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1 - 1 TRAINING OF PHYSIOTHERAPISTS AND DOCTORS IN HOSPITALS PT PROTOCOL FOR PATIENTS SUFFERING FROM BONE FRACTURE 1. General information on bone fractures 1.1. Definition and causes A bone fracture can be defined as a break in a bone (the bone is "broken"). Fractures generally happen because of a trauma (a hit on the bone, a fall, a car accident), but it also can be the result of a weakened bone (the bone may become weaker because of a disease, such osteoporosis or because of repetitive stress during intensive sport activities, for example- such as stress fracture) Types of fracture Here are some of the main kinds of fracture: Comminuted fracture A fracture of many relatively small fragments Open fracture A fracture which breaks the skin Simple fracture The bone broke into two pieces; the two parts of the bone did not move Multiple fracture More than one bone is broken or the same bone is broken in different places Greenstick fracture A fracture in which the bone bent but is not completely broken Spiral fracture A fracture which runs around the axis of the bone Displaced fracture: The bone is broken into two pieces and the two parts of the bone moved Closed fracture: The bones which broke do not penetrate the skin

2 Diagnosis In general, doing an X-ray is the best way to confirm a fracture. X-rays are a form of electromagnetic radiation (like light); they are of higher energy, however, and can penetrate the body to form an image on film. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of gray depending on density (the higher is the density, the whiter they appear). The X-ray on the right shows a double fracture (multiple fracture) of the tibia and the fibula Complications The complications of a bone fracture can appear directly or can appear during the consolidation of the bone (the healing process). Direct complications The bones are the place of production of blood cells. Therefore, a fracture of a bone will generally be accompanied by internal bleeding (hemorrhage ). If there is displacement of the fractured bone, the fractured extremity of the bone may damage internal organs. This may happen, for example, with a fracture of a rib () that will pierce the lung (pneumothorax ) or a fracture of the iliac bone () that will pierce the bladder. The fractured extremities of a broken bone may also damage blood vessels or nerves (peripheral nerve injury). This may happen, for example, with a fracture of the head of the fibula that will damage the fibular nerve or with a fracture of the ulna that damages the ulnar nerve. If the fracture is located on the spine or the skull, it can lead to spinal cord or brain damage and, therefore, paralysis.

3 - 3 Late complications If the fracture was open, it can lead to infection (bone or other tissues) A fracture can have problem to heal. This phenomenon is called pseudarthrosis (the bone doesn't heal). Compartment syndrome: compartments are groups of muscles in the limbs that are covered by a tough membrane that cannot expend easily. Within those compartments, there are also nerves and blood vessels. Severe swelling on the fracture site will cause pressure on the blood vessels because the membrane cannot expend much, which would decrease the blood supply to muscles and nerves. The decreased blood supply will lead to nerve damaged and muscle death. This most often happens with fracture of the leg s bones (tibia and fibula). Note: Patients with fractures that require staying in bed for a long time (complex fractures, tractions, fracture of the spine) may develop other types of complications that are linked to the fact that they have to stay in bed. Those are called bedridden patient complications. It is, for example: muscle weakness, muscle retraction, breathing problems, blood circulation problems, digestive problems For details, see below. Note: Plaster or other types of will generally lead to muscle problems around and close to the fractured bone. Those are: muscle weakness (the muscles don t work, so they become weaker) and muscle shortness (the muscle stay for a long time in a short position and then become shorter) Medical treatment To heal properly, a fractured bone should be realigned if displaced (the realignment of a displaced fractured bone is called "reduction") and immobilized. There are different ways of reducing and immobilizing a broken bone: Methods of reduction If there is no displacement, no reduction is needed. If there is a slight displacement, the reduction can be done without chirurgical intervention (without operation). This can be done by doing traction on the bone (manual traction or using weights).

4 - 4 If the displacement is too important, surgery will be needed to reduce the fracture. In this case, the reduction is said "open reduction" (because the surgeon cuts the skin to reduce the fracture). Traction Methods of Open reduction The most common way of immobilizing a bone is using plaster or splint. If the fracture is open, external fixation might be recommended to prevent from having plaster on the wound and risk infection. External fixation involves a surgery. External fixation is done with a device that supports the bone and holds it in the correct position while it is healing. An example of external fixation is shown on the drawing below. If the fracture is complex (comminuted, spiral, multiple), internal fixation might be the only way of stabilizing the bone. Internal fixation involves a surgery. It is generally done by using metal rods, screws or plates that remain in place in the bone after the surgery. Examples of internal fixations are shown on the drawings below. Note: Unless the internal fixation causes problems, it is not necessary or desirable to remove it. Plaster and splint External fixation Internal fixation

5 Healing process Healing is the process of recovery of the integrity of an injured system, such as a fractured bone. The healing process of a fracture bone occurs in 4 different stages: 1. Right after the injury, the integrity of the broken bone is provisionally restored by a blood clot (the blood clot takes the space left by the fracture between the bone fragments). 2. During the second stage, the blood clot will be replaced by fibrocartilaginous tissue. This fibro-cartilaginous tissue is called the callus. The callus is an irregular mass of tissue (it is bigger than the broken part) and it is not yet strong bone tissue. Meanwhile, the dead bone tissue is removed. 3. The 3rd stage corresponds to the replacement of the fibrocartilaginous callus by mature bone tissue. At that stage, the bone tissue is not yet lined up with the rest of the bone. 4. The last stage is the remoulding stage. During that stage, the bone tissue is re-organized in the right direction (the bone is ordered into parallel and concentric layers that are aligned in precisely the right way). The X-rays here below show different stages of the healing process of a broken bone: The fracture is well visible Here we can see the callus in the middle of the femur The callus disappeared and has been replaced by mature bone tissue. The new bone tissue has been remoulded in order to give back the bone its original shape. The new bone tissue is still visible (whiter). In general, we consider that it takes 6 to 8 weeks for a bone to heal, but in some case a longer might be required (a vertebra needs 10 to 12 weeks to heal completely).

6 - 6 Note: The time necessary for healing is influenced by various factors, such as: The patient s age (younger people heal faster than older people) The nutrition (varied food such as milk, rice, vegetables, meat) speed up the healing process The type of (using internal or external fixation help healing faster because they don t allow any movement in the bone while a plaster doesn t always stabilize the bone very well) The blood supply (more blood means better healing. Blood supply can be increase through exercises such as PT exercises) The type of fracture (complex fractures such as comminuted or displaced or multiple fractures- take more time to heal then simple fractures) The location of the fracture (some bones need more time to heal then others) The table here below presents the average time needed for healing for the main bones of the body with a cast: Bone fractured Iliac bone Femur Patella Tibia/Fibular Ankle Humerus Ulna/radius Wrist Vertebra Time for healing 2 to 6 weeks 12 weeks 6 weeks 6 to 8 weeks 6 weeks 4 weeks 6 weeks 3 to 8 weeks 10 to 12 weeks Note: The table above is just informative. As already explained, there are so many variables that can influence the time needed for healing that it is always recommended to have the doctor green light for starting exercises such as weight-bearing and mobilization.

7 2. PT protocol for patients with bone fracture Assessment Before setting up a treatment plan for a patient with bone fracture, it is important to collect some information on the patient, on his/her history and on the complications. Beside the general information on the patient (name, age, sex ), here is a non-exhaustive list of the main pieces of information that need to be collected: (a) History of the fracture and the treatment Which bone is broken? Where? What kind of fracture was it? When and why the bone was fractured? What kind of is used? Cast? External fixation? Internal fixation? What kind of internal fixation? (b) Assessment of the complications How are the ROM? Is there any decrease of range of motion? If yes, which movements have limitations? How severe is the limitation? How is the muscle strength? Is there any muscle weakness? Which muscles are weak? How severe are the weaknesses? If the patient had surgery, how is the wound? Is there any sign of infection? 2.2. Treatment in the hospital (early rehabilitation) Early rehabilitation will take place in the hospital, starting as soon as possible after the patient has been hospitalized. The main purpose of the treatment will be to prevent complications from appearing or to treat complications that are already present. In order to do so, and according to the information collected during the assessment, the exercises here below should be done with the patient. The exercises are presented by type of fracture. Note: The timeframe given hereafter are only informative and shouldn t be considered as universal reference. Indeed, there are many variables that will influence the healing process and the possibility to start some exercises at the expected time. Before starting exercises such as weight-bearing, mobilization or strengthening, the doctor s approval should be sought. Nevertheless, the timeframe given hereafter provides the PTs with a clearer idea on when to seek for such approval.

8 - 8 Note: In the treatment plans described here below, the obvious (such as active mobilization and/or strengthening of sound limbs, prevention of other complications if the patient stays in bed, as well as stretching and/or strengthening of some muscles after and consolidation ) are not always described. The priority in those plans is given to the injured parts of the limb during the time the patient will probably stay in the hospital. It is up to the therapist to complete those plans with other exercises he/she would consider relevant according to the patient s situation and needs. (a) Shoulder fracture Passive mobilization Elbow, forearm, wrist, fingers (and sound upper limbs and lower limbs, if needed). For details, refer to passive mobilization protocol. Elbow, forearm, wrist, fingers and (and sound upper Day 1 week 3 limbs and lower limbs, if needed). For details, refer to active mobilization and strengthening protocol. Forearm and hand muscles. For details, refer to active mobilization and strengthening protocol. Massage Neck, forearm and hand. From day one on Ice pack/ice cube Use cold (ice or pack) to decrease the pain in the shoulder. Pendular exercise and relaxing See below exercise Day 2/3 week 3 Passive mobilization Shoulder in all direction as tolerated (no stretching) (abduction, flexion, external rotation +++) Mobilization passive assisted Shoulder in all direction as tolerated and possible (no stretching) (abduction, flexion, external rotation +++) Isometric contractions Deltoid, biceps, triceps Form week one Humerus head lowering exercises Teach the patient how to actively lower the head of the humerus Shoulder in all direction (no resistance) (abduction, Week 3 week 6 flexion, external rotation +++) Stretching Light stretching in all directions as tolerated (abduction, flexion, external rotation +++) Shoulder in all directions (abductors, flexors and From week 6 on external rotators +++) Stretching Shoulder in all directions (abduction, flexion, external rotation +++)

9 - 9 Here are examples of exercises that the patient can do by him/herself for the elbow fractures: Pendual exercise Relaxing exercise Passive mobilization Passive mobilization Stand. Lean forwards. Let your arm hang down. Circle your arm clockwise & anti- clockwise. Repeat 10x2 times. Stand or sit. Let your arm hand down (or the arm can be in the arm sling). Circle you shoulder clockwise and anti-clockwise. Repeat 10 times. Lying on your back. Support your operated arm with the other arm and lift it up overhead. Repeat 10 times. Lying on your back. Grasp a stick in both your hands. Lift the stick up and gently take overhead until you feel a gentle stretch in your shoulder. Repeat 10 times. Standing in front of a wall. Put you hand on the wall and climb up using your fingers. Try to reach as high as possible. Repeat 10 times. Stretching internal rotators Stretching internal rotators Lying or sitting. Put your hands behind your head, and gently stretch the elbows towards the floor/ backwards to feel a gentle stretch on the front of your shoulders. Repeat 5 times. Standing with your hand on the wall. Flex the elbow to 90 degrees & hold the elbow close to your body. Gently turn your body away until you feel a stretch at the front of the shoulder. Hold for 5 seconds. Repeat 10 times.

10 Stretching internal rotators Stretching flexors extensors abductors external rotators Lying on your back, keeping the elbow to your side. Hold a stick in your hands. Move the stick sideways, gently pushing the hand on your operated arm outwards. Repeat 10 times. Standing with your arms behind your back and grasp a stick between them. Gently lift the stick up away from your body. Repeat 10 times. Standing with your back against a wall. Keep the arm close to your side, elbow bent. Push the elbow back into the wall. Hold for 5 seconds. Repeat 10 times. Only use less than half your maximum effort. Standing side on to the wall. Push arm into the wall. Do not allow the operated arm to move. Only use less than half your maximum effort. Hold for 5 seconds. Repeat 10 times. Standing, with elbow flexed to 90 degrees, and held close to body, grasp the wrist of the affected arm with the good hand. Attempt to move the hand of the affected arm outward resisting the motion with the good hand. Keep the affected arm still. Only use less than half your maximum effort. Hold for 5 seconds. Repeat 10 times (b) Humerus fracture Day 1 week 6 ( period) Passive and passive assisted mobilization Massage From week 6 Passive mobilization (after All upper limb. Finger and wrist (and sound upper limbs and lower limbs, if needed). For details, refer to active mobilization and strengthening protocol. If cast: Light passive mobilization of shoulder joint (abduction and flexion, no rotations). If internal fixators: Passive-assisted mobilization of shoulder joint (abduction and flexion, no rotations) with good support (from the therapist) on the fracture. If possible: Passive mobilization elbow, wrist and fingers. For details, refer to passive mobilization protocol. Forearm and hand muscles. Isometric contractions of deltoid. For details, refer to active mobilization and strengthening protocol. Neck, forearm and hand. All upper limb.

11 - 11 ) Shoulder and elbow, against light resistance and good support (from the therapist) on the fracture. No resistance applied below the fracture for strengthening exercises of the shoulder. Then increase slowly the resistance, depending on needs. (c) Elbow fracture Day 1 day 10 ( period) Ice-pack / ice cube If possible, apply clod on the elbow to decrease pain. Passive, passive assisted and active mobilization Shoulder, hand. If there no fracture of the epicondyles or the trochlea, the wrist can also be mobilized. Massage Neck, forearm (not too close to the elbow) and hand. No elbow mobilization before 10 days even with internal fixation!!!! Mobilization passive assisted Elbow in flexion-extension and light pronationsupination From day 10 to week 3 and strengthening Week 3 to week 6 From week 6 on Stretching All upper limb (except elbow and forearm and except wrist if fracture of epicondyles or trochlea). Elbow in flexion-extension (+++) and pronationsupination Elbow in flexion-extension (+++) and pronationsupintaion (start with light resistance and increase progressively) Stretching with participation of the patient (active mobilization plus stretching force applied by the therapist) in flexion (+++) and extension (++).

12 - 12 (d) Forearm fracture During (1 month if internal fixation / 3 month if cast) After Passive, passive assisted and active mobilization and strengthening Shoulder, fingers. If internal fixation (after 2 weeks): wrist (flexionextension) and elbow (flexion-extension) If cast: isometric contraction wrist flexors-extensors and elbow flexors-extensors No pronation-supination!!!!! All upper limb (no resistance, then light resistance for elbow and wrist in flexion and extension). After 8 weeks: active mobilization pronation-supination forearm (no resistance then light resistance) (e) Wrist fracture During (3 to 6 weeks) After Passive, passive assisted and active mobilization and strengthening Shoulder, elbow, fingers. All upper limb (hand, elbow +++) Wrist (flexion-extension). No resistance, then light resistance

13 - 13 (g) Pelvis fracture With pelvic fractures, the time of might vary a lot depending on the stability of the fracture (which part of the iliac bone is fractured) and the type of (cast or internal fixation). During strict After strict (the patient is still immobilized, but he/she can change position) After (2 months) Massage Both lower limbs Chest therapy Refer to chest therapy protocol. and Both upper limbs. strengthening. Ankle, foot, toes. Isometric contractions (back, abdominal muscles, hip extensors and abductors, knee extensors and flexors except the muscles that have insertion on the fractured part of the iliac bone). Passive mobilization Patella. Knee if passive flexion of the hip joint is allowed. No mobilization of the pelvis!!!!!!! Passive mobilization Hip (abduction, flexion, extension +++) Hip (abduction, flexion, extension +++) Transfers Weight-bearing Gait training Isometric contractions hip extensors, abductors adnd knee extensors Learning to change position Sitting position and sitting up Lower limb muscles (hip extensors, abductors and knee extensors +++) Standing with partial weight bearing. If the fracture is located on 1 side of the pelvis, the weight bearing is first done on the sound leg. If both sides of the bone are fractured, the weight bearing should be done on the arm. First with walking aids (parallel bars, walking frame, crutches), then without.

14 - 14 (h) Hip fracture If there is no internal fixation, the treatment will look like the one for the pelvis fracture (see above). Here below is a treatment plan for the fracture of the hip joint (neck of femur, inter-trochanter line, trochanter fracture) with internal fixation. The timeframe for standing and weight bearing should be confirmed with the doctor because it will depend on the type of fixation that was used, the patient s general conditions (age, type of fracture, difficulties during surgery) and the patient s weight. Chest therapy Refer to chest therapy protocol) Upper limbs. From day 1 on Ankle and foot Isometric contraction (knee extensors, hip extensors +++ and knee flexors). From day 2/3 on Sitting Sitting in bed. From day 4 on Passive and active assisted Hip: flexion-extension and abduction-adduction mobilization No hip rotation, no leg elevation (lift up the leg with the knee in extension)!!!! Isometric contraction of hip abductors. From day 8 on Knee extensors against resistance (sitting with the legs out of the bed). From day 15 on Standing and walking Without weight-bearing (walking with movement of the lower limb and with the foot touching the ground but without weight bearing). Balance exercises in standing position without weight Balance exercises bearing. For details, refer to balance exercises protocols. Weight bearing Partial weight bearing (a few kilos only) Walking Walking with partial weight-bearing (a few kilos only) From day 21 on Hip and knee muscles, with light resistance, then increase. From day 30 on Walking Walking with two crutches Hip internal rotation From day 60 on Walking Walking without crutches Hip external rotation

15 - 15 (i) Femur (body) fracture Without internal fixators: Ankle, foot, toes. During (6 weeks) Isometric contraction knee extensors (+++), knee flexors, hip extensors and abductors. After 2/3 weeks, if possible (traction): slight flexionextension hip and knee After (week 7 and 8) Passive, passive assisted and active mobilization Standing and walking Hip and knee (see hip fracture) with good support (from the PT) on the fracture. Standing and walking without weight bearing After Standing and walking Partial weight bearing and increasing. consolidation (week 9) The whole lower limb With internal fixators: Ankle, foot, toes. During in bed (2/3 weeks) Isometric contraction knee extensors (+++), knee flexors, hip extensors and abductors. After 2/3 weeks, if possible (traction): slight flexionextension hip and knee After (week 3 to 6) Passive, passive assisted and active mobilization Standing and walking Hip and knee (see hip fracture) with good support (from the PT) on the fracture. Standing and walking without weight bearing After Standing and walking Partial weight bearing and increasing. consolidation (week 7) The whole lower limb

16 - 16 (j) Knee fracture With cast: During (6/8 weeks) After (week 7 to month 3) Hip (passive assisted if necessary), ankle, foot, toes. Isometric contraction knee extensors (+++) and strengthening Stretching Passive and passive assisted mobilization Standing and walking Hip, ankle and foot Hip, ankle and foot (if needed). Knee (flexion-extension) After Standing and walking consolidation (after 3 months) The whole lower limb Standing and walking without weight bearing (but with movement f the leg and the foot touching the ground) Partial weight bearing and increasing. With internal fixation: Hip (passive assisted if necessary), ankle, foot, toes. From day 1 Isometric contraction knee extensors (+++) Passive mobilization Knee flexion-extension. and Hip, ankle and foot strengthening After 10 days Knee flexion-extension (with help) Standing and walking Standing and walking without weight bearing (but with movement f the leg and the foot touching the ground) After Standing and walking Partial weight bearing and increasing. consolidation (after 3 months) The whole lower limb

17 - 17 (k) Leg fracture During in bed During (out of bed) (day 8 if internal fixation) Standing and walking Passive and passive assisted mobilization Standing and walking Hip (passive assisted if necessary), foot, toes. Isometric contraction knee extensors, hip extensors and hip abductors (+++) Isometric contraction ankle dorsal and planter flexors. Standing and walking without weight bearing Hip, knee extensors. Knee (flexion-extension) Standing and walking without weight bearing (but with movement f the leg and the foot touching the ground) After Standing and walking Partial weight bearing and increasing. consolidation The whole lower limb (l) Ankle fracture During (cast) After the cast has been removed Passive and passive assisted mobilization Standing and walking Hip, knee (+++), toes. Hip extensors and abductors Isometric contraction knee extensors (+++) Isometric contraction ankle dorsal and planter flexors. Ankle Ankle Standing and walking without weight bearing (but with movement f the leg and the foot touching the ground)

18 - 18 After Standing and walking Partial weight bearing and increasing. consolidation The whole lower limb 2.3. Treatment in the rehabilitation centre and in the community (long-term rehabilitation) Once they left the hospital, most of patients that suffered bone fracture (unless there are other problems secondary to the fracture peripheral or central nervous system damage, for example- or to the fact that the patient had to stay in bed) won t require long-term rehabilitation. If they do, details can be found in other protocols (according to the reason why the patient needs long-term rehabilitation).