Orthopedic

Rehabilitation
FRACTURE REHABILITATION
 Fracture:
 A fracture is a
disruption of bone
continuity.
 The separation of bone
tissue caused by
external or internal
forces or the disruption
of the anatomical
integrity and
continuity of the bone
is called "fracture".
 Fracture Classification
 Closed Fracture: In closed fractures,
there is no relationship between the
fracture and the external environment
 Open fracture: In open fractures, the
fracture is in contact with the
environment.
 The type of fracture varies
depending on the direction and
force of the impact.
 sprains cause spiral fractures
 longitudinal forces cause
compression or comminuted
fractures
Reason of Fractures
Trauma: It may be a direct impact, falling from a height, or falling on
the body. The causes of stress fractures that occur as a result of long
distance walking or running are repetitive minor traumas.
Pathological fractures: Due to disease, bone tissue becomes weak
and tend to fracture, for example: Paget's disease, carcinoma,
osteomyelitis, osteogenesis imperfecta.
 Clinical features of fractures
Pain: It occurs immediately after trauma. There is significant sensitivity around the fracture.
Edema: It begins to occur and spread immediately after injury. A temporary cast or splint is
applied. Elevating the extremity is recommended. You can recommend contract-release isometric
exercise to the patient in a cast.
 Abnormal movements and crepitus: A sound may occur as a result of broken bone ends
rubbing against each other. This sound is called crepitation.
 Movement limitation:There are many factors that affect movement. Adhesion, pain, spasm, fear,
mechanical blockage, swelling.
 Muscle atrophy: Unused muscle weakens and atrophy! Muscles often atrophy in the cast during
immobilization.
 Fracture Healing
 Bone has an incredible ability to repair itself with new bone.
 Wolf's law: According to Julius Wolff's law, known as the ability of bones to respond to physical
stress; It is defined as "in a bone of a given shape, the elements of the bone position themselves
according to the forces acting on them, and increase or decrease their mass to reflect the amount
of the acting forces.
 Fracture healing is examined in 5 stages.
 1. Hematoma: As a result of the rupture of blood vessels, a
hematoma appears at the fracture area within a few seconds. The
resulting dead bone areas are absorbed.
 2. Periosteal and endosteal proliferation: These cells, which are
osteoblast precursors, they produced at the broken bone ends and
begin to proliferate. And these tissues start to make a bridge
between two bone ends. At this stage, the hematoma is slowly
absorbed.
 3.Callus Formation: periosteal cells transform into osteoblasts and
chondroblasts. Osteoblasts combine with calcium and collagen to
form bone tissue called callus. It is visible in radiological images. It
is proof that healing has begun.
 Consolidation: The callus formed as a result
of osteoblastic activity turns into bone
structure. At the end of this phase, bone union
is completed.
 Remodeling: As a result of this phase, the
bone structure almost transforms into its
original version. With therapies, the bone
becomes stronger along the line where the
stress is placed on it (wolf law).
Fracture Complications
 The two most likely complications are pulmonary embolism and deep vein thrombosis.
 Hypovolemia; The patient may go into shock from excessive blood loss; blood loss of up to 1.7
liters in femur fractures and 3.4 liters in pelvic fractures may occur.
 If it is an open fracture, infection and tetanus.
 The layer of dry skin that forms on the skin after the plaster is removed. Redness caused by
plaster or splint
 Muscle atrophy: Muscle fibers may be damaged after injury, and muscle atrophy may occur due
to disuse after casting.
 Compartment syndrome: In some body parts, tissue nutrition is impaired
due to injury and tissue death occurs due to insufficient blood supply. 5P
rule; pale, pain, pulseless, paresthesia, paralysis

 Avascular necrosis :If there is a problem in the nutrition of the bone tissue
after a fracture, avascular necrosis may occur. It is mostly seen in femoral
neck fractures. Avascular necrosis causes the bone to fail to union.
 Sudeck's atrophy (reflex sympathetic dystrophy (RSD): It is also
called complex regional pain syndrome. The underlying cause is not
fully known. Swelling in the extremities, shiny skin, and severe pain
are observed.

 Nerve injuries: While some fractures occur, nerve damage may also
occur or may be caused by tight casting. For example, if the plaster is
wrapped too tightly around the head of the fibula, the peroneal nerve
may be damaged, this affects the tibialis anterior muscle and drop
foot may develop.
 Basic Treatment Principles Of Fractures
 Reduction: Bringing the bone back into its proper position and bringing it as close to
the anatomical position as possible. It can be done open or closed. Closed reduction
does not require surgery, open reduction does. Orthopedists do it.
 İmmobilization: The purposes of immobilization
are as follows:maintaining reduction, providing an
optimal healing environment for the fracture, pain
management
 Plaster immobilization: It is frequently used in
fixation of fractures after reduction of fractures.
 A plaster saw is required to remove the plaster, the
plaster saw is vibrating and helps to remove the
plaster without damaging the skin.
 İmportant Notes:
 If you see these after applying a cast or splint, consult a doctor.
 Pallor and bluing of the affected body skin (compartment syndrome)
 Numbness, tingling, throbbing (nerve injury)severe pain, swelling, shiny skin
(sudeck atrophy), loosening of the plaster.
 Internal fixation
 It is an open reduction method performed
surgically using a plate. Open reduction internal
fixation (ORIF) is used.
 Intramedullary nailing:
 A hollow metal rod is passed through the bone and the bone is fixed.
Surgeons mostly prefer it for hummerus and tibia fractures.
 External fixation
 It is fixed outside the body
with the help of wires and
pins and a device. It is
mostly used in extremity
lengthening procedures.
 It depends on the surgeon
which method he will use;
they prefer it more in
multiple and fragmented
fractures.
 Physiotherapy and Fracture Rehabilitation
 The most important thing you need to know is that there is no prescription for fracture treatment.
 Not all orthpedic patients are alike.
 The treatment process does not proceed the same way for every patient. Because patients don't
always behave as written in the book
 Do not look for a ‘treatment prescription’, your approach should be flexible and dynamic,
changing according to many factors.
 Know the general evaluation framework, but create your own evaluation and adapt it to the
patients
 keep an open mind recognize when treatment isn't working and change and readjust
EVALUATION
medical history ;is there a systemic or chronic disease, is the patient taking
medication
patient history; When and how did it happen, when did the surgery take place,
how many days passed, what is his profession, daily habits, physical activity
level? How many days did he stay in a cast after the surgery?
Objective Evaluation
Pain ; What are the location, type, duration of pain, and the situations that increase the pain?
For quantitative data, you can use VAS (visual analogue scale) at the beginning of treatment.
Patients want their pain to go away first, then they want to get better.
Observation Feel it Move it
Edema edema Active
spasm heat Passive
deformity sense What is the quality and
quantity of movement and
how does the end feel?

atrofy spasm
sensitivity to touch
 Muscle strength
 Muscle testing should be performed on the affected area and surrounding
muscles. Muscle atrophy develops due to disuse, especially after the cast is
removed. For example, if a patient had a Colles fracture, he could not use his arm
due to immobilization for 3 weeks and his rotator cuff muscles may have
weakened, you should check and test.
TREATMENT
 PHYSIOTHERAPY DURING IMMOBILIZATION
 Reducing edema and pain;
•Massage (classical, functional…)
•Electrotherapy
 Increasing blood flow
•Massage (classical, functional…)
•Electrotherapy
•Passive/active-assistive/active muscle control.
 Increasing muscle functions
•Active/isometric!!!
•NEH in possible joints
•Increasing functionality as much as fixation allows •Auxiliary apparatus (KT, cane, walker,
Kanedien cane…) training
AFTER İMMOBİLİZATİON
EARLY PERIOD
•Cold application. (Cold pack, sprays, cryocuff)
•Hot application. (hydrotherapy, hot pack, fluidotherapy)
•Elevation
•Massage, (scar, circulation…)
•Electrotherapy (TENS, Faradik, DC, Laser, HVGS)
•Exercises
•Active/active-assist. •Isometric •Active stretching
•Special (Codman, Pendulum, wand…) •CPM (Continuous Passive Motion)
 LATER PERIOD
•Hot application.
•Electrotherapy (for functionality)
•EMS!!
•Exercises : Isokinetic, stretching, spring and pulley systems, Functional
Endurance, balance, proprioception, pilates, walking, coordination, group
• Occupational Therapy •Sporty, recreational •Return to sports…
Common Types of Fractures Encountered
in Clinic
Upper extremity fractures
Clavicle and Scapula Fractures: It is not
very common and is usually caused by
direct trauma or by falling on the
outstretched hand.These fractures are
usually immobilized with a splint or arm
sling. It causes pain and limitation of
movement.
Humerus Fractures
 Humerus shaft fractures
• It usually occurs in the middle 1/3 of the
bone, and is caused by direct trauma.
Since fractures generally occur in the
middle part of the trunk, the radial nerve
may also be affected. Dropped hands
may be seen because the raidal nerve
innervates the forearm and wrist
muscles.
 Humerus Condyle Fractures
 It is usually seen in children after
a fall. Since it is close to the joint
face, it causes joint limitation.
One of the most serious
complications is brachial artery
injury. Since it passes close to the
fracture site, the artery may be
crushed or ruptured. Be sure to
check and observe the circulation.
Radial Head Fractures
 Radius or ulna fractures occur as a result
of falling on a hand stretched to the side or
as a result of direct or indirect trauma.
Radius distal end fractures are called
'Colles fractures'. Supination and
pronation are affected. The most common
complication is Sudeck atrophy. Median
nerve compression after casting is another
complication.
Scaphoid fractures
 In adults, it is usually seen when
falling about a tense hand.
Individuals may consider this as
hurt and ignore it. When the pain
persists for a long time, they come
to the clinic. Recovery is slow due
to poor nutrition. Therefore,
avascular necrosis is among the
common symptoms.
Lower Extremity
Fractures
 Pelvic fractures: occur as a
result of direct trauma, fall or
impact injuries. The patient
may lose a lot of blood, internal
organs may be damaged
(bladder, uterus). Surgery is
required. There must be
cooperation with the
physiotherapist and doctor.
Femoral neck
fractures
 It is the most common type of
fracture. The mortality rate after
this fracture is high. For this
reason, it is the fracture that
receives the most attention in its
treatment in developed
countries. It is usually seen in
the elderly following a fall. The
surgeon reduces the femoral
head with internal fixation or
repairs it with a prosthesis. The
most common complication is
avascular necrosis.
Femoral Shaft
Fractures
 It usually occurs as a
result of a violent
impact. It can be
transverse, oblique or
spiral. Intramedullary
nailing is mostly used
in reduction.
Knee fractures
 It includes tibia and femoral condyle
fractures and patella fractures. Since it
is close to the joint surface, movement
limitation develops as a result of
deterioration of the surface of the knee
joint. Osteoarthritis may develop in the
knee joint.
Patella Fractures
 It occurs as a result of sudden
and violent contraction of the
quadriceps or a direct blow to
the knee. It causes limitation in
the knee joint, and if it
progresses, osteoarthritis
occurs.
Tibia and Fibula Fractures
 It is a very common type of fracture. It
can be seen at any age as a result of
direct or indirect impact. Oblique or
transverse fractures are more common
as a result of a car accident or a blow
during football. After fixation, it is
immobilized with plaster.NOTE!!!!: In
case of lower extremity fractures, be
sure to consult your doctor when to
start body weight transfer exercises!
Ankle Fractures
Calcaneus fractures usually
occur as a result of falling on
the feet from a height.
Calcaneus fractures are very
painful. The ankle is a
difficult joint because there
are so many articular surfaces
and ligaments. If eversion and
inversion cannot be restored,
loss of function occurs.
TAKE HOME MESSAGES
 Make your own subjective evaluation
 Read the surgery report (What did the surgeon do, what method did she/he use?
 Ask your doctor when you can start weight-bearing exercises.
 Make an exercise and treatment program suitable for your patient, and do not forget to use specific
physiotherapy methods such as manual therapy and soft tissue techniques.
 We are physiotherapists, we do not have a magic wand, teach and explain the homework and
exercise program to the patient.
 There is no ready-made prescription for treatment in rehabilitation. Know the general rules and
anatomy and create your own treatment program using your professional knowledge according to
the patient's condition.
THANK YOU FOR ATTENTİON