Histochemical and biomechanical findings show that when the limb is immobilized, fibrofatty tissue infiltrates and accumulates in the periarticular saphenous fossa, and over time, fibrosis of the fibrofatty tissue results in saphenous adhesions; histology shows that the main changes in the tissue occur in the matrix, which has a significant loss of glucosaminoglycan and water, and no loss of collagen fibers. The primary function of the matrix is hydration, binding to water and maintaining hydration; another function of the matrix is to maintain the necessary distance between fibers and to provide lubrication for fiber movement. Therefore, when water is lost from the matrix, collagen fibers move closer to each other and adhere to each other in an interwoven web, resulting in reduced tissue suppleness and expandability; newly formed collagen fibers accumulate arbitrarily in a /haystack0 fashion, adhering to already existing collagen fibers and limiting tissue movement. At this point, 10 times the normal rehabilitation may be required to restore joint motion.
After the limb is immobilized, both active and passive activities prevent the collagen fibers from building up in a /haystack0-like manner and stimulate matrix production. When the immobilized connective tissue is subjected to stress movement, the tissue rehydrates, cross-linking between collagen fibers is reduced, and newly formed collagen fibers are more orderly aligned in the direction of stress; the adhesions formed during immobilization are partially torn and the fibers are elongated.
As early as 1945, JohnMennell pointed out that any exercise or massage can only have two effects, reflex and mechanical. The purpose of postoperative rehabilitation is to promote the recovery of reflexes, reduce the degree of muscle atrophy, prevent joint adhesions and stiffness, promote swelling, and promote fracture healing. Through rehabilitation, it can promote the hydration and rehydration of connective tissue; prevent and interrupt the adhesions between collagen fibers; make the newly formed collagen fibers arrange more orderly in the direction of stress and the fibers are elongated; stop the atrophy of scar tissue; promote the blood flow of new tissues and promote cell metabolism.
Principles of post-operative fracture rehabilitation: individualized rehabilitation plan according to the patient’s degree of trauma (whether the fracture is stable or not), type of surgery, and whether internal fixation is used; must maintain good alignment of the fracture and promote fracture healing; repeated, patient, and gradual; active activities are the mainstay and passive activities are supplementary; the range of activities is from small to large, the number of activities is from small to large, and the speed of activities is from slow to fast, giving full play to the The patient’s role should be given full play.
Functional exercise should be started from the time of fixation until the fracture heals and function is restored to the maximum extent. The goal of rehabilitation treatment 1. It indirectly or directly supports the upper and lower extremities, while accommodating, supporting and protecting the internal organs and spinal cord. Therefore, the main objective in rehabilitation is to maintain the stability of the spine.
After spinal fracture surgery, it is important to know the type of fracture, whether it is accompanied by spinal cord injury, the mode of surgery and surgical approach, whether internal fixation is applied, the mode and firmness of internal fixation, and the number of fused segments and how much, before developing a rehabilitation program, because rehabilitation training will affect the stability of the spine.
The neutral position of the spine is upright, with both eyes level, jaw inward, measuring flexion, extension, left flexion, right flexion, left rotation and right rotation, etc. Anterior flexion of the cervical spine: 35b~45b; posterior extension: 30b~45b; left and right lateral flexion: about 45b; left and right rotation: 60b~80b. Anterior flexion of the lumbar spine in the standing position: the tip of the middle finger can touch the ground in a normal person, usually up to 90b; posterior extension: 30b; lateral flexion: about 30b on each side; lateral rotation: fixation of the pelvis and rotation of the spine to the left and right of about 30b. When a vertebral fracture is surgically fixed and fused, the spine The mobility of the spine will be reduced. The focus of rehabilitation training at this time is to restore the muscle strength damaged by trauma and surgery, to restore the flexibility of the spine while maintaining the stability of the spine, to restore its proprioception, and to train the patient in proper motor habits. In the rehabilitation training, it should be noted that in unstable fractures without applying firm internal fixation, as the formation of bone scabs often takes 6~8 weeks, any rehabilitation training that leads to spinal instability should be avoided during this stage; in addition, when the spine is fused, the stresses exerted by the rehabilitation training or activities often act on the adjacent segments of the spine, easily leading to degeneration of the adjacent segments of the spine.
2, the goal of upper limb rehabilitation: the main function of the upper limb is the use of the hand. The main function of the upper extremity is the use of the hand, and through the use of the hand, various complex labor and life activities are completed. Therefore, the goal of upper limb rehabilitation therapy is to restore its flexibility.
After upper limb fracture surgery, it is equally important to clarify the type of fracture, surgical method and surgical access, whether to apply internal fixation, the way of internal fixation and the degree of firmness before making a rehabilitation plan; because after upper limb fracture surgery, it often affects the movement of adjacent joints and the function of the hand. Therefore, in the treatment of bone and joint injuries of the upper limbs, except for the functional recovery of the joints belonging to the local part of the injury, all other uninjured parts should be functionally exercised during the treatment process to prevent the occurrence of functional disorders. For example, in addition to the functional exercise of the hand, patients with forearm fracture should also pay attention to the activity of the shoulder during the treatment process, which is especially important for the elderly.
The mobility of each joint of the upper limb is as follows: shoulder flexion: 70b~90b, extension: 40b, abduction: 80b~90b, adduction: 20b~40b, internal rotation: 70b~90b, external rotation: 40b~50b, shoulder supination: 160b~180b, and 360b gyration. Elbow flexion 135b~150b, hyperextension 0b~10b, anterior rotation 80b~90b, posterior rotation 80b~90b. Wrist dorsiflexion: 30b~60b, palmar flexion 50b~60b, radial deviation 25b~30b, ulnar deviation 30b~40b. Hand metacarpophalangeal joint dorsiflexion: 0b, flexion 60b~90b; proximal interphalangeal joint dorsiflexion: 0b, flexion 90b; distal interphalangeal joint dorsiflexion: 0b, flexion 90b. Dorsal extension of interphalangeal joints: 0b,flexion 60b~90b; thumb abduction: up to 40b; opposite palm.
Opposite thumb nail and ring finger nail, compared with the opposite side; medial: thumb and index finger radially tight, compared with the opposite side; flexion: palmar thumb joint flexion 20b~50b; interphalangeal joint up to 90b. When the joint function cannot be adequately restored, it is necessary to ensure its most effective and minimum range of motion, that is, to gradually expand its movable fracture centered on the functional position of each joint after surgical repositioning and fixation. It often causes different degrees of joint dysfunction and disuse muscle atrophy, and the longer the braking time, the more obvious it is. Therefore, the correct rehabilitation training has a very important impact on the functional recovery. Repeated, patient and gradual rehabilitation will help to recover the function; while inappropriate rehabilitation not only prolongs the recovery time, but also sometimes leads to fracture displacement or even re-fracture.
I. Histological and biomechanical properties of connective tissue The effects of trauma, surgery, fixation, posture and different stresses on postoperative rehabilitation of fractures are mainly produced by the effects on connective tissue. Connective tissue is widely distributed throughout the body, accounting for 25% of body weight and 16% of body water, and includes structures such as ligaments, tendons, periosteum, joint capsules, tendon membranes, superficial fascia, myofascia, and nerve sheaths.
The components of connective tissue include cells and extracellular matrix.
Among them, the most important cells are fibroblasts. Fibroblasts synthesize collagen fibers, elastic fibers, reticular fibers, and matrix. The extracellular matrix consists of fibers and matrix, with collagen fibers being the strongest of the fibers and reticulocyte fibers being more extensible. When the tissue contains more elastic fibers and less collagen fibers, the tissue is softer and more expandable. The matrix is a viscous, gel-like substance that is present in the cells and between the fibers. It maintains the necessary distance between fibers and provides lubrication for fiber movement; it is also a medium for the diffusion of nutrients and waste and acts as a mechanical barrier to invading microorganisms. Compared to collagen fibers, it has a shorter renewal cycle and is more susceptible to fixation.
According to the strength and position structure of fibers, connective tissue can be classified into three categories: dense and regular, dense and irregular, and lax and irregular.
Dense and regular connective tissues include ligaments and tendons, which are composed of strong collagen fibers arranged in a single direction, with relatively little water content and vascular distribution, and are the strongest and least expandable connective tissues in the body; they take longer to heal after trauma. The dense and irregular connective tissue includes periosteum, joint capsule, tendon membrane and other tissues; the relatively dense and regular connective tissue has multidimensional arrangement of fibers, its water content and vascular distribution are also less, nutrient diffusion is slower and healing takes longer; the loose and irregular connective tissue includes superficial fascia, muscle membrane, nerve sheath membrane and visceral structure, which is the same as the dense and irregular connective tissue, and its fiber authors Unit: Department of Orthopedics, Second Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510120, China, but it contains fewer collagen fibers and is richer in water content and vascular distribution, so it is more flexible, expandable, takes less time to heal, and is more mobile.
Connective tissue has the property of deforming with stress, thus effectively reducing the shock received by the body, which is determined by its own viscoelasticity. When the stress is withdrawn, on the one hand, the connective tissue has the elastic characteristic of returning to its own shape like a spring; on the other hand, the connective tissue has the viscous characteristic of maintaining its deformation like a piston.
Therefore, in the rehabilitation training, when the body receives a stronger force to make the joint move beyond its range of stiffness, the range of joint movement will increase; however, after a few days, the range of joint movement decreases compared with the rehabilitation, but still exceeds its range of stiffness.
The effects of trauma, surgery, fixation, and rehabilitation (re-activation) on connective tissues often lead to scar tissue after trauma and surgery. The biomechanical properties of scar tissue are different from those of normal connective tissue. Normal connective tissue is biomechanically stable, while immature scar tissue is in dynamic change and has a great variability. The formation of scar tissue is divided into four phases: the first phase is the inflammatory phase, which appears immediately after trauma; in the trauma local blood clot formation, macrophages and histiocytes gather and phagocytose to remove necrotic tissue. This phase lasts for 24~48 h. During this phase, complete braking should be applied. The second phase is the granulation phase, characterized by vascular proliferation. The granulation phase varies greatly depending on the type of tissue and the degree of trauma. Generally speaking, the formation of scar tissue after trauma is relatively long when the tissue is normal and blood flow is low. During this period, exercise will be beneficial for recovery, but there is also a risk of damaging scar tissue. The third phase is the fibrogenesis phase, in which fibroblasts proliferate and collagen fibers and matrix are formed.
Collagen fibers begin to accumulate and are connected to each other by weak hydrostatic bonds, making it easier for the tissue to be stretched and lengthened during this period. This period is the best time for rehabilitation, and scar sculpting is easy while the risk of scar tissue destruction is low. This period lasts 3-8 weeks depending on the type of tissue and blood flow. The fourth phase is the scar maturation phase, characterized by collagen maturation, sclerosis and atrophy. During this phase, collagen fiber synthesis continues and scar tissue can still be more plasticized with proper exercise; at the end of the maturation phase, tissue plasticization will be more difficult because scar tissue is more mature, less active, and less pliable. If this stage is missed, collagen fibers will intertwine with each other and tissue atrophy will be evident.
Scope.
3. The goal of lower limb rehabilitation therapy: The main function of the lower limb is weight bearing and walking. Therefore, the goal of lower extremity rehabilitation therapy is to maintain adequate stability of the joints of the lower extremity. After the surgery of lower limb fracture, according to the patient’s weight, tolerance, the type of fracture, the preoperative movement of each joint of the lower limb and the stability of internal fixation, etc., the corresponding stage rehabilitation training plan is formulated.
The walking function of the lower limbs is mainly assessed by walking ability and gait analysis. Walking ability can be evaluated according to the Hoffer classification and is divided into: unable to walk, non-functional walking (walking with orthotics or crutches in the treatment room without functional value), home-based walking (walking with orthotics or crutches at home) and community-based walking (walking outdoors with or without orthotics or crutches). Normal human gait is divided into a weight-bearing phase and a swing phase. The normal gait is driven by the foot, and the foot leaves the ground with a sharp movement, and the gait distance is basically equal. When striding, the ipsilateral pelvis swings forward and the body weight moves to the front of the hip joint. In the stride, both sides of the pelvis remain horizontal, and the lumbar spine and lumbar muscles are involved in the movement, requiring the support of strong gluteus maximus, quadriceps and calf triceps. After lower limb fracture surgery, avoid premature weight-bearing and walking, train the gluteus maximus, quadriceps and triceps early to promote the recovery of joint function and avoid joint adhesions, review the X-ray regularly, and develop an exercise plan according to the growth of bone scabs; at the same time, the whole body and local conditions should be taken into account, and the activities of other parts of the body should be paid attention to while exercising the affected limb, so as to help reduce the occurrence of complications and This will help to reduce complications and promote early recovery.
V. Rehabilitation therapy techniques and methods Rehabilitation therapy is very rich in content, including physical therapy, cultural and physical therapy, occupational therapy, speech therapy, psychotherapy, rehabilitation engineering, etc..
Among them, physiotherapy is more commonly used in physical rehabilitation.
Physiotherapy refers to the use of force, electricity, heat, cold, light and other artificial physical energy for treatment. Including exercise therapy, electrotherapy, light therapy, ultrasound therapy, traction therapy, massage therapy, etc., of which the most widely used in the rehabilitation of post-operative fractures is exercise therapy.
1, the classification and role of exercise therapy: according to the source of power can be divided into active and passive exercise; according to the form of muscle contraction can be divided into isometric exercise, isotonic exercise and isometric exercise; according to the application of apparatus is divided into unarmed exercise and apparatus exercise. Among them, active exercise can be divided into casual exercise, assisted exercise and resistance exercise according to the involvement of external force. In the postoperative rehabilitation of fracture, the rehabilitation program should be based on active activities and supplemented by passive activities; in the early postoperative period of fracture, isometric exercises should be performed first. According to the different stages after fracture surgery, different methods should be applied to carry out joint activities, loosen joints, stretch soft tissues and improve muscle strength.
The role of exercise therapy is mainly manifested as.
(1) Maintain and improve the function of motor organs and promote fracture healing; moderate exercise can not only promote local and systemic blood circulation, provide adequate blood supply to the fracture end, but also enhance muscle strength and endurance; at the same time, through muscle contraction, with the help of fixation to maintain good contact with the fracture end, and make the fracture end produce longitudinal extrusion, as well as stabilize the position of the fracture after reset, and promote fracture healing.
(2) Promote the recovery of nerve reflexes and improve the coordination of the nervous system.
(3) Enhance cardiopulmonary function.
(4) Prevent and reduce the occurrence of complications. Exercise can prevent urinary system and lung infections caused by long-term bed rest after fracture surgery, prevent venous thrombosis, and prevent the early appearance of postoperative osteoporosis, etc.
2. Rehabilitation procedures after fracture surgery.
Phase I: Around the 3rd day after fracture surgery (fixation), the post-traumatic inflammatory reaction starts to subside and the swelling and pain is reduced.
(1) Elevate the affected limb and passively move the joint that is not fixed.
(2) Active movement of the muscles in the fixed limb and isometric contraction exercises can be started after 3 days.
(3) For stable fractures with strong internal fixation, movement of the joint at both ends of the fracture can be started after the pain of the surgical trauma is relieved, with a range of movement from small to large.
(4) For stable fractures close to the joint, perform continuous passive functional exercise (CPM) at an early stage.
(5) Timely and reasonable application of physical therapy, such as ultrasound, low and medium frequency electrical stimulation device, etc., to improve blood circulation, reduce pain, and reduce adhesions.
Phase II: 4~12 weeks after surgery, when the fracture is gradually healing and bone scabs are formed.
(1) Gradually carry out muscle strength exercise of the affected limb, perform power-assisted exercise and resistance exercise.
(2) Patients with unstable fractures start active and auxiliary functional exercises from the 4th week, which can prevent muscle atrophy and promote the recovery of muscle strength around the fracture.
(3) Active and passive activities of the affected joint in all axes, such as exercising the metacarpophalangeal joint and forearm muscles with a grip strength device; exercising the hip flexors by sitting up in the horizontal position or straight leg raising; knee joint loosening can be performed for those with quadriceps contracture and knee stiffness due to prolonged braking, and if necessary, a one-time tear of the scar tissue can be performed under anesthesia to loosen the adhesions (must be performed after the fracture heals).
(4) Six to eight weeks after surgery, before discharge, the patient should be taught to walk with proper crutches, to choose a suitable crutch, and to practice walking in a supported position using both crutches and the healthy limb as well as walking with the affected limb in a non-weight-bearing or partially weight-bearing (20 kg) state.
Stage 3: The fracture has healed.
(1) Exercise the joint through oscillation exercises, axial movements of the affected joint, and movement of the joint by the action of gravity of the limb and the synergistic action of muscle power.
(2) Strengthening muscle strength and restoring muscle function through resistance exercises.
(3) Move the joint with the help of a healthy limb, self-help exercises with equipment or functional traction of the joint.