FRACTURE

FRACTUREMIDSHAFT OF FEMURINTRODUCTIONA # may be a complete break in the continuity of a bone or it may be an incomplete break or crack.SIGNS & SYMPTOMS- The most common signs & symptoms are :Pain around the injured area. Swelling around the injured area.Loss of function around the injured area.Bruising around the injured area.Deformity of the limb.CLASSIFICATIONOpen / compound #.when there is a wound of the skin surface leading down to the site of #.when a direct communication exists between the body surface & the fractured bone endsClosed / simple #.when there is no communication between the site of # & the exterior of the body.is free from that risk.PATTERNS OF FRACTURE

DR MANAGEMENTConservative managementClose manipulative reduction (CMR)followed by POPTractionskin tractionskeletal tractionSurgical managementDynamic hip screw (DHS)K-Nail/intramedullary nail (IMN)Interlocking nail (ILN)Screw & plate

PT MANAGEMENTActive free exs / mechanical resisted / manual resisted exs.Static gluteus.Static quads of the immobilized limb.Active free exs / manual resisted exs for non immobilized joints of the affected limb.breathing exercise & coughing.Isometric muscle contraction for the immobilized limb.Teach crutch walking & maneuvering up & down steps curbs & slopes.

Swelling : Massage, exercise & elevation.Exercise : Assisted active to free active exercise.Ensure full support at the # site.Ambulation : PWB/NWB ambulation depends on the type of surgery.

CASE STUDYPATIENTS PARTICULAR :Unit : OrthopedicName : Ms. NAge : 14 years oldSex : FemaleNo R/N : D.O.Admitted : 13th Mac 2015 D.O.Ass : 18th Mac 2015Diagnosis : Closed # Rt. midshaft femur.Doc. Management :Post K-nail done on 17/3/15 for Rt femur.

SUBJECTIVE ASSESSMENTpt c/o : pain over anterior aspect of Rt thigh.

Pain VAS : 6/10 (rest)

Pain nature : deep aching

Pain area : anterior aspect of Rt. Thigh (refer to body chart)

Aggravating : movement of the Rt. Thigh (VAS 8/10)

Ease : rest (VAS 6/10) , took about 5 minutes for pain to reduce

24 hour behaviour:Am Pm Night

Irritability : medium

On movement / activityPresent Hx:admitted in ward on 13/3/15 due to alleged MVA (MB vs Car) at 6.00pm on 13/3/15.

Past Hx:Nil

PMHx/PSHx :NilMedication :NilFamily history : NIL

Social Hx :Form 2 students.non smoker & non alcoholicstay with parents.single storey house.toilet : sitting

Ix/MRI/x-ray :x-ray : on 13/3/15 :closed # midshaft Rt. FemurOn 17/3/15 :Post K-nail Rt. femurOBJECTIVE ASSESSMENTGeneral observation :pt on POD 1Malay woman, middle body size, 16 yrs oldpt lying on his bedpt alert & co-operativeabrasion wound at lat. aspect of Lt arm.Local observation :no muscle wastingswelling at Rt. thigh & calf muscle.Redness at operation site of Rt. thigh

Palpation :slightly in local temperature at operation site.tenderness around the operation site.Measurement ROM :generally both UL : AFROMgenerally Lt. LL : AFROMfor Rt. LL ( in supine lying position)

ActivePassiveHip flex w kn. bending-Hip abductionunable to-Hip adduction do d/t pain-Knee flexion -Knee extension-Ankle plantarflexionFROM-Ankle dorsiflexionFROM-Muscle power : (in sup. lying pos.)

LeftRightIliopsoasGluteal mediusunableAdductor muscleto doHamstring 5/5d/t painQuadricepsTibialis anterior3/5GastrocnemiusLimb girth/muscle bulk : (in cm)

From sup border of patellaLeftRightDiff- Vastus medialis (5cm)46.550.53.5- Quadricep( 10cm)50.554.54.0- Hamstring (15cm)55.560.04.5Rt > Lt swelling

From head of fibulaLeftRightDiffCalf muscle (10cm)39.540.00.5Rt > Lt swellingLeg length : (in cm)

LeftRightDiffTRUE LIMB LENGTH- ASIS to med. malleolus93921APPARENT LIMB LENGTH- Umbilicus to med. malleolus100991 NormalANALYSISProblem listing :pain due to # & operation.swelling LL due to inflammation.limited ROM of hip & knee joint due to pain.muscle weakness due to pain.

Short term goals :to maintain clear airway.to reduce swelling.to increase ROM at affected side ( hip & knee joint)to maintain ROM at unaffected side (Lt. LL) & both ULto improve muscle strength of Rt. LLto encourage pt. ambulation.Long term goals :to regain functional ability ADL.

PLAN OF TREATMENTDeep breathing exercise.Active free exercise.Stretching exercise.Strengthening exercise.Circulatory exerciseAmbulate pt.Intervention : 1) Deep breathing exercise.- pt in lying position.- do 5x/hrly/day2) Incentive spirometer-sit up in bed-10x/hourly3) Active free exercise for both UL & Lt. LL.- pt. in lying position.- for UL sh.flex through elevation, sh.abd. & add., elb.flex & ext, hand grip.- for Lt LL hip & knee flex, SLR, hip abd & add.- do 5x/hrly/day

4) Circulatory exercise for both feet.- pt in lying position.- do ank.dorsiflex & plantarflex actively & movement of toes.-10 rep/3 set/hourly/day

5) Static quads exercise(SQE) for Lt. knee.- pt in lying position.- ask pt to press down knee & hold 10 sec.- do hold 10 sec./5x/hrly/day.6) Encourage pt to do DBE, active free exercise for both UL & Lt. LL, circulatory exercise, SQE.* do every exercise 5x /hrly/day.

Evaluation :pt able to do all exercise given.

Review :reassess pain scale,ROM,muscle power,limb girth.PROGRESSION NOTE :19/03/2015SO same as initial assessmentA P Intervention : Cont. the same treatment1) Deep breathing exercise. - do 5x/hrly/day.2) Incentive spirometer - do 10x/hourly3) Active free exercise for both UL & Lt. LL. - do 5x/hrly/day.4) Circulatory exercise for both feet. - do 5x/hrly/day.

5)Static quads exercise for both knee. - do hold 10 sec/5x/hrly/day.

6) Encourage pt to do DBE, active free exercise for both UL & Lt LL, circulatory exercise, SQE7) Ambulate pt.-transfer from bed to wheelchair.