Orthotic Management of Upper Extremity Fractures

Fracture

an interruption in the continuity of bone and/or cartilage

Fracture-Dislocation

a fracture through or near a joint, accompanied by dislocation of the joint

Pathological Fracture

a fracture occurring through a weak or abnormal bone

Stress Fracture 

Repeated overuse of the body part not yet accustomed to stress

Simple (closed) Fracture

this is a kind of fracture that does not break through the skin

Compound (open) Fracture

This is a kind of fracture that breaks through the skin and the bone is visible

Complete Fracture

a break all the way through the bone

Incomplete Fracture 

A break that still has bone maintained. 

Undisplaced Fracture

no shift from normal alignment

Displaced Fracture

fragments are shifted out of their normal alignment

Displacement Categories

• translation

• rotation 

• angulation 

• overriding 

• compression 

• distraction 

Translation is

the movement of fractured bones away from each other in a % form

Overriding is

% apposition (being side by side or close together) describes the amount of overlap

Fracture Configurations

• transverse

• oblique

• butterfly

• spiral

• comminuted

• greenstick

Transverse

fracture occurs at right angles to the long axis of the bone

Oblique

fracture line less than 90 degrees to the long axis of the bone

Longitudinal

fracture occurs along or nearly along the long axis of the bone

Butterfly

usually due to a 3 point bending force

• transverse on the tensile side of the bone and oblique on the compressive side

Spiral 

fracture line curves around the bone 

Comminuted 

two or more fracture fragments 

Greenstick

incomplete fracture of the long bone; young, soft bone bends and cracks

Location of Fracture

• diaphyseal 

• metaphyseal 

• epiphyseal 

• intra-articular 

Diaphyseal

affecting the shaft of a long bone

Metaphyseal

affecting the portion of a developing bone between the diaphysis and the epiphysis

Epiphyseal

affecting the ossification centers

Intra-articular

includes the articular surfaces

What type of fracture?

humeral, mid-shaft, diaphyseal, simple, complete

General Management Goals 

Restoration of the function and cosmesis in the shortest time possible

• reduction of the fracture 

• immobilization and maintenance of the reduction 

• early restoration of function

Factors Affecting the Rate of Healing

1. age

2. extent/ type/ location of fracture

3. area of contact and accuracy of reduction

Complications of Fx

• synostosis 

• malalignment 

• delayed and non-union (pseudarthrosis)

• skin issues 

• vascular compromise 

• refracture 

• poor muscle strength and ROM

• nerve palsy infection

Synostosis

fusion of separate bones

Pseudarthrosis

false joints

Objectives of Orthotic Management

• successful union through early graded function in fracture orthosis capable of responding to volume changes 

  • Sarmiento Principle 

• control angular, torsional, and compressive stresses 

• permit joint function 

• support and stabilize pseudarthroses

General Principles of Fracture Management

Long Bones

• employ fluid mechanics

  • Sarmiento Principle 

• Closed volume - fracture brace with viscous fluid tissue - optimum healing environment

General

• Rule of Thirds

Rule of Thirds

if the third of the bone closest to a joint is broken the next segment must be braced (immobilized)

Clavicle Fx

• usually benign 

• rare - can also puncture the trachea causing acute dyspnea

Clavicle Shaft Fx 

• most common - Greenstick or Complete 

• unites quickly - almost always a mal-union

• treatment is with a figure eight harness for comfort not union 

• following union - ossification results in a visible anterior lump

Intervention for Clavicle Fx 

Figure 8 Harness 

Sling 

Scapula Fx

• associated with high energy/trauma

• other injuries to head, clavicle, spine, ribs 

• more commonly seen for chronic dislocation or separation 

• very rarely treated orthotically 

• immobilization and sling

Humeral Fx

• proximal 1/3 - immobilize shoulder through traction immobilization or Statue of Liberty cast 

• mid-shaft without significant angulation can use fx brace 

• distal 1/3 - immobilize elbow 

Options for a Humeral Fx other than Statue of Liberty cast?

Circumferential and clam-shell style humeral fx bracing

Elbow Dislocations/Fractures

• possible orthotic treatment - humeral/forearm fracture brace system

• used with joints

• used with arm sling 

• often internally fixated - pins/intramedullary rods 

• sometimes traction immobilization

Elbow Traction Devices 

Forearm - Radial/Ulnar

• BBF - both bone fracture usually requires percutaneous pinning

• proximal third radial or ulnar - immobilize elbow 

• mid forearm radial/ulnar BBF 

• Distal third of forearm (radial ulnar of BBF)

  • immobilize the wrist 

  • align wrist at 0 degrees extension - not functional position

  • fracture orthosis with palmar extension (pre-fab)

What was the mechanism of injury for this x-ray?

FOOSH - fall on outstretched hand 

BBF

both bone fracture

Colles Fx

• distal radius fx

• brachioradialis - distal radius attachment, pronation/supination 

• may require plates and screws if dislocated 

• acute - cast above the elbow and below the elbow 

What is unique about this brace?

It separates the radius from the ulna 

Colles Fx Interventions

Wrist Fx

Scaphoid - snuff box pain

• immobilize thumbs, fingers, and wrists up to the elbow 

• controls pronation/supination

• carpal row neutral? 

Fracture Orthosis with palmar extension aligned with wrist a 0 degrees extension - not a functional position 

Metacarpal Fx

Immobilize hand, fingers, and wrist.

WHFO pre-fab 

HO, MC fx Ox, pregab 

Digit Fx

• Buddy splint 

• finger strips/splints 

  • FO, PIP, DIP, Static, Pre-fab 

• volar strut stabilization 

Rehabilitation

• patient education is critical

• atrophy may occur

• PT and OT are essential for certain injuries 

  • exercises and ROM may be limited by MD 

• Functional bracing - predicated on premise that physiologically induced motion at Fx site is conducive to osteogenesis 

  • immobilization of adjacent joint and rigid fixation can deter healing 

• continual compression of the soft tissue is essential for maintenance of alignment and edema reduction 

• frequent x-rays may be necessary as well as instructions to discontinue orthosis