Treatment of UE Fractures

Treatment of Fractures: 

Treatment of Fractures Cindy Mathena, PhD, OTR/L Associate Professor

Key Terms: 

Key Terms Anatomic Snuff Box Articular Cartilage Base Bennett’s Fracture-Dislocation Biaxial ellipsoid joint Bony Mallet Injury Boutonneire deformity Boxer’s Fracture

Key Terms : 

Key Terms Colle’s Fracture CRPS Diaphysis DRUJ Distal transverse arch Epiphyses External Fixator

Key terms: 

Key terms FOOSH Fracture Growth Plate Injuries Head Inflammatory Process Kienbocks disease Longitudinal Arch Neck Negative ulnar variance Periosteum

Key Terms: 

Key Terms Positive ulnar variance Primary healing Proximal transverse arch Purulence Radiocarpal joint Reduction Remodeling phase Repair phase Secondary healing

Key Terms: 

Key Terms Shaft Smith’s fracture Stress Fractures TFCC Tuft Ulnocarpal abutement syndrome Uniaxial pivot joint Unstable fracture Watson’s test

Outcomes: 

Outcomes 1. Define terms related to treatment of fractures with emphasis on UE fractures. 2. Analyze treatment protocols for a variety of fractures. 3. Give examples of exercise, modality, and activity that may be suitable for above protocols. 4. Articulate the importance of edema control techniques. 5. Demonstrate use of teaching techniques for scar management, UE ROM and exercise, and home programs. 6. Design a home program for a fracture discussed in class.

General Timelines and Healing-Secondary Healing: 

General Timelines and Healing-Secondary Healing Secondary Healing=Callus Healing=Indirect Healing Goal=regenerate mineralized tissue and restore strength

A Stable Fracture…: 

A Stable Fracture…

An Unstable Fracture..: 

An Unstable Fracture..

General Timelines and Healing-Primary Healing: 

General Timelines and Healing-Primary Healing If ORIF is performed on a fracture and vascular supply is good, the fracture may bypass the three phases Direct regrowth occurs Adequate stability Advantages? Strengthening cannot occur any sooner but AROM can! Rigid Fixation=Primary Healing

Etiology: 

Etiology trauma disease tumor old age excessive over use Osteoporosis

Medical Management: 

Medical Management Relieve pain, realign, provide bony union for healing, restore optimal function. Early specific use of the injured extremity during healing diminishes or eliminates the need for treatment after immobilization, early movement prevents the unwanted effects of immobilization, stiff joints, disuse atrophy and weakness.

Healing Times General Principles-Secondary Fractures: 

Healing Times General Principles-Secondary Fractures Secondary fracture-average of 7 weeks or longer Controlled AROM can begin between 3-6 weeks Two weeks later PROM and Dynamic Splinting can occur PRE at 8-10 weeks

Complications: : 

Complications: -delayed union-abnormally slow to heal -nonunion-bone stops healing just short of a firm union -malunion-bone heals but not in satisfactory alignment Related Syndromes: -CRPS -contractures -loss of ROM -edema Watch this video for an example of a malunion: http://www.youtube.com/watch?v=3dcbS1bGE9Y

Complications Continued: 

Complications Continued

Prognosis:: 

Prognosis: ….depends on type of break, associated injuries, health, smoking, pt. compliance Unfavorable Prognosis: …open injury, comminution, significant associated soft tissue injury, prolonged mobilization

General Therapeutic Management: 

General Therapeutic Management Active and Passive ROM of wrists and digits, including composite flexion of digits Grip and Pinch Strengthening Edema Control-elevation and muscular contraction Restore joint and tendon glides Hand Prehension skills/dexterity ADLS Work readiness

Patient Education: 

Patient Education -keep the fractured area and surrounding joints immobilized until otherwise approved by the physician -teach pt. to observe for edema, tingling, burning pain (ischemia) or arterial occlusion (Volkmann’s ischemia-pale blue skin color, absence of radial pulse, decreased hand sensation, severe pain) -teach pt. elevation techniques -regard for other medical conditions

Phalangeal Fractures and Dislocations: 

Phalangeal Fractures and Dislocations

Proximal Phalangeal (P-1) Fractures: 

Proximal Phalangeal (P-1) Fractures 10-29 year olds, sports, palmar angulation Angulation causes shortening and thus poor gliding of extensor tendon=lag Impaired tendon gliding

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment: 

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment Closed, non-displaced P-1 shaft fx=stable fx Tx: Buddy Taping, Gentle AROM, Edema Control

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment: 

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment Simple non-displaced, stable fractures are sometimes treated with a splint: Tx: Gentle AROM by 4 weeks, Edema Control

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment: 

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment Minimally displaced fractures-K-wire fixation:

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment: 

Proximal Phalangeal (P-1) Fractures-Timelines, Healing and Treatment Open reduction and rigid fixation:

Middle Phalangeal (P-2) Fractures-Timelines, Healing and Treatment: 

Middle Phalangeal (P-2) Fractures-Timelines, Healing and Treatment Nondisplaced and closed reduction: -buddy tape for three weeks -require little if any therapy Displaced Fractures (without IF) -immobilize 3-4 weeks and then begin AROM Displaced Fractures (ORIF) -immobilize 3-6 weeks

PowerPoint Presentation: 

Casting in “safe position” or anti-deformity position Types of Immobilization or Orthotics Dynamic Splinting Static splinting in “safe position” or anti-deformity position

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment: 

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment Very Common Long Finger then thumb most frequent If extensor tendon involved=Bony Mallet Injury MOI=crush, jam, car doors, industrial and sports

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment: 

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment If does not require fixation: Use a Stax Splint or similar that immobilizes the DIP joint in 0-15 degrees of hyperextension for 6 weeks to prevent extensor lag. Continue use of the splint for 2 to 3 weeks if extensor lag occurs.

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment: 

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment With Internal Fixation: Edema control with coban AROM and gentle PROM for uninvolved joints Pin care Protective splinting Upon stabilization (between 3-6 weeks): AROM and blocking for DIP Desensitization PROM and grip strengthening 2 weeks after AROM

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment: 

Distal Phalangeal (P-3) Fractures-Timelines, Healing and Treatment Increase DIP AROM 6 to 8 weeks after immobilization. Block proximal joints to isolate the motion of the flexor profundus and the terminal extensor tendon activity. Encourage the patient to make a fist and suitcase hold (intrinsic minus hand) as part of your exercise program. If active ROM does not increase DIP motion, introduce passive exercise at 7-8 weeks after immobilization.

Important Points for Therapy…: 

Important Points for Therapy… Isolated joint motion Specific tendon gliding: EDC for MCP fractures; FDS/FDP for proximal and middle phalangeal fractures Prevent rotation-buddy straps Treat soft tissues!

Distal Radius Fractures-Timelines, Healing and Treatment: 

Distal Radius Fractures-Timelines, Healing and Treatment Most wrist fractures occur from a FOOSH Postmenopausal women with osteoporosis Colle’s most common of the DR fractures (also one of most common in the human body)-complete fracture with dorsal displacement Smith’s Fracture-complete fracture with palmar displacement

Distal Radius Fractures-Timelines, Healing and Treatment: 

Distal Radius Fractures-Timelines, Healing and Treatment Extraarticular , stable fractures-closed reduction and casting for 3-8 weeks -CTS! Unstable DR fractures-pinning and/or casting, external fixation, immobilize 8 weeks For complex fractures (i.e. Barton’s) –ORIF-allows for early AROM within 2 weeks Healing and function on all DR fractures may take years.

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines: 

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines Splinting-protective wrist splint may be used post cast or hardware removal Pin Care Decrease edema (retrograde massage, elevation, external elastic support and exercise). Ensure proper education and use of splints, wear schedule, care, etc and can verbalize precautions back to therapist. Maintain AROM of uninvolved joints to avoid stiffness, daily ROM of uninvolved joints. Check and monitor shoulder/elbow motion!

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines: 

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines Scar management and desensitization: a ssess for adherent tissue Assess tendon gliding Topical scar compression products (when?) Desensitization program

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines: 

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines AROM: All joints! Posture! Begin with 3-4 sets of ten per day Hold at end-range Avoid substitutions (finger extensors) Tendon gliding Importance of supination/pronation

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines: 

Distal Radius Fractures-Timelines, Healing and Treatment Guidelines When Strengthening? ADL adpatations? PROM Dynamic Splinting

Carpal Fractures-Timelines, Healing and Treatment Guidelines: 

Carpal Fractures-Timelines, Healing and Treatment Guidelines Wrist: Scaphoid constitute more than 60% of all injuries are generally immobilized in a plaster cast for 2 weeks or as long as two months. Later placed in thumb spica with wrist in slight dorsiflexion and radial deviation. A radial or ulnar gutter splint may be the splint of choice, depending on the carpal bones involved.

Carpal Fractures-Timelines, Healing and Treatment Guidelines: 

Carpal Fractures-Timelines, Healing and Treatment Guidelines Longer than normal immobilization Frequent AROM Full function by 10-12 weeks Healing is unpredictable, scaphoid is poorly vascularized

Metacarpal Fractures-Timelines, Healing and Treatment Guidelines: 

Metacarpal Fractures-Timelines, Healing and Treatment Guidelines Usually stable Keep in safe position splint Boxer’s Fracture/Base Fracture Bennet’s Fracture Focus on restoring MCP motion, monitor rotation

Elbow Fractures-Timelines, Healing and Treatment Guidelines: 

Elbow Fractures-Timelines, Healing and Treatment Guidelines Elbow fx: Begin gentle, nonresistive active ROM approximately 5 days after injury. Perform active ROM in gravity eliminated plane. PROM in early stages is discouraged. Pt may not achieve full elbow ext. but a useful arc of motion for ADL’s should be regained.

Humeral Fractures-Timelines, Healing and Treatment Guidelines: 

Humeral Fractures-Timelines, Healing and Treatment Guidelines Humerus fracture:Begin AROM as soon as acute pain diminishes, to avoid stiffness. Passive motion is contraindicated. Encourage isometric exercises during and after immobilization as this will stimulate fx healing. Encourage Codman’s exercises for gentle active exercises of the shoulder. Make functional with board games, puzzles, checkers, etc on low table, contraindicated for edematous UE. If full ROM has not been achieved in 6 to 8 weeks, discuss dynamic splinting with MD.

PowerPoint Presentation: 

-Assist pt. in managing hypertrophic scarring, begin massage to healed incision. -Provide graded activities for prehension and hand dexterity:small blocks, pegs, coins, opening and closing safety pins, buttons, etc -Provide adaptive equipment as needed -Instruct pt. and family in home program to include: ROM, activities, splint instruction, scar massage, desensitization, precautions, exercises and activities -Assist pt. and family in coping and understanding disability -Initiate vocational assessment if necessary

Discharge: 

Discharge Discharge: reevaluate, assess compliance and understanding of home program, encourage follow/up, complete recommendations and summary, communicate with MD and those following.