1. The bone fractures General information

Transcription

1 - 1 PT MANAGEMENT OF PATIENTS SUFFERING FROM BONE FRACTURE AND FOR BEDRIDDEN PATIENTS Contents : The bone fractures general information Physiotherapy for patients suffering from bone fracture Physiotherapy for bedridden patients 1. The bone fractures General information 1.1. Definition and causes A bone fracture can be defined as a break in a bone (the bone is "broken"). Fractures generally happen because of a trauma (a hit on the bone, a fall, a car accident), but it also can be the result of a weakened bone (the bone may become weaker because of a disease, such osteoporosis or because of repetitive stress during intensive sport activities, for example- such as stress fracture ) Types of fracture Name Definition Drawing(s) Simple fracture Displaced fracture Comminuted fracture Spiral fracture Closed fracture Open fracture Greenstick fracture Multiple fracture The bone broke into two pieces; the two parts of the bone did not move The bone is broken into two pieces and the two parts of the bone moved A fracture of many relatively small fragments A fracture which runs around the axis of the bone The bones which broke do not penetrate the skin A fracture which breaks the skin A fracture in which the bone bent but is not completely broken More than one bone is broken or the same bone is broken in different places A B C D E F

2 - 2 Answers: 1. Simple fracture = C; 2. Displaced fracture = B and D; 3. Comminuted fracture = A; 4. Spiral fracture = F; 5. Closed fracture all except B; 6. Open fracture = B; 7 Greenstick fracture = E; 8. Multiple fracture = D Diagnosis In general, doing an X-ray is the best way to confirm a fracture. X-rays are a form of electromagnetic radiation (like light); they are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density (the higher is the density, the whiter they appear). The X-ray on the right shows a double fracture (multiple fracture) of the tibia and the fibula with a slight displacment of the tibia Complications The complications of a bone fracture can appear directly or can appear during the consolidation of the bone (the healing process). Direct complications The bones are the place of production of blood cells. Therefore, a fracture of a bone will generally be accompanied by internal bleeding (hemorrhage ). If there is displacement of the fractured bone, the fractured extremity of the bone may damage internal organs. This may happen, for example, with a fracture of a rib () that will pierce the lung (pneumothorax ) or a fracture of the iliac bone () that will pierce the bladder. The fractured extremities of a broken bone may also damage blood vessels or nerves (peripheral nerve injury ). This may happen, for example, with a fracture of the head of the fibula () that will damage the fibular nerve or with a fracture of the ulna () that damages the ulnar nerve. If the fracture is located on the spine or the skull, it can lead to spinal cord or brain damage and, therefore, paralysis.

3 - 3 Late complications If the fracture was open, it can lead to infection (bone or other tissues) A fracture can have problem to heal. This phenomenon is called pseudarthrosis (the bone doesn't heal). Compartment syndrome : compartments are groups of muscles in the limbs that are covered by a tough membrane that cannot expend easily. Within those compartments, there are also nerves and blood vessels. Severe swelling on the fracture site will cause pressure on the blood vessels because the membrane cannot expend much, which would decrease the blood supply to muscles and nerves. The decreased blood supply will lead to nerve damaged and muscle death. This most often happens with fracture of the leg s bones (tibia and fibula). Note: Patients with fractures that require staying in bed for a long time (complex fractures, tractions, fracture of the spine) may develop other types of complications that are linked to the fact that they have to stay in bed. Those are called bedridden patient complications. It is, for example: muscle weakness, muscle retraction, breathing problems, blood circulation problems, digestive problems For details, see below. Note: Plaster or other types of immobilization will generally lead to muscle problems around and close to the fractured bone. Those are: muscle weakness (the muscles don t work, so they become weaker) and muscle shortness (the muscle stay for a long time in a short position and then become shorter) Curative treatment To heal properly, a fractured bone should be realigned if displaced (the realignment of a displaced fractured bone is called "reduction") and immobilized. There are different ways of reducing and immobilizing a broken bone: Methods of reduction If there is no displacement, no reduction is needed. If there is a slight displacement, the reduction can be done without chirurgical intervention (without operation). This can be done by doing traction on the bone (manual traction or using weights). If the displacement is too important, surgery will be needed to reduce the fracture. In this case, the reduction is said "open reduction" (because the surgeon cuts the skin to reduce the fracture). Traction Open reduction

4 - 4 Methods of immobilization The most common way of immobilizing a bone is using plaster or splint. If the fracture is open, external fixation might be recommended to prevent from having plaster on the wound and risk infection. External fixation involves a surgery. External fixation is done with a device that supports the bone and holds it in the correct position while it is healing. An example of external fixation is shown on the drawing below. If the fracture is complex (comminuted, spiral, multiple), internal fixation might be the only way of stabilizing the bone. Internal fixation involves a surgery. It is generally done by using metal rods, screws or plates that remain in place in the bone after the surgery. Examples of internal fixations are shown on the drawings below. Note: Unless the internal fixation causes problems, it is not necessary or desirable to remove it. Plaster and splint External fixation Internal fixation 1.6. Healing process Healing is the process of recovery of the integrity of an injured system, such as a fractured bone. The healing process of a fracture bone occurs in 4 different stages: 1. Right after the injury, the integrity of the broken bone is provisionally restored by a blood clot (the blood clot takes the space left by the fracture between the bone fragments). 2. During the second stage, the blood clot will be replaced by fibrocartilaginous tissue. This fibro-cartilaginous tissue is called the callus. The callus is an irregular mass of tissue (it is bigger than the broken part) and it is not yet strong bone tissue. Meanwhile, the dead bone tissue is removed.

5 3. The 3rd stage corresponds to the replacement of the fibrocartilaginous callus by mature bone tissue. At that stage, the bone tissue is not yet lined up with the rest of the bone. 4. The last stage is the remoulding stage. During that stage, the bone tissue is re-organized in the right direction (the bone is ordered into parallel and concentric layers that are aligned in precisely the right way). - 5 The X-rays here below show different stages of the healing process of a broken bone: The fracture is well visible Here we can see the callus in the middle of the femur The callus disappeared and has been replaced by mature bone tissue. The new bone tissue has been remoulded in order to give back the bone its original shape. The new bone tissue is still visible (whiter). In general, we consider that it takes 6 to 8 weeks for a bone to heal, but in some case a longer immobilization might be required (a vertebra needs 10 to 12 weeks to heal completely). Note: The time necessary for healing is influenced by various factors, such as: The patient s age (younger people heal faster than older people) The nutrition (varied food such as milk, rice, vegetables, meat) speed up the healing process The type of immobilization (using internal or external fixation help healing faster because they don t allow any movement in the bone while a plaster doesn t always stabilize the bone very well) The blood supply (more blood means better healing. Blood supply can be increase through exercises such as PT exercises) The type of fracture (complex fractures such as comminuted or displaced or multiple fractures- take more time to heal then simple fractures) The location of the fracture (some bones need more time to heal then others) 2. Physiotherapy for patients suffering from bone fracture The needs in term of physiotherapy will depend on various factors: The time (when the treatment is provided) The type of fracture, its location and the type of immobilization The complications

6 Treatment in bed If the fracture requires that the patient stay in bed (complex fracture of the lower limbs, patient in traction, patient with external fixator, fracture of the spine ), the patient will have the same needs, in term of physiotherapy, than other bedridden patients (patients that have to stay in bed for a long time). This means that they will needs mobilization, strengthening, massage, breathing exercises, changing position For details on bedridden patients, see below Note: Specificity for muscle strengthening Isometric contractions Compared to other bedridden patients, when doing strengthening exercises with patients that have fracture, a specific kind of exercise has to be used. Those are called: isometric contractions. Isometric contraction means that when doing the muscle contraction, the muscle length doesn t change the muscle doesn t become shorter nor longer; its length remains the same during the contraction). Such contraction doesn t create any movement in the joint. Therefore, it can be used with the muscles around the fractured bone. If there is no movement I the joints near the fracture, there won t be any risk to displace the fractured bone. Nevertheless, such contraction is very efficient to prevent muscle weakness Treatment during consolidation (healing) If the patient doesn t have to stay in bed (simple fracture, fracture of the upper limbs), the exercises recommended for bedridden patients are not necessary anymore. Nevertheless, exercises should be done to prevent the classical complication of plaster: muscle weakness and muscle shortness. To prevent too serious muscle weakness of the muscles around the fracture, isometric contractions can be used (see note above). The movements that are not limited by the plaster should be done regularly in the joints near the plaster to prevent muscle weakness and muscle shortness (for example, if the femur is broken, active movement should be done in the hip joint if the immobilization allows it- to prevent muscle shortness and muscle weakness due to a limited use of the hip the patient will walk with crutches and therefore won t use much the muscles of the hip). If the patient uses crutches to move around, he ll also need to learn how to use the crutches depending on the possibility or not to do some weight-bearing () on the fracture limb (is the patient allowed to put part of body-weight on the fractured limb when walking). Latest studies have shown that the use of ultrasound (low frequency) can speed up the healing process (even thought, not so long ago, fracture was a contraindication for the use of ultrasound). Nevertheless, ultrasound should be used with care when there is a fracture. First of all, only low intensity can help (high intensity will slow down the heeling process). Ultrasound cannot be used if there is a piece of metal (internal fixation or previous surgery) in the limb or if there is infection. Indeed, ultrasounds would warm up the pieces of metal and lead to internal burning and if there is infection it would speed up the infectious process. Pulsed Electromagnetic Field Therapy (PEMFS) can also help for healing of fracture, especially when there is a gap between both fracture extremities or if there is pseudarthrosis. PEMS can be used even when there are implants (internal fixations).

7 Treatment after consolidation The exercises needed after consolidation depend on the type of fracture and the presence of complications. For example, if the bones of the leg were fractured, the patient will need weightbearing exercises (slowly put more and more weight on the leg). Exercises might also be necessary to strengthen the weakened muscles and to stretch the shorter muscles. For details, see below. 3. Physiotherapy for bedridden patients 3.1. Definition A bedridden patient is a patient that, for some reason, as to stay in bed for a long period of time. Such patient might quickly develop serious complications that are not directly linked with the reason why he has to stay in bed. Some of those complications might be life threatening, most of them might be disabling (leading to a disability even if the first problem wouldn t have lead to disability), and all of them will make the treatment more difficult (the patient will need more time to recover because the complications will also have to be addressed during the treatment- and/or he might not recover as well as he would have without complications). Most of those complications can be very easily prevented using simple exercises and teaching the patient or the caretaker. Therefore, adapted exercises have to be done to prevent the complications from appearing 3.2. Reasons for which a patient has to stay in bed The reason why a patient has to stay in bed can be various: multiple trauma, fracture of the spine, paralysis, severe disease, coma, surgery, head injury 3.3. Common complications The most common complications of bedridden patients are: Muscles weakness/atrophy (a) Muscle shortness (b) Pressure sores (bed ulcerations) (c) Respiratory problems (lung infection) (d) Blood circulation problems (e) Bone demineralization (f) Physiotherapy exercises will aim to prevent to complications from appearing. (a) Muscle weakness/atrophy Description : A patient that has to stay in bed won t use much (or won t use at all) his muscles. Muscles that are not used regularly will quickly become weaker. Indeed, regular use of the muscle is needed to maintain proper and functional muscle strength. This weakening process is due to the fact that, when not usd, muscles will loose part of their cells (the less cell there is, the weaker the muscle becomes) and the remaining cell will become thinner and, therefore, less strong. The result is a thinner and weaker muscle (this process is also called muscle atrophy).

8 - 8 Consequences : Muscle weakness would make it more difficult later on for the patient to stand (weakness in the muscles of the legs) or even to sit (weakness of the muscles of the trunk) or to use the hands (weakness of the muscles of the upper limbs). (b) Muscle shortness Description : If the patient always remains in the same position (lying or sitting), some of his muscles will stay in a short position (a position in which those muscles are relaxed). The muscles quickly adapt their length to the position in which they remain. This means that if a muscle remains in a short position for a certain time, it will become shorter. Once the muscle is shorter, it cannot be stretched as usual. This will result in decreased possibilities of movements in the joint (decrease of Range Of Motion or ROM). A classical example is the knee and hip flexors that become shorter when the patent remains in sitting position. Or the plantar flexors (calf muscle) that becomes shorter when the patient is in lying position (with drop foot). Consequences : Short muscles and consequent decreased ROM will lead to functional difficulties such as standing, walking or using the upper limbs. Indeed, if the knee flexors became shorter, the patient won t be able to extend the knee. Without knee extension, standing and walking is very hard. (c) Pressure sores Description : Pressure sores are wounds that will appear on parts of the body where there is pressure on the skin close to a bone prominence. This is, for example the case on the side of the hip where the greater trochanter (of the femur) comes out and there s not much muscle around it. When the patient is lying on the side, the greater trochanter creates a point of pressure on the skin and stops the blood supply from reaching the skin on that particular area. Without blood supply, the skin dies and an ulcer (a wound) appear. Such wound is generally quite hard to heal.

9 Classic locations of pressure sores: - 9 Iliac crest (a) Greater trochanter (b) Patella and head of fibula (c) External malleolus (d) Internal condyle of femur (e) Internal malleolus and base of 1st toe (f) Back of the head (g) Shoulder (h) Elbow (i) Inside of the knees (j) Heel (k) Ischial tuberosity (l) Lower back (posterior part of sacrum) (m) Shoulder blades (scapula) (n) Pressure sores can appear with any patient that stays in bed (or in a wheelchair), but patients with sensory problems (patients that can not feel), are even more likely to have pressure sores (patient that can feel will feel the pain before the pressure sore appear and they will change position automatically; but he cannot feel the pain, the patient won t change position). Consequences : Pressure sores are difficult to heal and require heavy medical attention. This will generally increase the length of the treatment (the patient will have to stay even longer I bed). Most important, pressure sores can easily get infected and such infection can be life threatening (the patient can die from such infection if it spreads to the rest of the body). (d) Respiratory problems Description : Respiratory problems means that the respiratory system will get infected (lung infection such as pneumonia). With bedridden patients, lung infection will occur because the patient, when staying in bed, as a lower breathing magnitude than usual (he will do smaller breathing movements). Consequences : The lower breathing results in a lower flux of air in the respiratory tracts (trachea, bronchii and bronchioles ). The lower flux of air in the respiratory tracts will results in a less efficient expectoration system (the expectoration system is the system that allows the pulmonary secretions to climb up the respiratory tracts and to get out of the lungs). The decreased expectoration system leads to accumulation of secretions in the lungs, which can easily get infected (if the secretions stay in the lungs they will easily get infected which leads to lung infection). (e) Blood circulation problems Description : The two main blood circulation problems that bedridden patients might suffer from are thrombosis and embolism. Both of them are caused by callus (clot of blood) that will form in the blood vessels. Normally, the blood stays liquid unless it is in contact with air (like when you cut yourself). Whe the blood is in contact with air, it start to form a clot to close the wound. But if the blood circulation is decreased in some part of the body, the blood might also form clot inside the vessel (a callus or a thrombus). This callus will decrease and eventually stop the blood circulation (the callus forms an obstacle to the blood) creating thrombosis (a stop of blood circulation). In other cases, the callus will get loose in the blood circulation. We then call it an embolus.

10 - 10 This embolus will then reach smaller blood vessels, get stuck and stop the blood circulation there. We call that an embolism. Blood clots will form faster when the blood circulation decreases (the speed of the blood circulating in the vessels decreases). This is the case with bedridden patients (indeed, blood circulation is stimulated by movements and bedridden patients don t move much so their blood circulation decreases). Consequences : Thrombosis and embolism will lead to tissue damages (the tissues that won t receive blood supply will die). Depending on where the thrombosis or the embolism is located, it can have huge consequences. For example, if an embolus gets stuck in a vessel that supplies a part of the heart in blood, it will lead to a heart attack. Another common type of embolism is called pulmonary embolism and it is caused by an embolus that gets stuck in a pulmonary artery. This will lead to breathing difficulties and in some case to death. (f) Bone demineralization Description : Bone demineralization (also called bone mineral density loss or disuse osteoporosis) means that the bone become weaker (it looses too much minerals and minerals make the bone strong). This happens when the bones are not simulated enough. Bones are stimulated when constraints are applied on them (for example, when walking, constraints the body weight- are applied on the bones. Those constraints help the bone to remain strong. That s why astronauts also suffer from bone demineralization when they come back on earth). When a patients stays in bed, there are less constraints applied on the bones; this results in bone demineralization. Consequences : a demineralised bone is more fragile and would break quite easily. This might be a serious problem when the patient starts to stand after a long period in bed. If the bones of the legs are too weak, they might be able to bear the body weight Physiotherapy needs Adapted and early physiotherapy exercises can help prevent those complications. For each of them, there is, at least, one adapted and easy PT technique that can be used and taught to the patient or the care-takers. Here s a table that present the PT techniques that can be used with the bedridden patients to prevent the most common complications:

11 - 11 Bedridden patients complications Appropriate PT technique Muscle weakness / atrophy Muscle strengthening Muscle shortness Pressure sores Respiratory problems Blood circulation problems Bone demineralization A. Passive mobilization B. Massage Passive mobilization Active mobilization Muscle stretching Changing position Massage Passive mobilization Breathing exercise (breathing stimulation, clapping, coughing) Passive mobilization Active mobilization Massage Active mobilization Muscle strengthening C. Muscle strengthening D. Changing position E. Active mobilization F. Breathing exercise G. Muscle stretching Practical training on those techniques will take place later on. Note: there are other means to prevent those complications (such as weight-bearing I standing frame to prevent bone demineralization) but there are not usable with bedridden patients).