How do most fractures occur?
1.) Trauma/force applied to bone, rapidly, or too heavy, compression
2.) Repetitive stress- stress fractures/microfractures/shin splints, jackhammer, walking, running, femoral neck, metatarsals
3.) Avulsion- translated from a muscle into a tendon- 5th metatarsal, malleolar
4.) Pathological fractures- infection in bones can create a fractures, cancer as well, Ewing’s sarcoma
What are some names for different types of fractures?
Describe an open/compound fracture and what you should think about with these, especially when you are a first responder.
Open fractures exit the skin
Think about infection and covering the exit wound
Describe a closed/simple fracture.
Closed fractures remain within the skin
Describe a displaced fracture.
A displaced fracture is poorly aligned where malunion or nonunion will occur without resetting.
Describe a non-displaced fracture.
A nondisplaced fracture is aligned and apporoximated which allows for healing/union without resetting.
Describe a transverse fracture.
A transverse fracture runs through in a straight line perpendicular to the bone.
Describe an oblique fracture.
An oblique fracture occurs at an any angle through the bone.
Describe a comminuted fracture.
Comminuted fractures are typically in 3 or more pieces with possible fragments.
Describe a spiral fracture.
Spiral fractures usually occur with rotary forces and have a sort spiraled or curled shape along both bones.
Describe a greenstick fracture and what age group is this type of fracture most common in?
Greenstick fractures typically look like someone tried to bend a green twig to break it into two pieces, however it does not break in two, but merely splinters a bit.
Most common in children as their bones are softer and more flexible.
What type of disease causes curved bones?
What should we think about when faced with someone with an acute fracture?
1.) stabilizing the patient- could have cut or occluded an artery
2.) check pulses
3.) If starting to swell rapidly and you suspect a bleed, add pressure proximally
4.) You should not try to reduce it
5.) If it’s open, you should try to cover it
6.) You probably shouldn’t try to transport them, but if they’re your family member you may decide to
Describe the steps of bone healing including all necessary time frames.
3.) Forms hematoma- inflammatory mediators, fibrin, white blood cells (macrophages), platelets, osteoblasts, osteoclasts, hangs out about a week
4.) Pro-callus- granulation tissue forms- osteogenin (turn cells into matrix of building bone), get a little bit of a soft callus on the radiograph, 2-4 weeks
5.) Callus- bony matrix forms and osteoblasts envelope hematoma- 4-6 weeks
6.) Callus breakdown- osteoclasts
7.) Remodelling- original shape- up to a year (or more)
Name one disease process that may lead to bone fragility and recurrent fractures in babies and young children.
What is osteogenesis imperfecta?
OI is caused by genetic defects that affect the body’s ability to make strong bones. In dominant (classical) OI, a person has too little type I collagen or a poor quality of type I collagen due to a mutation in one of the type I collagen genes. It is a genetic disorder characterized by bones that break easily, often from little or no apparent cause.
What are several ways the medical team attempts to fixate a fracture?
1.) Casting (clamshell initially until swelling goes down)
2.) External fixator
What is a positive/difference when using an external fixator over a cast?
Casts allow some wiggle room and the patient still needs to be NWB, where an ex fix can often allow immediate weightbearing to aid in bone healing.
List some things to think about when seeing someone with a fracture.
1.) Nutrients- calcium, vitamin D, magnesium, phosphorous
2.) Smoking- slows the process of healing
3.) Comorbidities can slow down healing- osteoporosis, necrosis, diabetes, and disease that leads to blood flow issues
What is Osteoporosis?
A disease characterized by decreased bone density >-2.5 SD from the norm.
List some risk factors for osteoporosis.
2.) post-menopause (early menopause, late menarche (decreased fertility time, so decreased estrogen levels (bone density))
5.) very thin or obese (malnourishment)- high caloric, low nutritional value
6.) metabolic diseases
7.) advanced age
10.) poor diet
12.) drinking (ETOH)
13.) some medications (steroids, PPI's, aluminum containing antacids, Depo-Provera, chemo drugs, SSRI's, etc)
15.) Your name is MaryBeth
How do we diagnose osteoporosis?
What reading on a DXA constitutes a diagnosis of osteoporosis?
>-2.5 SD from norm
What reading on a DXA constitutes a diagnosis of osteopenia?
>-1 to -2.5 SD from the norm
When does peak bone density occur?
When do women see the most drastic change/decline in bone density?
Within the first 5 years after menopause.
When does menopause most often occur?
late 40's - early 50's
What are 3 common fracture sites for people with osteoporosis?
3.) Wrist (FOOSH)
How is osteoporosis treated?
Medications, resistance exercise, weight-bearing exercise, pool therapy
What should we evaluate/teach someone with osteoporosis?
Proper lifting technique/keep objects close to body when lifting
What motions should we avoid in someone with osteoporosis, particularly those who have had anterior wedging of the vertebral column?
Extreme flexion/extension, side bending, and rotation
What is the principle of overload?
Resistance increases as the patient is able to tolerate more.
What hormone is responsible for maintaining the balance between osteoblasts and clasts?
What leads to decreased height with age?
decreased disk height/fluid, kyphotic posture, losing/lose cushion of cartilage, bones start to compress
How much height is lost per decade after age 60-65?
When exercising a patient with osteoporosis, you notice she's having a bit of trouble with her form. What do you do?
Stop her. Poor form can lead to poor mechanics which can later lead to fractures.
What are some ADLs that would require modifications in someone with osteoporosis?
putting on their shoes (sock aids and shoe horns), bending over to pick things up off the floor (use a reacher), emptying a dishwasher (rotation, flexion and picking up weight triple no, do dishes by hand or have someone else load and unload), look at height of chairs, vacuuming/sweeping, laundry (front loader on risers may help with this), gardening (kneel), lifting (keep heavy items such as kitchen appliances elevated to about waist height for easy access, light items can go up higher or lower into cabinets and a reacher can be used, avoid step stools)
What kind of thoracic postural changes and issues do you expect with an osteoporosis patient?
kyphosis, FHP, neck pain, radiculopathy, thoracic outlet syndrome, forward rounded shoulders, higher risk for falling, pneumonia, skin breakdown (spinous processes sticking out)
What does the PT do for a patient with osteoporosis?
1.) mobilize to prevent pneumonia
2.) skin breakdown
4.) make sure she can get up and move when she leaves the hospital
5.) decrease risk of other causes of death
6.) determine PLOF and where they should go do they have the support system, will they be safe to go home- SNIF, skilled nursing facility/nursing home, inpatient rehab, outpatient, home health, etc.
Name/describe several surgeries doctors can do for someone with vertebral compression fractures.
1.) kyphoplasty- cement-like substances inside the vertebral body however it puts greater pressure on everything above and below and may increase risk of fracture, need to look at bone density
2.) disk replacement- can also increase pressure/create fractures
What thoracic postural change do you expect in the elderly?
Kyphotic, FHP, forward rounded shoulders
What is the typical location for vertebral compression fractures?
They typically occur in the lower thoracic and upper lumbar segments where the kyphotic curvature is the greatest and places the greatest stress on the anterior vertebral column.
What is the best way to instruct a patient with vertebral compression fractures in assuming supine to sit?
Log roll to the edge of the bed before swinging legs over and pushing up into sitting with her arms
What is the best way to instruct a patient with vertebral compression fractures in sit to stand?
Feet slightly underneath/behind knees, forward bend with nose over toes, push up from chair, don’t pull up from the walker
What is the typical functional mobility status of a patient with vertebral compression fractures?
Moderate assist from supine<>sit and sit<>stand, mostly independent in standing with decreased pain
What single exercise would be helpful in preventing another vertebral compression fracture by plopping into a chair?
What are some exercises that can increase a patient's bone density in their humerus?
What is the best way to increase bone density in the hip of an osteoporotic patient?
Who is currently losing bone at the highest rate (assuming equal calcium intake and activity): 35 y.o. woman; 55 y.o. woman; 75 y.o. woman
the 55 y.o.
What are some hallmarks of OA?
pain, guard or brace it, puts joint in biomechanically disadvantageous position, typically a compartment
What part of the joint is affected by OA first?
Does cartilage thicken or thin first? Why?
Thicken. Inflammatory mediators initially invade cartilage, causing it to thicken before thinning.
What is the order of events in OA breakdown of cartilage?
1.) Inflammation starts
2.) inflammatory mediators come into cartilage
3.) cartilage thickens because it’s inflamed
4.) thins and breaks down cartilage
What is affected second in the OA process after cartilage?
The synovial membrane
What is the synovial membrane responsible for?
Lubrication of the joint
What is the order of events of OA on the synovial membrane?
Bringman said it was similar to that of cartilage, but didn't give a list. He said it is also a source of pain.
OA on cartilage:
Inflammatory mediators come into cartilage
Cartilage thickens because it’s inflamed
Thins and breaks down cartilage
What happens to ligaments and muscles in OA?
ligaments- some become shortened, some become overstretched/stressed due to altered biomechanics due to pain- instability and abnormal alignment- more wear and pain, and stress on joint above and below
muscles- shortened and lengthened in certain areas- getting muscle weakness and imbalance, making the joint even more unstable, patient won’t go full range, inhibition of movement, adaptive shortening trying not to go into that certain range
What happens to bone during OA?
bone on bone leads to inflammation leading to osteophytes, subchondral cysts, bony block, loose bodies from fractures (joint mice) (OCD- osteochondritis dissecans) (can have a bony contracture as well as muscular)
How would we describe gait in someone with OA?
gait- antalgic, decreased stance time, decreased step length (unaffected side), decreased weight bearing (affected side), walking slow, decreased swing (risk of falls)
Describe the overall picture of someone with OA
depression, more sedentary, postural changes, reduced energy levels (takes longer to get places so it takes more energy), slower
List some predisposing factors to OA
3.) injury at a joint
4.) surgery at a joint
7.) extreme, prolonged valgus (like in skating)
8.) muscle weakness
9.) joint laxity
What are Heberden's nodes and where do you find them?
hard or bony swellings that can develop in the distal interphalangeal joints (DIP)
What are Bouchard's nodes and where are they found?
hard, bony outgrowths or gelatinous cysts on the PIP joints
How do Heberden's and Bouchard's nodes usually present?
usually bilateral on knuckles- like bone spurs, osteochondral cysts, etc
What is RA?
a chronic progressive autoimmune disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles
How is RA different from OA?
RA is immune mediated and has on/off presentation
OA affects weightbearing joints predominately, whereas RA affects weightbearing and non-weightbearing
RA has myositis (muscle inflammation) you won't see in OA
RA causes sleep disturbances, overall fatigue (not just from energy expenditure as in OA, just general fatigue)
OA can have Bouchard and Heberden's nodes, however RA can have nodules all over the body, especially over extensor surfaces, bony prominences, and in the heart
RA is characterized by pannus in the joint and affects the synovial membrane first, unlike OA affecting the cartilage first
Name the 7 criteria for RA
1.) morning stiffness lasting greater than 1 hour
2.) arthritis of 3 or more joint areas
3.) arthritis of hands
4.) symmetric arthritis (OA less symmetric)
5.) rheumatoid nodules over extensor surfaces or bony prominences (different than heberden/bouchard, typically further down- extensor surface or the palm, spine, spinous processes, elbows, etc
6.) rheumatoid factor (not everyone qualifies with just this)
7.) radiographic changes that are more indicative of this
How many of the 7 criteria for RA does a patient have to have, and for how long do they have to have it to be considered to have RA?
patient has to have at least 4 of the criteria for at least 6 weeks
Describe the events of RA
Attacks the synovial membrane (in OA is cartilage first)-> creates pannus
synovial membrane is attached to cartilage and bone so slowly starts invading cartilage and eating that away
ligaments sit on top of the synovial membrane, similar things start happening as in OA to muscles, tendons, bones, abnormal biomechanics, leads to weakness and deformity
What is pannus?
Pannus is merely the hypertrophied synovium following infiltration of inflammatory mediators and new blood vessel growth
Name 4 potential deformities seen in the hand with RA patients
1.) Ulnar drift
2.)Swan neck deformity
3.) Boutonniere deformity
4.) Zig-zag deformity
What's the difference between replacing a joint in an OA patient and an RA patient?
An OA patient's pain is usually resolved, whereas an RA patient's problem will persist, and now you have brought more inflammation to the area due to the trauma of surgery
As a PT, what should we be doing for an RA patient?
stretch and strengthen in proper plane of motion/biomechanics- have to know what normal is so avoid stretching/strengthening into an abnormal position or you’re just helping the disease process along
What is normal ROM for wrist flexion?
What is normal ROM for wrist extension?
What is normal ROM for wrist radial deviation?
What is normal ROM for wrist ulnar deviation?
List the normal ROM for finger MCP, PIP, and DIP flexion and extension.
List the normal ROM for thumb CMC, MCP, and IP abduction, flexion and extension.
Who more commonly gets RA?
Women 40-65 more common
How would a PT treat an RA patient differently than an OA patient?
RA has flare ups so less exercise so maintenance in those times, PROM and isometrics at different ranges, don’t want to push to exhaustion (already tired), would never use heat on either of these patients, and would want to do cardio with both. Pool is probably best in the case of cardio.
What is the best time of day for an RA to schedule an appointment for PT?
mid-day 11-1 o’clockish
What type of medicine are most RA patients on and what do you have to be mindful of with these medications?
immunosuppressants- slow down RA, bad because risk for infection (TB), don't work with them if you're sick!
What are the 3 main sites of hip fracture?
intracapsular- through the neck
intertrochanteric- through greater trochanter
subtrochanteric- through the shaft of the femur
Why is the ligamentum teres significant?
artery runs through (branch of the obturator), head of femur doesn’t have a redundant blood supply, so blood supply can reduce/calcify, smoking and drinking, leading to avascular necrosis
What kinds of things can injur the ligamentum teres and the artery it houses?
fracture, aging, lack of blood supply, dislocation, swimmers, frog kick/breaststroke higher incidence