Fracture and dislocation

Management Process

• Fracture Union: Understanding the complex biological and mechanical processes involved in the healing of fractured bones, aiming for structural integrity and restoration of function.

• Diagnosis: Systematic steps in accurately diagnosing a fracture, distinguishing it from other musculoskeletal injuries through clinical and imaging assessment.

  • Recognizing potential fractures through patient history, mechanism of injury, and initial clinical signs.

  • Comprehensive Assessment and Management strategy adapted to the specific fracture type and patient needs.

  • Consideration of whether the fracture needs to be Cast Immobilised or managed otherwise.

  • Ensuring Safe, Effective, and progressive Rehabilitation protocols tailored to the healing stages.

Diagnosis of Fractures

• Physiotherapists Role: Key involvement in the diagnostic process, often acting as primary contact practitioners or as integral members of sports medical teams, performing initial assessments and differential diagnoses.

• Signs and Symptoms: Crucial indicators for suspecting a fracture:

  • Localised tenderness (pain upon palpation), often sharp and specific to the fracture site. Specific palpation tests can help localize the pain.

  • Possible deformity, such as angulation, rotation, shortening, or displacement of the limb, though not always visibly present especially in hairline or undisplaced fractures.

  • Pain, a common and often severe symptom, which can be constant, sharp, or aggravated by movement or weight-bearing.

  • Noise (audible sounds) like a 'crack' or 'pop' at the time of injury, or crepitus (grating sound) upon movement.

  • Swelling (inflammation response) around the injured area, which can develop rapidly due to bleeding and fluid accumulation.

  • Mechanism of injury: understanding how the injury occurred (e.g., high-impact trauma, twisting force, repetitive stress) provides strong clues for fracture suspicion.

  • “Spring sign”: a specific indicator for certain fractures (e.g., pelvic fractures), where compression of opposite sides of a bony ring elicits pain at the fracture site.

Imaging and Assessment

• If in doubt: Always perform X-ray imaging or refer promptly to a specialist (GP or orthopaedic surgeon) for definitive diagnosis.

  • When discussing suspected fractures, clearly explain the potential diagnosis to the patient; this may affect the specific imaging views required (e.g., oblique views, stress views).

  • Trust the clinical examination findings, even if initial X-rays are negative, as subtle fractures or stress fractures may not be immediately visible, warranting follow-up imaging or advanced scans like MRI or CT.

Management of New Fracture

• Referral: Timely referral to a General Practitioner (GP) and/or orthopaedic specialists is crucial for proper medical management and definitive treatment planning.

• POLICE (an updated RICE protocol):

  • Protect: Reduce the risk of further injury by supporting the limb, using crutches, or limiting aggravating movements.

  • Optimally load: Gradually apply controlled and progressive mechanical loading to promote healing, once stability allows, as opposed to complete rest.

  • Limit movement: Initially reduce excessive mobility to prevent exacerbation and dislocation of the fracture fragments.

  • Ice: Apply ice packs (e.g., for 15-20 minutes, several times a day) to help manage pain and reduce acute swelling.

  • Compression: Use bandages or wraps to minimize swelling and provide support, ensuring it's not too tight to impede circulation.

  • Elevation: Keep the injured area elevated above the level of the heart to decrease swelling by promoting venous and lymphatic drainage.

• Check Neurovascular Status: Crucial to assess and ensure that blood flow (pulses, capillary refill, skin color, temperature) and nerve function (sensation, motor function) remain intact distal to the injury, checking for signs of compartment syndrome.

• Cast/Plaster: Where appropriate, refer to doctors for decisions regarding immobilization using casts or plaster, considering fracture type, stability, and patient factors.

Management Options for Fractures

• Observation without immobilisation: Suitable for very stable, undisplaced fractures where movement is unlikely to cause displacement or impede healing (e.g., some toe fractures, stable rib fractures).

• Closed management: Non-surgical treatment involving the use of splints, braces, or plaster casts to immobilize the fractured area, often for non-displaced or minimally displaced fractures.

• Closed reduction and immobilisation: Manual manipulation of the bone fragments to restore proper alignment without surgical incision, followed by immobilization with a cast or splint.

• Open reduction and Internal fixation (ORIF): A surgical method involving an incision to expose the fracture site, directly align the bone fragments, and then secure them with internal hardware such as plates, screws, rods, or wires. This is typically used for unstable, complex, or open fractures.

• External fixation: Use of external devices (pins or wires inserted into the bone and connected to an external frame) to stabilize complex or contaminated fractures, often used temporarily in cases of severe trauma or open fractures.

Immobilisation Considerations

• Assess need for immobilisation: Decision influenced by factors such as fracture type (stable vs. unstable), location, degree of displacement, patient's age and activity level, and associated soft tissue injuries.

• Non-immobilised fractures: In cases where full immobilization is not required:

  • Stable fractures may utilize a removable splint or brace for support and protection, allowing for gentle, controlled movement and hygiene.

  • When stable internal/external fixation has been used surgically, early, guided movement can often begin to support healing and prevent stiffness.

• Immobilised fractures: For fractures requiring external stabilization:

  • Use of a cast (fiberglass or plaster of Paris) to provide rigid support and prevent movement at the fracture site.

  • Traction methods (e.g., skin traction, skeletal traction) for stabilizing fractures, particularly those of long bones, to maintain alignment and length during the initial healing phases.

Immobilisation During Healing

• Stability versus immobilisation effects: Ensuring adequate stability for bone healing is paramount, even though prolonged immobilisation can lead to negative impacts such as muscle atrophy, joint stiffness, and decreased bone density. The benefits of stability often outweigh these risks in the early stages.

• Maintain Range of Motion (ROM): Actively work on uninvolved joints (e.g., fingers, toes, shoulder if a lower limb is fractured) to prevent stiffness and maintain overall mobility. For the injured joint, passive or active-assisted ROM may be carefully initiated if the fracture is stable and cleared by a specialist.

• Muscle Strength Maintenance: Consider isometric co-contractions of muscles within the cast (e.g., pressing against the cast) to help preserve muscle strength and reduce atrophy. Electrical stimulation may also be used in some cases.

• Aerobic Fitness: Emphasize maintaining cardiovascular health and skill levels through alternative activities that do not load the injured limb (e.g., cycling with one leg, swimming, upper body ergometry) to mitigate deconditioning.

Cast Types

• Materials Used:

  • Plaster of Paris: Traditional, inexpensive, easily molded, but heavier, less durable, and not water-resistant.

  • Fiberglass: Lighter, more durable, stronger, and often water-resistant, allowing for better patient comfort and hygiene.

  • Padding materials (e.g., gortex and webril): Essential for protecting the skin from pressure sores and providing comfort underneath the rigid cast material.

• Application: Typically cast both the joint above and below the fracture site to ensure complete immobilization of the fractured bone and prevent joint movement from affecting the fracture.

• Warnings to Monitor: Patients must be vigilant for:

  • Increasing or intractable pain levels, especially if disproportionate to the injury, which could indicate complications like compartment syndrome or pressure points.

  • Loss of sensation (numbness, tingling) or motor function in the area distal to the cast, indicating nerve compression.

  • Swelling, discoloration (pale or blue), coldness, or inability to move fingers/toes, suggesting circulatory compromise.

  • Importance of providing clear warning cards or instructions under specific circumstances, detailing signs of complications and when to seek urgent medical attention.

Non-Immobilised Fractures

• Healing process indicates that not all fractures may always require full immobilisation; potential risks of complications (e.g., severe muscle atrophy, joint stiffness) might outweigh the benefits of complete immobilisation for certain stable fractures.

• Guidance by Orthopaedic Surgeons: For non-immobilised fractures, this guidance is crucial for:

  • Techniques to safely maintain/regain Range of Motion (ROM) of involved and uninvolved joints while being mindful of pain levels and fracture stability.

  • Focused exercises to retain/regain muscle strength and endurance during the recovery period, including progressive resistance exercises.

  • Pain and swelling management using appropriate modalities, medication, and activity modification.

• Stability Considerations: Always factor in the inherent stability of the fracture (e.g., undisplaced, impacted, or surgically stabilized) when determining the extent and progression of rehabilitation activities.

Healing of Fractures

• Differences: Significant differences exist in the healing processes between cortical and cancellous bone due to their distinct microstructures and vascularity.

Healing Phases of Cortical Bone (Indirect or Secondary Healing)

1. Inflammatory stage:

   • Duration: Commences immediately post-injury and lasts for several hours to a few days.

   • Process: Formation of a hematoma at the injury site as blood vessels rupture. This hematoma clots, providing a scaffold for inflammatory cells, which then clear necrotic tissue and initiate angiogenesis (new blood vessel formation).

2. Soft callus formation stage:

   • Duration: Days to weeks (typically begins around 2-3 weeks post-injury).

   • Process: Cellular proliferation of fibroblasts, chondroblasts, and osteoprogenitor cells migrating into the hematoma. They produce granulation tissue then fibrocartilaginous callus (containing type II collagen), bridging the fracture gap but not yet providing rigid stability.

3. Hard callus formation stage:

   • Duration: Weeks to months (usually 1-2 months, but varies). The callus begins to mineralize.

   • Process: Endochondral ossification occurs where woven bone is formed by osteoblasts replacing the fibrocartilage. This bridging callus strengthens, providing increasing mechanical stability as calcium is deposited, transforming the soft callus into hard callus.

4. Bone remodelling:

   • Duration: Months to years (can continue for several years after initial healing).

   Process: The immature woven bone of the hard callus is gradually resorbed by osteoclasts and replaced by mature lamellar (cortical) bone by osteoblasts. This process, guided by Wolff's Law, remodels the bone back to its original shape, strength, and structural efficiency in response to mechanical stresses (Tortora & Derrickson, 2006).

Healing of Cancellous Bone (Direct or Primary Healing)

• Healing Characteristics: Tends to heal more quickly than cortical bone, primarily through a membranous bone formation process that typically lacks significant cartilage and external callus formation, especially under rigid fixation.

  • Minimal callus formation: Due to its high vascularity and trabecular structure, cancellous bone often heals by direct bone formation across the fracture site rather than through a large cartilaginous callus.

  • Direct bridging of gaps: Osteoblasts directly form new bone along the existing trabeculae, bridging small gaps without an intermediate cartilage phase.

  • Requires direct contact for effective healing: Optimal healing of cancellous bone is facilitated by minimal gap and stable fixation, allowing for direct bone apposition (Sandberg & Aspenberg, 2016).

Bone Healing Timeline

• Estimated Duration: Varies significantly, typically from 4 to 12+ weeks, depending on numerous factors including bone location (e.g., phalanges heal faster than tibia), injury severity, fracture type, patient age, general health, nutrition, and blood supply to the fracture fragments.

• Preventing Impairments: Focus on maintaining range of motion and strength in both the injured and uninjured limbs; these factors are directly correlated to the choice of immobilisation strategies and the stability of the fracture. Early, controlled mobilization can promote healing and prevent secondary complications.

Bone Healing - Union

• Clinical union indicators: These signify that the fracture is stable and pain-free, allowing for progressive weight-bearing or increased activity:

  • Absence of visible or palpable movement at the fracture site.

  • No pain upon palpation of the fracture area.

  • No pain with gentle stress applied to the area (e.g., axial compression, rotational stress).

• Radiographical union indicators: Visual confirmation of healing through imaging studies:

  • Visible callus bridge formation across the fracture gap in at least three cortices (on two orthogonal X-ray views).

  • Continuity through trabecular architecture across the fracture line, confirming bone remodeling.

Cast Removal Process

• Tools for Removal: Specialized tools are used, primarily a plaster saw (oscillating saw); caution is required as it vibrates powerfully and generates heat, and while designed to cut rigid material, it can cause skin abrasions or burns if not used correctly.

• Techniques:

  • Employ plastic protectors or strategic padding to safeguard the skin during the cutting process.

  • Avoid sliding the saw across the skin; instead, use an up-and-down motion, lifting it off the skin after each cut.

  • Practicing on old casts is advisable for safety training and to develop proficiency in handling the saw.

  • Patients should be informed about the sound and sensation (vibration, warmth) of the saw to reduce anxiety.

Post-Cast Management

• Following Cast Removal: This crucial phase focuses on restoring full function and addressing potential issues from immobilization:

  • Removal of immobilisation: Gradual transition from external support to unsupported movement.

  • Addressing impairments and activity limitations: This includes joint stiffness, muscle weakness and atrophy, decreased proprioception, and reduced cardiovascular fitness.

  • Focus on regaining full range of motion and strength: Through targeted exercises, manual therapy, and progressive loading.

  • Addressing pain and swelling post-cast: Managing residual pain and swelling with modalities (e.g., ice, heat, contrast baths), compression, and graded activity.

  • Retaining motor control and functionality is crucial: Re-establishing normal movement patterns, balance, coordination, and proprioception to facilitate safe return to daily activities, work, and sport.

  • Remember to continually consider fracture stability during this phase, gradually increasing load and stress based on healing progress and specialist guidance.

Abnormal Healing of Fractures

• Types of Abnormal Healing: Complications that can arise during the fracture healing process:

  • Malunion: A fracture that has healed with a deformity (e.g., angulation, rotation, shortening) despite healing within a normal timeline. This can lead to functional deficits, pain, or cosmetic concerns.

  • Delayed union: A fracture that takes an abnormally long time to heal but eventually resolves. Factors such as poor blood supply, infection, inadequate immobilization, or underlying systemic conditions can contribute.

  • Non-union: A complete failure of the fracture to heal, resulting in a persistent pseudarthrosis (false joint) at the fracture site. This often requires surgical intervention to stimulate healing.

  • Avascular necrosis (AVN): Bone death due to insufficient blood supply to a segment of bone, often seen in specific fractures (e.g., scaphoid, femoral head, talus). It can lead to collapse of the bone and joint arthritis.

Stress Fracture Management

• Activity Adjustments:

  • Reduction or modification of activity, often involving a period of relative rest or complete cessation of the aggravating activity (e.g., running) and substitution with non-impact cross-training (e.g., swimming, cycling).

  • The majority of stress fractures heal within 6 weeks of initiating appropriate rest and suitable modifications, though complex cases may take longer.

  • Assessment and treatment of predisposing factors are essential to prevent recurrence, such as:

    • Training errors: rapid increase in intensity, duration, or frequency of exercise.

    • Equipment inadequacies: worn-out footwear or improper protective gear.

    • Technique errors: inefficient movement patterns that place excessive stress on specific bones.

    • Muscle length and strength imbalances: leading to altered biomechanics and increased stress on bony structures.

  • Ongoing Maintenance: Focus on preserving skill fitness and range of motion