Frature management

[twilight]

Hi,

Could you help me with tips or links to physio management of fracture. If I take for eg. shoulder fracture post 6 wks with limited ROM, wanted to know when u would start mobs or wud u do hold relax or start with active assisted movement? I know its a very generalised question, but would appreciate ur inputs. I haven't worked in MS and have lost touch with it. ...trying to relearn.....

Thanks.

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[alophysio]

Hi Twilight,

Very difficult to answer these questions. No doubt you have tried to look up textbooks and found they tell you everything

Some very general prinicples are (and these are loose off the top of my head)
1. Support the fracture - this should be done in a cast usually but sometimes neck of humerus is difficult. Jull in the 80s produced some sort of protocol i think about mobilisation of these fractures.

2. If a muscle crosses the joint, then be careful with activating it strongly - such a general statement i know but this is a general question!

3. The principles of fracture management should be in textbooks - for instance, i just looked up Clinical Sports Medicine by Brukner and Kahn and it had many different fractures listed in the index and management for them. Otherwise, i usually sit there and think up what i want to do and then chat to someone about my ideas to make sure i am not off my head!

Perhaps some case studies??

[twilight]

Thanks Alo.
Yep, I myself feel the need for case studies here, i guess i didn't convey my doubt properly either. I had referred to books like brukner and atkinson, but wanted to get some idea from clinicans who see such cases as outpatients. So here's one: ( i hope i can do justice to it !!)

A young person with a surgical neck of humerus fracture, immobilized for 6 wks, cleared by his doctor as healed, comes to physio( first treatment session).
Lets say his AROM is not more than 100 deg in flx and abd and has typical hiking of shoulder and has limitation of int and ext rotation ( I don't really remember which movmnt wud be limited most in such a fracture but presume most movements wud be). His PROM say is limited at 110 degree of flxn and abd. . I assume the shoulder muscles would be weak as well. Lets say his pain levels are less and willing to participate well with physio ( the most ideal situation . No other previous problems with shoulder or other joints and no relevant past medical history.

I wanted to know what would be the ideal treatment of choice to improve ROM here. also any other things I have to think about while assessing?

cheers

[Dapy]

I would just be brief!
once you are okay that there are no Yellow flags (SIN- severity, irritability of pain and others), I woulg go for Mulligan technique (Mobilization with movement),
passively gliding the joint (arthrokinematic) with concave-convex rule in mind, then ask for active movement from the patient.You must see improvement immediately, once you achieve 50% of AROM, Graded Maitland technique cf 3 minus and 3 could be combined .You can compliment these with others adjunct treatment.

[alophysio]

Hmmm, I am not sure i am good at these - basically i just see what it looks like during movement and get them to focus on one thing during Active Movements.

Then look at something to do with passive ROM and then get them to do one stretch (being careful not to twist the fracture!).

Then look at C/S and T/S and make sure they are all ok.

The reason i stick with one exercise and one stretch to start with is to make their home programme seem less daunting - you can't really have a whinge if you only have ONE thing to do - people will just think you are lazy. Once they are in the swing of things and see that is is beneficial, then load them up with more and replace older exercises with progressions.

The above information is good as well from dapy...

I know you were probably expecting something more insightful but i tend to pass on fracture management to my other physio - i am more interested in spinal rehab and motor control - i take the peripheral stuff as it comes but not my speciality - gotta know what you are good at! sorry - but happy to help if able...

[twilight]

Thanks Alo and Dapy. Those were both useful to me.
Alo, I agree with ur concept of not overloading the patient with exs. I very much appreciate ur efforst to answer this.

Dapy, just to clarify, when giving mobs, in this case being # NOH, what u mean is you give AP if you need to improve flexion isn't it? whatz the frequency that u give in the first session? Me having not much idea abt mulligan, if u don't mind could u explain just one technique eg.to improve flexion. Have u tried success with hold relax for this?
alo, though these questions are directed to dapy, ur comments are most welcome.

ta