Fractures and Surgical Fixation 2 CE Hours

By: Gordon Ward

Learning objectives ŠŠ Summarize the structure of the bone and discuss the basic types of ŠŠ Discuss the various operative and non-operative fixation fractures and their classifications. techniques employed by doctors; explain the advantages, ŠŠ Discuss the contribution of Maurice Müller and the importance of disadvantages and considerations of each technique. the AO Foundation within the history of orthopedics. ŠŠ List the specific rehabilitation considerations, describe physical ŠŠ Demonstrate an understanding of the stages of the healing process, and occupational therapy interventions used and summarize a and identify complications and factors that may adversely affect basic plan of care for postsurgical facture management. the healing process. ŠŠ Explain the various phases of orthopedic protocols for physical therapists and the goals and indications of each. Introduction Bone fractures affect thousands of Americans each year. The most operative) or if the fracture is displaced or angulated, doctors may common causes of bone injuries are falls, followed by motor vehicle turn to operative fracture management to position the bone into proper accidents, sports injuries and assaults. Although long bone fractures alignment for optimum healing. Operative techniques include the use are often results from traumas, more and more fractures are being of screws, plates, intramedullary nails and external fixation and depend associated with osteoporosis. Osteoporosis is a leading underlying cause upon the severity of the facture, the bone involved, or if it is open. of fractures, especially among the elderly: each year an estimated 1.5 Rehabilitation considerations after a surgical fixation of fractures are individuals suffer a fracture due to a bone disease, such as osteoporosis required to restore strength, functional mobility and joint motion. Post- (NCBI, 2016). The incidences in the United States for all types of operative complications are correlated with a patient’s health status fractures are 21 per 1000 people annually, according to BMJ Best and/or comorbidities. Complications may include infection, nerve/ Practice (2015). The tibia is the most commonly fractured long bone in blood vessel damage, poor/delayed healing, compartment syndrome the human body. or unequal leg length. Smoking increases delayed healing, as does Fracture management can be operative or non-operative. When more osteoporosis and diabetes. conservative techniques are not enough to treat fractures (non-

Bone basics Structure of bone tissue The human skeleton is made of two types of bone tissue: cortical bone 80 percent of the human skeleton. Long bones, such as the femur and and cancellous bone. They differ in structure and distribution within humerus, are examples of cortical bone. the body. Cortical bone - also referred to as compact bone or lamellar Cancellous bone - also called “spongy” bone or “trabecular” bone - bone - is dense and strong. Cortical bone constitutes approximately has a larger surface area and is ideal for metabolic activity. Cancellous bone is located at the ends of long bones, as well as in flat bones. Physiology of bone tissue Bone tissue is in a constant state of turnover: osteoclasts remove bone, osteoporosis, osteoclast activity is greater than osteoblast activity. and osteoblasts are continually creating new bone. The metabolic When fractures occur, the osteoblast activity increases to allow the needs of the tissue and the biomechanical loads placed on the bone bone to heal. The blood supply and health of surrounding soft tissue determine the balance between these processes. In the case of are important factors.

Bone healing occurs in four stages (Ito & Perren, 2016) 1. Inflammatory stage (3-5 days): 3. Bone callus formation stage (3 weeks up to 12 weeks): The inflammatory stage begins when the fracture occurs and may Minerals – including calcium and phosphate – release into the last for up to five days. The injury causes a disruption of blood cartilage as the fibrocartilage callus continues to transform into vessels and results in the formation of a hematoma at the site of bone. A fracture union occurs when the hard callus formation is the fracture. Any bone fragments without soft tissue attachment are complete. To promote bone growth, controlled weight-bearing devascularized and die, causing the release of cytokines. The blood activity may be allowed at the end of this stage. vessels dilate and the local tissue temperature rises. 4. Bone remodeling stage (up to several years): 2. Fibrocartilage callus formation stage (4 days – 3 weeks): The fracture site is slightly enlarged after the hard callous forms. Chemical and metabolic reactions form a soft, fibrocartilage callus. The bone remodeling process restores the normal shape of the Fibroblasts begin to form cartilage and fibrocartilage that fill the bone by removing mature bone and forming new bone. Osteoclasts gap between the fracture segments. The fracture remains weak to remove the mature bone, and osteoblasts form new bone. external stresses for up to six weeks and is usually immobilized with a sling or a removable plastic cast.

PT.EliteCME.com Page 1 Classification of fractures Fracture classification systems can be simple or more complex Other terms used when describing types of fractures are (Kellam & (e.g. AO Foundation method). The simple classification system Audige, 2016): describes the fracture based on the severity and pattern. It includes ●● Non-displaced fracture (a.k.a. “undisplaced” fracture): The two transverse, oblique, spiral, comminuted, segmental, and impacted. This ends of a fractured bone do not separate and remain in proper classification is appropriate for many general situations. Listed below alignment. are the definitions of each type of basic fracture. ●● Displaced fracture: The two ends of a fractured bone separate and Basic types of fractures (Singh, 2007): are out of their normal positions. ●● Transverse fracture: Occurs at a right angle to the axis of the ●● Stable fracture: Remains in proper alignment after reduction. long bone. ●● Unstable fracture: Tends to displace after reduction. ●● Oblique fracture: Occurs at an oblique angle relative to the axis ●● Complete fracture: Extends through both sides of bone, including of the long bone. the cortex and the periosteum. ●● Spiral fracture (torsion fracture): Occurs with a rotational force ●● Incomplete fracture: Involves only one side of the cortex and relative to the axis of the long bone. periosteum of the bone (i.e., Greenstick fractures). ●● Comminuted fracture: A fracture of a long bone into more than ●● Extra-articular fracture: The fracture line does not extend into two fragments; usually occur after high-impact trauma. the joint space. ●● Segmen tal fracture: Occurs in two places on a long bone; are ●● Intraarticular fracture: The fracture line extends into the joint difficult to reduce and often result in nonunion. space. ●● Impacted fracture: A fracture in which the bone fragments are ●● Complicated fracture: Involves significant soft tissue damage jammed together and the fracture line is difficult to distinguish. (including muscles, nerves, artery, and ligament). ●● Uncomplicated fracture: Has minimal or no soft tissue damage. ●● Closed fracture: The skin over the fracture site is intact. ●● Open fracture: The skin over the fracture site has been penetrated - either by a fragment of bone or a foreign object.

AO Foundation and Maurice Müller, MD: “The orthopedic surgeon of the century” Maurice Müller, MD – a Swiss orthopedic surgeon – created the The Foundation began as the study group “Arbeitsgemeinschaft AO Foundation with a small group of surgeons in 1958. Müller für Osteosynthesefragen” (German for “Society for the Study of was instrumental in the development of techniques and equipment Internal Fixation” or “AO”). The original intent of the study group for the internal fixation of bone fractures and was named “The was to scientifically evaluate the role and appropriateness of surgical Orthopedic Surgeon of the Century” by SICOT - an international fixation for fractures.In 1990, the AO Foundation released the Müller society of orthopedic surgeons. The AO Foundation was responsible AO Classification of Fractures in Long Bones, which has become a for creating a more complex fracture classification system.The AO worldwide standard and a source of training and reference materials Foundation is a nonprofit organization of international orthopedic for surgeons worldwide. surgeons who specialize in the treatment of trauma and disorders of the musculoskeletal system.

The Müller AO Classification of Fractures According to the AOFoundation.org, the Müller AO Classification of Bone and segment are considered to be part of the localization of the Fractures is a comprehensive system for classifying bone fractures, injury. Type, group, and subgroup fall under morphology. based on the location and severity. This system uses a five digit Müller AO Classification format: alphanumeric code to give a detailed description of the fracture.

The five digit alphanumeric code given to a fracture is composed of Sub- Bone Segment Type Group two parts: localization and morphology. There are five components of Group 1/2/3/4 1/2/3/4 A/B/C 1/2/3 the fracture classification:bone , segment, type, group, and subgroup. .1/.2/.3

Müller classification of fractures: Explanation ●● Bone: The first digit in the alphanumeric code describes which ○○ For proximal and distal segments: of the four major areas of long bone is involved in the injury. The A. Extra articular: The fracture line does not extend into the numbers are as follows: joint space. 1. Humerus. B. Partial articular: Part of the joint surface is involved, but 2. Radius/ulna. the other section remains connected to the bone shaft. 3. Femur. C. Complete articular: The fracture line separates the 4. Tibia/fibula. articular portion of the bone from the shaft of the bone. ●● Segment: Each bone is divided into three segments to give a more ○○ For diaphyseal segments: precise location of the bone’s fracture. Malleolar fractures are A. Simple: There is only one fracture line. described by the fourth segment. B. Wedge: There are three or more fragments resulting from 1. Proximal. the fracture that have contact after reduction. 2. Diaphyseal (shaft). C. Complex: There are three or more fragments that do not 3. Distal. have contact after reduction. 4. Malleolar. ●● Type – There are three types of fractures in this system and are described using letters A, B and C:

Page 2 PT.EliteCME.com Non-operative and operative interventions for fractures Fracture management can be divided into two methods: non-operative ●● Closed reduction; nail fixation and operative. Non-operative management involves realignment of the The closed reduction; nail fixation technique is used when there bone, followed by a period of immobilization with a cast or splint. This is an unacceptable deformity or risk of displacement, but the technique is used when there is an acceptable deformity and the risk of fracture requires greater stability that can be achieved with screw surgery outweighs the benefit. Immobilization of the bone is important only or plate techniques. This procedure requires good bone to improve pain level, to promote healing, and to prevent neurologic quality and allows for earlier mobilization of the surrounding or vascular problems. The advantages of non-operative management joints. The advantages of this technique include earlier motion of are reduced risk of infection and no operative risks. Disadvantages of surrounding joints and less exposure from surgery than is required non-operative techniques include the risk of displacement and limited for ORIF. The possible disadvantages of this procedure are greater initial use of the limb. disruptions of soft tissue and increased pain levels. Nail fixation Operative fracture management is divided into: Closed reduction; is performed to provide greater stability for long bone fractures. internal fixation, open reduction; internal fixation, and external fixation Reduction can be difficult compared to open reduction. During the (Theerachai, et al., 2012). Closed reduction techniques include fixation rehabilitation program weight bearing must be closely monitored. with screws or plates and the use of intramedullary nails. Open ●● Open reduction; screw fixation: reduction techniques typically use screws and plates. External fixation Open reduction; screw fixation is performed when closed reduction is used to stabilize fractures; however, it is also used to treat other cannot be achieved; yet there is an unacceptable deformity and/ conditions that affect bone tissue (Fragomen & Rozbruch, 2007). Each or risk for displacement of the fracture. The technique requires of these surgical techniques has specific indications, advantages, and good bone quality and a fracture pattern that is suitable for fixation disadvantages: with screws alone. It offers greater stability than closed reduction ●● Closed reduction; screw fixation: without fixation. The advantage of open reduction; screw fixation Closed reduction; screw fixation is performed when there is an is that less hardware is retained and earlier motion is possible after unacceptable deformity and/or there is a risk of displacement surgery. The possible disadvantages include limited stability of after closed reduction. This procedure requires good bone quality screw fixation; the screws must overcome the instability caused by and adds more stability to the fracture site. It may allow earlier the separation of impacted bone. mobility of the surrounding joints and earlier mobility for the ●● Open reduction; plate fixation: patient. The advantage of closed reduction; screw fixation is Open reduction; plate fixation is similar to the other procedures: minimal soft tissue damage from the procedure; however, scar it is used to address an unacceptable deformity and a risk of tissue management is an important component to the rehabilitation displacement. However, this technique does not require good program to normalize tissue response and to reduce the risk for bone quality and can be performed on osteoporotic bone. Another contractures. The disadvantages of this technique include no advantage of open reduction; plate fixation is that it is currently the exposure of the fracture for proper reduction, as well as possible most stable type of fixation. The disadvantage of this procedure limitations of stability. The screw fixation must overcome the is that it requires nearly anatomical reduction of the fracture. It instability caused by separation of the impacted bone. is also technically demanding and the fixation must be able to ●● Closed reduction; plate fixation: overcome the instability caused by the separation of the impacted The primary indication for closed reduction; plate fixation is an bone. unacceptable deformity or risk of displacement; however, a plate ●● External fixation: is used when greater stability is needed than can be achieved The external fixation technique is used for a variety of conditions with screw fixation. Like screw fixation, plate fixation requires including open fractures, periarticular fractures, pediatric fractures, good bone quality and adds more stability to the fracture site. The temporary stabilization of long bone, pelvic ring fractures, Pilon advantages of plate fixation are better stability than screws alone, fractures, and malunion/nonunion fractures. This procedure is the possibility of earlier motion, and less soft tissue damage that minimally invasive, quick to apply, flexible, and can be performed ORIF. The disadvantages of this technique include no exposure of as a temporary or definitive fracture stabilization method. the fracture for proper reduction, as well as possible limitations Customization of external fixation is possible to fit the situation of stability; plate fixation must overcome the instability caused and patient. A disadvantage of external fixation is that it could by separation of the impacted bone. Scar tissue can be a greater result in a malunion or a nonunion fracture that causes a loss of concern with plate fixation compared with screw-only fixation. function from the distraction of a fracture site. There are also risks Scar management is an important factor in regained joint range of for failure at the pin-bone interface, possible infection at the pin motion. sites, soft tissue damage, and contracture. The fixator device is often heavy and bulky and may cause functional mobility to be difficult.

Rehabilitation of fractures with surgical fixation Rehabilitation considerations A critical component of fracture management is rehabilitation ●● Weight-bearing status: performed by licensed physical or occupational therapists that have An orthopedic surgeon will determine a patient’s weight-bearing training in orthopedic rehabilitation. Therapists must be aware of status after a surgical fixation of a lower extremity fracture. The precautions, contraindications, and the impact of comorbidities weight bearing status will be determined by the type of fracture, on a patient’s progress and outcome. Weight-bearing status (lower the type of surgical fixation used, the quality of bone, and the extremity fractures), lifting restrictions (upper extremity fractures), surgeon’s professional judgment regarding the projected healing wound healing, and scar management are other factors that can affect time. Weight bearing status is described as a percentage of one’s the success of a rehabilitation program. body weight (i.e., 25% of body weight); however, some surgeons

PT.EliteCME.com Page 3 use terms such as “toe-touch” weight bearing to indicate light Patient education plays an important role: it informs and sets pressure (Firoozabadi, Harden & Krieg, 2012). The therapist realistic expectations for patients. It helps patients understand their should contact the surgeon to avoid miscommunication if a injury, the surgical procedure, and the plan of care. Patients receive patient’s weight bearing status is not indicated in the therapy information from their surgeon; however, therapists reinforce referral, the medical record, or the surgeon’s protocol. precautions and instruct patients about home exercise programs as Patients who undergo surgical fixation for upper extremity well as discuss their progress toward goals. fractures often have a short period of immobilization and lifting ●● Rehabilitation programs: Bone specific: restrictions to promote healing. A sling and/or a splint will achieve ○○ Humerus immobilization. Lifting restrictions are provided to the patients The rehabilitation of humerus fractures depends on the to minimize the stress applied to the healing fracture. Limited location of the fracture, the stability of the glenohumeral joint, active assisted range of motion is generally allowed during the and the type of fixation used to stabilize the fracture. Most early phase of rehabilitation; strengthening exercises and manual humerus fractures require short-term (two to three weeks) stretching are added more slowly to the program. immobilization of the shoulder using an orthopedic sling. A ●● Wound management and assessment: cushion also can help assist with proper positioning. Lifting Wound healing is another consideration in postsurgical fracture and weight bearing of the arm is limited until the fracture has management. Patients who undergo surgical fixation will have healed. wounds that require assessing and monitoring. Surgical incisions The rehabilitation protocol for humerus fractures with fixation are acute wounds and most undergo primary closure with sutures can be divided into three phases. Gentle range of motion or staples. The edges of the wound mend together within a couple exercises may begin early without stressing the fixation site. of days, but staples or sutures remain from one to two weeks Strengthening exercises and the return to full function should to ensure proper closure. Steri-Strips support the wound after be delayed until the fracture has healed enough to be secure removal of the staples or sutures and ensure wound closure to under stress. Rehabilitation timelines may vary depending on reduce the risk of infection. They will usually peel off after five to the location of the fracture, the type of fixation performed, seven days (Advanced Tissue, 2014). patient progress, healing, and the surgeon’s preference; basic Health issues that can affect wound healing include obesity, guidelines are listed on the following protocol. diabetes, malnutrition, smoking, weakened immune system, and a ■■ Phase 1 (0-3 weeks): history of prolonged use of corticosteroid medications. Infections □□ Immobilization of the shoulder for two to three weeks. will slow the healing process and potentially cause the formation □□ Gentle assisted motion (PROM). of additional scar tissue around the surgical site. Patients should □□ Pendulum exercises. follow up with their surgeons if they have severe pain around the □□ External rotation should be avoided for the first six incision, intense redness, excessive bruising, a low-grade fever weeks. of more than 100.5°F, or cloudy drainage from the incision. It is ■■ Phase 2 (3-9 weeks) – assumes no displacement and normal for healing wounds to have mild redness, light clear or pink evidence of healing on X-ray: drainage, and a slightly raised texture as scar tissue is forming. □□ Active assisted range of motion for flexion and abduction. Scar tissue formation is a natural part of the healing process. It □□ Gentle functional use, but no resisted abduction. occurs in three stages: the inflammatory stage, the proliferative □□ Progress toward AROM after week six. stage, and the remodeling stage. ■■ Phase 3 (9-12 weeks): The inflammatory stage lasts for a few days after a surgery. The □□ Patient may begin isotonic, concentric, and eccentric wound may appear red and swollen during this stage and may strength exercises (as tolerated). have a mild clear or pink drainage. A scab will usually form to □□ Manual stretching if bone has healed, but protect the wound while it heals. The proliferative stage occurs glenohumeral joint is stiff or restricted. over the next three to four weeks. Fibroblasts produce collagen Shoulder motion is less restricted for shaft and distal that pulls the edge of the wound together. As this process humerus fractures. Humerus shaft fractures may be continues, the wound may become thicker in appearance. During stabilized using a fracture brace that allows motion of the this stage, wounds should be monitored for signs of infection, or shoulder and elbow. Distal humerus fractures may require for an over-production of collagen - such as keloid scarring. The temporary elbow immobilization to protect the fixation. remodeling phase begins after a few weeks when the proliferation ○○ Radius/ulna stage is complete. The scar begins to thin and the color fades as Postoperative radius and/or ulna fracture fixation may the scar tissue matures. During this stage, therapists may perform require temporary immobilization of the elbow for proximal scar desensitization and scar mobilization as indicated. Early fractures - or the wrist for distal fractures - using a sling or the range of motion exercises further help to prevent adhesions and combination of a sling and a splint. As with any fracture, the contractures. treatment protocol may vary depending on the location of the ●● Rehabilitation programs: General: fracture, the type of fixation performed, and patient healing The goals in the early phases of rehabilitation are to protect the rate. fracture while it heals, minimize pain and swelling, ensure that uninvolved joints maintain their range of motion, and educate Early active assisted motion is encouraged for proximal radius the patient about any precautions or restrictions. Braces, splints, and/or ulna fractures with flexion, extension, supination slings, or CAM boots protect healing fractures. Pain control is an and pronation of the elbow. Active range of motion of the important part of the rehabilitation process; pain may limit the shoulder, wrist, hand, and fingers of the involved limb should patient’s ability to tolerate the required treatments. Medications be performed to restore motion; elbow active range of motion can help achieve pain control when combined with physical may be performed in cases with distal radius/ulna fractures. modalities such as cryotherapy (cold packs, Game Ready, Iceman). Patients are encouraged to use the elbow for low intensity Early active range of motion exercises for uninvolved joints will activities, but these activities should not be painful. The help to prevent stiffness, maintain normal motion, and prevent progress of the range of motion should be monitored to contractures. prevent soft tissue contractures and ensure return to normal

Page 4 PT.EliteCME.com motion. Patients should avoid loading the elbow and wrist Complete healing can take longer if the fracture is open or if for 6-8 weeks until the fracture has sufficient healing. Once the femur is broken into several pieces. the fracture’s healing has been verified, exercises that address The following is a sample for rehabilitation of a proximal strength, endurance, and return to function may be performed femur fracture with ORIF: (Cunneen & Gately, 2016). ■■ Phase 1 (0-2 weeks) Prevent wound complications: The following protocol shows guidelines for a distal radius □□ Control pain and edema. fracture with ORIF: □□ Non-weight-bearing precautions. ■■ Phase 1 (0-2 weeks): □□ Gait training with an assistive device. □□ Postoperative splint used. □□ Safety awareness training for ADLs. □□ Non-weight bearing on the operative limb. □□ Prevention of DVTs, including ankle pumps. □□ Patient is encouraged to move elbow and fingers □□ PROM and AAROM of operative limb. through full range of motion several times per hour. □□ Transfer training. □□ Elevation and cold packs are encouraged for edema ■■ Phase 2 (2-6 weeks): and pain control. □□ Begin weight-bearing activities - following weight- □□ Restrictions include: no lifting, pushing, pulling, or bearing precautions. operating heavy equipment; no lifting > 0.5 lb.; full- □□ Progress gait training while decreasing level of time splint use. assistance, per surgeon’s orders. ■■ Phase 2 (2-6 weeks): □□ Progress AAROM to AROM of operative limb. □□ AROM and PROM of all fingers. □□ Progress therapeutic exercises to active hip and thigh □□ AROM and AAROM of wrist. muscles. □□ No strengthening or PROM (manual stretching). □□ Begin functional exercises, focusing on postural □□ Control edema. control and endurance. □□ Modalities prn. ■■ Phase 3 (6-12 weeks): □□ Home exercise program. □□ Progress to WBAT. □□ Continue non-weight bearing on the operative limb. □□ Begin balance training. ■■ Phase 3 (6-12 weeks): □□ Progress aerobic conditioning. □□ Begin weight bearing on the operative limb – WBAT. □□ Progress to ambulation on uneven surfaces. □□ Aggressive AROM and PROM. □□ Improve gait pattern to normal. □□ Begin strengthening exercises: may begin light ○○ Tibia/fibula gripping exercises at six weeks; may begin wrist Fractures of the tibia are usually the result of a trauma; flexion, extension, supination, and pronation at eight however, they can also occur from stress (excessive or weeks. unusual activity) or from compromised bone strength (cancer, □□ Wean from static splint, as tolerated (if ROM is infection, or osteoporosis). Proximal tibia fractures can affect restricted in any direction at eight weeks, add static the knee joint’s range of motion, strength, and its function. progressive splint to address deficit). Distal tibia fractures can cause the same problems with ○○ Femur ankle joints. Traumatic tibia fractures may accompany fibula Femur fractures are often related to trauma and require surgical fractures. fixation. Several factors dictate the rehabilitation program - Proximal tibia fractures may require surgical intervention to including the type of fracture/fracture pattern, the location, and align the bone fragments. If the fracture occurs in the upper the quality of the bone fragments. quarter of the bone, but the fracture line does not extend The location of the fracture is a key factor. Fractures of the into the knee joint, a plate - or intramedullary nail - may be shaft generally allow a therapist to work on hip and knee used. A plate is fixed on the outside surface of the bone; an range of motion. However, if the fracture line extends into the intramedullary nail is inserted into the hollow medullary cavity joint line of either the hip or the knee, those joints will require in the bone shaft. Fractures that injure the joint require the use immobilization until the surgeon clears the patient to begin of plates and screws to achieve internal fixation. range of motion exercises. Tibia shaft fractures may require surgery if they are open or Patients with femur fractures are generally allowed to begin are extremely unstable, secondary to multiple bone fragments. early weight-bearing activities to help with bone healing. They Fractures that do not heal with nonsurgical treatments may will require assistive devices in the beginning, but might be also require surgical fixation. The most common form of able to progress rather quickly toward independent ambulation. surgical fixation for tibial fractures is intramedullary nailing; Many patients will begin with a walker and their status may although plates, screws, and external fixators can also be used. be partial weight bearing. They typically progress quickly Intramedullary nails may be hollow or solid. Tibial nails have to weight bearing as tolerated (WBAT). These patients can locking screws that assist with better fixation and alignment. progress to a cane when their pain level, strength, and ROM A tool called a “reamer” may be used during placement of allow them to walk with close to normal gait pattern – with no intramedullary nails to increase the diameter of the tibial significant limp noted. medullary canal. The reamed technique allows greater stability Rehabilitation of femur fractures following stable surgical because the nail fits snugly in the longer section of the tibial fixation focuses on restoring ROM, strengthening, and gait shaft. Reaming also assists with the use of locking screws. training (Pattern, et al., 2006). Other considerations include Distal tibia fractures can occur at the syndesmosis joint pain and swelling management, wound healing monitoring, between the tibia and fibula or in the ankle joint. Ankle and scar management. The progression of exercises will fractures typically involve the medial malleolus (anterior part depend on weight-bearing status from the surgeon, speed of of the distal tibia), the posterior malleolus (posterior part of healing, type of fixation, and the fracture pattern. Most femoral the distal tibia), and/or the lateral malleolus (end of the fibula). shaft fractures take four to six months to completely heal. These fractures are classified by the location of the fracture. Distal tibia fractures can be fixed using screws, plates with

PT.EliteCME.com Page 5 screws, or wiring techniques. Ankle fractures may involve a □□ Safety awareness training for ADLs. single malleolus, but bimalleolar and trimalleolar fractures are □□ Prevention of DVTs including ankle pumps. common. Trimalleolar fractures are unstable injuries that can □□ PROM and AAROM of hip and knee. be associated with an ankle dislocation. □□ Transfer training. Tibia fractures generally heal in three to six months; however, ■■ Phase 2 (2-6 weeks): a return to full function takes six to twelve months. Factors □□ Begin gentle range of motion depending on pain, including location, severity, surgical technique, and other swelling, and surgeon’s orders. health comorbidities - such as diabetes - can affect the rate of □□ Maintain non-weight-bearing status. healing. There are several possible complications related to □□ Continue use of CAM boot. fractures of the tibia and fibula. Among these are joint pain □□ Continue to monitor for signs and symptoms of DVT (knee or ankle), poor healing, infection (especially with open or infection. fractures), nerve/vessel damage, compartment syndrome, □□ Progress proximal range of motion and strength osteoarthritis, and unequal leg length. Patients with lower exercises. leg fractures may also be at risk for developing deep vein □□ Progress therapeutic exercises to active hip and thigh thrombosis (DVT). muscles. ■■ Phase 3 (6-12 weeks): Postoperative rehabilitation protocols for fractures of the □□ Progress to weight bearing status based on surgeon’s tibia and fibula vary based on the location of the fracture and orders. the type of surgery performed. Proximal and tibial plateau □□ Initiate proprioception and balance exercises. fractures may require the use of a brace. The program protects □□ Progress aerobic conditioning while observing the knee joint in the early phases. Distal tibia fractures and precautions. ankle fractures often require the use of a CAM boot to protect □□ Progress to ambulation on uneven surfaces toward the the ankle joint. In both cases, patients will be non-weight- end of this phase. bearing on the affected leg and use assistive devices - such as □□ Improve gait pattern to normal. a walker or crutches - for ambulation. Weight-bearing status □□ Syndesmotic fixation often requires hardware removal is determined by the surgeon and is progressed based on bone eight to twelve weeks after surgery. healing. ■■ Phase 4 (12+ weeks): This is a sample protocol for an ankle fracture with open □□ Achieve full AROM with compensation. reduction; internal fixation (ORIF): □□ Progress strength exercises and progress strength to ■■ Phase 1 (0-2 weeks): 5/5. □□ Prevent wound complications. □□ Restore normal gait pattern - if not achieved in Phase □□ Control pain and edema. 3. □□ Non-weight bearing precautions. □□ Progress balance and proprioception activities. □□ Patient education regarding precautions. □□ Return to full ADL participation, as tolerated. □□ Gait training with assistive device. □□ Gradually progress to previous level of activity. Case studies Humerus Anna is a sixteen-year old girl who sustained a right distal and was within normal range by nine weeks, except there was a ten humerus fracture when she fell and landed on her right arm. She degree extension lag. had surgery for open reduction; internal fixation with screws. Her Manual stretching was started at nine weeks to regain full elbow arm was immobilized for three weeks to prevent elbow movement extension. Anna began strengthening exercises during this phase as while the fracture healed. She was allowed to perform gentle well. By twelve weeks post op, she had full range of motion in her range of motion exercises for her wrist, but shoulder external shoulder, elbow, and wrist. Her strength was significantly improved, rotation was avoided. but she continued to perform her home exercise program to restore At three weeks post op, Anna began AAROM with progression to normal strength for the next month. Her surgeon was pleased with her AROM exercises by six weeks, but manual stretching of elbow flexion progress and cleared her for return to activity as tolerated at four to six and extension was not allowed. Her range of motion progressed well months.

Radius/ulna Dan is thirty-five year old man who fractured his left forearm in Dan started more aggressive range of motion exercises to restore his an auto accident when his vehicle was struck on the passenger’s movement to a functional range. side. He underwent surgery to fix a distal radius fracture with open He began light gripping exercises with progression to strengthening reduction; internal fixation using a plate and screws. His surgeon wrist flexion, extension, supination, and pronation at eight weeks. referred him for a custom splint to protect and support his arm. He During this phase, he was weaned from the splint and made progress wore his splint for four weeks. with his strength exercises. He was discharged from therapy after Dan was allowed to perform active range of motion exercises for his twelve week follow up visit with his surgeon. Dan continued to his left elbow and fingers during the first two to six weeks. He was perform his home exercise program and was cleared to return to his restricted from lifting, pushing, pulling, driving, typing, and bearing usual activities at four to six months. weight on the left wrist or hand for eight weeks. After six weeks,

Page 6 PT.EliteCME.com Femur James is twenty-eight year old semi-professional football running performed functional exercises to improve postural control and back who sustained a right femoral shaft fracture when he was endurance. tackled in a game. He underwent surgery to fix the fracture using James was cleared for weight bearing as tolerated during his six week an intramedullary nail and screws. He was non-weight-bearing on post op appointment with his surgeon. His physical therapist added his right leg for the first two weeks, but he began partial weight proprioception and balance activities to his clinic program as well bearing after three weeks. James ambulated using a walker for the as to his home exercise program. He was able to discontinue using first two weeks, but he was able to progress to bilateral axillary the crutches when his gait pattern returned to normal. His strength crutches within two to three weeks. exercises progressed to include more closed chain and functional His early exercise program included PROM and AAROM activities. strength activities and he advanced his aerobic conditioning. At six He progressed to AROM and light strength exercises for his hip months, James was cleared for running and to return to his previous and thigh by four to six weeks post op. During this phase, he also activities.

Tibia/fibula Marion is a sixty-two year old woman who fractured her left ankle She was allowed to begin weight bearing in her CAM boot at eight when she slipped while stepping down from an icy curb. Her weeks as tolerated,prt with progression to proprioception and balance X-ray revealed a bimalleolar fracture that involved the medial and training. Her therapist added light strength exercises and advanced lateral malleoli. She had surgery to fix her ankle fracture using ROM activities. As her weight-bearing tolerance improved, her gait a plate and several screws. Marion was non-weight-bearing and pattern also improved. She was able to walk using only the CAM boot wore a CAM boot for eight weeks. She ambulated using a standard by twelve weeks. walker. Marion achieved functional ankle range of motion and her strength Her initial therapy program focused on gentle range of motion, pain improved by twelve weeks; she was cleared to walk without her boot, control, swelling, and basic mobility. She performed light strength and as tolerated. Her balance, proprioception, and endurance improved stretching exercises for the hip and knee. Safety awareness and DVT to include close chain, functional strength activities. At six months, prevention instructions were included during this phase. Marion was cleared to return to her previous activities.

Conclusion Acute long bone fractures treated with surgical fixation require skilled with progression to AAROM and AROM exercises. Patient education, rehabilitation to enable patients to return to full function. Several transfer training, and gait training are important components of the factors affect fracture healing: bone quality, severity of the fracture, treatment plan and should not be overlooked. As the fracture heals type of surgical fixation, and the presence of comorbidities. Physical and weight-bearing restrictions are lifted, patients may progress to and occupational therapy plans of care must consider a patient’s closed chain functional strength exercises, proprioception training, and weight-bearing status, time required for healing, and previous level of balance activities to restore full function. function. The focus of postoperative treatment is to decrease pain and The success of fracture management following surgical fixation swelling, while restoring associated joint range of motion and strength. requires proper identification of the type of fracture, selection of the A short period of immobilization is often required immediately after appropriate surgical technique, and development of a treatment plan surgery. Early exercises including PROM begin within a few days that addresses impairments and functional limitations.

References ŠŠ BMJ Best Practice. (2015). Long Bone Fracture - Basics- Epidemiology. Retrieved 4/16/2016 from ŠŠ Pattern, M.V. et al. (2006). Early Rehabilitation Following Surgical Fixation of a Femoral Shaft http://bestpractice.bmj.com/best-practice/monograph/386/basics/epidemiology.html. Fracture. Physical Therapy 2006; 86:558-572). ŠŠ National Center for Biotechnology Information (NCBI). (2016). Bone Health and Osteoporosis: A ŠŠ Hiesterman, T.G., Shafiq, B.X., Cole, P.A. (2011). Intramedullary Nailing of Extra-articular Report of the Surgeon General. The Frequency of Bone Disease. Retrieved November 21, 2016 from Proximal Tibia Fractures. J Am Acad Ortho Surg. 19(11):690-700. https://www.ncbi.nlm.nih.gov/books/NBK45515/ ŠŠ Allier, H. A., Curetons, B.A., & Patterson, B.M. (2011). Randomized, prospective comparison of ŠŠ Ito, K., Perren, S. Biology of Fracture Healing. Retrieved March 15, 2016 from https://www2. plate versus intramedullary nail fixation for distal tibia shaft fractures. Journal of OrthopedicTrauma aofoundation.org/wps/portal/surgerymobile?contentUrl=/srg/popup/further_reading/PFxM2/12_33_ 25(12): 736-41. biol_fx_heal.jsp&soloState=precomp&title=&. ŠŠ Singh, A. P. (2007). Different types of Fractures – A Simple Classification of Fractures. Retrieved March 26, 2016 from http://boneandspine.com/types-fracturesa-simple-classification-fractures-long- bones. ŠŠ Kellam, J., Audige, L. AO Surgery Reference Terminology. Retrieved 4/4/2016 from https:// www2.aofoundation.org/wps/portal/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOKN_ A0M3D2DDbz9_UMMDRyDXQ3dw9wMDAx8jfULsh0VAdAsNSU!/?bone=Humerus&segme nt=Proximal&soloState=lyteframe&contentUrl=srg/popup/further_reading/PFxM2/15_Fx_Class_ terminology. ŠŠ AO Trauma. AO/OTA Fracture and Dislocation Classification. Retrieved March 6, 2016 from https://aotrauma.aofoundation.org/Structure/education/self-directed-learning/reference-materials/ classifications/Documents/AO-OTA-Fracture-and-Dislocation-Classification.pdf. ŠŠ OrthoInfo. (October 2012) Fractures (Broken Bones). Retrieved 3/12/2016 from http://orthoinfo. aaos.org/topic.cfm?topic=a00139. ŠŠ The Bone School. Principles of Internal Fixation. Retrieved 4/4/2016 from http://www.boneschool. com/trauma/principles-internal-fixation. ŠŠ Fragomen, A.T., Rozbruch, S.R. (2007). The Mechanics of External Fixation. Retrieved 3/19/2016 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504087. ŠŠ Theerachai, A., et al. (2012). CRIF - Intramedullary Nailing. Retrieved April 9, 2016 from https:// www2.aofoundation.org/wps/portal/surgery?showPage=redfix&bone=Tibia&segment=Shaft&classif ication=42-C1&treatment=&method=CRIF - Closed reduction internal fixation&implantstype=Naili ng&approach=&redfix_url=1285239039414&Language=e. ŠŠ Firoozabadi, R., Harden, E., & Krieg, J.C. (2015). Immediate Weight-Bearing after Ankle Fracture Fixation. Advances in Orthopedics Vol. 2015. ŠŠ Advanced Tissue. (2014). The Signs and Stages of Wound Healing. Retrieved March 26, 2016 from http://www.advancedtissue.com/signs-wound-healing-stages. ŠŠ Cunneen, P., Gately, C. Distal Radius Fractures: Rehabilitative Treatment and Care. Retrieved 4/17/2016 from https://www.hss.edu/conditions_distal-radius-fractures-rehabilitative-treatment.asp.

PT.EliteCME.com Page 7 Fractures and Surgical Fixation Final Examination Questions Select the best answer for questions 1 through 10 and mark your answers online at PT.EliteCME.com.

1. The ______stage is when the chemical and metabolic reactions 6. What is NOT a “basic” type of fracture, as classified by Singh? form a soft, fibrocartilage callus. a. Transverse fracture. a. Bone callus formation. b. Complicated fracture. b. Bone remodeling. c. Spiral fracture. c. Inflammatory. d. Oblique fracture. d. Fibrocartilage callus formation. 7. The ______status will be determined by the type of 2. Some issues that can affect wound healing include: fracture, the type of surgical fixation used, the quality of bone, a. Smoking. and the surgeon’s professional judgment regarding the projected b. Diabetes. healing time. c. Obesity. a. Rehabilitation. d. All of the above. b. Wound management. c. Goal. 3. What is NOT a goal in the early phases of rehabilitation? d. Weight-bearing. a. Protecting the fracture while it heals. b. Minimizing pain and swelling. 8. According to the AOFoundation.org, the ______is a c. Commencing isotonic, concentric and eccentric strength comprehensive system for classifying bone fractures, based on the exercises. location and the severity. d. Ensuring that uninvolved joints maintain their range of motion a. Müller AO Classification of Fractures. and educating the patient about any precautions or restrictions. b. Musculoskeletal system. c. Holistic. 4. Patient ______plays an important role: it informs and sets realistic d. Rehabilitation system. expectations for patients. a. Involvement. 9. What type of fracture has minimal or no soft tissue damage? b. Restriction. a. Open fracture. c. Education. b. Incomplete fracture. d. First aid. c. Uncomplicated fracture. d. Complete fracture. 5. Tibia fractures generally heal in three to six months; however, a return to full function can take up to how long? 10. The ______techniques include fixation with a. 9 months. screws or plates and the use of intramedullary nails. b. 15 months. a. Open reduction. c. 24 months. b. Internal fixation. d. 6-12 months. c. External fixation. d. Closed reduction.

PTNY02SFI17

Page 8 PT.EliteCME.com