I. Definition, causes and common classification of fractures.
Interruption or loss of bone integrity or continuity is called a fracture, which includes both obvious cortical bone breaks and interruption of bone trabeculae, i.e. microfractures. Fractures most commonly develop in the extremities, and extremity fractures are most often caused by violence, such as car accidents, falls, or blunt force trauma. If there are pathological changes in the extremity such as bone cysts or bone tumors, the fracture can occur under the action of a slight external force, which we call pathological fracture. If the fracture is connected to the outside world, it is an open fracture.
Clinical manifestations and radiological examination of extremity fractures.
The most characteristic clinical manifestations of limb fracture are its local changes, i.e., swelling, pain, dysfunction of the injured area and the exclusive signs of fracture, i.e., deformity of the injured limb, abnormal activity, bone rubbing sound and bone rubbing sensation. The most neglected aspect of the fracture is its systemic manifestations, i.e., shock and temperature changes. In fact, these two are very important in the management of fractures, for example, multiple fractures or pelvic fractures are prone to hemorrhage or shock due to concurrent visceral injury, which can often lead to death if not detected and treated in time. X-rays are the most visual representation of the fracture site and the fracture end fragmentation and displacement, and are very important to determine the treatment and to observe the efficacy before and after the treatment. However, it is difficult to see the separation of intra-articular fractures and microfractures of cancellous bone in the epiphysis with ordinary X-rays, so it is necessary to perform CT 3D reconstruction or even MRI.
III. Treatment principles and objectives of extremity fractures.
The principles of treatment for extremity fractures are repositioning, fixation and functional exercise. The purpose is to restore good movement and weight-bearing function of the limb.
The purpose of repositioning is to restore the normal anatomy of the fracture site as much as possible, and the methods are closed manipulative repositioning and open surgical repositioning. Manual repositioning is less traumatic, but it is difficult to achieve anatomical alignment. However, under the premise of conforming to functional alignment, the limb can still recover better function through reasonable functional exercises during treatment and the remodeling function of the bone after fracture healing. Although incisional reduction is more traumatic, the reduction effect is indeed effective, and after giving strong internal fixation, the patient can perform functional exercises early, which helps the affected limb to obtain the maximum functional recovery.
2. Fixation is to provide a stable healing environment for the fracture site and to maintain the results of the repositioning. The main methods of fixation are external fixation and internal fixation. External fixation is commonly used for small splint fixation, plaster fixation, and external fixation frame fixation. If there is no other special treatment, after external fixation, the patient can often go home to recuperate, but then must pay attention to observe the peripheral blood flow and sensory movement of the affected limb, if the fingers or toes continue to swell and pain, numbness, blue color, or peripheral joint movement disorders, then must quickly go to the hospital for appropriate examination, as well as early detection of possible osteofascial compartment syndrome and nerve injury, and make the appropriate treatment. Internal fixation is commonly used with plates, screws, wires, and intramedullary pins, etc. For fractures with defects, it is often necessary to give autologous or allogeneic bone grafts, which can help the fracture heal.
3. Functional exercise is to avoid a series of complications such as joint adhesions and muscle contractures caused by long-term fixation, especially external fixation, so that the function of the limb can be well recovered. Modern fracture therapy places great emphasis on functional exercise, which can not only avoid the above-mentioned side effects of fixation, but also promote the swelling of fracture in the acute phase and promote the healing of fracture. In addition, fracture healing takes a long time, and patients cannot wait until they are discharged from the hospital after healing. Therefore, it is very important for patients and their families to understand and apply functional exercises for limb fractures correctly to obtain the best functional recovery.
According to the pathology and healing process of fracture, functional exercise is usually performed in three phases.
1.Early functional exercise
Within 3 weeks after injury or surgery, the pathological manifestations of the fracture site are mainly soft tissue swelling and muscle spasm caused by pain, and the fracture is not yet stable. Therefore, the methods of functional exercise are mainly as follows
A. Elevate the affected limb to eliminate swelling. The distal end of the limb should be higher than the proximal end and the proximal end should be higher than the heart.
B. Active exercises for the joints at the end of the limb, such as moving the fingers of the upper limb or the toes of the lower limb, and isometric contraction exercises for the muscles of the affected limb, the so-called isometric contraction is to consciously tense the muscles without moving the joints for a certain period of time and then relax, the exercises are static exercises, which usually do not lead to fracture displacement, and can be performed several times a day, 15-20 minutes each time, doing 100 about 100 contractions.
The above two exercises are very important in early rehabilitation, they can promote venous and lymphatic return of the limb, reduce the adhesions between muscles, eliminate swelling and slow down muscle atrophy, promote close contact of the fracture ends, overcome the tendency of separation, and facilitate healing.
If the patient is comatose or has combined nerve injury, active exercise is not possible, gentle passive activities can be performed on the unstiffened joints, which can prevent muscle adhesions, joint contractures and deformities. If the upper tibiofibular fracture is combined with a common peroneal nerve injury, the ankle joint can be moved passively; this passive activity should be done in small amounts each day, but each individual movement must reach maximum amplitude.
If the fracture involves the articular surface and combined with articular cartilage injury, the affected limb can be placed on a continuous passive motion (CPM) machine in the early postoperative period to perform limited and regular continuous passive joint exercises, which have been shown in many studies to promote articular cartilage regeneration and repair and reduce the occurrence of traumatic arthritis.
Early functional exercise can be performed when the soft tissues inside and outside the joint have not yet formed adhesions or adhesions have not yet been completely muscled, which can restore the function of the joint and limb to the greatest extent and has the most ideal effect. . Try to avoid activities that are not conducive to fracture healing, such as activities consistent with the original displacement, activities that can cause shear, angular and torsional stresses between bone ends.
2.Mid-term functional exercise
From 3 weeks after injury or surgery to the clinical healing of the fracture, the pathology at this time is characterized by healed soft tissue wounds but possible adhesions, obvious atrophy of limb muscles, weakened strength but not yet contracture, and fibrous connection or bone scab formation at the fracture end. The purpose of exercise in this period is to restore muscle strength and move the joint. The exercise methods are mainly as follows
A. Pain-free principle: Because pain is a warning signal to cause or aggravate the injury, and the pain reflex can also cause inhibition of the anterior horn cells of the spinal cord, which prevents muscle contraction and makes the exercise ineffective. Theoretically pain should be avoided as much as possible, but in the actual process, many patients are often reluctant to carry out functional exercise because of the fear of pain, or only low-intensity exercise, affecting the effect of exercise, so it is recommended that patients just appear pain as an indicator of maximum exercise intensity.
B. Fatigue principle: according to the law of muscle fatigue and overload recovery, no obvious fatigue will not appear obvious overload recovery, so each muscle exercise should cause a certain amount of muscle fatigue. However, excessive exercise can cause acute muscle strain and should be avoided. How to master the best amount of exercise, it is currently believed that the most valuable or the patient’s self-perception, there is an overload recovery, the patient should feel the complete elimination of fatigue, muscle strength, a higher motivation to train again.
C, the principle of confidence: the effect of muscle strength exercise is closely related to the patient’s subjective degree of effort, the patient should fully understand the role and significance of exercise before exercise, to eliminate doubts. The stronger the confidence in functional exercise, the better the effect.
Exercise of joint mobility: the basic principle is to gradually stretch the contracted and adherent tissues instead of tearing them, so the magnitude and intensity of exercise should also follow the three principles of muscle exercise, the basic methods are.
A, active exercise joint mobility, the action should be smooth and slow, as far as possible to reach the maximum amplitude, force is also to feel just cause pain as degree. Multi-axis joint exercise to the main functional direction, taking into account the other directions of exercise, such as the hip joint to flexion and extension exercise, should also be carried out induction, abduction and internal and external rotation of the exercise. Repeat each movement 20-30 times, 2-4 times a day.
B. Passive exercise of self-controlled joints, mainly using the gravity of the body or limb, passive exercise of a joint, such as knee flexion disorder, the patient can stand on the head of the bed, holding the bed rail, with their own weight down, passive flexion of the knee joint. Patients can exercise 1-2 hours each day in the morning and afternoon. The strength and degree of passive knee flexion is controlled by the patient, which is safer than continuous passive motion (CPM) and other people’s manipulation to move the contracted joint.
C. Assisted movement exercise, which is done by the bare hands of the healthy limb or by means of sticks, ropes and pulley devices to help the affected limb to move, which has the advantages of both active and passive movement.
D, joint functional traction, the use of a certain period of sustained gravity traction, can better stretch the contracture and adhesion of the fiber tissue, the method and the above three methods in conjunction can play a good rehabilitation effect on some more serious contracture deformity.
3.Late stage functional exercise
At this stage, the fracture has reached clinical healing and removal of external fixation, the main pathological changes are residual intra-articular and extra-articular soft tissue adhesions, muscle atrophy and contracture. The purpose of rehabilitation is to enhance muscle strength, overcome contracture, and maximize joint movement. The methods of exercise are mainly as follows
A, the method of continuous medium-term functional exercise, the intensity and time of exercise can be increased accordingly.
B. Whole-body outdoor aerobic exercise can help improve the patient’s heart, lung and metabolic functions, as well as the patient’s psychological state, and improve the effect of local muscle strength and joint mobility exercises.
IV. Judgment of clinical healing of fracture.
The following five points are usually used as the criteria for clinical healing of fractures
1. No local pressure pain and axial percussion pain.
2. No local abnormal activity.
3. The fracture line is blurred on X-ray and there is continuous bone scab through the fracture line.
4.There is some recovery of limb function, the upper limb can lift 1KG weight forward flatly for one minute, and the lower limb can walk flatly for three minutes continuously without supporting crutches, not less than 30 steps.
5.No deformation at the fracture site for 2 weeks of continuous observation.