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172

ActITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Figure 3-2. Techniques of if/temal fixatiofl. A Plate af/d six screws for transverse or short oblique fracture. B. Screws for [ollg oblique or spiral fracture.

c. Screws for long butterfly fragment. D. Plate and screws for short butterfly

fragment. E. Medullary nail for segmental fracture. (\Vith permission from

PC Beare, JL Myers [eds[. Adult Health Nursing [3rd edt. St. Louis: Mosby,

1 998; 1243.)

when closed methods cannot maintain adequate fixation throughout

the healing phase. Immobilization of the fracture is required to maintain reduction and viability of the fracture site. Immobilization is accomplished through noninvasive (casts or splints) or invasive

(screws, plates, rods, pins, and external fixators) techniques. Regardless of the method of immobilization, the goal is to promote bone healing.

Bone healing occurs in four stages: (1) hematoma formation within

72 hours, (2) fibrocartilage formation in 3 days to 2 weeks, (3) procallus formation in 3-10 days, and (4) remodeling or permanent callus formation in 3-10 weeks.S I,O Table 3-4 lists the multitude of factors that contribute to the proper or improper healing of bone and

affect the time frames for healing.

Complicatio/IS of Fracture

Complications of fracrure may be immediate (within days), delayed

(weeks to months), or late (months to years). The immediate or early

MUSCULOSKELETAL SYSTEM 173

Table 3-4. Contributing Factors of Bone Healing

Favorable

Unfavorable

Early mobilization

Presence of disease, such as diabetes,

Early weight bearing

anemia, neuropathy, or malig

Maintenance of fracture reduction

nancy

Younger age

Vitamin deficiency

Good nutrition

Osteoporosis

Distal or proximal shaft fracture

Infection

Minimal soft tissue damage

Irradiated bone

Patient compliance

Severe soft tissue damage

Presence of growth hormone

Distraction of fracture fragments

Severe comminution

Bone loss

Multiple fracture fragments

Disruption of vascular supply to bone

Avascular necrosis

Corticosteroid use

Sources: Adapted from CA Christian. General Principles of Fracture Treatmem. In ST

Canale (ed), Campbell's Operative Onhopaedics, Vol. 3 (9th ed). St. Louis: Mosby,

1998;1999;JM Black. Nursing Care of Clients with Musculoskeletal Trauma or Overuse.

In JM Black, E Marassarian·Jacobs (005), Medical·Surgical Nursing Clinical Management

for Continuity of Care (5th ed). Philadelphia: Saunders, 1997;2134; and data from LN

McKinnis. Fundamentals of Orthopedic Radiology. Philadelphia: FA Davis, 1997.

medical-surgical complications of special interest in the acute care setting inciudelO

• Loss of fixation or reduction

• Deep vein thrombosis, pulmonary or fat emboli

• Nerve damage, such as paresthesia or paralysis

• Arterial damage, such as blood vessel laceration

• Comparrment syndrome

• Incisional infection

• Shock

174 AClITE CARE HANDBOOK FOR I)HYSICAL THERAPISTS

Delayed and late complications include'o

• Loss of fixation or reduction

•

Delayed IInion (fracture fails ro unite in a normal time frame in

the presence of unfavorable healing factors)

•

NOllullioll (failure of fracture to unite)

•

Malunion (fracture healed with an angular or rotary deformity)

•

Pseudarthrosis (formation of a false joint at the fracture site)

•

Post-traumatic arthritis

•

Osteomyelitis

•

Myositis ossi{icalls (heterotropic bone in muscle)

• AVN

Frachtre Managemellf According fo Body Regioll

Pelvis and Lower Extremity

Pelvic Ring Fracture

Pelvic fracture stability is defined by the degree of pelvic ring disruption. The pelvic ring is formed by the paired coxal bones, sacrum, sacroiliac joints, and symphysis pubis. UlIslable pelvic fractures or dislocations occur in the anterior or posterior column of the pelvis

owing to high-impact lateral or anteroposterior compression, or vertical shearing forces.) There is a disruption of the ring in two or more places, as shown in Figure 3-3.

Stable pelvic fractures, due to low-impact direct blows or falls, do

nOt involve or minimally involve the displacement of the pelvic ringJ

Stable pelvic fractures include localized iliac wing, pubic rami, or sacral

fractures. Avulsion fractures of anterior superior iliac spine, anterior

inferior iliac spine, or ischial tuberosity from strong contraction of

muscle (rypically seen in younger athletes) are considered stable pelvic

fractures7 When a pelvic fracture is described as stable, it is inherent

that further bony displacement will not occur on physiologic loading

and that invasive procedures are not needed before mobilization."

Chapter Appendix Table 3-A.l describes the fracture classification

and management of pelvic fractures. External fixation is used for stable