ΜΕΤΑΦΡΑΣΗ - TRANSLATION HERE

Παρασκευή, 28 Οκτωβρίου 2011

ΠΡΟΓΡΑΜΜΑΤΑ ΑΠΟΚΑΤΑΣΤΑΣΗΣ ΣΕ ΚΑΤΑΓΜΑΤΑ ( ΧΕΙΡΟΥΡΓΕΙΟ-ΦΥΣΙΟΘΕΡΑΠΕΙΑ)

Orthopaedic Fracture Rehabilitation Table by Dr. Mark McAndrew
Table 1. Upper Extremity
Fracture
X-rays Needed
Immobilization
Fixation
MobilityPrecautions
Scapula
scapular body
acromion process coracoid process
glenoid neck
glenoid fossa
AP/axillary/scapular shoulder sling screws
reconstruction plates
tubular plates
mini T-plates
Stable: WBAT
Unstable: protected weight-bearing 2-3 months no deltoid isometrics until 6 weeks post-stabilization
sling immobilization as needed

Clavicle
displaced
nondisplaced
AP/axillary Shoulder Sling or Figure of 8 Strap reconstruction plates dynamic compression plate (DCP) Stable: WBAT
Unstable: PWB-NWB 6-8 weeks postinjury sling, figure 8 immobilization as fracture/patient status dictates

Humerus AP/axillary Shoulder
AP/Lat Humerus
Coaptation Splint vs.Sling

plate NWB 8-12 weeks
sling, Neer protocol (circumduction, passive abduction & forward flexion, >4weeks then aarom)
1. Proximal fractures wires (tension-band, K-wire)
greater tuberosity 2.5-mm Schanz pins
lesser tuberosity screws
surgical neck external fixation
anatomic neck hemiarthroplasty (elderly patient)
2. Humeral shaft AP/Lat Humerus Coaptation Splint DCP
locked IM nail
NWB-WBAT as fracture pattern dictates
3. Distal humerus AP/Lat Elbow
AP/Lat Humerus
Posterior Elbow Splint screws NWB 8-12 weeks Aarom as soon as soft tissues allow
reconstruction plates
tubular plates
tension-band wire for olecranon osteotomy

Radius & Ulna
1. Olecranon AP/Lat ElbowAP/Lat Forearm Posterior Elbow Splint tension-band wiring
screw, wire fixation
Aarom as soon as soft tissues allow NWB
2. Radial head AP/Lat ElbowAP/Lat Forearm Posterior Elbow Splint closed reduction mini-fragment screws
mini T-plates
Aarom as soon as soft tissues allow NWB
3. Forearm
isolated radius, ulna - both bones
AP/Lat Forearm Sugar Tong Splint closed reductionplates
screws (rare)
IM nail (rare)
Aarom as soon as soft tissues allow NWB 8-12 weeks
Monteggia/Glaeazzi AP/Lat Forearm Sugar Tong Splint
4. Distal radius AP/Lat Forearm Sugar Tong Splint closed reduction external fixation ORIF Aarom as soon as soft tissues allow NWB 8-12 weeks

Wrist & Hand
carpal MC phalanx AP/Lat Hand AP/Lat
Hand & Fingers
Dorsal-Volar Splint Buddy Tape closed reduction wires
mini-plates
cast, splint immobilization
NWB-PWB 8-12 weeks
Terminology:
1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity
2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation
3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance
4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs.
5. (PWB) Partial weight-bearing - weight limit specified by M.D.
Table 1, Upper Extremity
Fracture
Initial Physical Therapy Program
Advanced Physical Therapy**
Scapula Days 1-5: shoulder pendulum exercises elbow, forearm; wrist, hand AROM; grip strengthening
Weeks 2-3: gentle PROM-AAROM shoulder;deltoid, rotator cuff isometrics
If stable fracture pattern- shoulder PROM-AAROM initiated1 week postinjury, ROM, strengthening progressed to tolerance

Stable:
PROM/strengthening as tolerated
Unstable: strengthening at 3 months; progress to isometrics, surgical tubing, and free weights
scapular body
acromion process
coracoid process
glenoid neck
glenoid fossa

Clavicledisplacednondisplaced Stable
Day 1 post-stabilization: early shoulder AROM-AAROM to tolerance; shoulder isometrics; elbow, forearm, wrist, hand AROM; grip strengthening
Unstable: limit ROM as fracture pattern dictates
Stable: PROM/strengthening as tolerated
Unstable: strengthening at 6-8 weeks; return to activity in 10-12 weeks

Humerus
1. Proximal fractures Day 1 post-stabilization: elbow, forearm, wrist, hand AROM; grip strengthening

Days 2-5:
pendulum shoulder exercises
Weeks 1-3: early gentle AAROM shoulder joint within mobility limitations; deltoid, biceps, triceps, isometrics
Weeks 3-6: AROM, gentle PROM shoulder
Week 12: begin strengthening; progress to isometrics, surgical tubing, free weights, isokinetics; scapular stabilization exercises are important
greater tuberosity
lesser tuberosity
surgical neck
anatomic neck
2. Humeral shaft Day 1 post-stabilization: elbow, forearm, wrist, hand AROM grip strengthening
Days 2-5: Pendulum shoulder exercises
Weeks 1-3: Early gentle AAROM shoulder joint within mobility limitations: deltoid, biceps, triceps, isometrics
Weeks 3-6: AROM, gentle PROM shoulder
Weeks 10-12: strengthening
Week 12: progression the same as for the proximal humerus
3. Distal humerus Day 1 post-stabilization: shoulder AAROM-AROM; wrist, hand active range of motion-CPM (elbow) as M.D. indicates
Days 2-5: gentle elbow, forearm AROM; deltoid isometrics; grip strengthening
Weeks 8-10: gentle PROM-AAROM elbow, forearm
Weeks 10-12: strengthening
Week 12: isokinetics

Radius & Ulna
Weeks 10-12: PROM; strengthening
1. Olecranon Days 1-7 post -stabilization: early gentle AAROM-AROM forearm, elbow (initiated after 2-3 days); shoulder, wrist, hand AROM; grip strengthening Weeks 10-12: PROM; strengthening
2. Radial head Days 1-7 post-stabilization: early elbow AROM shoulder, wrist, hand AROM; grip strengthening
3. Forearm isolated radius, ulna - both bones Monteggia/Glaeazzi Days 1-5 post-stabilization: immediate shoulder, hand AROM; early, gentle AAROM forearm, elbow, wrist as fracture stability allows; grip strengthening Weeks 10-12: PROM
Week 12:
Strenghtening
4. Distal radius Days 1-5 post-stabilization: immediate AROM shoulder, elbow, fingers; initiation of gentle wrist AROM as immobilization allows (after cast removal than splint); grip strengthening Weeks 8-10: PROM; light activity
Weeks 10-12:
strengthening

Wrist & Hand
carpal MC phalanx
Days 1-5 post stabilization: early AROM-AAROM fingers, wrist, forearm as fracture and stabilization allow; elbow, shoulder AROM; fine motor control, desensitization; techniques as indicated Weeks 8-10: PROM; light activity
Weeks 10-12: strengthening
Terminology:
1. (WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated
2. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercises
3. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion
*Post-stabilization to healing
**After fracture healing
Table 2. Lower Extremity: Acetabulum to Femur
Fracture
X-Rays Needed
Immobilization
Fixation
Mobility Precautions
Acetabulum
Posterior wall; posterior columns;
anterior wall; anterior column;
transverse; T-shaped;
posterior column/posterior wall;
transverse/posterior wall;
both column; anterior column with posterior hemitransverse (Letournel classification)
AP Pelvis
Judet Views
CT San (3mmCuts)
Distal Femoral Traction Lag screws
reconstruction plates
Kocher-Langenbeck approach: (posterior), avoid active hip extension rotation
Ilionguinal approach: (anterior), avoid active hip flexion,vigorous trunk and abdominal flexion
Extended iliofemoral approach: (posterolateral), no active hip abduction 6-8 weeks; weight-bearing; NWB 8-12 weeks; positioning ROM; posterior wall involvement - no hip flexion greater than 70 degrees for 6 weeks

Pelvis
1. Anterior ringpublic symphysis rami
AP, inlet & outlet Pelvis, CT scan See pelvic fracture disruption protocol plating
external fixation
lag screws
TDWB-WBAT 10-12 weeks postinjury (depends on associated, posterior ring involvement)
2. Posterior Ring
Sacrum SI fracture/dislocation iliac wing
screws
plating
TDWB-WOLWB 10-12 weeks

Femur AP Pelvis AP/Lat hip Distal Femoral Traction Screw fixation
hemiarthroplasty THA(in elderly patient as fracture dictates)
Toe-touch weight-bearing 8-12 weeksno straight leg raises (SLR) TTWB, WBAT dependent on prosthesis fixation (see femoral neck fracture)
1. Femoral head
2. Femoral neck AP Pelvis AP/Lat both hips (uninjured side with templeates) Buck's Traction screws
dynamic hip screw endoprosthesis (elderly)
WB as necessary for balance for ambulationWB as necessary for balance for ambulation WBAT
ROM precautions: avoid simultaneous/combination movements of the operative hip. Allow flexion, extension, abduction, adduction or rotation in cardinal planes of motion with no restriction; no SLR 6 weeks
Posterior surgical approach: no hip flexion greater than 60 degrees, avoid hip adduction, internal rotation past neutral; no SLR 6-8 weeks
WB as necessary for balance for ambulation
3. Interochanteric femur AP Pelvis AP/Lat hip Buck's Traction DHS
IM nail
TTWB; no SLR; no active hip abduction with blade-plate fixation
4. Subtrochanteric femur AP Pelvis AP/Lat Femur Distal Femoral Traction DHS
Blade plate
IM nail
Interlocked nail/plate TTWB 6-8 weeks
5. Femoral shaft AP/Lat Femur AP/Lat KneeAP PelvisIf severely comminuted get scanogram opposite femur Distal Femoral or proximal tibilal Traction IM nail
DCP, LC, DCP
Note: Knee immobilizer, external support may be needed
To allow early crutch training if quad control slowly achieved; DCP fixation same as IM nail protocol
6. Supracondylar, intracondylar femur AP/Lat Femur AP/Lat Knee AP Pelvis Knee Immobilizer condylar blade plate; condylar buttress plate; screws TDWB 10-12 weeks
Terminology:
1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity
2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation
3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance
4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs
5. (PWB) Partial weight-bearing - weight limit specified by M.D.
Fracture
Initial Physical Therapy Program
Advanced Physical Therapy**
Acetabulum Days 1-discharge: bilateral UE strengthening; AAROM knee, ankle; quad, hamstring isometrics, TKE; early mobilization initiated (exercise instruction, bed mobility, transfer, ambulation training); hip AAROM, flex<60 if post wall fx; lying prone is encouraged to preven hip flexion contracture (2-3x/day, 20 min intervals); Weeks 6-8: AROM -AAROM hip, no limits; hip abductor isometrics; hip extensor strengthening Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunkmuscles; initiate balance/proprioceptive awareness training; aerobic/fitness training; rehabilitation is tailored to the surgical approach (i.e., extended iliofemoral approach requires more extensive hip abductor strengthening)

Pelvis
1. Anterior ring public symphysis rami
Day 1-discharge: bilateral UE strengthening; AAROM hip joint as fracture stability/pattern allows; quad/hamstring sets, terminal knee extension; AROM knee, ankle Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness training
2. Posterior Ring Sacrum SI fracture/dislocation iliac wing Day 1-discharge: bilateral UE strengthening; PROM hip joint as fracture stability/pattern allows; quad/hamstring sets, terminal knee extension; AROM knee, ankle Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness training

Femur
1. Femoral head Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative hip; hip abductor & extensor strengthening; balance/proprioception training
Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training
2. Femoral neck Day 1-discharge: bilateral UE & contralateral LE strengthening; quad/hamstring, AAROM, isometrics, AP involved AAROM; bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative hip; hip abductor & extensor strengthening; balance/proprioception training
Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training
3. Interochanteric femur Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training
Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training
4. Subtrochanteric femur Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training
Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training
5. Femoral shaft
6. Supracondylar, intracondylar femur Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training
Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training
Terminology:
1. WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated
2. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercises
3. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion
*Post-stabilization to healing
**After fracture healing
Table 3. Lower Extremity: Patella to Foot
Fracture
X-Rays Needed
Immobilization
Fixation
Mobility Precautions
Patella
Nondisplaced;
AP/Lat Knee knee immobilizer cylinder cast,
lag screw (s)
tension-band wiring
Stable: WBAT
Unstable: TTWB 4-8 weeks
displaced

Tibia AP/Lat KneeCT Scan knee immobilizer buttress T-plate DCPscrews TDWB 8-12 weeks
NO TKE exercise
(avoid excessive end-range
anterior tibial glide)
1. Tibial plateau
2. Tibial Shaft AP/Lat tibia Cadillac Splint IM nail reamed and unreamed;
plates and screws; external fixator
PWB 6-8 weeks
TDWB 8-12 weeks
PWB 6-8 weeks

Ankle
1. Pilon
AP/Lat AnkleMortise View AP/Lat Tibia Cadillac Splint Calacneal Traction screws and plates NWB 12 weeks
2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C) AP/Lat Ankle Mortise View Cadillac Splint screws, plates, and tension-band wiring PWB 8-12 weeks

Foot
1. Calcaneus extraarticular intraarticular
Lat Foot Oblique Foot Harris Heel ViewCT Scan (3mmCuts) Cadillac Splint, Use a lot of Padding to protect from Inevitable swelling. Reconstruction plateH-plate; lag screw K-wires NWB 12 weeks
2. Talus Lat Foot /Oblique Foot Cadillac Splint With toe plate lag screws K-wires (rare) NWB 12 weeks
3. Metatarsals and phalanx AP/Lat & oblique Foot Cadillac Splint With toe plate screws, wires, and pins closed reduction immobilization
Terminology:
1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity
2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation
3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance
4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs.
5. (PWB) Partial weight-bearing - weight limit specified by M.D.
6. (WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated
7. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercise
Table 3. Lower Extremity: Patella to Foot (Continued)
Fracture
Initial Physical Therapy Program
Advanced Physical Therapy**
Patella
Nondisplaced;
Days 1: bilateral UE strengthening; ankle AROM;
knee CPM post-op if indicated
Days 2 to discharge: quad hamstring isometrics***;
knee/AROMas fracture pattern allows***; SLR***
Weeks 4-8: strengthening; progress knee A/AAROM;
begin quad Isometrics and SLR if there was quad mechanism involvement
Week 8: WBAT, wean from crutches; concentrate on short arc/end range; quadriceps strengthening; closed kinetic chain activities (i.e., cycling, partial squats, leg press); balance proprioceptive training
displaced

Tibia Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training
Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training
Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training
1. Tibial plateau
2. Tibial Shaft Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training
Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training
Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training

Ankle Immediate post-stabilization: bilateral UE strengthening; gluteal, quad, hamstring isometrics
Day 2 to discharge: hip, knee toe AROM; SLR, TKE
Week 2: ankle subtalar AROM; progressive hip and knee strengthening
Week 12: PROM initiated; strengthening; balance/proprioceptive awareness training; WBAT, wean from crutches; closed kinetic chain program
1. Pilon
2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C) same as pilon fracture Weeks 8-10: gait progression after fracture healing; AROM/PROM ankle and subtalar joints; balance/proprioceptive awareness training

Foot
1. Calcaneus
extra articular
intra articular
Preoperative: UE strengthening; uninvolved extremity strengthening Involved extremity hip, knee isometrics; crutch training for short distance (primary elevation of extremity)
Day 1: UE strengthening; uninvolved extremity AROM strengthening involved extremity hip- knee isometrics; AROM, Toe AROM to tolerance
Days 2-3: crutch training, NWB involved extremity (limited time in dependent position)
Days 4-7: early ankle, subtalar AROM when surgical incision is sealed
Week 1 to month 3: continue early AROM ankle, subtalar, toes; gentle PROM toe dorsiflexion and plantar flexion; progress involved extremity; hip-knee conditioning

Same as calcaneus
Month 3: gradually increase weight-bearing starting at 20lbs to FWB over 1 mo; gradually wean from assistive devise as patient tolerates; pool therapy if available; gait training, re-education;desensitization techniques as needed; ankle subtalar AAROM isometrics; low impact endurance training
Months 4-6: gait progression, advanced balance and proprioceptive activities; ankle, subtalar isometric, isotonic strengthening with tubing/theraband; no free weights; soft-tissue immobilization
Month 6: ankle, subtalar PROM; joint mobilization; isokinetic assessment, strength-endurance training; advanced balance, gait training as indicated
2. Talus Day 1 post-stabilization: biliateral UE strengthening; hip, knee AROM, isometrics; ankle, subtalar, toe AROM as fracture Pattern allows
3. Metatarsals and phalanx Same as calcaneus
Weeks 8-12: WBAT; wean from crutches; proprioceptive/balance training;; closed kinetic chain activities
Terminology:
1. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion
2. (UE) Upper extremity
3. (LE) Lower extremity
*Post-stabilization to healing
**After fracture healing
***Note: No active quads if quadriceps mechanisms involved or disrupted 



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