FRACTURE

3) According To Displacement
a. Undisplaced - fragments or ends of
GENERAL MEDICAL BACKGROUND fracture sites are not separated
b. Displaced - separation of bone
fragments exists.
I. DEFINITION 4) According To Involvement Of
 Any break in the continuity of the bone Epiphyseal Plate
 Used interchangeably with the term broken
bone

ANATOMY

 Blood supply of bone

1) Nutrient artery
 High pressure system that branches from
major systemic arteries
 Enter the cortex through the nutrient
foramen and enter the medullary canal
 Then branch into ascending and
descending branches
 Then branch into arterioles and supply the HARRIS AND SALTER CLASSIFICATION OF
inner 2/3 of mature bone via the EPIPHYSEAL INJURIES
Haversian System TYPE DEFINITION
I Epiphyseal slip only; fx. involves only the
2) Periosteal vessels cartilage plate
 Low pressure system that supplies the II Involves the plate and a triangular segment of
outer 1/3 of bone connected by: the metaphysis
a. Volkman's artery (perpendicular to III Fx. thru the epiphysis extending into epiphyseal
long axis) plate/Fx. traverses the bony epiphysis and
b. Haversian system (parallel to long involves the cartilage plate
axis) IV Fx. of epiphysis and shaft, crossing epiphyseal
plate; involves the epiphysis, the growth plate,
3) Metaphyseal-Epiphyseal vessels and the metaphysis and often causes growth
arrest/growth stunt
V Damage to the epiphyseal plate; crushing of
part of the growth plate
*notes from Brashear

5) According To Plane Or Fracture Surface

a. Transverse Fx - the plane of the
fracture surface is perpendicular to the
axis of the bones.
b. Oblique Fx - fracture surface forms an
angle with the axis of the shaft. Break
runs in slanting direction of bones.
c. Spiral Fx - fracture surface is spiral
and is produced by torsional stress
which fracture the bone
II. CLASSIFICATION 6) According To Pathology
a. Agmetic - spontaneous fracture due to
1) According to Completeness imperfect osteogenesis
a. Complete b. Neoplastic - Fx in bone weakened by
b. Incomplete neoplasm or malignancy
c. Dyscrasic – Fx caused by weakening
2) According to Wound, if present or not of specific bone from debilitating
a. Open Fracture disease
b. Closed Fracture d. Endocrine - Fx resulting from
weakness due to endocrine disorder
Open Fracture
Gustillo Anderson’s Open Fracture 7) According To Part Affected
Classification a. RADIUS
GRA DEFINITION  Chauffer’s - fx of distal styloid
DE
process produced by twisting or
I Clean wound, wound <1 cm in length
snapping injury
II Wound > 1 cm but < 10 cm in length without  Colle’s - extraarticular fx w/ dorsal
extensive soft-tissue damage, flaps, avulsions displacement of distal fragment
III A Wound is >10 cm with adequate periosteal & radial shift of wrist/ hand
coverage of the fracture bone despite the b. ULNA
extensive soft-tissue laceration or damage  Monteggia’s - fx of proximal half
III B Extensive soft-tissue loss and periosteal of ulna w/ dislocation of
stripping and bone damage. Usually proximal radio-ulnar joint
associated with massive contamination. Will c. HAND
often need further soft-tissue coverage  Boxer’s - fx of neck of 5th
procedure metacarpal
III C Extensive soft-tissue loss and periosteal  Mallet - avulsion fx of dorsal base
stripping and bone damage. Usually of distal phalanx
associated with massive contamination. Will
often need further soft-tissue coverage
procedure
 d. HUMERUS  Pathological or imbalances of bones
a. Holstein–Lewis - is a fx of the  Occurs through a bone that is already
distal third of the humerus weakened by a disease
resulting in entrapment of the
radial nerve.
b. Intercondylar - Fx between the V. PATHOPHYSIOLOGY
condyles of the Humerus
e. FEMUR
a. Intertrochanteric - fx of proximal
femur between greater and
lesser trochanters
b. Penurel’s - fx of the proximal
femoral neck w/ varying degree
of angulation
f. TIBIA
a. Paratrooper - fx of the distal tibia
& malleolus as a result of
external force on an ankle
g. FIBULA
a. Pott’s - fx of the distal fibula
usually of the spiral oblique type
w/ asso. ligamentous damage or
medial malleolus injury
h. FOOT
a. Lisfranc - fx dislocation of the
foot
VI. CLINICAL MANIFESTATIONS
b. March - stress fx of one or more
Fracture usually presents the following:
metatarsal shaft usually
 Pain
attributed to excessive marching
 Radiating - compression of a neural
i. SPINE
structure
a. Hangmans - fx through pedicle of
 Localized - musculoskeletal in origin
C2
 Referred
b. Jefferson’s - bursting type of fx @
 Tenderness
the ring of the atlas
 Muscle spasm
j. PELVIS
 Bruising or Ecchymosis
a. Malgaigne - fx dislocation of SI
 Crepitus or Abnormal Mobility between the
joint
broken bones
 Swelling – usual when the fracture is fairly
8) PEDIATRIC CLASSIFICATION
superficial; gross swelling usually implies
a. Greenstick (Torus)
vascular rupture
 Incomplete  Bruising or Ecchymosis
 Occurs on flexible bones  Deformity- a limb may look "out of place" or a
 Bends and fractures only outer part of the bone may puncture through the skin
edge

b. Epiphyseal VII. COMPLICATIONS

 Fx located at site of epiphysis
 Sometimes with associated  Classification of complications
dislocation  Immediate-within days
 Delayed-within weeks or months
 Late- years after
III. EPIDEMIOLOGY
 Immediate complications
 The epidemiology of osteoporosis-related  Injury to Nerves - either neuropraxia or
fractures includes factors related to axonotmesis
underlying osteoporosis and those related  Injury to Arteries - major artery involvement
to injury, such as age and falling. means that surgery will be necessary
 Vertebral fracture- >50y/o  Injury to viscera
 Hip Fracture- >70y/o  Injury to skin
 W>M  Injury to joints
 Shock

IV. ETIOLOGY  Delayed complications

 Dysfunctions- associated with avascular
 Fractures caused by injury – occurs in bones bone and non-union
previously free from disease  Joint stiffness
 Direct Trauma/Violence
 Most common  Late complications
 Injury force is applied directly to the  Shortening(LLD)
bone at the site of fracture  Residual deformity
 Usually open, either comminuted or  Osteoarthritis
transverse  Avascular necrosis
 Indirect Trauma  Affectations in growth
 Force is transmitted along the bone
 Usually follow rotational injuries and  Other complications
may be oblique or spiral  Myositis ossificans
 Atrophy
 Fatigue or Stress  Volkmann`s contracture
 Does not occur from a single violent injury.  Follows after a supracondylar fx
Instead, from repeated stress
 Common in athletes and Military recruits
 Metatarsal often affected
  Delayed union FACTORS THAT INFLUENCE HEALING
 Tibia – 20 weeks
 Femur – 20 weeks Factors Ideal Problematic
 Humerus – 10 weeks
Advanced age (>40
Age, years Youth
Can be due to: y)
 Inaccurate reduction
 Inadequate/interrupted mobilization Multiple medical
 Severe local trauma Comorbidities None comorbidities (eg,
 Impaired bone circulation diabetes)
 Loss of bone substance(nutrition)
 Separation of fragments Nonsteroidal anti-
inflammatory drugs
Medications None
Can be avoided by: (NSAIDs),
corticosteroids
 Early accurate and gentle reduction
and immobilization
 Maintenance of function Social factor Nonsmoker Smoker
 Avoidance of repeated trauma
 Sound judgment and technique in the
use of internal fixation Nutrition Well nourished Poor nutrition

 Non union
Closed fracture,
 Bone fragments maybe connected by a Open fracture with
Fracture type neurovascularly
fibrocartilaginous tissue poor blood supply
intact
Common sites of non-Union:
 Femoral neck Multiple traumatic
Trauma Single limb
 Femoral shaft injuries
 Tibia - most common site (due to
impaired circulation) Local factors No infection Local infection
 Humerus
 Radius and Ulna
 Scaphoid
VIII. DIAGNOSIS
STAGES OF FRACTURE HEALING
IMPACTION The dissipation of the energy from an HISTORY  A brief history is essential in order to
insult assess the mechanism of injury and
INDUCTION Is the stage when cells that possess raise suspicion of other, less apparent
osteogenic capabilities are activated injury
INFLAMMA  Begins after point of impact and lasts  Details of the injury or accident should
TION until some fibrous union at the be recorded, as well as the time,
fracture site place and age of the patient
 Blood vessel disruption causes  In Open fracture, know if the patient
formation of mass of clotted blood, had tetanus immunization
hematoma, at the site of fracture  Inquiry concerning allergies,
 Fibrous and Cartilage Callus begins particularly to medication ised in
to form connection with anesthesia and
 with swelling, lasting 2-3 weeks antibiotics
SOFT  Capillaries grow in the hematoma; PHYSICAL  Examine skin for presence of wounds
EXAMINATION or laceration
CALLUS phagocytes clean up debris;
fibroblast, chondroblasts and  Test sensibility, motor function and
osteoblasts begin reconstruction sweating are sufficient to indicate
 Splinting of the broken bone whether or not there has been an
 This takes until week 4-8 post-injury injury to the nervous system
and is not visible on X-ray  State of circulation
HARD New bone trabeculae appears in the soft RADIOLOGICAL  X-ray examination in at least 2
EXAMINATION planes, usually at the right angles
CALLUS callus
 Osteoblasts  CT scan is useful in aiding diagnosis
form new of difficult injuries (pelvis and spine
lamellar bone fx) and for planning the details for
in the form of surgery
trabecullar  MRI, same as CT scan, but offers
bone improved imaging for soft tissue
 Eventually all structures
of the woven
bone and
cartilage IX. DIFFERENTIAL DIAGNOSIS
becomes
trabecullar Dislocation and Subluxation
bone
This is visible on X-ray and should fill the Definition
fracture by weeks 8-12 post-injury Dislocation is a displacement of a part, usually
BONE - Substitutes the trabecullar bone with the bony partners on a joint resulting in the loss of
REMODELLI compact bone anatomical relationship and leading to soft tissue
NG - Takes 3 to 5 years depending on damage, inflammation, pain, and muscle spasm.
many factors
Subluxation is an incomplete or partial
dislocation of the bony partners in joint that often
involves secondary trauma to tissue.
Etiology  LE
 Direct Violence  Walking plaster
 Indirect Violence  Crutches
It may also happen with association of fracture
 Non-Operative Treatment
Pathophysiology  CASTING (CREF – Closed Reduction
When a joint surface loses it contact or External Fixation)
relationship with other surfaces, this cannot occur without  Traction
some damage to the protective ligaments to the joint  Buck’s extension traction
capsule. Usually, one or more ligaments are torn,  Bryants’s traction
permitting the one articular surface of a bone to escape.  Russel’s traction
Sometimes, the capsule is not torn in its substance but is
stripped from its bony attachments. Method of traction:
 Skeletal – 25-40 lbs.
Clinical Manifestation  Skin
 Pain – especially during movement
 Inflammation (swelling, redness, heat and loss  Operative Treatment
of function)  ORIF(Open Reduction Internal Fixation)

SEVERITY OF TISSUE INJURY

Grade 1 Mild pain at the time of injury or within the
(First first 24hrs. Mild swelling, local tenderness,
Degree) and pain occur when the tissue is stressed.
Grade 2 Moderate pain that requires stopping of
(Second activity. Stress and palpation of the tissue
Degree) greatly increases the pain. When injury is to
the ligament, some of the fibers are torn,
resulting in some increase joint mobility.
Grade 3 Near-Complete or complete tear or avulsion
(Third of the tissue (tendon or ligament) with severe
Degree) pain. Stress to the tissue is usually painless;
palpation may reveal defect. Torn ligament
results in instability.
 Fixation may take the form of:
Diagnosis  Transfixion screws - for oblique fx;
 Obvious cases, diagnosis based in clinical accompanied by a cast
features (sufficiently striking)  Bone plate
 Doubtful cases, depend on radiographic  Intramedullary rod or nail
examination (must be taken into two planes,  used commonly on femoral shaft fx
right angles to one another)  Kuntscher nail
 Special test:
 Shoulder: Sulcus sign, apprehension test,
push to pull test, Feagin Test
 Wrist: Murphy’s sign
 Hip: Ortolani’s test, Barlow’s test
 Patella: Q-angle, apprehension test
 Ankle: Swing test

X. PROGNOSIS

Simple, uncomplicated fractures usually heal in 6 to

12 weeks; loss of function is uncommon. Any increase in
severity of the fracture or added complications will delay
recovery for weeks to months and may compromise
function. While the fracture may heal, damage to the
surrounding structures can result in poor function of an
extremity and a less than optimum outcome. PHYSICAL THERAPY EXAMINATION, EVALUATION,
& DIAGNOSIS
Prevention or reduction of fracture risk may be
significantly reduced in individuals over age 50 by regular I. POINTS OF EMPHASIS ON EXAMINATION
exercise and using calcium and vitamin D supplements
(Tang).  Evaluation Procedure
 Before casting
 Ocular inspection
 Palpation
GENERAL HEALTHCARE MANAGEMENT  Sensory test
 X-ray
I. MEDICAL, SURGICAL, & PHARMACOLOGIC  ADL test
 After casting
 Pharmacologic care  ROM
 Analgesics- NSAIDS, opiods  Ocular inspection
 Anti-depressants-Fluoxetine, venlafaxine,  MMT
Amitriptyline  Sensory testing
 General principles for Fracture treatment  X-ray
 Reduction  Palpation
 Fixation  MBT
 Protection  Postural test
 UE  Gait analysis
 Sling  ADL
 plaster slab
 Metal splint
II. PROBLEM LIST Post immobilization phase(Chronic)
1. Pain GOALS PLAN OF CARE
2. Inflammation Address pain from stress • Modalities
3. Edema on contractures and/or • Selective stretching of
4. LOM adhesions limiting structures
5. Contractures
6. Weakness
7. Postural deviation
8. Gait deviation
Increase soft tissue, mm • Selective stretching, PJM
9. Impaired B/T
or joint mobility
10. Impaired ADL
Strengthen supporting • PREs
III. PT DIAGNOSIS and related mm

MSG – impaired mobility, muscle performance and

ROM associated with fractures Progress fxnal • Assistive devices until
independence ROM is fxnal with good jt.
Play and mm strength
• Ambulation, stair climbing
PHYSICAL THERAPY PROGNOSIS, PLAN OF CARE & and other appropriate act.
INTERVENTIONS

Principles of treatment
 Adequate circulation is needed for callus
formation
 Joint mobility and muscle power must be
maintained on the free joints

Treatment plan
 Rest
 Active movement
 Exercise should be started as soon as possible
nd rd
usually on the 2 or 3 day after the injury
 Heat
 Massage-only until firm union has been
obtained
 PRE`s

Immobilization phase(Acute)
GOALS PLAN OF CARE
Decrease effects of Ice, elevation, intermittent muscle
inflammation setting
Decrease effects of Intermittent muscle setting, AROM
immobilization to jt. Above and below
immobilized region
Maintain strength and Resistive ROM to major muscle
ROM in major mm groups not immobilized
groups
Teach final Use of assistive or supportive
adaptations devices for ambulation or bed
mobility

Post-immobilization phase(Subacute)
GOALS PLAN OF CARE
Control pain, edema, Monitor response of tissue to
and joint swelling exercise progression

Increase soft tissue, Progress from PROM -> AAROM-

mm or joint mobility >AROM

Massage(Cross friction massage)

Stretching
Strengthen supporting PREs
and related structures

Maintain integrity and Gradually decrease the amount of

fxn of associated support from assistive device
areas