Independent learning package: principles of fracture complications + physiotherapy management

Management for metabolic response to trauma

Strengthening programme when  condition stabilise

Management for pressure area

Patient education + self management  Physical barriers : heel wedges + pressure relieving matresses  Early mobilisation  Regular checks of skin integrity + changes of resting positions  Engrit beds ( unstable spines )

Management for falls

Fall risk assessment before first mobilisation  ( cognitive status/ limitations due to current injury/ environment/ vital signs/ strength of unaffected limbs )  Appropriate mobility aid + footwear + environment  Systematic progression

Local late complications

Union

Avascular necrosis

Myosistis ossificans

Volkmann’s ischaemic contracture

Complex regional pain syndrome

Joint complication

Types of union complications

1. Delayed union

2. Non-union

→ healing slower than predicted rate 

3. Mal-union

→ anatomical fracture reduction not achieved 

4. Cross-union

→ 2 separate fractures heal to each other

5. Growth disturbance

→ disruption of epiphyseal plate → X synthesis of new bone ( paediatric )

Avascular necrosis

Blood supply to bone lost —> fragment dies

Symptoms: unresolving pain post intercapsular femoral neck/ talar neck/ scaphoid fracture

Myositis ossificans

Post traumatic ossification of haematoma around joint

Volkmann’s ischaemic contracture

Pressure on brachial artery —> ischaemia + necrosis of wrist flexor compartment

Joint complication

Fractures in nearby joints/ in joint —> joint instability/ stiffness/ osteoarthritis

Local early complications

Vascular complications

Neural complications

Necrosis

Joint complications

Visceral : caused by high velocity trauma

Vascular complications symptoms

Pain  Pallor  Pulselessness  Paraesthesia  Paralysis

Neural complications causes

DIrect trauma  Prolonged pressure  Traction injury  Compartment syndrome  Infection

forms of necrosis

Compartment syndrome  Gas gangrene  Pressure areas

Joint complications

Haemarthrosis ( bleeding into joint )  Infection from wound  Dislocation  Subluxation  Joint stiffness

Types of management

Conservative	Auto-fixation
	Traction
	Casting/ bracing
Surgical	Open reduction internal fixation
	External fixation ( Ilizarov frame )

Application for methods of conservative fracture management

Auto-fixation	Fractures immobilise themselves
Traction	Pelvic + lower limb trauma  Cervical spine  Principle: traction force maintains bone fragments in anatomical alignment while healing 2 types:  Skin: weight connected to traction device → short term  Skeletal: pin inserted to bone + weight connected
Casting/ bracing	Fracture first anatomically reduced → immobilized by the cast  Other unrelated joints should move freely

Applications + complications of surgical methods of management

Open reduction internal fixation	Surgical fixation with pins/ nails/ screws  Adv:  anatomical reduction  Early mobilisation  Reduced time resting in bed	Disadv:  Respiratory/ circulatory infection p-surgery  Delayed/ non-union  Breakdown of overlying skin
External fixation ( Ilizarov frame )	Soft tissue damage preventing immobilisation by casting/ ORIF  Risk of infection  Not well enough for prolonged surgery  Reduces stiffness complications  Allows skin + muscle grafting  Debride + treat infected wound w/ antibiotics  Less blood loss + time in surgery	Infection entering bone thru pin sites  Post anaesthetic respiratory + circulatory complications  Pressure areas from fixator

Safety principles as physio student

Supervision for

1) Patient mobilisation

2) First time ambulation of patient

3) Progressing to a diffeent aid

4) Mobilising on stairs

5) Application of continuous passive motion for first time

6) Electrotherapy application

Considerations when treating patients in orthopaedic ward

1) Check post-op orders + charts + x-rays before physiotherpy

2) Time pain relief appropriately for mobilisation

3) Discuss mobility plan with nurses

4) Notify nurses of change in mobility status

5) Ensure appropriate footwear/ bare feet when mobilising

6) Wheelchair + bed brakes —> avoid falls

7) Wash hands

8)Familiarise with emergency procedure + phone no.

9) Countersign chart entries by educator

What not to do

1) Show patient the chart/ x-ray

2) Remove dressing/ slings/ bandages w/o educator permission

3) Treat another therapists’ patients

4) Remove/ overwrite others’ entries on chart

5) Sitting on pt beds/ chairs

Role of physiotherapy systems management

1) Assess respiratory + circulatory systems immediately post-op

2) Initiate exercises until pt return to previous mobility level

—> Circulation exercises ( static gluts/ quads/ foot / ankle exercises ) —> repeat large volumes initially + reduce

—> musculoskeletal maintenance exercises for unaffected joints + muscles

—> neurovasclar observations: peripheral light touch + capillary refill at nail bed regularly checked for pt in cast

Flow chart for what to consider for discharge

1) Need for ongoing physiotherapy at discharge

2) Inpatient ?

3) Can consent/ co-operate ?

4) Require further intervention to reach pre-morbid level of function ?

5) Mobilising w/ assitance ?

6) SMART goals

7) WB status ?

8) Require daily physio/ multidisciplinary team ?

9) Falls history ?

10) Home environment ?

—> inpatient rehab

Discharge planning

Place to stay:

1) Own home

2) Own home w/ modifications

3) Family member’s home

4) REhab unit

5) Residential accomodation

Organise walking aids + home exercise programs + follow-up appointment in advance

Appropriate aids selected in conjunction w/ OT