Management of fracture

B Y- D R . V R A J PAT E L
PT Assessment of Fracture
1. History of sudden trauma
2. Sign and symptoms
3. Investigation

2
1- History
History of sudden trauma, localized pain and bony tenderness are the definite features of
fracture

3
2- Sign and Symptoms
Signs
a. Muscle spasm and tenderness
◦ Reflex muscular spasm appears in the muscle groups close to the site of fracture.
b. Oedema
◦ The soft tissue injury accompanying fracture often results in haematoma, and oedema over the fracture site. The process of repair
begins with inflammation.
c. Warmth
◦ There may be a rise in the local temperature due to increased vascularity to the area of injury.

4
d.Crepitus
◦ Passive movements over the fracture site produce grating between the broken ends which is called crepitus. It is, however,
painful and therefore should be avoided.

e. Deformity
◦ Deformity is obvious in a displaced fracture. However, it may be missed in the presence of profuse oedema.

f.Abnormal mobility
◦ The diagnosis of a fracture is obvious when abnormal mobility is seen in the limb at the fracture site or swelling is present
over the fracture site.

g.Ecchymosis
◦ This is commonly seen in the skin due to soft tissue injuries around the site of the fracture. A common example is fractures of
the proximal humerus, where ecchymosis is seen in the arm, axilla and even the chest wall.

5
 Symptoms

a.Pain is the most consistent symptom present in every fracture.

b.Localized swelling occurs due to
(i) haemorrhage from the fracture ends and injury to the
surrounding soft tissues and
(ii) inflammation within an hour of injury.
c. Deformity: A deformity occurs in a displaced fracture or in a
dislocation. Sometimes, the deformity is masked in the
presence of profuse oedema.

6
d.Loss of movement
 In dislocation, no movement is possible at that joint. The function is also impaired in the
joint or the extremity, itself.

e. Inability to use or bear weight

 In fractures or dislocations of the upper extremity, the patient is not able to use the
extremity, whereas in the injuries of the lower extremity, the patient is not able to bear
weight on the affected extremity.

7
 3- Investigations
1. Radiography: important tool in diagnosis of fracture. AP, Lateral and Oblique views are done in every
case.
2. CT scan: CT scan is not routinely used. However, it is useful to diagnose fracture of small bones and
spine. 3D image helps in better evaluation of fracture.
3. MRI scan: MRI scan gives a better delineation of soft tissue, ligaments and bones. It is useful in
showing changes in soft tissue after trauma.
4. Radioisotope scan or bone scan: This is useful in the diagnosis and differentiation of various traumatic
and nontraumatic conditions.

8
Treatment of fracture

9
Principles
Newer techniques of treatment are added every now and then. However, the basic principles are as follows:
1. To achieve anatomical alignment of the fractured bon ends (reduction)
2. To ensure correct immobilization (maintenance of reduction), till the fracture unites
3. To reduce inflammation and pain
4. To provide necessary compressive forces to the embryonic callus and, at the same time, discourage stretching
situation to this raw callus
5. To restore maximum possible functional independence to the patient as a whole and the fractured limb in particular

10
Stages of management of fracture
Fundamental stages of the management of fracture are:
1. Reduction
2. immobilization, and
3. mobilization and rehabilitation

11
1. Reduction
Purpose: To secure closet apposition of fractured bony ends in the perfect anatomical alignment
– at the earliest (at least within 48 h)
Method: manipulative reduction under general or local anesthesia. ORIF in displaced or unstable
fractures.

12
2. Immobilization
Purpose
◦ Ensures union of the fracture in perfect anatomical alignment
◦ Reduce pain
◦ Allows functional freedom to the fractured limb

Method
◦ POP cast
◦ Skin or skeletal traction
◦ Open reduction and internal fixation (ORIF)
◦ External fixation by applying external fixator

13
3. Mobilization and rehabilitation
Purpose
• To restore maximum possible functional self sufficiency to the patient by various physiotherapeutic
measures.

Method
• Restoring normal ROM to the joint affected following immobilization.
• Achieve minimal possible required functional ROM when a fracture involves a joint
• Restore to the maximum all the functions of the muscles affected by fracture and immobilization
• Training to use assistive aids for functional self sufficiency
• Use of specialized exercise techniques

14
PT management
Any bone fracture or joint dislocation goes through the following two main stages:
1. Immobilization
 Reduction of fracture by either by conservative or surgical approach
 Retention of reduction

2. Mobilization
 It is required when the joints adjacent to the fracture bone get stiff and painful because of prolonged
immobilization
Physiotherapy care during
immobilization
The major principle of management is to retain the perfect anatomical alignment of the
fractured bony fragments, achieved by closed reduction or open reduction and internal fixation
(ORIF).
Try to minimize the adverse effects of acute inflammation and immobilization like pain, oedema
and active movements of the distal joint with the affected limb placed in elevation.
Check POP cast
 ensure that it is neat and tidy
Ensure that it is not digging in the limb at any end
Ensure that is it not blocking the movement of distal joints
Check the finger/toes for cyanosis, cold feel
Joints and muscle complexes not included in the immobilization should be vigorously exercised to improve
circulation to the limb.
The muscle groups under immobilization should be exercised with isometrics within the limit of pain and
discomfort.
Gradually increase the strength and duration of these isometric contractions.
Rest is only for the affected area and limb and not for the whole body; direct the patient to carry out activities
of daily living (ADLs) by the nonaffected part of the body.
Begin bedside standing on one leg and non-weightbearing (NWB) ambulation on a walker.
Explain the expected schedule of exercise on the nonaffected side.
Each fracture is susceptible to develop related complications besides the usual complications of
immobilization. Educate the patient on the symptoms and alarm of such susceptible situations and report
immediately to the nurse to prevent them from occurring, so that necessary care can be taken on the spot
This will greatly prevent the miseries of organized complication, after the removal of immobilization.
During the entire phase of immobilization, keep a watch on the possibility of developing complications due to
the immobilization itself.
Keep a watch on general complications of immobilization, e.g., plaster cast.
Tight POP cast or a bandage may cause cynosis, ischemia, compartment syndrome or nerve compression,
pressure sore, etc.
Loose POP cast: Attempts or involuntarily moved immobilized limb will give rise to sharp intractable pain at the
fracture site and the whole limb, especially during NWB walking on a walker.
Eventually it leads to nonunion.
Skeletal traction sites of pin piercing the skin should be examined every day for suspected infection. Skeletal
long pin may even cause injury to the soft tissue or vessels.
Physiotherapy during mobilization
Objective of physiotherapy:
 Physiotherapy restores preinjury status to the affected limb.
 The most important aspect is to mobilize the immobilized joints and all functions (e.g., strength, power,
endurance, and flexibility) of the muscles of immobilization.
Methodology of approach
 Examine the health of the skin under the cast, and surgical scar in operated cases.
 Soothing massage for a short period over the skin, before exposure to superficial heat will prepare the limb for
mobilization.
 Always begin with small-range, free and relaxed rhythmic pendulum movements to ensure better relaxation and
educating the exact groove of the range of motion (ROM).
 Gradually introduce progressive modes of exercise like self-assisted, self-resisted ones performed several times by
the patient.
 Techniques like proprioceptive neuromuscular facilitation (PNF) and progressive resistive modes are introduced
gradually to meet the goal of optimal muscle functions, full or at least a functional range of joint movement of the
injured joint or a bone close to the site of a fracture.