MSK L01 (Fracture)

PHSI N203F Orthopaedics and Musculoskeletal Physiotherapy I

Learning Objectives

1. Types of fracture

2. Fractures in pediatric population

3. Risk factors of fracture

4. Diagnosis of fracture

5. Healing of fracture

6. Management of fracture

7. Complications of fracture

8. Rehabilitation of fracture and roles of physiotherapy in fracture management

Physiotherapy Management Considerations

• Questions to Consider:

  • Which bone is affected?

  • Where is the fracture located?

  • When did the injury occur?

  • Is treatment conservative or surgical?

  • For OT （Operation Therapy） at Acute Stage:

  • - Assess wound and dressing

  • - Ensure patient is medically stable

  • - Check for any drains or IV drips

  • - Follow doctor's post-operative orders

  • Assess patient's age, gender, daily activities, occupation, and chronic diseases

  • Be aware of caregiver involvement and home environment

  • Determine weight-bearing status (especially for lower limb fractures)

  • Monitor for red flags related to the patient's condition

Pathology of Fractures

Key Considerations:

• Definition:

  • A fracture is a discontinuity in a bone due to mechanical forces surpassing the bone's capacity to endure.

• Epidemiology:

  • Common fracture sites include the proximal humerus, proximal femur, ankle, distal radius, pelvis, and clavicle.

  • Incidence varies by age group:

    • ≤ 14 years: distal radius, distal humerus

    • 15-59 years: ankle, hand, distal radius

    • 60-74 years: hip, distal radius, ankle

    • ≥ 75 years: hip

• Etiology:

  • Potential causes include trauma, repetitive stress, weakened bone structure (e.g., osteoporosis), and biomechanical failures.

Types of Fractures

Basic Classifications

• Closed vs Open

• Simple vs Comminuted

• Displaced vs Non-displaced (移位？)

• Complete vs Incomplete (whole fracture across the bone？）

• End-segment vs Middle segment

  • Intra-articular vs Extra-articular (involve joint？）

• Special types:

  • Transverse, Oblique, Spiral, Wedge

  • Avulsion

  • Compression

  • Stress （due to fatigue & insufficient metabolic conditions）

Pediatric Fractures

• Common types:

  • Torus/Buckle Fractures:

    • Characterized by buckling of the cortex without a clear cortical break.

    • Results from low-energy axial loading force,

    • Prognosis: stable and heals well.

  • Greenstick Fractures:

    • Incomplete fractures on one side of the bone, often with a transverse break without opposite cortex fracture.

    • Prognosis: Higher energy injuries, often unstable and may re-angulated (bone have angle).

  • Bowing Fractures:

    • Occur due to deformation of immature bone without a clear fracture line.

  • Growth Plate Fractures:

    • Use Salter-Harris classification to categorize (Type I and II most common).

Risk Factors for Fractures

Key Risk Factors

• Demographic Factors:

  • Age, gender (e.g., postmenopausal osteoporosis in women).

• Health Conditions:

  • Osteoporosis, diabetes, other metabolic bone diseases.

• Low physical function:

  • balance and fall (posture, gait speed, quadriceps strength, req. walking aid, impaired cognition)

• Lifestyle Factors:

  • Inactivity, poor nutrition, substance abuse

    
    

Fracture Diagnosis

Imaging and Assessment

• Imaging Techniques:

  • X-Ray, CT scan, MRI, Bone scan, Ultrasound.

• Clinical Examination:

  • Observation

    • Bruising, Abnormal position

    • Swelling, Deformities

  • Palpation

    • Tenderness, Temperature

    • Distal pulses, Sensation of the injured part

  • Mobilization

    • Unable to bear weight, for lower limb)

  • Clinical features (Pain, Loss in function)

Fracture Healing

Types of Healing

• Direct Healing:

  • Occurs post-surgery with internal fixation; stable and rigid immobilization techniques required.

• Indirect Healing:

  • Occurs with mild motion and weight-bearing promoting healing; stages include hematoma formation, callus formation, and remodeling.

Complications of Fractures

Early and Delayed Complications

• Early:

  • Shock, acute compartment syndrome, fat embolism syndrome, deep vein thrombosis, and pulmonary embolism.

• Delayed:

  • Malunion, non-union, avascular necrosis, complex regional pain syndrome, infection.

Management of Fractures

Open vs Closed Fractures

• Open Fractures:

  • Require debridement, irrigation, antibiotics, and immobilization.

• Closed Fractures:

  • Managed with conservative reduction or surgical intervention depending on severity.

Roles of Physiotherapy

In the Management of Fractures

• Goals:

  • Pain management, promote healing, maintain mobility and strength, and assist in gradual return to activity of daily living (ADL).