Mona Selim Faggal

OBGECTIVES OF THE LECTURE

At the end of this lecture, the student will be able to:

 Define the Principles of Fractures management.
 Understand How to Handle Fractures.
 Know the bone healing process.
 Understand the different types of fixation.
 Differentiate between different types of internal fixation
 Differentiate between different protocols of rehabilitation for lower limb fractures
 Complications of the fractures:

• Infection
• Avascular necrosis
• Mal-union (deformity of shortening)
• Joint disruption
• Adhesion
• Injury to large vessels
• Injury to muscle
• Injury to nerves
• Injury to viscera
• Contracture
Union of fractures
It depends on the following factors
 Type of bone
 Classification of fracture
 Blood supply
 Fixation
 Age
Delay union – This indicates that healing is
taking longer than would normally be
expected.
Mal union- This indicates that healing is
taking with deformity
Non-union- This indicates no healing
occurs
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DR. Mona selim
 In rigid fixation
 Very slow
 2 weeks from the time of injury.
 Intact intramedullary vasculature
 New bone grows directly across bone ends
 Cannot bridge fracture gabs
 No radiographic evidence of a bridging callus
 Depends on osteoclastic resorption of bone followed by
osteoblastic new bone formation

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 The most common type of bone healing

 absence of rigid fixation.

 characteristic radiographic appearance of callus formation.

 bridging callus adds stability to the fracture site

 Greater motion at fracture site greater callus

 Occurs with casting, external fixation, & IMN

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The Gustilo-Anderson Classification of Soft Tissue Injury in Open
Fractures
Type I Wound less than 1 cm long
Minimal soft tissue damage, no signs of crush
Usually simple transverse or short oblique fracture with
little comminution

Type II Wound more than 1 cm long

Slight-to-moderate crushing injury, no extensive soft
tissue damage, flap, or avulsion
Moderate fracture comminution and contamination

Type III Extensive wound and soft tissue damage, including

muscles, skin, and (often) neurovascular structures
Greater degree of fracture comminution and instability
High degree of contamination
 Three stages of fracture
management

Deal with any open wound

Attend to the fracture until it is united

Mobilize the joint and rehabilitate the limb

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First aid
• The patient should not be moved

Definitive treatment:

1-Reduction

2-Fixation

3-Rehabilitation
Reduction:

Closed (Manipulation) Usually with anesthesia

Open reduction( when closed is failed)

• – Allows very accurate reduction
• – Risk of infection
• – Usually when internal fixation is needed
Methods of fixation:

•External fixation(plaster casting)

•Frame fixation(skeletal external
fixation)
•Internal fixation:– Intramedullary nails,
compression plates, screws, wire sutures
•Sustained traction
 Skin traction

Skeletal traction sites

External fixation(plaster
casting) Frame fixation (skeletal external
Internal Sustained Traction
fixation)
fixation
 The disadvantages of internal fixation are:
1-No casts. 1. The risk of infection at
2- Prevent skin pressure the time of operation.
3- No complications of bed
2. The additional trauma of
rest
operation.
4-Important for the elderly
5- Early motion 3. A wide exposure is
6- Avoid stiffness needed to apply screws
and plates
7-Enhance fracture healing
8-Prevent muscle atrophy

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Method of fracture FIXATION determines the mode of
bone healing

 Stress-sharing devices do
not provide rigid fixation.
 Stress-sharing devices Permit
partial transmission of load
across the fracture site.
 Micro motion at the fracture site
induces 2ry bone healing with
callus formation.
 E.g. casts, intramedullary nails
& external fixators
 Shields fracture site from stress by transferring stress
to the device.
 Fractured ends held under compression and no
motion at fracture site.
 Stress shielding devices provide rigid fixation result in
1ry bone healing without callus formation.
 E.g. compression plating & static locked intramedullary
nail.
 Because primary bone healing is a slow process,
compression plate fixation requires a long period of
non-weight bearing (3 months).
 Before fracture healing all weight is borne by the plate,
which may not withstand early loading.
 External Pin, screw, plate rod cast
fixator wire
biomechanics Stress sharing Stress sharing Stress shielding Stress sharing Stress sharing

Type of bone 2ry (callus) 2ry (callus) 1ry 2ry (callus) 2ry
healing (no callus) (callus)

Rate of bone fast fast slow fast fast

healing

Weight bearing early delayed late early early

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1. To prevent respiratory complications → breathing
exercises.

2. To prevent circulatory complications →

• -active exercise either by static or isotonic muscle activity- circulatory

exercises
• - changing position every 2 hours
• - alternating air mattress

3. Maintain joint range where possible To prevent stiffness,

weakness & atrophy of the free parts →
• - ROM exercises
• - strengthening exercises
4-Reduce edema – to prevent the adhesion formation (bandaging and
elevation)

5-Maintain muscle function by active or static contraction

6-To prevent weakness of immobilized parts → static & isometric

exercises

7-Maintain as much function as allowed by the particular injury and

the fixation

8-Teach the patient how to use special appliances such as crutches,

sticks, frames, and how to care for these or any other apparatus
Goals:
•To reduce any swelling
•To regain full range of joint movement
•To regain full muscle power
•To re-educate full function
 Is the most commonly used to classify intracapsular femoral neck
fractures
 Surgery may be indicated depending on the type of fracture.
In general:
 Type I is an incomplete fracture or valgus impacted fracture.
 Type II is a complete fracture without displacement.
 Type III is a complete fracture with partial displacement of fracture
fragments.
 Type IV is a complete fracture with total displacement of fracture
fragments

 Garden stage I and II are stable fractures and can be treated with internal
fixation eg Dynamic hip screw DHS
 Garden stage III and IV are unstable fractures and hence treated with hemi
or total hip replacement.
Garden classification for femoral neck fractures
Non-displaced or stable and can bear the full weight •
minimally displaced immediately after surgery, with no limitations
femoral neck fractures: on range of motion (ROM)

Early mobilization to prevent morbidities •

Displaced femoral neck
associated with recumbence.
fractures
Full weight bearing (FWB) is encouraged. •
WB is not allowed •
(TDWB) or non-weight bearing (NWB) until fracture •
Intertrochanteric hip healing is demonstrated.
Unstable fractures WB should be delayed until good •
bony healing

Subtrochanteric compression screw device and a static locked

fractures intramedullary nail
REHABILITATION PRINCIPLES
Postoperative rehabilitation of patients with operatively treated fractures depends on the following factors:
• Open or closed fracture. Open fractures have much higher incidences of delayed union and nonunion and have a poorer
prognosis for healing than do closed fractures.
• Extent of injuries associated with open fracture: this considers the mechanism of injury (high or low energy); the degree of
soft tissue damage; the fracture configuration, comminution, and stability; the level of contamination; and concomitant
neurovascular injuries.
• Stability of fracture fixation (strength and type of fixation used)
• Concomitant fractures of the ipsilateral or contralateral lower extremity. Other fractures may change the rate of
rehabilitation and the progression of weight bearing.
• Overall medical condition of the patient. Some conditions are associated with delayed fracture healing, such as alcoholism,
immunocompromise, and systemic diseases.
• Presence of superficial or deep infection.
OTHER CONSIDERATIONS
• Bone graft by history. If bone loss is more than 50% of cortical surface, early bone grafting is recommended at 6 to 8 weeks after
the soft tissue environment has stabilized. Autogenous cancellous iliac bone is preferred.
• Knee and foot ROM. Active ROM exercises of the knee and foot should be continued whenever possible throughout the
rehabilitation protocol to avoid knee flexion contracture or equinus deformity.
• Early stabilization of fractures in patients with multiple injuries reduces the incidence of pulmonary complications (adult
respiratory distress syndrome, fat embolism, and pneumonia), decreases the number of days in the intensive care unit, and shortens
the hospital stay.
• The rate of rehabilitation may be slowed in type III wounds by soft tissue considerations. Anderson found that type III
fractures averaged 3 months until soft tissue healing was complete.
FRACTURES OF THE LOWER EXTREMITY
•The goals of successful treatment of lower
extremity injuries are
•(1) restoration of functional ROM
•(2) rehabilitation of all muscle-tendon units
•(3) unrestricted weight bearing.
GENERAL PRINCIPLES OF REHABILITATION

-Phase 1(0 to 6 weeks),

• mobilization of adjacent joints
• protected weight bearing

-Phase 2 (6 weeks to 3 months),

• strengthening and endurance exercises
• progressive weight bearing;

-Phase 3 (3 to 6 months),
• progression to full unsupported weight bearing,
• agility and endurance training,
• reentry into work and recreational activities

-Phase 4 (more than 6 months),

• resumption of normal activities.
Rehabilitation after ORIF of hip fractures
•Bed mobility while maintaining proper alignment
of the operative limb
•Lying flat on back for 1 hour/day to avoid hip
flexion contractures.
•Forced hip flexion or rotation avoided for the 1st
7-10 days postoperatively.
•Semi reclined position is allowed after 24 hours.
Patients are assisted into protectively
positioned side-lying as soon as possible(2-3
days postoperatively).

• Side lying position greatly aids in:

• - toiletry
• - pulmonary postural drainage
• - prevention of decubitus (pressure) ulcer.

An over head trapeze is essential during the 1st

few days postoperatively (using elbows & heels
to elevate hips→ 4 times body weight force acts
on the hip).
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Gait training with walker or crutches if balance
& mobility are good.

Over 12-16 weeks gait pattern will evolve into

full weight bearing based on:
• - surgical procedure
• - area of fracture
• - radiographic findings
• - patient comfort
Gait training with walker or crutches if balance & mobility
are good.
Active exercises through a comfortable range

Pool exercises to regain strength,

proprioceptive sense & mobility. ( there is
approximately 75% off-loading with immersion
to the level of the xiphoid process and about
50% with immersion to the level of umbilicus.

• Nb.
• Tying a shoe with foot on floor requires 124o hip flexion
• Ascending stairs requires 67o hip flexion
• Sitting down on a chair requires 104o hip flexion
Day 1:
•Quadriceps sets
•hamstrings sets
•gluteal sets
•ankle pumps
Active assisted hip
abduction & adduction

Supine leg slides for

flexion of hip & knee

Upper extremity
exercise
Day 2:
•Ambulation with TDWB with
walker, then PWB with walker

Days 3-7
•SLR in all directions
•Thomas stretch of anterior
capsule and hip flexors

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Discharge criteria:
• 1. Get out of bed independently
• 2. Able to ambulate 50 feet with assistive device
• 3. In & out of bathroom independently.

• Standing hip abduction, adduction, flexion, and

extension & hip and knee flexion exercises.
• Progress ambulation from walker to use of a cane
• Stationary bicycle, pool exercises, and treadmill
During gait training Youssef has difficulty maintaining TDWB on the
affected lower extremity. He tends to place approximately 20% of
his weight onto affected leg.

How to solve this problem??

 Intra-articular fractures
Fractures of the femoral condyles & tibial plateau

(Fractures of the femoral condyles:

a) oblique fracture of the lateral condyle;
(b) Y-shaped fracture into the notch;
(c) comminuted fracture with (d) rotation of the
condyles. mona selim
 Phase 1 (0-6 weeks)
- CPM in first 24-48 hours (0-90
degrees)
- OKC exercise e.g. SLR,
quadriceps & hamstrings sets
- TDWB( touch down)

Phase 2 (6-12 weeks)

- Stationary bicycle
- PWB using the scale technique
- CKC exercises
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Mona Selim
 lunges
• Wall slide.

Stool slide
CKC
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- FWB
Phase 4 (>6 months)
- Return to work & recreational activity
- Avoid excessive squatting & jumping & contact
sports for 6-12 months

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  Phase 1 (0 to 6 weeks): Non weight bearing exercises.

• Begin straight leg raises, quadriceps sets, and other muscles sets.

• Begin patellar mobilization techniques (medial, lateral, superior, and inferior).

• Begin active and active-assisted knee ROM exercises (non-weight bearing).
• Begin gentle passive ROM techniques for extension and flexion, including prone hangs,
passive extension with roll under heel, and wall slides while lying supine (flexion).
• Begin progressive weight bearing (PWB),
depending on fracture-fixation stability.

• Allow stationary bicycling with minimal or no tension.

• (8 to 12 weeks) Begin closed-chain exercises, initially with

limited weight on affected extremity
 Tibial Shaft Fracture Treated With Bi-planar
lIizarov External Fixation

Phase 1 (0 to 6 weeks)

Weight Bearing:

• Allow patients to be weight bearing as tolerated.

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 *Most patients with an Ilizarov-type fixator choose a position that places the foot in
plantar flexion and the knee in flexion.

 Contractures may be avoided by stretching exercises, night positioning,

 splinting, and functional use of the extremity (Passive exercises are far more
effective in preventing contractures than are active exercises).

 Patients are taught to place a pillow under the most distal ring to keep the knee
extended and to wear a shoe with the foot tied in dorsiflexion to the frame.

 Passive stretching exercises for the calf and hamstring muscles should be done 2 to
3 hours each day e.g. towel stretches, use of an incline board, and use of rubber
bands for dorsiflexion.
 Mechanism of injury:
 A history of a direct blow, a severe muscle contraction, or
an unexpected, rapid knee flexion while the quadriceps was
contracted

 Causes of Patella Fractures

 Direct blows (e.g., dashboard)
 Indirect blows (e.g., jumping)
 Types of Patellar Fractures :
 *Indications of surgical treatment:
 1-Displaced fractures
 2-An inability to extend the knee (disruption of the
extensor mechanism and functional loss)
 3-Comminuted fractures (that requires total or partial
patellectomy)
 4- an intra-articular fracture.

 *Non displaced fractures with the patient having the ability to perform
a straight-leg raise are generally treated non operatively.
Ankle Fractures

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Fractures in the forefoot:
(a) crush fracture of the phalanx;
(b) dislocation of the metatarsophalangeal joint;
(c) fatigue fracture
d)spiral fracture of the metatarsals;
e)transverse fracture of the fifth metatarsal;
f)fracture of the styloid process of the fifth Mona Selim
 Treatment Considerations
• Anatomic reduction is necessary to restore this weight-bearing
joint.
• a 1-mm lateral shift of the talus in the mortise reduces the contact area
of the ankle by 42%. This can cause tibiotalar joint arthritis.

• Un-displaced fractures with an intact mortise are treated with cast

immobilization.

• Displaced fractures are treated with open reduction and internal

fixation.

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REHABILITATION PROTOCOL
After Stable Open Reduction and Internal Fixation
First 2 weeks;
• Ensure non-weight bearing with crutches.
• avoid equinus deformity.
• Maintain maximal elevation for 48 to 72 hours.
2 to 3 weeks
• begin gentle, non-weight bearing active ROM exercises:
• Plantar flexion & Dorsiflexion : 4 sets of 15 each day
• Straight leg raises (SLRs) and quadriceps sets for general lower extremity
strengthening
• Gentle towel stretches (especially dorsiflexion) 2 to 3 times a day for ROM.

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• After 4 weeks
• Touchdown weight bearing with crutches and Continue for 6
weeks.
• If no pain & fixation is very stable, we allow partial
(scaled)weight bearing with crutches.

After 6 weeks
• Allow weight-bearing as tolerated for 2 to 4 weeks.
• Begin advanced stretching exercises.
• Use joint mobilization (For capsular tightness and stable fracture)
• Do proprioception activities:
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 Isometric strengthening exercises & eccentric strengthening & TheraBand
exercises

A, Resisted eversion of ankle., slowly turn involved foot outward

(eversion). This exercise is the most important of this series.
B, Resisted inversion. Inversion against TheraBand.
C, Resisted dorsiflexion of ankle. Pull foot toward body.
D, Resisted plantar flexion of ankle. Place tubing around foot.
Press foot down against tube into dorsiflexion. Mona Selim
• Begin advanced stretching exercises.

• Use joint mobilization For capsular tightness and stable fracture

are present.
Incline
• Do proprioception activities: board.

Balance board or kinesthetic agility training

• Perform toe crawling with towel

• Perform closed-chain activities:
Progression as tolerated Wall slides

Towel stretches of cal

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