Ace Your Musculoskeletal Science Exams

I have found these notes fundamental for Physiotherapy Musculoskeletal Science 251 Exam Revision.

Physiotherapy Students Practicing for an upcoming practical exam/ OSPE Scenario

Law of Facilitation

· When an impulse has passed once through a certain set of neurons (known as the “facilitated section”) to the exclusion of others, it will tend to take the same course on future occasions. And, each time that impulse traverses this path, the resistance will be less

· The more times you do something the easier it becomes from a neurological standpoint.

· incorrect movements can be neurologically facilitated just as much as correct ones → up to therapist to teach correct techniques

Stages of Exercise Progression

MOBILITY → POSTURAL CONTROL → CONTROLLED MOBILITY → FUNCTION

· Clinical decision-making tool

· Assessment of a patient to decide which stage of progression they are at, and follow a logical progression of interventions, through the stages until they achieve their functional goals

· Mobility = achieving full PROM & AROM, development of muscle performance

· Postural Control = first part: sustained muscle performance/endurance in postural muscles, NWB position, second: WB posture, static balance around joint, improving overall body balance in a static bilateral weight-bearing posture, muscles trained to sustain these postures

· Controlled Mobility = move in a controlled way from a bipedal stable base and in optimal alignment from one weight bearing posture to another e.g. one leg to the other aka gait, controlled squat, later stage: static and dynamic single limb balance

· Function = trunk control & coordinated limb movement specific to patient’s individual functional goals, limbs move away from stable base of trunk, timing and coordination

Clinical Pathways

· Accelerated post-op recovery program

· Designated activities set forth by surgeon

· Any deviation from pathway addressed immediately by team

· Coordinated effort to combine pre-operative education

· Hospital in the home HITH/RITH

Purpose

· Decrease length of stay

· Decrease costs without compromising quality of care

· Streamline patient’s care and maximise resources

· Increase quality of care

· Address hospital bed shortage

· Decrease post-op complications

Criteria

1. Multidisciplinary intervention plan of care

2. Integrate current guidelines/evidence into intervention

3. Plan very clearly and detail what is required day to day — detailed steps for each person in group

4. Definitive time frames or criteria-based progressions e.g. day 3 patient must have 80–90 degrees knee flexion

5. Intervention is standardised for a specific population — within a specific problem/procedure e.g. TKR patients

Falling off the Clinical Pathway

· Leads to increased LOS and costs

· Increased age, women, pre-operative disability, overweight, wound/lung infection during hospitalisation, reaction to anaesthesia, post-surgical complications; DVT etc.

Typical Inpatient Orthopaedic Assessment

1. Locate patient charts — systems, surgical report, history & demographics, previous physio/OT/nurse notes

2. HAND SANITISER!!!!

3. Introduce yourself to patient — name, student, how they are feeling today, pain levels, nausea, goals for today, consent

4. Safety & Equipment check — brakes, attachments, position of patient, how they are dressed, type of bed, where controls are, mobility device available

5. Locate and read current observation chart at foot of bed

6. Unaffected limb: PROM & AROM (goniometry), MMT — knee, hip, ankle

7. Affected limb: sensation, circulation, peripheral perfusion refill, edema, dorsal pulse, DVT symptoms

8. Affected limb: PROM & AROM, MMT — knee, hip, ankle

9. Upper extremity bilaterally: grip strength, elbow flexors/extensors, pushing, pulling

10. Mobility

11. Treatment

12. Chart intervention, findings, etc.

Post-Op Attachments Found in Hospitals

Intravenous Drip

· Vein in f/arm or dorsum of hand

· Isotonic solution, fluid/electrolyte replacement, antibiotics, narcotics

· Removed when adequate oral fluid replacement begins

· Maintain neutral wrist position, avoid extension during transfers, WB allowed

Drains

· Redivac & hemovac

· Prevent collections of blood, serum, lymph, etc. under skin

· Situated adjacent to incision

· Drains into bag either by gravity or vacuum

Indwelling Catheter (IDC)

· Monitors urine output

· Patients w/ problems urinating post-op e.g. spinal, epidural, immobility

· Inserted intermittently or permanently

· Removed when able to ambulate to bathroom

· Taped to inside of thigh — hip abduction & flexion perform with care

Patient Controlled Analgesia (PCA)

· Delivers measured doses of pain relief medication through IV cannula

· For moderate to severe pain — inadequate analgesia from oral, intermittent IV

Patient Charts Found in Hospitals

General Orthopaedic Patient Systems Checklist

· CNS — LOC, orientation to time/place, agitated, confused, uncooperative

· CV — BP, pulse, perfusion/circulation, edema, IV fluids, blood results

· Respiratory — chest physio, cough, sputum, SPO2/O2 rate delivery

· Integumentary — wounds, ulcers

· Pain — type, location, intensity, pain relief given

· Musculoskeletal/ADL’s — falls risk, mobility aid, manual handling

· Psychosocial — emotional status/affect, social worker, family issues

· Mental Health/Behaviour — speech, mood, suicide risk, drug/alcohol use

· Gastrointestinal — nutritional status, appetite, swallowing, nausea, bowel movement

· Renal System — fluid balance chart, urinalysis frequency/colour/smell, IDC change due

Patient History and Demographics

· General — age, gender, ethnicity, language

· Social History — culture, family support

· Occupation — work status, community/recreational activities

· Growth & Development — hand & foot dominance

· Living Environment — stairs, slopes, dirt driveway

· PMH — past musculoskeletal problems, co-morbidities, hospital admissions

· Reason for admission — events leading up to, elective/traumatic surgery

Surgical Report

· Surgeon

· Limb/joint, which side

· Date & time — length of surgery

· Type of surgery & approach — prosthesis used

· Anaesthesia — spinal, general

· Fluids administered, blood loss

· Complications during

· Surgeon’s immediate post-op instructions & precautions

· Weight bearing status & mobility status

Current Observation Chart (foot of bed generally)

· Medications & when

· Temperature, pulse rate, respiratory rate, blood pressure

· Current post-op complications — DVT, infection, pneumonia

· Other medical investigations — current findings

Total Hip Replacement Surgery

· Antero-lateral (Hardinge), lateral (modified Hardinge) or postero-lateral approach

· Metal stem and ball with a plastic shell held in place with methyl methacrylate cement or press fitted

· The lifespan of cemented and cementless is 80% performing well at 20 years

· The development of porous prostheses have partially eliminated the need for cement/glue

· Non-cemented (press-fitted) prostheses encourage bony in-growth, allow bone to intertwine with the irregular metal finish

· Hemiarthroplasty — only femoral head replaced and not acetabulum

Minimally invasive THA

· 1. Single incision technique — use of traditional approaches but incision smaller <10cm

· 2. Dual incision technique — one for preparation and insertion of acetabular component and one for preparation and insertion of femoral component

· Less soft tissue trauma

· More rapid recovery & mobilisation

· Fewer precautions

· Require use of modified, specialised equipment — technically more demanding

Hip Surgery Precautions or THA Precautions

· Minimise risk of dislocation and disruption of soft tissue healing — adhered to first 3 months

HARDINGE Hip Replacement (antero-lateral)

• No flexion >90 degrees
• No external rotation
• No hyperextension
• No adduction
• Large incision through most/all abductor muscles

MODIFIED HARDINGE Hip Replacement (lateral)

• No flexion >90 degrees
• No external rotation
• No hyperextension
• No adduction
• SOMETIMES no abduction
• Smaller incision; posterior fibres glut med preserved

POSTERO-LATERAL Hip Replacement

• No flexion > 70 degrees
• No internal rotation
• No adduction
• Incision through superficial & deep gluteals

Knee Surgery

· Osteotomy — uni-compartmental osteoarthritis; wedge of bone removed from medial or lateral tibial plateau; correct varus/valgus deformity; delay TKR

· Uni-compartmental arthroplasty; unicondylar; biondylar; tricompartmental

· Total knee arthroplasty — for knee pain & disability from OA, two knee compartments

· Arthrodesis — knee joint fusion, when complete joint destruction from severe ligament/articular damage or following failed TKR. Fusion in 15 degrees flexion and 0–7 degrees valgus best

· TKA contraindicated by severe neurologic or cognitive disease, active unstable medical problems e.g. angina

· Traditional intramedullary procedure or minimally invasive

· Prostheses: gender specific, can be mobile bearing (for younger or higher demand patients — larger contact area, does not restrict natural movements of femoral component) or stabile bearing

· Cemented — WBAT directly after surgery

Minimally Invasive Surgery

• Arthritis most common cause of joint replacement — OA, AS, gout — caused by genetics, obesity, injury, overuse, age-related, inactivity

Advantages of Minimally Invasive Surgery

· Less trauma to muscles (TKR quads spared, THA gluteals)

· Not so traumatic to tissues , lose less blood

· Recovery and rehab time much shorter

· Less pain and discomfort

· Fewer post-op movement restrictions

· Smaller incision → smaller scar

Disadvantages of Minimally Invasive Surgery

· Technically challenging; more difficult for surgeon

· Less room to see for surgery — relying on cameras rather than own eyes

· Increased risk of fracture or mal-alignment

· Takes longer to perform — more time for complications

· Limited scientific data — long-term efficacy unknown

Simple Post-Op Exercises after Surgery

· Ankle pumps

· Gluteal squeeze

· Quads setting

· Short arch quadriceps

· Knee flexion

· Hip flexion

· Hip abduction

· Standing hip flexion

· Standing hip extension

· Standing abduction

· Must discuss: reps, sets, times/day, rest periods in between each rep and set, holding time for isometric ex’s, speed of contraction

Active Assisted Range of Motion (AAROM)

· Providing a measure of assistance/support to move a limb when patient is unable to do so independantly

· Used when AROM is impaired; muscles < grade 3 and no contraindications

· Muscle strengthening at a lower level (strengthening usually > grade 3 )

· Restoring full AROM and optimum muscle performance

· During transition from passive to active movements

· When severity of patient’s pain too much immediate post-op

· RI or external aids such as pulleys, slide-boards

Post-Surgical/Fracture Complications

Compartment Syndrome

• Develops when swelling/bleeding occurs within compartment
• Fascia does not stretch à increased pressure on capillaries, nerves, muscles
• Blood flow and nerve cells to muscles disrupted, possibly enough so muscles/tissues die
• Re-established blood flow after blocked circulation, fracture.
• Surgery: tourniquet wrapped too tight/too long (decreases bleeding), saline pumped through knee leaks out into tissues, surgery where legs are raised for a long time
• Emergency fasciotomy

The 5 P’s You Have to Ask Patients for Post-Surgical Fracture Complications:

1. Pain — pressure, stretch, elevation or hanging the limb down

2. Paraesthesia (pins and needles)

3. Passive stretch

4. Pressure — tenderness over area

5. Pulselessness

DVT or Deep Vein Thrombosis

• 20% popliteal vein — 50% popliteal thrombi embolise
• Immobility causing sluggish blood flow
• Inflammation from IV drip
• Likely to form embolus → pulmonary embolism
• Risk factors = endothelial injury, abnormal blood flow, hypercoagulability
• Symptoms of DVT or Deep Vein Thrombosis = pain, swelling, tenderness, increased warmth, changed skin colour, decreased distal pulse IN ONE LEG
• Symptoms of pulmonary embolus = sudden shortness of breath, sharp chest pain, coughing up blood, sudden collapse
• Prevention = anticoagulants (blood-thinning, decrease clots): heparin, warfarin BUT increased chance of bleeding, compression stockings & pumps, early mobilisation (ex’s e.g. ankle pumps), no smoking

Peri Prosthetic Fracture (Fractures around implants or fixation)

• Technical issues during placement — structural deformation
• Change structure of bone — increase susceptibility to fracture
• Complicated by OA
• Implant may impair fracture healing due to endosteal ischaemia
• Up to 10 years post-surgery
• End of device becomes a stress rise — osteoporotic bone tends to fracture first when excessive load is applied
• Symptoms = pain, deformity, swelling, limb length discrepancy, non-use of limb

Urinary Tract Infection UTI

§ One or more parts of the urinary system become infected — usually bacterial (E.Coli)

§ Cystitis — bladder

§ Pyelonephritis — Kidney

§ Sometimes due to catheter

§ Symptoms = strong, persistent urge to urinate, burning sensation when urinating, passing frequent, small amounts of urine, blood in urine (haematuria) or cloudy, strong-smelling urine, bacteria in urine (bacteriuria)

Peroneal Nerve Injury (Common fibular nerve) /Neuropathy Post TKA (Knee Surgery)

· Compression of peroneal nerve between external object and fibular head, or trauma eg fracture of fibula, knee dislocation, stretch injuries (severe inversion sprains)

· Usually seen in posterior approach hip surgery or correcting knee valgus deformity — nerve is stretched, stretching the nerve while positioning the knee

· Causes = knee trauma/injury, injury during knee surgery, being placed in awkward position during anaesthesia, fibula fracture, tight plaster cast

· Risk Factors = valgus deformities, epidural anaesthesia, previous nerve disease, very thin people, toxin exposure that damage nerve, diabetic neuropathy

· Symptoms = decreased dorsiflexion “foot drop”, pain, weakness, numbness on shin/dorsal foot, high stepping walk, slapping gait, toes drag while walking

Avascular Necrosis (AVN) of Femoral Head

• Blood supply of Femoral Head (FH) limited — covered with articular cartilage which Blood vessels (BV’s) do not penetrate
• Fracture interrupts circulation and necrosis ensues
• top of femoral head collapses, flattens, changed biomechanics à wear & tear, pain, OA
• Infarction à osteocyte and bone marrow death
• Causes: dislocation of head out of socket in surgery damaging blood vessels, screws placed into socket piercing blood vessels, NOF fractures
• Risk Factors: corticosteroids, smoking, alcohol abuse
• Symptoms: pain in weight bearing positions (groin, buttocks, thigh front), limping, stiffness
• Usually takes several months to show up

Prolonged Bed Rest/immobility

· Immobilisation — holding a joint or bone in place with a splint, cast or brace — prevents injured area moving while it heals

· De-conditioning — multiple changes in organ system physiology induced by inactivity

· Decreased PROM & AROM of joints (shortening of soft tissues, muscle contracture)

· Softening & fragmenting of cartilage surfaces

· Loss of proteoglycans in cartilage

· Poor quality tissue healing — haphazard orientation of CT; excessive fibrin deposition = scar tissue

· Decreased protein synthesis rate

· Muscle mass loss; atrophy

· Less motor neuron activity; decreased transmission speed & recruitment

· Decreased intramuscular capillary density

· Resorption of bone — increased osteoclast activity, decreased bone formation

· Increased chance of fracture

· Reduced Stroke Volume (SV), resting tachycardia, exaggerated increased HR w/ exercise

· Venous pooling

· EARLY MOBILISATION = optimised healing time, enhanced properties of healing tissues, gently stretches tissue encouraging elongation, promotes blood flow, BUT not too aggressive

Reciprocal Inhibition

· Active lengthening of an antagonist muscle caused by contraction of the agonistic muscle

· Active lengthening to achieve muscle balance

· Agonist contracts → muscle spindle senses resistance à inhibitory signals to antagonist via inhibitory interneuron = inhibited/relaxed antagonist

· Relaxes to accommodate contraction of agonist

Autogenic Inhibition

· HR — Antagonist

· Sudden relaxation of a muscle on high tension

· Protective mechanism against muscle tear

· Carried out by golgi tendon organ

Patient Feedback

· Absolute feedback — given after every practice attempt

· Faded Feedback — therapist begins with lots of feedback, absolute in nature in the first stages, gradually reducing frequency until none is given at all at the end of practice

· Summary Feedback — feedback is given after a certain number of practice trials, with summary of performance

· Self-Selected Feedback — the patient learning the task asks for feedback from the therapist when they want it

Spinal VS Epidural Block

· Numb down legs and feet — can be awake during operation

· Avoid risks of general anaesthesia

Spinal Block

· Injected into cerebrospinal fluid sac of spinal cord

· Done only once — no catheter

· Works immediately (Spreads easily in csf)

· Smaller needle

Epidural Block

· Injected just outside fluid sac (epidural space) — does not penetrate dura

· Single dose or catheter (lasts longer) (catheter — Sits in epidural space so drugs can be delivered as needed)

· Ten minutes to work (Because anaesthetic spreads through tissue)

FRACTURES

FRACTURE CLASSIFICATION

• Various systems
• Salter Harris
• Orthopaedic Trauma Association
• AO Classification
• Saunders Classification System
• Muller AO Classification
• Localisation — bone (humerus, radius/ulna, femur and tibia/fibula) AND segment (proximal, disaphyseal, distal)
• Morphology — Type ABC, Group 123, Subgroup 123

PELVIS AND PROXIMAL FEMUR

PELVIC FRACTURE

• The pelvis lies in close proximity to numerous vascular, neural and soft tissue structures that are vulnerable during pelvic ring disruption
• Lower energy # — avulsion and acetabular fracture
• Higher energy # — pelvic ring disruptions
• Breaks occur at weakest points

Mechanisms of Injury

• Requires significant force
• Motor vehicle accident 50–60%
• Motor cycle crash 10–20%
• Pedestrian struck 2–10%
• Crush
• Falls esp. elderly — proximal femoral and pubic rami fractures
• Bony avulsion younger athletes

Morbidity & Mortality

• 10–15% secondary to retroperitoneal haemorrhage or infection
• Mortality approaches 50% if hypotensive on presentation; 30% if open fracture
• Significant decrease in morbidity/mortality with prompt stabilisation of unstable #
• Fracture more common in patients >55 years but increased morbidity/mortality <55

Pelvic Fracture Classification

According to the stability of the pelvic ring & integrity of posterior sacroiliac complex

Pelvic Fracture According to the Stability of the Pelvic Ring and INtegrity of posterior sacroiliac complex

Type I / Type A Pelvic Fracture

• Stable
• pelvic ring intact,
• no major instability,
• results in slight widening of pubic symphysis,
• may avulse parts of pelvis e.g. iliac wing
• mechanism — low to moderate energy force, direct blow/crush injury, fall in elders
• conservative management
• reduction conservative — open reduction often not necessary
• mobilise early — as soon as pain controlled
• PWB/NWB on affected side with gait aid until pain permits WB’ing or evidence of union

Type II / Type B Pelvic Fracture

• stable vertically but unstable rotationally (partially stable)
• “open-book” fractures
• External rotational/internal rotational/lateral compression forces
• Disruption of symphysis pubis, occasionally pubic rami
• Pelvic floor ruptured if severe
• Posterior column/complex usually intact

Type III Pelvic Fracture— unstable rotationally but unstable vertically

• Complete disruption of post SI complex and pelvic floor
• Posterior and vertical translation possible = unstable pelvic
• High energy trauma — shearing forces — MVA, fall from height, crush
• Higher risk of visceral, arterial and neural damage, and death

Associated Injuries and Complications of Pelvic Fractures

• Vascular injury + haemorrhage — femoral, internal iliac artery, thoracic aorta rupture — loss of massive volume causing shock — can result in sepsis, adult respiratory distress syndrome or lung infection
• Hypovolemia — increased pulse rate and respiratory rate
• Neural injury — sciatic, femoral, obturator, lumbosacral plexus
• Visceral (organ) injury –liver, spleen, GI, bladder, urethra, reproductive, pancreas
• Chronic Pain
• Arthritis
• Immobility — increased risk for coagulation — should be anti-coagulated once stabilised
• Consider spinal cord injury if mechanism was severe enough to fracture pelvic

Signs and Symptoms of Pelvic Fracture/ Complications

• Hypovolemia — increasing pulse and respiratory rate
• Diminishing mental status
• Look, listen (crepitus) and feel for pelvis stability by compressing the ring of bones
• Feel for deformity — look for abrasions/bruising
• Compare limb length — shortening of one leg, swelling, gross deformity
• Warrants ambulance/transport to hospital due to concern about severe internal bleeding and hypovolemia — life threatening
• Severe pain — buttocks, back, hip, groin or pelvis
• Bleeding from vagina, urethra or rectum
• Difficulty urinating
• Profuse bruising
• Patient refuses to move — increased pain with movement
• Pubic ramus fractures if pain in front of pelvis
• Walking is slow and painful
• Numbness or tingling in groin or legs

Clinical Significance & Implications for Rehabilitation

• Assess for impairments of musculo, Cardiovascular CV and neuro function
• Hospital exercises — deep breathing, ankle pumps, quads setting, gluteals, imagery training, pelvic floor exercises, UL/LL ROM, bed mobility

Sacral Fracture

• Osteoporosis is leading cause of sacral insufficiency fractures
• Risk factors — radiation to pelvis, steroid use, RA, hyperparathyroidism, anorexia, osteopenia, Paget’s disease, hip joint replacement
• Also in pregnant or breastfeeding women due to temporary osteoporosis
• Can occur spontaneously
• 60% results in pubic ramus fracture

Complications of Sacral Fractures:

• Visceral structures — bladder, bowel or urethra via fragment of bone
• Neural structures — lumbosacral plexus — pelvic floor dysfunction (loss of/impairment of sexual, urinary and bowel function or control)
• Vascular structures — haemorrhage, major iliac vessels — death
• Disruption of bony sacral ring — decreased WB capacity

Proximal Femur Fracture

• Either # of region of femoral neck or # of femoral shaft
• Intracapsular (subcapital, transcervcial) or extracapsular (intertrochanteric, pertrochanteric, subtrochanteric)
• NOF # common in elderly in association with falls
• Signs and Symptoms — unilateral pain, edema, bruising, deformity, leg shortening
• Inability to move leg or stand
• Surgical management — external fixation: less damage to blood supply of bone, minimal interference with soft tissue, rapid application in emergency situation, good solution if high risk of infection or established infection
• Internal fixation: diastase of pubic symphysis > 2.5 cm, SIJ dislocation, displaced sacral fracture, posterior/vertical displacement, rotationally unstable pelvic ring injury

DISTAL FEMUR & KNEE JOINT FRACTURES

• Supracondylar (distal 9cm of femur) — stronger diaphyseal bone meets the thinner and weaker metaphyseal bone prone to fracture
• Condylar
• Patella tibial plateau

Mechanism of Injury

• Twisting — High energy twisting trauma/ Twisting in elderly (Be careful when mobilizing them)
• Hyperextension
• Any age usually due to direct trauma
• Low energy — osteoporotic # in elderly
• High energy — trauma in the young
• Pathologic — due to metastatic lesion
• Post total knee replacement

Associated Complications of Distal Femur and Knee Joint Fractures

• Can be life threatening

Signs and Symptoms of Distal Femur/ Knee Joint Fractures

• Swelling
• Visible deformity
• Unable to move hip or knee
• Functionally useless
• Impaired circulation or sensation
• Extreme pain, nausea, shock
• Dizziness, confusion
• Diminishing mental status

Clinical Significance and Implications for Rehabilitation of Distal Femur/ Knee Joint Fractures

• Warrants ambulance/high priority transport due to concern about severe internal bleeding or hypovolemia
• Condylar # — joint surface involvement — principle objective of surgery to restore optimal continuity of articular surface — congruency of femoral condyles essential for knee function

Patella Fracture

Mechanisms — of Patella Fractures

• direct blow or fall onto the knees,
• Indirect # sudden, resisted extension à transverse #
• If un-displaced extensor mechanism remains intact
• Displaced # will result in loss of quadriceps extensor mechanism

Signs & Symptoms: Patella Fracture

• Knee swelling
• Usually rests in slight flexion
• Gap may be palpable
• Bruising
• Pain
• Inability to walk

Complications of Patella Fractures

• Non-union or inadequate union — usually avoided by ORIF
• Secondary PFJ OA — can lead to severe chronic pain that warrant patellectomy
• Loss of knee joint ROM
• Loss of quads function

Tibial Plateau Fracture

• Displaced or non-displaced

Complications of Tibial Plateau Fractures

• Prolonged bed rest — DVT, deconditioning
• Disuse osteoporosis
• Muscle atrophy
• Mal-union/non-union with pseudoarthrosis
• Joint incongruity
• Knee joint stiffness

Aims of surgical management (Tibial Plateau Fracture #) –

• Types = conservative skeletal traction, casting, bracing, external fixation, ORIF intramedullary nail, plates and screws
• Restore neurological and circulatory function
• Congruent anatomical reduction of articular surface to reduce post-traumatic arthritis
• Restoration of normal alignment of the limb and limb length
• Early mobilisation of knee

DISTAL ANKLE AND FOOT FRACTURE

ANKLE FRACTURE

• Refer to distal tibia, distal fibula, talus, calcaneus

Mechanism of Injury (Ankle Fractures)

• Usually consequence of very severe and complicated ankle sprain injury
• High energy or low energy twisting injury
• Usually involves foot being anchored while momentum of body weight continues backwards of forwards
• Most common — inversion injury: adduction/inversion/PF of foot upon leg — avulsion # lateral malleolus and/or shearing of medial malleolus — leads to unstable ankle mortice
• Less common — eversion injury: external rotation/abduction/eversion/DF of foot upon leg — shearing of deltoid ligament, injury to lateral complex and/or avulsion of medial/lateral malleolus

Classification of Ankle Fractures

1. Weber Fracture:

Weber Fracture Classification

• according to radiologic appearance, r/ship between syndesmosis and fibular #
• type A — below tibiotalar joint — conservative management
• type B — at or above tibiotalar joint — usually ORIF
• type C — above syndesmosis — usually ORIF

2. other descriptions — unimalleolar, bimalleolar, trimalleolar (disruptions of three parts of the ring — medial, lateral and posterior malleoli — high energy)

3. pilon # — axial compression talus driven into plafond and both shattered — comminuted, displaced, soft tissue damage

Signs and Symptoms of Ankle Fracture

• Clasping of affected ankle region
• Unable to move foot and ankle — associated loss of function
• Typically unable to bear weight
• Swelling, depending on severity
• Tender palpation
• Deformity, depending on severity
• Deep throbbing pain — increasing with activity, decreasing with rest
• Paraesthesia or anaesthesia
• Know your Ankle Rules (Ottawa)

OTTAWA ANKLE RULES

Ottawa Ankle Rules for use of radiography in acute ankle injuries

Associated Complications of Ankle Fractures

• Soft tissues — nerve, vascular, ligament, tendon, cartilage, muscle
• Compartment syndrome
• Malunion or non-union
• Post-traumatic osteoarthritis
• Surgical site infection

Clinical Significance and Implications for Rehabilitation (Ankle Fractures)

• Physical examination — function, palpation, ROM, sensation, circulation
• Restore normal alignment of talus within mortice — joint congruity
• If ligaments damaged — possible reconstruction
• Immobilised NWB 6–12 weeks — rehab upon removal
• ORIF — ensures congruency of articulating surface, allows earlier mobilisation, decreased risk of on-union
• NWB 4–6 weeks, PWB to week 12
• Rehab — CV training, cycle, swim, water running, then strength training, then proprioceptive and balance retraining, then gait retraining, retrain specific function

UPPER LIMB FRACTURE

Humeral Fracture

• Poor blood supply of head of humerus b/c covered by cartilage, no soft tissue

Mechanism of Injury Humeral Fracture

• Low energy — osteoporotic fractures in elderly
• High energy — direct trauma in the young
• Pathologic # — due to metastatic lesion
• Violent muscle contractions — seizure activity, electrical shock
• Falling onto outstretched hand
• Axial loading transferred from elbow
• Fall — secondary to osteoporosis

Classification of Humeral Fractures

• Intra-articular or extra-articular

Stability index:

• Stable # — where head and shaft impacted
• Unstable # →1cm displacement, >45 degrees rotated
• Neer’s 4 segment classification — 2 main components: number of fracture parts (humeral head, humeral shaft, greater and lesser tuberosity) and displacement (>45 degrees, >1cm)

Signs and Symptoms Upper Limb Fracture

• Unable to raise/move arm due to pain
• Clutch/cradle arm
• Swelling
• Change in alignment
• Extreme pain
• Nausea/shock
• Dizziness/confusion
• Impaired sensation

Associated Complications Upper Limb Fracture

• Vascular supply — lateral ascending branch of anterior humeral circumflex artery — damage may lead to AVN, arcuate artery interrupted
• Mal-union or non-union with pseudoarthrosis
• Shoulder joint stiffness
• Complications associated with prolonged immobility
• Muscle weakness and atrophy

Clinical Significance and Implications for Rehabilitation Upper Limb Fractures

• Principle objective of surgery to restore optimal continuity of articular surface
• Immobilisation 2–6 weeks
• Rehab — maintain shoulder mobility, prevent stiffness and ROM loss

Clavicle Fracture

• Sagging shoulder, inability to lift arm due to pain
• Grinding sensation if attempt to raise arm
• Bruising, swelling, tenderness over collarbone
• Deformity/bump over the break

SURGICAL MANAGEMENT: TRAUMA AND FRACTURE

• Fracture management can be either conservative or surgical
• Aim to anatomically reduce, stabilise the fracture, correct any deformity and restore function of soft tissues and joints
• Reduction = realignment of displaced, angulated or rotated fracture fragments; often unnecessary
• Surgical reconstruction dictated by the demands of the patients’ work/sport/ADL
• High demand treatment = fixation; Low demand activities = minimal treatment
• All severe soft tissue injuries require urgent treatment — or will delay fracture healing

Surgical Management for Trauma and Fracture the pros and cons of Operative and Non-Operative Methods

Conservative Management

• Non-operative
• Casting (POP, fibreglass)
• Closed fracture
• Reduce the fracture
• Restore anatomical alignment
• Hold/secure the fracture effectively with cast or splint until bone healing has occurred
• Manipulation under anaesthetic (MUA)
• Immobilise # with cast or splint — usually immobilised joints proximal and distal — retained until bony union achieved — more suited to long bones
• Auto-fixation — fractures that immobilise themselves and require no fixation
• Traction — used mostly for lower limb and spinal fractures, common with paediatrics, either skin or skeletal method, force applied via weights and acts to keep bone fragments in proper alignment, unpopular due to risks associated with prolonged immobility and bed rest

Surgical Management of Fractures

• Often best option — results in best long term outcomes
• Earlier mobilisation, earlier WB possibly, earlier joint ROM
• Invasive — so associated risks
• ORIF or external fixation

Internal fixation — screw, plates, pins and wires, intramedullary rods and nails, cages

• Screws — for large well defined bone fragments, used both to fixate plates and as standalone devices to fixate fragments, cortical or cancellous, dynamic hip screws, interference screws (secure bone/tendon graph — ACL)
• Plates — assist in withstanding external compressive and bending forces, buttress plates (hold in place fractures at end of long bones), broadened and contoured at the joint end of the plate to be secure
• Pins and wire — less secure, used in areas of weak external forces e.g. elbow, Kirschner wire
• Cables — provide compression to the bone, facilitates contact with the prostheses
• Intramedullary rods and nails — long metallic implant inserted at one end of long bone through the medullary canal
• Cages — in decreased spaces between vertebral bodies

External fixation

• Treating compound fractures particularly when associated soft tissue damage that requires treatment and prevents cast
• Pins fixed above and below site and immobilised via frame of external bars — bars connected to pins and run parallel to long axis of bone
• Allows for skin/muscle grafting and infected wounds to be treated
• Ilizarov frame — allows # bone to be gradually elongated to correct for shortening