ORTHOPAEDICS I

FRACTURES OF UPPER EXTREMITIES

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Anatomy of the shoulder girdle

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 Fracture of clavicle
• Fractures of the clavicle are common.
• The cause of the fracture could be either
direct violence. E.g:
– A fall on the point of the shoulder
– Direct violence over the clavicle such as RTA
• Indirect (usually the fracture is caused by a fall
on the outstretched hands).
• If displacement occurs, as it usually does, the
lateral fragment is displaced downwards and
medially.
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Clinical features of clavicular #
• Usually the patient presents with pain, swelling,
deformity and inability to raise the shoulder.

Medical & surgical treatment:

• Majority of the fractures of the clavicle are
treated conservatively.
• Treatment methods include cuff and collar slings;
and or figure of 8
• Rarely fractures of clavicle would require surgery.
• The fracture unities in around 3 weeks
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Common sites of Clavicle Fracture

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 Cuff and Collar Sling

Complication of # of clavicle: Malunion, injury to subclavian

vessels or brachial plexus which can be caused by a spike of the
bone, non-union (very rare).

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 Physiotherapy treatment
• Basic objectives:
– To regain active full range of all movements of the
shoulder complex.
• During immobilisation:
– To check the alignment of the fractured bone ends with
immobilization
– Check the arm sling to ensure that there is total support to
the elbow to avoid gravitational force exerting any pull to
shoulder girdle.
– Confirm that bandage in the axilla is not causing undue
pressure on the brachial plexus
– Properly supported resistive full range of movements to be
explained to the patient for elbow, forearm and wrist.
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 During mobilisation (after 3 weeks)

• Shoulder movement should be initiated in small range

• Relaxed movement using Codman’s pendular exercise
• Gradually increase the range for this relaxed passive
movement with the patient in supine position
• Resisted exercises using dumbbells of self resistance
• Self resisted exercise and mobilisation with a wand should be
taught to the patient as home exercise regime besides the
functional use of the whole limb.
• By 6 weeks, the results are good.

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N.B: in case of surgical treatment by open reduction, internal
fixation and/or bone grafting:
• Gradual mobilisation should be started by 8-10 days.
• Initially the mobilisation is started with a sling by teaching
relaxed pendular movements, assisted by gravity and
momentum
• The rest is as the above (during mobilization).

Caution: while initiating early movements within the sling, it is

necessary to be sure that no movement is occurring at the
fracture site.

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 # of the Scapula
• The scapula is subjected to # usually due to direct violence.
• Such fractures are un-common and in most cases are un-
important because they do well without special treatment.
• Often, however, there is marked bruising of the adjacent soft
tissues, so that for a time there may be severe swelling and
pain.
Common 4 areas of #:
 Body of the scapula
 Neck of the scapula
 Acromion process
 Coracoid process.

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Medical & Surgical Treatment
• Fractures of the scapula are usually managed conservatively.
• Often a sling is worn at first but as soon as the pain begins to
subside active exercises are begun, and are continued until a
full range of movement is regained.
• If the acromion process is comminuted or markedly displaced
then operative measures are advisable.
• Likewise for the coracoid process.

Physiotherapy management: same as for clavicle #

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 Fractures of the Humerus
• Fractures of the humerus may be classified into six sub-
divisions namely:
– Fracture of the neck of humerus
– Fracture of the greater tuberosity
– Fracture of the shaft
– Supracondylar fractures (very common in children),
– Fractures of the condyle
– Epicondyle fractures
• The majority of the fractures of the humerus are the result of:
– Direct violence, usually from RTA
– Fall onto the limb
– Fall with an outstretched hand or a blow on the limb.

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Complications of # of humerus:
• Neck of the humerus: Stiffness of the glenohumeral joint.
• Greater tuberosity of humerus: may result into painful arc
syndrome (sometimes referred to as supraspinatus
syndrome).
• Fractures of the humeral shaft may cause injury to the radial
nerve (at the radial groove).
• Supracondylar fractures of the humerus may result into
damaging the brachial artery.
• Fractures of the medial epicondyle of the humerus may cause
injury to the ulnar nerve.

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Greater tuberosity #

• 2 types: (i) Contusion # (no displacement),

(ii)Avulsion # (with displacement)
• Mode of injury: fall on the side of shoulder, direct blow to the
side of the shoulder
• Medical & surgical treatment:
– if it is contusion #, to support the limb for 2 weeks in a sling.
– If it is an avulsion #, ORIF.
• Physiotherapy management: same as for clavicle #

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Neck of humerus #
• 2 types: (i) impacted or undisplaced #,
(ii) unimpacted or displaced
• Mode of injury: fall on outstretched hand. Common in elderly
women.

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Physiotherapy Management
Neck of humerus_Impacted #
• Aim: to regain full AROM of the shoulder joint.
• During immobilisation (2-3 weeks)
– Initially cryotherapy, Tens for reducing pain
– Self resisted full range elbow, forearm, wrist and hand movements to
be encouraged

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Neck of humerus_impacted # (Physio cont’)

During mobilisation:
• Relaxed pendular movts in small range for shoulder can be
started
• Relaxed passive movts of shoulder:
– Working up gradually to overhead abduction
– As well as rotation should be attempted as soon as sling is removed
– Progressing from supine to sitting and to standing position

• The full range can be achieved by 6-8 weeks.

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Neck of Humerus_Unimpacted #
During immobilisation (3 weeks)
• If a sling is given for 3 weeks: the treatment will be the same
as impacted #.
• In a conservative approach when closed reduction and
manipulation is done, shoulder is immobilized in an axillary
collar and cuff:
– No movt is permissible at the shoulder for 3 weeks.
– The chances of developing a painful stiff shoulder are therefore quite
high.

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During mobilisation
• Deep heating thermotherapy procedures like:
– US,
– Hot packs,
– Relaxed passive movements.
• Maximum emphasis has to be given in educating the patient
for repeated relaxed active assisted shoulder movt with due
stress on abduction, starting with pendular movts.
• Once AROM is achieved, resisted exercise can be started
• Full range can be achieved by 6-8 weeks.
• N.B: in case of surgical management where ORIF is done for younger
patients, emphasis should be put on isometric exercise to the deltoid and
strengthening exercises at the earliest.
• Relaxed passive movements and active assisted exercise by the help of
other hand should be done immediately after the sling is removed.

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Shaft of humerus #

• Mode of injury:
– Direct injury which can cause comminuted #
– Indirect injury which can cause spiral or oblique #

• Types of #:
– Transverse #
– Oblique #
– Comminuted #
– Spiral #
• Medical Rx:
– # is manipulated with the patient in sitting, elbow is held in 900 of flexion,
then POP and forearm is supported in a sling.

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 Shaft of humerus # Cont’

Surgical Rx: ORIF

Surgery can be done in following conditions:
• Unacceptable reduction following closed manipulation which
may be due to interposition of soft tissues between #
fragments.
• Non-union
• Injury to the radial nerve
• Post-operatively, the limb is immobilised for 6-8 weeks.

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Shaft of humerus # Cont’

Physiotherapy management
During immobilisation
• Check the limb for the presence of radial nerve injury (wrist
drop).
• Many times, radial nerve may get involved later at the time of
callus formation around the # site.
• Strong wrist & finger movements can be started
• Isometric exercises for the deltoid, triceps, and biceps

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During mobilisation
• Longer period of immobilisation results in stiff and painful
elbow and shoulder.
• Before initiating shoulder movements, pain relieving
modalities like TENS, US, SWD can be applied.
• Mobilisation at the first day starts by relaxed passive
movements in a small range
• Self assisted movements to the shoulder can be taught
• Progress to “Codman pendular exercise” in standing position
• Then relaxed passive self-stretching of abduction and
elevation in supine
• Active exercises
• Resisted exercises.
• Elbow joint mobilisation
• Recovery varies from 3 to 4 months.
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Supracondylar # of humerus
Mode of injury:
• Direct injury to the elbow: eg: fall at the point of elbow
• Indirect injury: fall on outstretched hand.

Displacement:
• Anterior displacement (called Flexion type of #)
• Posterior displacement (called Extension type of #)

Medical and surgical Rx

• Closed reduction under general anaesthesia
• If the closed reduction fails, as in case of brachial artery injury associated
with nerve injury, a surgical intervention will be done.
• In surgery, # fragments are internally fixed by Kirshner-wire (K-wire).

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 Supracodylar # Humerus

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 Physiotherapy management
Aim: to regain active full range of elbow and forearm.
During immobilisation
• Allow mvts to the thumb, fingers and other free joints.
During mobilisation
• Accurate evaluation of ROM at the elbow and forearm
• Before starting mobilisation, thermotherapy modalities to the
elbow and forearm for relaxation, pain reduction, and
circulation increase can be given.
• Movements at the elbow should be initiated in the form of
active assisted rythmic mvts in the gravity eliminated position.
• This gradually progress to active full range of mvts
• Progress to resisted exercises by the use of dumbbells and
pulleys with weights
• Full range of mvts is expected within 6-8 weeks.
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Complications
1. Stiffness of elbow joint
2. Injury to the brachial artery.
• This results into Volkman’s ischaemic contracture (VIC).
• Because of damage to the brachial artery, the blood supply to
the forearm reduces leading to ischaemia of the cells.
• The affected muscles are gradually replaced by fibrous tissue
which contracts and draws the wrist and fingers into flexion.
3. Injury to the median nerve
4. Deformity from malunion called “cubitus varus”

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 Intercondylar # of humerus

• Mode of injury: fall at the point of the elbow

• Types of #:
– T-shaped fracture
– Y-shaped fracture
– H-shaped fracture
• Treatment: skin or skeletal traction maintained for 3 weeks.
• If this comminuted # is severe: surgery is performed: open
reduction, then internal fixation with plates and screws.

• Physiotherapy management: the same as suppracondylar #

of humerus.

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Intercondylar # of humerus

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 Epicondylar # of humerus
• It usually affects medial epicondyle.
• Mode of injury:
– Direct injury.
– It can be a simple # or avulsion #.

• Treatment: elbow is immobilised for 3 weeks.

• Complications:
– Intrusion of medial epicondylar fragment into the joint
– Injury to the ulnar nerve.

• Physiotherapy management: the same as for supracondylar #

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 FRACTURES AROUND THE ELBOW JOINT
• Olecranon fracture

• Fracture of the head of radius

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 Olecranon fracture
Mode of injury:
• Direct injury: fall at the point of the elbow
• Indirect injury: fall on the hand with elbow in slight flexion

Types of #:
• It may be only a crack # without displacement
• It may be a clean fracture with separation of the fragments
• It may be a comminuted fracture, with the fracture line always
entering the joint near the middle of the trochlea notch.

Treatment:
– The crack is treated by POP for 2 to 3 weeks.
– The clean fracture with separation is treated by ORIF followed by
immobilisation for 2 weeks.
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 Olecranon fracture Con’t

Physiotherapy management
• The same as supracondylar # of humerus.
• Stretching and strengthening exercises of Triceps should be
instituted early to regain the full function of triceps, especially
in case of comminuted #.

Complications:
• The significant complications are:
– Non union as a result of a gap being allowed to remain
between the fragments
– Osteoarthritis.
– A degenerative joint disease that may develop later after the
injury
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 # of the head of radius

• Mode of injury: Fall on outstretched hand.

– It is commonly seen in adults.

• Types of #:
– It may be only a crack # of the head of radius
– It may be a comminuted fracture of the head of radius.

• Treatment:
– The crack is treated by a plaster of Paris for 2 to 3 weeks.
– In comminuted fracture: bone fragments are excised, then
immobilisation.

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 # of the head of radius cont’

Physiotherapy management:
• The same as supracondylar # of humerus.
• NB: rotation movements of the forearm (pronation and
supination) need extra attention.

Complications:
• Volkmann’s Ischemic Contracture (VIC)
• Injury to the peripheral nerves
• Malunion
• Myositis Ossificans
• Osteoarthritis

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 VOLKMANN’S ISCHEMIC CONTRACTURE (VIC)

•VIC condition is commonly seen in fractures around elbow, forearm and

hand.
•This lesion occurs due to temporary occlusion of arterial circulation to
the region.
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Signs and symptoms for the VIC
Within 3-4 hours following immobilization
– Severe pain along the area distal to the site of occlusion.
Pain increases in intensity on passive finger extension
– Fingers become swollen and discoloured
– Absence of radial pulse
– Muscular spasm with hard and woody feeling to touch
– Loss of muscle extensibility: it gives stiffness in distal joints
– Gradual loss of sensory status and motor function
– If not attended immediately, it may progress to irreversible
typical VIC deformity: the fibrosis of flexor group muscle
leads to flexion deformity at the elbow, wrist, and fingers,
and the forearm remains in pronation, MCP joints in
hyperextension.

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Causes of VIC
• Sustained pressure on blood vessels due to tight POP or
bandage
• Injury to the brachial artery
• Disease of blood vessels
Preventive measures
• Education of the patient about the signs and symptoms of VIC
expected
• Check the radial pulse regularly
• Check the nail bed circulation by applying pressure on the nail
beds
• Check the motor power and sensory status of fingers free
from immobilisation
• Check the distal limb joints for the feeling of coldness in
comparison to the normal area
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Treatment of VIC

Treatment for suspected cases

• Immediate removal of pressure causing factor(s) like bandage
or POP
• Passive or active movements of the segments distal and
proximal to the affected area
• Thermotherapy modalities can be applied to the opposite
limb to improve general vasodilatation

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 Treatment of established cases of VIC

• The prognosis depends upon the degree of permanent

damage to the muscle and nerve tissues.
• The prognosis is poor when there is total loss of sensation,
weak motor function, stiffness in the joint, and fibrosis of the
muscles.
• Treatment depends on the types of VIC:
First type: Mild VIC: there is ischemia of flexor digitorum
profondus.
• Exercises, dynamic splinting to maintain finger extension
Second type: Moderate VIC: it involves deep and superficial
finger flexors and flexors of the wrist and thumb.
• Graded splinting (distal to proximal), exercises, stretching of
the affected muscle(s)
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 Treatment of established cases of VIC (cont’)

• Third type: Severe VIC: there is VIC deformity (fibrosis of

flexor group muscle leads to flexion deformity at the elbow,
wrist, and fingers, and the forearm remains in pronation, MCP
joints in hyperextension).
• Surgery: shortening of the forearm bones to overcome the
contracture of flexor muscle groups, excision of dead muscles,
and nerve grafting for the damaged nerve(s) beyond repair.
• Physiotherapy to increase the extensibility of the contracted
soft tissues: deep friction massage, Ultrasound (US), relaxed
passive movements, and stretching.

• If swelling persists in severe VIC, strong voluntary movements

with the limb in elevation should be given.
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 Injury to the peripheral nerve

• Median and ulna nerves can be injured in fracture of neck and

head of radius.

• However, shortening or fibrosis of flexor muscles may lead to

ineffectiveness of the muscles supplied by the radial nerve.

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 Injury to the peripheral nerve Cont’
Treatment
Prevention of contractures: it is achieved by:
• Relaxed passive full range movements which should be self
assisted
• Low intensity sustained stretching procedures
• Splints which can maintain constant small stretch should be
given
• Maintenance of circulation to the innervated muscles
• Passive range of motion exercises
• Thermotherapy and electric stimulation can be given when
there is no sensory deficit

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Injury to the peripheral nerve (Treatment Cont’)

• Strengthening of muscles
• Strengthening exercises balanced with stretching techniques
form most effective aspect of improvement
• Concentration on functional movements
• Graduated assistive functional movements as they are
performed in the daily routine are to be stressed.

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Myositis ossificans or post-traumatic ossification

• It is a rare cause of joint stiffness after a fracture with

dislocation.
• It occurs only in cases of severe injury to a joint and especially
if the capsule and periosteum have been stripped from the
bones by violent displacement of the fragment.
• Blood collects under the stripped soft tissues forming a large
haematoma in the joint.
• The haematoma is invaded by osteoblasts and become
ossified.

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 Myositis ossificans or post-traumatic ossification
(Cont’)

Preventive measures
• Fixation of # in a proper alignment.
• Proper immobilisation of the elbow joint following injury
• Discourage early passive mobilisation of the elbow so that the
haematoma around the joint is allowed to get absorbed
• Massage and passive movements should be strictly avoided in
cases of elbow injury.

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 Myositis ossificans or post-traumatic
ossification (Cont’)
Treatment of suspected cases
• Rest with immobilisation has to be continued further.
Treatment of confirmed cases
• Once the progress of the myositis ossification is stopped,
vigorous exercise program includes graduated sustained but
gentle passive stretching to regain maximum ROM.
• The patients need to be educated and guided on the process
of this exercise to make the home exercise program effective.

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 Sideswipe # of the elbow
• Sideswipe fracture of the elbow is an open fracture and
consists of fractures of the lower end of humerus, upper end
of ulna and radius with anterior dislocation of the elbow.
• The limb is immobilized in an external fixator for 6-8 weeks.

Physiotherapy management in mobilisation period

• Suitable thermotherapy modalities
• Relaxed rythmical passive assisted movements of the elbow
and forearm.
• Strengthening of wrist, fingers, shoulder and forearm to
provide maximal compensation for the stiff elbow joint.

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 # of radius and ulna or both bone fracture of the upper limb
Mode of injury:
– Direct injury
– Indirect injury: fall on outstretched hand
Treatment
– Conservative treatment: a non displaced # does not need manipulation.
– For displaced #, closed reduction under anaesthesia.
– After the reduction, the limb is immobilized in above elbow plaster cast with
elbow in flexion, forearm in midprone position.
– The plaster is maintained for 3-6 weeks in children and 8-10 weeks in adults.
– Operative Treatment: it is indicated where closed manipulation has failed or
good initial reduction has been lost subsequently in plaster.
– Internal fixation is done by plate and screws or intramedullary nails.
– The limb is immobilized in an above elbow plaster cast for 6 weeks with elbow
in flexion, forearm in midprone position.

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 Both bone fracture of the upper limb (Cont’)

Complications: Some of the common complications include:

• infection in open fractures
• functional impairment
• delayed union
• non-union
• malunion
• cross union between the radius and ulna
• shortening of the two bones.

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 Both bone fracture of the upper limb (Cont’)
Physiotherapy management
During immobilisation
• Active full range of movements for the joints not immobilised
• Emphasis on shoulder joint and isometric exercises to the
elbow extensors and flexors.

During mobilisation
• Active movements at the elbow and wrist
• Relaxed pronation and supination movements carefully
• As pain becomes less, self assisted stretching by the
contralateral hand should be started

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 # of the upper end of ulna with dislocation of the
head of radius = Monteggia #

Mode of injury: fall associated with forced pronation of forearm

or a direct blow on the back of the upper forearm.

Treatment:
• Closed manipulation or internal fixation of the ulna and
reduction of the head of the radius.
• Then immobilization in above elbow plaster cast with the
elbow in flexion and forearm in supination for a period of 4-6
weeks.

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 Montaggia #

Types II
Types I

Types III Types IV

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Monteggia # Cont’

Physiotherapy management

• Initial measures are taken to control inflammation, pain and

swelling.
• Strong and full range movements especially to the MCP joints
need to be emphasized.
• After removal of plaster cast, vigorous exercise program for
elbow and forearm movements has to be concentrated and
progressed as for management of both bone fracture of the
upper limb.

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 # of the shaft of radius with dislocation of inferior
radio-ulnar joint : Galeazzi fracture-dislocation
• Mode of injury: Fall on the hand
• Treatment: ORIF is preferred, then immobilization in an above
elbow plaster cast for 4-6 weeks.

Physiotherapy management: same as Montaggia #.

– Care should be taken in the inferior radio-ulna joint because dislocation
of that joint delays the return of pronation and supination of the
forearm.
– Therefore, these movements need special emphasis.

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 Fractures of the lower end of the radius (colles
fracture)
• Fracture of the distal end of radius was first described by
Abraham Colles in 1814.
• He reported that it was not just a fracture of the lower end of
radius, rather a fracture dislocation of the inferior or distal
radioulnar joint, which occurs about 2.5 cm above the carpal
extremity of the radius.
• The common cause of this injury is a fall on an outstretched
hand with dorsiflexion of the wrist (40 – 90 degrees of
dorsiflexion)
• The fracture pattern is usually sharp on the palmar aspect and
comminuted on the dorsal aspect of the lower end of radius.
• The lower fragment is displaced slightly backwards and
laterally, and is tilted backwards.

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 Colles # (cont’)

Clinical features
•Often the patient complains of pain and swelling, deformity, loss of
function.

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 Colles # (cont’)
Medical & Surgical Treatment
• In displaced fractures the standard method of treatment is to
undertake a manipulative reduction, followed by
immobilisation of the forearm and wrist in a below elbow PoP
for 4-6 weeks.
• Sometimes colles fractures are best treated by operative
measures.
• This is often indicated in extensive comminuted fractures,
impacted fractures, median nerve entrapment fractures and
other associated injuries, especially in adults.
• It consists of ORIF with plate and screws.
• External fixation is another method of treating colles fractures
and has been found to be extremely useful in highly
comminuted fractures, unstable fractures, compound
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fractures and bilateral colles fractures.
 Colles # (cont’)

Complications
– Stiffness of fingers and shoulder
– Malunion: This is the most common complication and is
said to be attributed by several factors such as improper
reduction; improper and inadequate immobilisation;
rupture of the inferior/distal radioulnar ligament;
osteoporosis and recurrence
– Rupture of the extensor pollicis longus tendon
– Carpal tunnel syndrome
– Non-union

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 Colles # (cont’)
Physiotherapy management: same as for both bone # of the
upper limb
During immobilisation (care to reduce swelling and stiffness)
• Elevation of the hand above the level of the heart
• Intermittent use of a sling with elbow in at least 70 degrees of
flexion.
• Full range of passive as well as strong forceful active
movements of fingers effectively drain the excess of lymphatic
fluid from digits in the hand
• Active full range movements of shoulder and elbow
• Applying a compressive stocking to the hand and wrist

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Colles # (cont’)
During mobilisation
• Hot pack, Infrared or cryotherapy and TENS can be useful for
reducing pain and increasing circulation
• wrist mobilisation is initiated with small range of relaxed
speedy flexion and extension with forearm in midprone
position.
• As the wrist is immobilized in ulna deviation, the movement
of radial deviation needs to be emphasized in the initial stages
• If swelling and pain persist even after a session of exercise,
use of intermittent sling may be necessary
• Exercises to improve wrist flexion and extension
• As the ROM improves, the movements can be made strong by
teaching isometric as well as isotonic self resistive exercises or
exercises using weights.
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Smith’s # or # of the lower end of radius with anterior
displacement or reverse colles #
• The distal fragment is displaced forwards in Smith’s fracture
while it is displaced backwards in Colles fracture.

Medical & surgical treatment

• Closed manipulation under anaesthesia followed by above
elbow plaster cast for 2-6 weeks with elbow in flexion and
forearm in supination.
• In surgical procedures, ORIF by plate and screws is used.

Physiotherapy management: Same as Colles #.

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 Colles & smith #

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Barton’s fracture

• It is an intra-articular fracture of the lower end of radius.

• The fracture line is oblique.
Medical treatment
• Closed manipulation under anaesthesia followed by above
elbow plaster cast.

Physiotherapy management: Same as Colles #.

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Injuries of wrist and hand

• Fracture of scaphoid bone

• Fracture of the lunate bone
• Fracture of the metacarpals
• Fracture of the phalanges

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 Fracture of scaphoid bone
Mode of injury: fall on outstretched hand

Treatment:
• Manipulation is rarely necessary as the # fragments are
undisplaced or minimally displaced
• A scaphoid plaster cast is applied with the wrist in slight
dorsiflexion and radial deviation.
• The thumb is held away from the palm in glass holding
position.

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Fracture of scaphoid bone (cont’)

Physiotherapy management
• During immobilisation:
– Active range of shoulder, elbow, forearm, MCP and IP joints
• During mobilisation:
– Active exercises of the thumb should be started immediately, and
relaxed passive mobilisation of the wrist to be initiated and resistance
to be added as early as permissible.
• Complications:
– Non-union, avascular necrosis, osteoarthritis of the wrist and delayed
union.

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Fracture of the lunate bone
• The lunate may be fractured through its body following a fall on
outstretched hand.
• Treatment: the # of the lunate is immobilised in a below elbow plaster
cast for 3 weeks.
• Complications:
– Avascular necrosis called Keinbock’s Disease,
– Osteoarthritis of wrist.
Physiotherapy management:
• During immobilisation:
– Maintain strength and full range of motion of all uninvolved joints of the
upper limb
– Median nerve compression should be checked repeatedly
• During mobilisation:
– Reduction of pain
– Relaxation of stiff wrist joint
– Mobilisation should be started in gravity eliminated position
– Then progressive resisted exercises should be started using low weight
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 Fracture of the metacarpals
• This is caused by direct injury to the hand or due to fall of
heavy objects on the hand.
Treatment: Below elbow POP for 3 weeks.
• Fracture through the neck needs reduction and
immobilisation by an Aluminium strips in flexion.
• Fracture to the shaft needs internal fixation by intramedullary
wire or K-wire.
• Severely displaced #s are treated by a wire through the
adjacent metacarpals.
• Post-operatively, a below elbow POP is maintained for 10
days.

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Fracture of the metacarpals
Physiotherapy management
During immobilisation:
• To control oedema of the hand to prevent extensor tendon
adhesions and future deformity
During mobilisation:
• Active movements to prevent adhesion between bone and
tendon (osteotenodesis), tendon and skin (dermotenodesis)
• Passive mobilisation to glide the tendon of flexor digitorum
profundus and superficialis, extensor digitorm, extensor
indicis and extensor digiti minimi
• Passive and assisted exercises to the finger joints.

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 Fracture of the phalanges
• The phalanges are fractured due to direct trauma in direct
injury.
• Distal phalanges get fractured due to crushing injuries.
• The fracture may be comminuted, transverse, oblique or long
spiral
• Treatment: Proximal and middle phalanges are treated by
closed manipulation and splinting the injured finger to
adjacent finger for a period of 3 weeks.
• Grossly displaced #s may need internal fixation by K-wire or
screws.

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Fracture of the phalanges cont’
Physiotherapy management
During immobilisation
• Measures to control oedema, inflammation and pain
• Resistive exercises to the free joints

During mobilisation
• Relaxed passive movements
• Very supported active movements
• Resisted exercises to the finger joints.

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