Fracture

Rehabilitation :
Don’t Just Wait
dr. Ibrahim Agung, Sp.KFR – KSM Kedokteran Fisik dan Rehabilitasi FKUI RSCM
 OVERVIEWS

▰ Brief of fracture: Definition, causes, and types of fracture

▰ Impact of body function due to fracture based on fracture location
▰ Process of bone healing and the factors that affect the process
▰ Principle of fracture rehabilitation: when and how to start
▰ The role of general practitioners in helping patients to maintain or
regain functional capacity due to fractures

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Brief of Fracture

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What is Bone Fracture ?

▰ A break in the structural continuity

of bone
▻ Secondary Injuries : soft tissue
(nerve, spinal cord, etc)

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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
 Causes of Fracture

Injury Repetitive Stress Pathological

Direct Force Repeated heavy loading Abnormal weakening of the bone

due to change in its structure
(Osteoporosis, Paget’s disease,
etc), through lytic lesion (Bone
Cyst, Metastasis, etc)
Indirect Force
(Twisting, Compression, Bending,
Tension, Combination)

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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
 Types of Fracture

▰ Complete fracture
▻ Transverse, Oblique, Spiral,
Comminuted, Impacted
▰ Incomplete fracture
▻ Greenstick, Compression
▰ Closed fracture
▰ Open fracture

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018. 6
Physiopedia contributors. Fracture [Internet]. Place of publication: Physiopedia; 2022 [cited 2022 Jul 5]. Available from: https://www.physio-
pedia.com/index.php?title=Fracture&oldid=298815
 Fracture Displacement

▰ Translation (shift) -> fragments shifted away, backward

or forward
▰ Angulation (tilt) -> fragments tilted / angulated -> may
lead to deformity of the limb
▰ Rotation (twist) -> One of the fragments twisted around
its longitudinal axis
▰ Length -> fragments distracted and separated, or they
may overlap, shortening of the bone

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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Lippincott Williams & Wilkins; 1999.
 Pathological Fractures

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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Functional Problem of Fracture

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 Health Condition

Fractures

Body Functions and Structures Activities Participations

(Impairment)
Energy & drive, sleep, emotional,
sensational of pain, exercise tolerance,
joints mobility, muscles power,
movement
(Limitation)
Carrying out daily routine, changing
basic body position, maintaining a body
position, transferring oneself, using
transportation
(Restriction)
Vocational performance, family
relations, recreation & leisure, social
life, participation in political & religious
activities

Environmental factors
Personal factors
Housing & transportation
Health behaviours, age &
facilities, health service,
gender, comorbidity,
families & friends, work space

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Functional Problem of Fractures

▰ Early Phase:
▻ Nerve Injury
▻ Compartment Syndrome
▰ Late Phase:
▻ Muscle Contracture
▻ Joint Stability and Stiffness
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 Early : Nerve Injury

▰ Common with Fractures of Humeral Shaft /

injuries around Elbow & Knee
▰ Closed Nerve Injuries: seldom severed,
spontaneous recovery (90% within 4 months)
▰ Open Nerve Injuries : usually complete, needs
debridement / surgery
▰ Acute Nerve Compression : numbness
(Common : ulnar, median, posterior tibial nerve)

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Liepert LS. Clinical Kinesiology and Anatomy. 5th ed. Philadelphia: FA Davis; 2011.
Liepert LS. Clinical Kinesiology and Anatomy. 5th ed. Philadelphia: FA Davis; 2011.
 Secondary Injuries due to Fracture
▰ Thoracic injuries
▻ injury to the lungs or heart
▰ Spinal cord injury
▻ Damaged spinal cord or nerve roots
▻ a baseline for later comparison of neurological signs
▰ Pelvic and abdominal injuries
▻ important to enquire about urinary function
▰ Pectoral girdle injuries
▻ may damage the brachial plexus or the large vessels at the base of the neck
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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
 Clavicula Fracture

▰ 3.8% of all fractures, 35.0% to 45.0% of all shoulder girdle injuries

▰ Approximately 15% are distal third, 80% are middle third, and 5% are medial third
▰ Medialization of a clavicular fracture more than 20 mm is associated with a
measurable decrease in functional outcome.
▰ Nonsurgical -> nondisplaced or minimally displaced fracture
▰ Surgical -> injuries to subclavian neurovascular structures, 100% displacement,
>15 mm of shortening, highly comminuted fractures, and multiple upper or lower
extremity fractures (polytrauma)
▻ Intramedullary screw fixation, superior plate fixation, and anteroinferior
plate fixation. Both plating techniques have advantages -> Middle third
▻ Open reduction and internal fixation (ORIF) -> Medial third
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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018
Boyer MI. AAOS Comprehensive Orthopaedic Review. 10th ed. USA: AAOS; 2014
 Humeral Fracture

Proximal (the head, greater tuberosity, lesser tuberosity, and diaphysis) Humeral Shaft Distal
▰ Brachialis plexus injuries (highest ▰ Associated of radial nerve palsy ▰ Associated of radial, median, ulnar
risk of axillary nerve injury ▰ Non-surgical treatment -> choice nerve injury
▰ Non-surgical -> Minimal for most humeral shaft fractures ▰ Non-surgical treatment
displacement, medical
comorbidities, osteoporosis ▻ coaptation splinting (7-10 ▻ Splint for 1-2weeks,
▻
days) followed by a immobilization for
Sling and rest, rotator cuff functional brace or a nondisplaced fractures
program, ROM activities hanging arm cast. ▰ Surgical treatment
▰ Surgical -> displaced fractures, ▰ Surgical treatment ▻ ORIF
▻ Open reduction and plate
dislocations, adequate bone quality
▻ Closed reduction and fixation, IM nailing, external ▻ Total elbow arthroplasty
percutaneous pinning, ORIF, fixation
Intramedullary nailing,
Arthroplasty
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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York: Demos Medical Publishing; 2015
 Radial Head Fractures

▰ 20% of all elbow fractures involve the radial head

▰ Pain and decreased ROM in elbow flexion, extension,
pronation, supination
▰ Non-surgical treatment -> minimally displaced (< 3 mm)
radial head fractures
▰ Surgical treatment
▻ ORIF, radial head replacement for comminuted
fractures, radial head excision
Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
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Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York: Demos Medical Publishing; 2015
Liepert LS. Clinical Kinesiology and Anatomy. 5th ed. Philadelphia: FA Davis; 2011.
 Pelvic Fracture

▰ The lumbosacral plexus, lateral femoral cutaneous nerve,

obturator nerve, femoral nerve, sciatic nerve
▰ Initial management -> pelvic binder
▰ Non-surgical -> stable injuries or those in whom substantial
medical comorbidities prohibit surgical intervention
▰ Surgical -> ORIF

Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014

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Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York: Demos Medical Publishing; 2015
 Hip Fracture

▰ Commonly in women 70years or older

▰ Mostly should be stabilized surgically to prevent
displacement -> ORIF, hemiarthroplasty, total hip
arthroplasty
▰ Nonsurgical management should -> only in non-
ambulatory patients and who are deemed too
medically ill for surgical intervention.

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
 Femoral Shaft Fracture

▰ Associated with peroneal nerve

▰ Early stabilization within first 24hours
▰ Non surgical -> skeletal traction
▰ Surgical -> IM nail, external fixation

Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014

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Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 3rd ed. New York: Demos Medical Publishing; 2015
 Tibial-Fibula Shaft Fracture

▰ Associated with peroneal nerve, posterior

tibial nerve
▰ Non surgical -> low-energy stable tibial
fractures (such as axially stable fracture
patterns)
▻ Long leg casting
▰ Surgical -> IM nail, plate & screws, external
fixation

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
 Early : Compartment Syndrome

▰ Bleeding & Oedema → increase the pressure within

the osseofascial compartments → reduced capillary
flow → muscle ischaemia, further oedema, greater
pressure → muscle & nerve necrosis
▰ Nerve = capable of Regeneration
▰ Muscle = can never recover → replaced by inelastic
Fibrous tissue (Volkmann’s Ischaemic Contracture)
▰ 5P’s = Pain, Paraesthesia, Pallor, Paralysis,
Pulselessness

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
 Late : Muscle Contracture

▰ Following arterial injury or compartment

syndrome
▰ Nerves injured by ischemia -> deformity &
stiffness, but numbness is inconstant
▰ Common sites : Forearm and Hand, Leg and
Foot
▰ Forearm → wasting of the forearm and hand,
clawing of the fingers (Volkmann’s)
▰ Calf muscle (Distal Tibia/Fibula) → claw toe

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Late : Joint Instability & Stiffness
Instability
• Ligamentous Laxity → knee, ankle, MCP joint of the thumb
• Muscle Weakness → prolonged splintage, inadequate exercise -> knee,
ankle
• Bone Loss → post open fracture
• Recurrent Dislocation → Shoulder (Glenoid Labrum), Patella
(Patellofemoral Ligament)

Stiffness
• Site : knee, elbow, shoulder, small joint of hand
• Etiology : oedema and fibrosis of the capsule, ligaments, and muscles around
the joint / adhesion of the soft tissues to each other or to the bone
• Worsened by prolong immobilization
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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Bone Healing Process

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 Bone Healing

▰ Process of new bone formation with fusion of the bone

▰ Two types of bone healing :
▻ Primary Healing (Direct Union) → Absolute Stability and
Compression = Contact Healing
▻ Secondary Healing (Indirect/Callus) → Relative stability

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Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
 Five Staging in Secondary Healing Process

Hematoma Soft callus Hard callus

formation Inflammation formation formation Remodelling

• at the time • 1–7 days • after 2–3 weeks. • fracture ends • lamellar
of injury post fracture • growth factor are linked bone
• Osteoclasts expression • the hard replaces
are formed callus starts woven bone
• progenitor cells • (months-years)
are stimulated • fragments are
Blom A, Warwick D, Whitehouse MR. Apley firmly united 29
and Solomon’s System of Orthopaedics and
Trauma. 10th ed. CRC Press; 2018. • osteoblasts (3–4 months)
Factors Associated With Bone Healing

Patient Factor Injury Factors Tissue Factors Treatment Factors

• Age • Open Fractures • Form of Bone • Apposition of

• Nutrition • Severity • Bone Necrosis Fracture Fragments
• Medication • Intra-articular • Bone Disease • Loading and
• Smoker Fractures • Infection Micromotion
• Segmental Fractures • Fracture Stabilization
• Soft Tissue
Interposition
• Damage to Blood
Supply

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
30
Salter RB. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Lippincott Williams & Wilkins; 1999.
 Abnormal Healing Of Fracture

▰ Malunion → normal time, unsatisfactory position with

residual bony deformity
▰ Delayed Union → not at expected rate and time, but healing
is possible (>6 months without Callus formation)
▰ Non-Union → fracture that has not healed 9 months post
op / no visible progress of healing during the last 3 months
à fibrous union or a false joint (pseudoarthrosis)

Blom A, Warwick D, Whitehouse MR. Apley and Solomon’s System of Orthopaedics and Trauma. 10th ed. CRC Press; 2018.
Principle of Fracture
Rehabilitation
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 Principle of Fracture Rehabilitation

▰ Rehabilitation during immobilization : ▰ Rehabilitation after the removal of

▻ Reduce edema fixation:
▻ Maintenance of the circulation to the ▻ To reduce any swelling
area
▻ Maintain muscle function ▻ To regain full range of joint
▻ Maintain joint ROM movement
▻ Maintain function as allowed by the ▻ To regain full muscle power
fracture and the fixation
▻ Teach the patient to use crutches, ▻ To regain full function
sticks, frames
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El-kader SM. Physical Therapy for Fractures and Orthopedic Disorders. 3rd ed. 2013.
 Clavicula Fracture (Rehabilitation)

▰ Immobilization in internal rotation for 2-4 weeks using sling

/ figure-of-eight brace
▰ Self-mobilization of the elbow and wrist out of the sling
several times/day to avoid stiffening of the elbow and wrist
▰ Strengthening is begun 4 to 6 weeks postoperatively.

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
Humeral Fracture (Rehabilitation)

▰ Immobilization using sling or splint

▰ Passive motion started within 2 weeks, active motion after
6 weeks
▰ Immediate passive ROM (forward flexion, abduction), but
with limited external rotation to neutral.

Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014

35
El-kader SM. Physical Therapy for Fractures and Orthopedic Disorders. 3rd ed. 2013.
 Elbow Fracture (Rehabilitation)

▰ Nondisplaced fracture
▻ immobilization in a sling for 7 to 10 days
▰ Surgically treated fracture
▻ Well-padded posterior splint with the elbow at 90°, the
forearm in pronation -> protect a lateral-side ligament
repair
▻ Passive and active-assisted flexion/extension and
supination/pronation are initiated at 1 week
▻ Strengthening is instituted at 8-12weeks

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
 Pelvic, Hip, and Femur Fracture
(Rehabilitation)

▰ Bear weight as tolerated

▰ In high-energy femoral neck fracture, early weight bearing
should be avoided (possible risk of fixation failure)
▰ In femur fracture
▻ mobilization and weight bearing, early motion of the hip
and knee joint

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/femoral-shaft/simple-transverse-middle-1-3-fractures/nonoperative-treatment-with-limited-resources#first-aid
 Tibial-Fibula Shaft Fracture
(Rehabilitation)
▰ Bear weight as tolerated after 1 to 2 weeks
▰ Surgical treatment -> weight-bearing depends on the
fracture pattern and implant type.
▻ Axially stable fracture patterns with bony
contact -> weight bearing as tolerated is
allowed.
▻ Comminuted fractures -> partial weight bearing
is allowed until radiographic signs of healing are
apparent.

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Boyer MI. AAOS Comprehensive Orthopaedic Review. USA: AAOS; 2014
http://nursing411.org/Courses/MD0533_Treat_Fract_Field/4-04_Treat_Fract_Field.html
Role of General Practitioner in
Maintaining Functional Capacity
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 Health Condition

Fractures

Body Functions and Structures Activities Participations

(Impairment)
Energy & drive, sleep, emotional,
sensational of pain, exercise tolerance,
joints mobility, muscles power,
movement
(Limitation)
Carrying out daily routine, changing
basic body position, maintaining a body
position, transferring oneself, using
transportation
(Restriction)
Vocational performance, family
relations, recreation & leisure, social
life, participation in political & religious
activities

Environmental factors
Personal factors
Housing & transportation
Health behaviours, age &
facilities, health service,
gender, comorbidity,
families & friends, work space

1. Knowing how to immobilize the site of fracture to prevent further injuries

2. Pain management -> reduce the pain to promote passive/active movement
3. Prevent complication 40
4. Improve functional status
 CONCLUSIONS

▰ Fracture is discontinuity of bone; caused by injury, repetitive stress, and pathological

▰ Functional impairments of musculoskeletal system in fractures usually due to injury
nerve, joint instability and stiffness
▰ Rehabilitation of fractures plays an importance role in patient’s recovery and to
regain the full body function
▰ ‘General practitioners can take a role in the first aid of fractures to
prevent further injuries’
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THANK YOU
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