muscles?• Ligaments?• Circulation?
• How would your plan your rehabilitation process?
Summary• Fixation of fracture allows for early ambulation• Rehabilitation important in fracture management – starts in the early
phase• Healing phases are not mutually exclusive• Look at the patient as a whole when planning rehab program• Consider exercising other joints without compromising the healing of the
fracture• Patient education (on fracture healing, effects of prolonged
immobilisation on muscles and joints, cardiovascular fitness etc) important.
References• AO foundation website (www.aofoundation.org)• Boris AZ, Kurt RW and Freddie HF: Pathogenesis of soft tissue and
bone repair. In Lisa M and Jim M, editors. Rehabilitation for the post surgical orthopaedic patient (2nd ed). Mosby Elsevier: St Louis.• SGH protocols• Pictures from google.