Fractures

Rebecca J Saunders PT/CHT

Curtis National Hand CenterBaltimore, MD

October 6-8, 2017

Promoting fracture healingOnce anatomic reduction takes 

place there is a balancing act between providing stability and mobility

Joints need to be splinted in a “close‐pack” position to maintain ligament length and provide maximal congruency

Distal joint motion encourages tendon gliding while decreasing edema and scarring

Epiphysis Physis Metaphysis Diaphysis Periosteum Endosteum

Cortical bone – compact bone◦ Concentrated in diaphysis of long bone◦ Houses osteons (contain osteocytes)◦ 80% of skeletal mass

Cancellous bone – trabecular or spongy) ◦ 20% skeletal mass◦ Concentrated at epiphysis and

metaphysis of long bones◦ Metabolic turnover is greater than for

cortical; usually faster healing

Energy absorbed by bone

mechanical & structural failure

Loss of Continuity of Bone

vascular disruption at fracture site

soft tissue injury

Location in Bone◦Diaphyseal◦Metaphyseal◦Articular

Depth of fracture: complete, incomplete Angle: transverse, oblique, spiral, longitudinal, Complexity: simple, comminuted or crushed Closed versus Open Intra articular vs. extra articular Avulsion

Inflammatory Phase (0-2 weeks)◦ Accumulation of a hematoma between fracture ends under elevated periosteum

◦ Bone necrosis (osteocytes lose nutrition)◦ Proliferation of fibroblasts and osteoblasts◦ Invasion of leukocytes and macrophages

Hematoma organizes forming fibrin scaffold

External carilagenous callous forms from periosteum

Internal callous forms from endosteum

Gradual increase in stability toward clinical union

New bone and oteogenic cells bridge fracture site

Occurs over prolonged period of time

Process of continuous bone resorption and formation

Bone is remodeled as oteoclasts reabsorb callous

Can be influenced by stress

Primary Healing: ◦ No Callus

formation◦ Direct apposition

of bone ends with compression◦ Rigid fixation

(substitute for callus)

Secondary Healing: Callus

formation Slight

movement /micromotion

Patient’s age Complexity/Character

of fracture Systemic Disease Bone Disease/metabolic

bone disease Medications Nutritional factors,

ETOH, tobacco use

Nicotine has detrimental effects on the health of bone

Has deleterious effects on blood vessels and the transport of O2 to body cells

Decreases red blood cell function

Higher nonunion, delayed union rates

Higher rates of postop infection

Compliance

Emotional status

Other injuries: tendon, nerve, soft tissue, multiple fx’s

Joint stability

Infections

Buckle or Torus fracture (incomplete fracture) Greenstick fracture Physeal fractures

Greenstick fractures occur midshaft where bone is slower to healRequire 6 wks of cast immobilization

Pediatric Fractures

(http://davidlnelson.md/articles/Fracture_Physeal_Fx.htm)

Salter –Harris Fracture Classification system

Salter I – separation through growth plate (physis)

Salter II – injury through physis with part of metaphysis attached

Salter III – injury thru physis; longitudinal fracture thru epiphysis

Salter IV – longitudinal fx extending into metaphysis,physis,epi-physis; complete reduction necessary to restore joint surfaces

Salter V – crush injury to germinal cells of physis; premature closure of growth plate “This cast won’t slow me down!”

Angular deformities better tolerated in children, greater capacity for remodeling as bone grows

Cast/splint may need to include more proximal joints to keep cast on

StabilityMobilityFunction

Surgeon: Obtain and maintain anatomic reduction of the fracture/s

Therapist: Restore upper extremity function by achieving the best attainable ROM and strength of the shoulder, elbow, forearm, wrist, fingers, and thumb, in as pain-free and timely manner as possible

*Stability *Mobility *Function

Therapists should have understanding of:◦ Fracture stability/alignment◦ Operative procedures performed◦ Potential dysfunction at uninvolved joints◦ Appropriate timing for ROM, splinting,

strengthening◦ Balancing act between protection and applying

controlled stress for motion and strength

◦ ***Motion or stress to the bone promotes bone healing.

Edema control Pain management

Protection AROM PROM Sensory eval and desens.

Functional activities

Strengthening

Closed reduction◦ Indication - stable fracture◦ Immobilized with cast/orthosis

Advantages◦ Less chance of infection◦ No incision/scar

Complications◦ Loss of reduction◦ Edema◦ No access to skin/wounds◦ Issues with fit of cast (https://meds.queensu.ca/central/assets/mo

dules/cast-application/short_arm_cast.html)

External Fixation-provides traction to prevent fx. shortening or angulation

Indications◦ unstable fx’s

◦ fx’s requiring early motion

◦ fx’s w/ high incidence of non-union

K-wires: open vs. closed

Screws Plates Wires Intermedulary Nails Bone Grafts

Soft tissue injury

Periosteal stripping

Hardware irritation

Adhesions

Tendon Ruptures What’s wrong with the xray at 6 weeks?

Non union Malunion/Bone length

alteration Delayed union Edema Pain Stiff joint Tendon adhesions Decreased strength Nerve entrapments or

compressions Post-traumatic OA

6 P’s: Pain, paresthesia, pallor, paralysis, pulselessness, pressure

Radial Inclination = 21-25°x=22 Palmar Tilt = 11-12°Radial Height = 10-13mm All components are important for a stable & pain-free wrist capable of accepting forces 35

Ulnar head articulates with radius at sigmoid notch

Separated from proximal row by TFCC

Radius rotates around fixed ulna

(http://www.markgardnergibson.com/projects/robotarm/forearm/index.shtml)

Reduction in distal radius length alters the force distribution through the radius and the ulna to the proximal row.◦ Normal 80% radius and 20% ulna◦ The ulnar side of wrist is not intended to be the

primary weight-bearing joint ◦ Positive ulnar variance has a greater chance of TFCC

injuries ◦ Ulnar sided wrist pain

Ulnar variance = length of ulna relative to radius◦ Neutral◦ Ulnar plus (ulna is

longer)◦ Ulnar negative (ulna is

shorter) Before diagnosing,

compare to other wrist

Ryu (1991): 40 flex and ext, 40 combined RD/UD

Brumfield (1983): 10 flex, 35 ext Palmer: 5 flex, 30 ext, 10 RD, 15 UD Gartland and Werley: 45 ext, 30 flex, 50

sup/pro Gates et al. (2016): 38 flex, 40 ext, 28 RD,

38 UD, 13 pron, 53 supMoral of story- Functional ROM is not full/normal ROM

Colles◦ Extra-articular◦ Complete fx. of distal

radius w/ dorsal displacement◦ 80% require reduction

Colles fractures often do not stay reduced and need surgery to maintain alignment.

Smith’s: ◦ Reverse Colles

fracture◦ Distal radius with

volar displacement Barton’s: ◦ Distal radius

fracture with dislocation of radial carpal joint.◦ Rim of distal radius

fracture with volar or dorsal displacement

Oblique fx of distal radius involving radial styloid

Intra-articular fx Generally require

surgery

Fracture stability/alignment – access x-rays as able Operative procedures performed – access op report Potential dysfunction at uninvolved joints Appropriate timing for ROM, orthoses, and

strengthening Balancing act between protection and applying

controlled stress for motion and strength◦ Motion or stress to the bone promotes bone healing

Importance of good patient history, understanding patient, and empowering through education

Orthoses for stability, protection◦ Cross-education during immobilization phase

Edema control Pain management Range of motion – shoulder to fingers Reestablish independent wrist extension Sensorimotor training Restore function Patient education – anatomy and pathology, help

patients accept responsibility for their part in the rehab process

Watch for substitution of EDC when attempting to perform wrist ext Teach patient isolated wrist extension to learn to control EDC substitution

Initiate blocking exercises early especially FPL which can be adherent

Inability to flex IP during oppostion indicates FPL adherence

Strengthening FES – mm. weakness

and retraining Dynamic splinting Work

simulation/hardening Activity Modification

Stiffness, swelling, pain Malunion/radial shortening DRUJ dysfunction RSD/CRPS Median nerve compression Radiocarpal arthritis Weakness Carpal instability Shoulder stiffness

Radial shortening is the most common, disabling deformity◦ Slight shortening

changes axial forces across wrist◦ > 6mm affects flexion,

UD, and pronation, and grip ◦ < 6mm affects forearm

rotation◦ Dorsal tilt >10°

decreases wrist flexion(http://www.handtoelbow.com/images/photos/large/u

lna1.jpg)

Occur 1/10th as frequently as distal radius fractures

Scaphoid: account for 60-70%

Triquetrum/Lunate: second most common- account for 20%

Others: combined account for only 7-10% of fx

90% occur from force applied with wrist in extension (FOOSH)

Vulnerable to injury ◦ position in both proximal and

distal rows

Difficult to diagnose - often made based on clinical signs◦ Pain in snuff box

Variable healing times according to fracture site

5-20+ weeks depending on level

◦ poor vascular supply Direction of fracture

affects healing-horizontal quicker than vertical

Middle 2/3 10-12 weeks

Proximal 1/3

12+ weeks

Conservative treatment: Immobilization◦ Thumb spica long arm cast then short arm cast- IP

free with wrist slight extension and radially deviated◦ Literature demonstrates that there is no difference

between LAC, SAC thumb spica and a wrist cast without the thumb included.

Surgical treatment: ORIF with bone graft Herbert screw, Russe Technique◦ Immobilize 4-16

weeks in cast or orthosis with IP free until bone union

(www.eatonhand.com/img/18412.htm)

Complications◦ Non- union SNAC wrist◦ Carpal ligament injuries Carpal instability Waist fractures often accompanied by SL ligament

injury◦ Delayed diagnosis◦ Normal anatomical alignment not restored◦ Persistent pain

AVN of the scaphoid Etiology is unknown Can cause carpal instability if untreated

AVN of lunate Associated with negative

ulnar variance Varying degrees of

disability – central wrist pain, limited extension, weak grip

Point tenderness over dorsal aspect of lunate

Immobilization leveling and/or vascularization procedures salvage procedures

Non- union Carpal ligament

injuries◦ Carpal instability

Delayed diagnosis Normal anatomical

alignment not restored

Persistent pain SLAC wrist

SLAC WristS scaphoidL lunateA advanced C collapse

Triquetrum: 2nd most common. FOOSH Lunate: Can result in avascular necrosis

(Kienbocks disease) Trapezium: often associated with

fractures/dislocations involving thumb Pisiform/Hamate: trauma over ulnar/volar

wrist, proximal hypothenar eminence Capitate: rare because this carpal is in a

centrally located and protected position Trapezoid: rare; crush or high energy impact

EDEMA CONTROL Splinting for stability and

protection Motion Modalities Pain management-watch for

increased sympathetic reaction, TENS

Function

Focus on wrist and thumb ROM, and composite flexion

May require protective splint between exercise post cast removal

Functional ADL’s encouraged

Static progressive or dynamic splinting for wrist flexion and extension or composite motion

Grip strengthening Wrist strengthening within pain free range Work hardening depending on RTW status

Quick healing Occur more commonly

in the border digits Degree of angular

deformity accepted varies for each ray

Complications of angulation are extensor lag and decreased grip strength

Multiple fractures Open fractures Comminuted fractures Displaced fractures Malrotation Multitrauma◦ i.e. head injury

Spiral fractures◦ Tend to be unstable

Oblique fractures◦ Tend to shorten

(http://doctorlib.info/surgery/plastic/75.html)

Most common fracture site as is weakest portion

Caused by compressive force- (i.e. blow with closed fist)

Boxer’s Fracture in 4th or 5th

metacarpal Angulation (rotation

deformity) can cause pain in palm, claw deformity, trapping of digits)

Can protrude into palm

If including the MP’s in the orthosis, the MP’s need to be immobilized in flexion to keep the collateral ligaments lengthened

Goal is to achieve alignment without rotation or shortening

Shortening of 3-5 mm can produce intrinsic/extrinsic imbalance

Malrotation= finger overlap

Angulation tolerated better in 4/5th MC

(Cindy Glaenzer PT, CHT)

Some degree of angular deformity is acceptable

Rotatory deformityie: fingers overlapping(scissoring) is not acceptable

This check is used for phalangeal fractures also

MP’s need to be immobilized in flexion to maintain collateral ligament length

Goal is to achieve alignment without rotation or shortening

Shortening of 3-5 mm can produce imbalance intrinsic/extrinsic

Malrotation= finger overlap

Angulation tolerated better in 4/5th MC

MC fx’s can result in soft tissue damage

Often excessive dorsal edema

Common because less soft tissue between extensors and MC’s

Result in MCP extension lags and extrinsic extensor tendon tightness

Treatment: isolated EDC exercises, scar massage, FES, combined wrist/finger flexion, other modalities

RME orthosis to support MP ext while allowing ROM

MP joint contractures can occur following metacarpal head and neck fractures

Proper positioning in splint crucial, at least 60⁰ MP flexion; if unable to obtain correct position readjust in a few days

“Hand Fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment”

Alfred Swanson

Type varies◦ Oblique, transverse,

spiral

Spiral/oblique tend to be unstable

Often cause soft tissue adherence

Comminution = more soft tissue damage

Reduction and immobilization

Remember that the Extensor tendons and FDS/FDP are in close proximity to the proximal phalanx tendon adhesions easily develop

Surgery:◦ Percutaneous Pins◦ Screws◦ Plates

Can start motion earlier due to stability of fixation

Addition of scar management

Soft tissue involvement

PIP flexion contracture Limited active PIP

extension Tendon adherence at fx

site

Edema control Splinting

Hand based Buddy taping

Motion: AROM AAROM

Once Healed PROM/dynamic splinting Functional activities Strengthening

Account for 50% finger fractures

Thumb/middle most commonly injured

Crush common mechanism of injury

Classified by location

Heal w/out excessive treatment

Crush/ comminuted fx of fingertip

Painful-hematoma

Soft tissue injury Rehab:◦ Restore DIP motion◦ Desensitization◦ Protective splinting

to DIP

Extensor tendon avulsion fx or dorsal intra-articular fx

“Flexion drop” deformity

Tx: Mallet splint◦ Slight hyperextension

A/PROM to MP/PIP

Splinting in extension for 6-8 weeks is standard. Once healed/stable may begin DIP flex

Continue splint use between exercise and at night

Watch for extensor lag with exercise (resume splint use if lag increases)

Resume motion and normal activities.

Numbness Hypersensitivity or

tenderness Cold intolerance Limited DIP ROM Nail abnormalities

Follows similar guidelines as for digits

Special considerations: ◦ Thumb joints can lose

motion faster than in fingers◦ Motion at basal joint

helps when MP joint motion is lost◦ Prevent 1st webspace

contracture

Bennett Fracture: ◦ Most frequent◦ Fracture dislocation at CMC◦ Oblique intra-articular metacarpal fx

Rolando Fracture:3 part intra-articular fracture at base of metacarpal

“A specialist knows the worst mistakes which can be made in his field and how best to avoid them”

- Nils Bohr

Cannon N: Rehabilitation Approaches for Distal and Middle Phalanx Fractures of the Hand. Journal of Hand Therapy 2003; 16(2): 105-116

Seu,M, Pasqualette,M :Hand Therapy for Dysfunction of the Intrinsic Muscles:, Hand Clin 28 (2012) 87–100

Kollitz M, Hammert WC et al: Metacarpal fractures: treatment and complications HAND (2014) 9:16–23

Sammer DM, Husain T, Ramirez R:Selection of Appropriate Treatment Options for Hand Fractures, Hand Clin 29 (2013) 501–505

Neumeister M et al: Non-surgical Management of Metacarpal Fractures Clin Plastic Surg 41 2014 p451-461

Suh N et al: Carpal Fractures J Hand Surg Am 2014, 39 (4) 785-791 Lalonde D et al: Pain Guided Hand Therapy for Hand Fractures: the Saint John

Protocol: contact Amanda Higgins at grashay@nb.sympatico.ca for a digital copy of the protocol.

Feehan, L, Early Controlled Mobilization of Potentially Unstable Extra-articular Hand Fractures. Journal of Hand Therapy 2003; 16(2): 161-170

Slade,J, MD, et al, (eds), Hand Clinics: Scaphoid Fractures, Volume 17, No. 4, November 2001

Berger,R et al, (eds), Hand Clinics: External Fixation, Philadelphia, WB Saunders, Volume 9, No. 4, November 1993

Freeland A, Lindley, S, (eds), Hand Clinics: Hand Fractures and Dislocations, Philadelphia, WB Saunders, Volume 22, No. 3, August 2006.

Fischgrund, J, (ed), Orthopaedic Knowledge Update, Chapter 2, Fracture Repair and Bone Grafting, AAOS, 2008, pgs 13-19.

LaStayo, P, Winters, K, et al, Fracture Healing: Bone Healing, Fracture Management, and Current Concepts Related to the hand. Journal of Hand Therapy 2003; 16(2): 81-92

Altman, E. (2016). The ulnar side of the wrist: Clinically relevant anatomy and biomechanics. Journal of Hand Therapy, 29, 111-122.

Bain, G. I., MacLean, S. B., Yeo, C. J., Perilli, E., & Lichtman, D. M. (2016). The etiology and pathogenesis of Kienböck disease. Journal of Wrist Surgery, 5, 248-254.

Brogan, D. M., Richard, M. J., Ruch, D., & Kakar, S. (2015). Management of severely comminuted distal radius fractures. Journal of Hand Surgery, 40A, 1905-1914.

Capo, J. T., Rossy, W., Henry, P., Maurer, R. J., Naidu, S., & Chen, L. (2009). External fixation of distal radius fractures: Effect of distraction and duration. Journal of Hand Surgery, 34A, 1605-1611.

Carlson, M. G. (Ed.). (2012). Elite athlete’s hand and wrist injury [Special issue]. Hand Clinics, 28(3).

Chung, K. C. (Ed.). (2012). Current concepts in the treatment of distal radius fractures [Special issue]. Hand Clinics, 28(2).

Dell, P. C., Dell, R. B., & Griggs, R. (2011). Management of carpal fractures and dislocations. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 988-1001). Philadelphia, PA: Mosby.

Jørgsholm, P., Thomsen, N. O., Björkman, A., Besjakov, J., & Abrahamsson, S. (2010). The incidence of intrinsic and extrinsic ligament injuries in scaphoid wrist fractures. Journal of Hand Surgery, 35A, 368–374.

Karagiannopoulos, C., & Michlovitz, S. (2016). Rehabilitation strategies for wrist sensorimotor control impairments: From theory to practice. Journal of Hand Therapy, 29, 154-165.

Kim, J. K., Kim, D. J., & Yun, Y. (2016). Natural history and factors associated with ulnar-sided wrist pain in distal radial fractures treated by plate fixation. Journal of Hand Surgery, 41E, 727-731.

Lawton, J. N. (Ed.). (2013). Management of hand fractures [Special issue]. Hand Clinics, 29(4). Lenoir, H., Coulet, B., Lazerges, C., Mares, O., Croutzet, P., & Chammas, M. (2012). Idiopathic

avascular necrosis of the scaphoid: 10 new cases and a review of the literature. Indications for Preiser’s disease. Orthopaedics & Traumatology: Surgery & Research, 98, 390-397

Magnus, C. R., Arnold, C. M., Johnston, G., Dal-Bello Haas, V., Basran, J., Krentz, J. R., & Farthing, J. P. (2013). Cross-education for improving strength and mobility after distal radius fractures: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94, 1247-1255.

Malick, A., & Prem, H. (2017). Physeal injuries in children. Surgery, 35, 10-17. Mathews, A. L., & Chung, K. C. (2015). Management of complications of distal radius fractures.

Hand Clinics, 31, 205-215. Means, K. R., Saunders, R. J., & Graham, T. J. (2011). Pathophysiology and surgical

management of the stiff hand. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 885-893). Philadelphia, PA: Mosby.

Medoff, R. J. (2010). Essential radiographic evaluation for distal radius fractures. In D. J.

Medoff, R. J. (2011). Distal radius fractures: Classification and management. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 941-948). Philadelphia, PA: Mosby.

Michlovitz, S., & Festa, L. (2011). Therapist’s management of distal radius fractures. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 28-35). Philadelphia, PA: Mosby.

Monaco, N. A., Dwyer, L., Ferikes, A. J., & Lubahn, J. D. (2016). Hand surgeon reporting of tendon rupture following distal radius volar plating. HAND, 11, 278-286.

Packham, T. L., Ball, P. D., MacDermid, J. C., Bain, J. R., & DalCin, A. (2016). A scoping review of applications and outcomes of traction orthoses for the management of intra-articular fractures and fracture dislocations in the hand. Journal of Hand Therapy, 29, 246-268.

Reichel, L. M., Bell, B. R., Michnick, S. M., & Reitman, C. A., (2012). Radial styloid fractures. Journal of Hand Surgery, 37A, 1726-1741.

Rosenthal, E. A., & Elhassan, B. T. (2011). The extensor tendons: Evaluation and surgical management. In T. M. Skirven, A. L. Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 487-520). Philadelphia, PA: Mosby.

Schwartz, D. A. (2012). Static progressive orthoses for the upper extremity: A comprehensive literature review. HAND, 7, 10-17.

Sendher, R., & Ladd, A. L. (2013). The scaphoid. Hand Clinics, 44, 107-120. Shin, E. K. (2011). Fractures: General principles of surgical management. In T. M. Skirven, A. L.

Osterman, J. M. Fedorczyk, & P. C. Amadio (Eds.), Rehabilitation of the Hand and Upper Extremity (6th ed., pp. 351-360). Philadelphia, PA: Mosby.

Strauch, R.J. (2011). Scapholunate advanced collapse and scaphoid nonunion advanced

Szekeres, M., MacDermid, J. C., Birmingham, T., Grewal, R., & Lalone, E. (2017). The effect of therapeutic whirlpool and hot packs on hand volume during rehabilitation after distal radius fracture: A blinded randomized controlled trial. HAND, 12, 265-271.

Tsang, P., Walton, D., Grewal, R., & MacDermid, J. (2017). Validation of the QuickDASH and DASH in patients with distal radius fracture through agreement analysis. Archives of Physical Medicine and Rehabilitation.

Weinstock-Zlotnick, G., Page, C., Ghomrawi, H. M., & Wolff, A. L. (2015). Responsiveness of three Patient Report Outcome (PRO) measures in patients with hand fractures: A preliminary cohort study. Journal of Hand Therapy, 28, 403-411.

Boundless. (2016). Supply of Blood and Nerves to Bone. In Boundless Anatomy and Physiology. Retrieved from https://www.boundless.com/physiology/textbooks/boundless-anatomy-and-physiology-textbook/skeletal-system-6/introduction-to-bone-71/supply-of-blood-and-nerves-to-bone-436-9154/

When designated, images are courtesy of Primal Pictures

References – Images