Orthopedics has come a long way since the days of Nicholas Andry—a French physician, who is credited for coining the term, orthopedics from two words, Ortho= straight and Paedics = child in 1741.
What was a primitive branch then restricted to correcting deformities in children, has developed into a full-fledged specialty with diverse scope ranging from simple treatment, as done by traditional bonesetters to highly advanced joint, spine and hand surgeries.
The development of orthopedics as a specialty was pedestrian till 18th century. The discovery of anesthesia and aseptic surgical techniques opened up new avenues of treatment like open reduction, debridement, etc. The discovery of X-rays by Roentgen and the introduction of the usage of plaster of Paris by Albert Mathysen in 1852 revolutionized the diagnosis and management of orthopedic disorders. Thus, orthopedics started breaking through the deadlocks of a crude branch to that of a science.
But what really set the ball rolling was the sudden surge of orthopedic cases firstly by the two World Wars and of late by the road traffic accidents which is on the rise, both in the developed and developing countries.
Polytrauma, multiple fractures, high-velocity injuries, severely exposed the limitations of the conventional treatment in orthopedics, as the fracture patterns were bizarre and complicated. Thus newer modalities of treatment like improved methods of internal fixation, the AO systems, the interlocking nail system, Ilizarov method, etc. were introduced into orthopedic management. Suddenly orthopedics was being considered a highly specialized branch with vast scope.
Needless to say many pioneers both at the international and national level have contributed enormously for the development of this branch to the present what is today. We salute them for their contribution. A fitting tribute to them is to carry on the good work done by them and to raise the level of this branch to such dizzy heights so that the sufferings of mankind due to orthopedic disorders are mitigated.
But orthopedic treatment does not end at merely fixing the fracture efficiently. The pre-injury functional status of the individual has to be restored back and further complications or recurrence of the problem has to be prevented. This is where the specialty of physiotherapy steps in to bridge the gap in treatment. In fact orthopedics and physiotherapy are two faces of the same coin. A good orthopedic surgeon is one who has a good physiotherapist within himself while a good physiotherapist is one who was a sound knowledge of orthopedics. While the orthopedician fixes the fracture, a physiotherapist rehabilitates the patient back to normal or as near normal as possible. Similarly in chronic orthopedic disorders merely managing the patient conservatively or surgically is not sufficient. Here also rehabilitation of the patient is extremely important and the role of the physiotherapist is sometimes more important than that of the therapist.
Thus, a perfect blending of the art of orthopedics and physiotherapy is what is required to put the patient back to the pre-injury status. While the role of an orthopedician begins after the fracture or after the disease strikes. The role of a physiotherapist does not start after the fracture is fixed or after the disease is healed but starts from day one of the onset of disease or fracture. Apart from the therapeutic role, physiotherapy has a restorative role in restoring the lost function but also has preventive role in preventing the recurrence of the problem. Here physiotherapy plays a very important role in the rehabilitation of a patient suffering from fractures or any other orthopedic related disorders.4
The triple role of orthopedic physiotherapy
- Therapeutic role
- Restorative role
- Preventive role
Thus, orthopedic physiotherapy is an important branch of medicine which has come to occupy the centre stage of the treatment of orthopedic related disorders which is some he has to assist the orthopedic surgeon in treating a patient while in others he has to play a leading role.
Thus like never before, a physiotherapist needs to have a comprehensive knowledge of orthopedics to treat these patients better. He has to begin by making a proper diagnosis of the orthopedic problem before he embarks on treating them with the vast armamentarium of physiotherapy treatment modalities available at his disposal.
DIAGNOSIS IN ORTHOPEDICS
Approach to a Patient with Orthopedic Disorders
As in other branches of medicine, the diagnosis of orthopedic disorders revolves around the following fundamentals (Fig. 1.1A).
So we will try to discuss in brief the three steps of diagnosis in orthopedics.
At the end of history
History is “His- Story”, as told by the patient. History taking is an art. Caution has to be exercised in the story “told” and the story “untold”. Everything told should be taken with a pinch of salt lest the examiner is misled.
Certain points of importance in the history
Age Certain diseases have predilection for certain age groups, e.g. Perthes disease and acute osteomyelitis are common in children. Avascular necrosis and degenerative disorders are common in the elderly. Some diseases may be seen in all the age groups, e.g. tuberculosis of bone and joints (Table 1.1).
Sex Congenital dislocation of hip (CDH) is common in females. Congenital talipes equinovarus (CTEV) is more common in males.
Sex vs orthopedic disease
- Males: Perthes, slipped epiphysis, traumatic disorders, multiple myeloma, etc.
- Females: Rheumatoid arthritis, CDH, osteoporosis, etc.
Onset May is sudden or gradual.
Trauma could be a predisposing factor or the causative factor and it is usually due to road traffic accident (RTA), fall, assault, etc. (Fig. 1.1B).
Fever may be high as in acute osteomyelitis or low grade as in tuberculosis.
Pain This could be continuous or intermittent, low or high grade. One should be on guard about the radiating pains as these often mislead the examiner (Table 1.2).
Any constitutional problems like weight loss, anorexia, etc. if present are a pointer towards neoplasm, tuberculosis, etc.
Seasonal variation If present it is suggestive of rheumatoid disorders. Apart from these points, relevant past history, socioeconomic status and personal history should be taken into account.
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An attempt should be now made to place the problem into one of the following categories at the end of history taking (Table 1.3).
Is the problem congenital?
If so, it will be present since birth or seen within few years from birth. A strong family history is elicited able.
Is it developmental?
Here the disease gets manifested during the process of development.
Is it an infective disorder?
History of fever, chills, rigors, sweating, etc. are present.
Is it inflammatory disorder?
Seasonal variation, remissions and exacerbation, multiple joint involvement, etc. are present.
Is it a metabolic disorder?
Nutrition, socioeconomic status, generalized skeletal disorder, etc. assume importance in this group.
Is it an endocrinal disorder?
Look for other evidences of hormonal imbalance, e.g. Hypothyroidism → cretinism Hypopituitarism → dwarf, etc.
Is it traumatic?
History of fall, road traffic accident (RTA), assault, etc. is elicited.
Is it degenerative?
Advancing age, slow progress is the hallmark.
Is it neoplastic?
Look for the features of either benign or malignant bone tumors.
If it cannot be categorized into any of the above, then it could be idiopathic.
Having made a tentative diagnosis at the end of history, next important step is resorted to.
EXAMINATION
A good systematic clinical examination will help to clinch the diagnosis with certainty. No sophisticated technology can replace the value of a good clinical examination. A good clinician will make the diagnosis clinically and will make use of the investigation armamentarium judiciously. A clinician should command the investigation and not vice versa.
Examination of the locomotor system involves four steps:
STEP I
Examination of Gait
An examination of the gait is extremely important as it gives vital clues regarding the diagnosis.
Definition It is a term used to describe the style of walking. This is dependent not only on normal muscles and joints but also upon an intact central nervous system (CNS), peripheral nervous system and normal labyrinthine function (see chapter 21 Human Gait for details).
STEP II
General Physical Examination
A good general physical examination (GPE) from head to toe gives vital clues in the diagnosis of most of the orthopedic disorders, particularly generalized disorders of the skeleton, e.g.
- Metabolic disorders, e.g. rickets, etc.
- Developmental disorders, e.g. osteogenesis imperfecta, etc.
STEP III
Clinical Examination
The following are the usual presenting symptoms in a patient with orthopedic disorders:
Pain This is the first and the most common complaint. It is a highly subjective complaint and can be classified as mild, moderate or severe.
The must-ask questions regarding the pain are: How did it start? Is it related to trauma? Site of pain? Does it radiate? What are the aggravating and relieving factors? Does it interfere with sleep? Etc.
Swelling It may precede or follow pain. Relevant questions to be asked are: Site of the swelling, painful or painless, is it rapidly growing (e.g. malignancy) or slow growing (benign growth), is it associated with fever, chills, etc. (e.g. infective origin), single or multiple (e.g. neurofibromas, etc.).
Deformity Sudden onset of deformity is usually seen in fresh fractures and dislocations. Long-standing deformities are usually seen in old fractures and other nontraumatic disorders like congenital, developmental, and metabolic conditions. Patient may complain of cosmetic and functional impairment due to the deformity.
Limitations of joint movements In the initial stages, it may be due to muscle spasm and in the later stages it may be due to intra-articular adhesions (e.g. TB, septic arthritis, rheumatoid arthritis, etc.) or extra-articular contractures (like post burn contractures, Volkmann's ischemic contracture, etc.).
Limp This could be painful (e.g. arthritis of hip, trauma, etc.) or painless (e.g. CDH, coxa vara, etc.). Patient may complain of difficulty or alteration in various day to day activities like walking, squatting, running, working, etc.
Limb weakness This may be due to disuse atrophy, motor problems like polio, motor nerve disease, etc. muscle problems like muscular dystrophies, etc. or due to peripheral or diabetic neuropathies.
Signs
General Look for the signs of anemia, fever, weight loss, etc.
Local Deformity may be due to an abnormality of bone or joint. If a joint is out of its anatomical position, a deformity is said to exist. And in case of bone, deviation from its normal anatomy is deformity. In cases of old fractures and dislocations, the deformity may be fixed.7
A fixed deformity is the angle between the neutral position of the normal joint and the position the deformed joint will reach
Temperature This is always compared with the normal side. Check with dorsum of the hand as this is the most sensitive part.
Tenderness (Fig. 1.3) This is elicited by examining from the normal to the affected area and is graded I to IV (see p. 42).
Swelling The following things are noted in the examination of a swelling.
- Decide the anatomical plane. The plane of the swelling could be either bone (swelling decreases in size when muscle is put into contraction) or could be in the muscle (swelling slightly decreases in size and gets fixed on muscle contraction) or could be between the muscle and the skin (no change in the size at the swelling when muscle is put into contraction).
- Describe the shape as globular, oval or round, etc.
- Grade the consistency (see below).
- Decide whether it is congenital, neoplastic, etc. (see Table 1.3 diagnostic fact, p. 5).
- Look for slipping sign, sign of emptying, indentation sign and expansile impulse.
Grading of consistency:
| — | Very soft (like jelly). |
| — | Soft (as relaxed muscle). |
| — | Firm (like a contracted muscle). |
| — | Hard (as a contracted biceps). |
| — | Stony and bone hard. |
Movements of joint
- Active movement Patient himself moves the joint in one direction and later in the other. The extent of active movement is noted. Both the joints should be tested.
- Passive movement of the joint is tested by the examiner without causing pain. The extent of passive movement is noted.
- Limitation of all movements of a joint indicates arthritis.
- Limitation of certain movements of a joint indicates an extraarticular lesion or mechanical block.
- If passive movements exceed active movements, paralysis of muscle is likely.
Measurements Accurate limb length measurements give vital clues regarding the diagnosis. Measurement should be taken for two purposes.
To know the limb length For this measurement is taken between two fixed bony points and is always compared with the normal.
Upper limbs
- Arm length From the angle of acromion to the lateral epicondyle of humerus (Fig. 1.4).
- Forearm length From the lateral epicondyle of humerus to the radial styloid process.
- Thigh length from anterior superior iliac spine to the medial knee joint line.
- Leg length from the medial knee joint line to the medial malleolus.
- Entire lower limb length is measured from the anterior superior iliac spine to the medial malleolus below:
To know the girth of the limb To detect wasting of muscles, the circumference of the limb is measured at fixed points on both sides, e.g. 18 cm above joint line in the thigh (Fig. 1.6).
Irregular thickening of bone and persistent discharging sinus (Fig. 1.7) If this is present along with scars fixed to bone, it indicates osteomyelitis (see box for causes of persistent sinus).
Peripheral, vascular and nervous system examination should be done next. This is discussed in appropriate sections.
Causes of persistent discharging sinus:
- Unobliterated cavities
- Unabsorbed sequestra
- Epithelialisation of sinus tract
- Presence of foreign body
- Secondary infection
- Diabetes, steroid therapy, etc.
- Malignant change in the sinus
STEP IV
Investigations
These help to confirm the diagnosis and in some cases help to make the diagnosis (e.g. crack fracture, etc. can be diagnosed only by X-ray). One has to choose carefully from the following vast armamentarium:
Routine laboratory investigation This consists of blood investigations like routine haemogram, urine examination, ECG, chest X-ray, etc.
Special investigations:
- Radiography At least two views of the affected part should be taken, oblique views and some special views are required in some cases.
- CT scan To study the cross-section of the limb anatomy and bones.
- MRI This is the recent gold standard in the investi-gative armamentarium of bone disorders. It helps to study the bone, soft tissues, medullary spread, etc. with greater accuracy. The only problem is its prohibitive cost.
- Angiography and biopsy in tumor diagnosis.
Thus, a reasonably accurate diagnosis can be made by following the guidelines discussed above.
Treatment Methods
After having made a diagnosis, the orthopedic surgeon proceeds to treat the condition. The conventional treatment methods in orthopedics are conservative management, surgical management and physiotherapy. Treatment of fractures, their complications and other orthopedic disorders are discussed in relevant sections. Emphasis in this chapter is the role played by the physiotherapist and the various treatment modalities at his command.
Role of a Physiotherapist
In treating fractures and other orthopedic related disorders, a physiotherapist is required to play the following roles:
- Rehabilitation is a team effort and he is part of a team.
- He has to make a subjective and objective assessment of patient's condition and needs.
- To decide on the form of treatment and explain it to the patient.
- To do cardiopulmonary conditioning before subjecting the patient to the rigors of physiotherapy.
- To restore the lost functions.
Assessment
By careful clinical examination mentioned above he makes an assessment of the problems of the patient and how he should go about to rehabilitate him back to normal. His plan of treatment should aim to fulfill the following short-term and long-term goals.
Short-term Goals
These include:
- Limit the bleeding if any
- Further damage should be prevented at all cost
- Pain and swelling should be reduced
- Prevent joint stiffness and contractures
- Preserve the muscle power.
Long-term Goals
These include:
- Kinaesthetic and proprioceptive mechanism to be restored back to normal.
- Mobility of joint and soft tissue to be increased.
- Muscle power to be increased.
- Movement reeducation.
- Daily functional activities to be restored back.
- Prevention of swelling and recurrence of the injury
- Restoring back the post confidence to the affected limb and person.
- Short-term goals (of physiotherapy): This is for simple fractures, strains, sprains, etc. This is given usually on an OPD basis.
- Long-term goals (of physiotherapy): This is required for patients with major orthopedic disorders like rheumatoid arthritis, OA, hemiplegia, quadriplegia, etc. Major complications of fractures like nonunion, avascular necrosis (AVN), etc.
Note There are two categories of patients who need long-term physiotherapy:
- Prolonged physiotherapy for a short time: For example, After hip/knee surgeries, etc.Here prognosis is good and patient may resume full or near normal function
- Prolonged physiotherapy almost permanent: For example, Patients with hemiplegia, paraplegia, etc. where the chances of recovery are extremely bleak.
After having made a thorough assessment of the problem and having determined the short- or long-term goals, the therapist plans the rehabilitation programme like exercises, physical agents, massage, etc. But before subjecting the patient to the rigors of prolonged or vigorous physiotherapy, he has to determine whether the heart, lung and general condition of the patient is fit enough to with start the stress. If not, he has to make the cardiac and the lungs fit through sustained efforts as follows:
CARDIOPULMONARY CONDITIONING (CPC)
CPC is defined as an exercise programme aimed to improve the cardiac and pulmonary efficiency of the patient.
Benefits of CPC
- It improves the functions of the heart and lungs.
- It improves metabolism, glucose tolerance, hormone production, hemodynamics, etc.
- It improves muscular strength, endurance, joint and muscle flexibility, neuromuscular skeletal system, coordination, exercise tolerance, etc.
Due to the various benefits of CPC, they are widely recommended before resorting to the routine orthopedic physiotherapy measures. A candidate for CPC is chosen after preliminary screening of risk factors for heart diseases, clinical examination and evaluation for assessing the existing heart conditions, exercise tolerance, etc. and then finally formulating the exercise program for the patient.
The exercises chosen are isotonic, isokinetic and isometric ones. The intensity, duration and frequency of exercises chosen are individualized depending on the patient's condition. The conditioning exercises chosen are done in three phases namely the warm-up phase, conditioning phase and cool-down phase.
Phases of Exercises
- Warm-up phase
- Done for 5-10 minutes
- Adapts the heart and lungs for future exercise
- Stretches and loosens the muscles, ligaments, tendons, etc.
- Conditioning phase
- This is the most important phase of CPC
- Done for 15-20 minutes, progressed to 30-45 minutes
- Careful monitoring to maintain the heart rate.
- Cool-down phase
- Here the intensity of the exercise is gradually tapered off as sudden tapering may increase the heart rate, hypotension, dizziness, etc.
- Done for 4-10 minutes.
- Ideally should be followed by relaxation techniques.
After a thorough CPC, orthopedic physiotherapy can now be instituted by the therapist. Orthopedic physiotherapy consists of therapeutic exercises, physical agents, massage, traction, manipulation, assistive devices, ergonomics, ambulation, etc. Each of the above methods is now described in detail.
ROLE OF PHYSICAL AGENTS IN PHYSIOTHERAPY
Various physical agents like heat, cold, sound, hydrotherapy, electrical stimulation, etc. can be used to reduce pain and discomfort in patients. The primary role of these agents is to prepare the muscles and joints of a body for exercises.
HEAT THERAPY
Mode of action Heat helps in the following ways:
- It reduces pain
- It relieves the stiffness of the joints
- It reduces the muscle tightness
- It increases the blood flow to the area by causing vasodilatation.
Benefits The heat therapy warms up the tissues and readies it for the future exercise therapy. Its action is similar to that of the warm-up exercises before the main exercises by sports persons.
Goal It aims to increase the temperature and increase the blood flow to the area of treatment.
Time Optimal benefits are achieved within 20 minutes of application. Beyond this time, there is no further increase or raise of temperature noted.
Types Two types are described:
- Superficial heating agents these heat only the skin and subcutaneous tissue (i.e. structures upto 10 mm beneath the skin).
- Deep heating agents these heat the deeper structures like muscles and bones.
SUPERFICIAL HEATING AGENTS
In this category are included the hydrocollator packs, infra-red lamps and paraffin baths. These are the most popular and common form of heat therapy advised after fractures.
Hydrocollator packs these packs contain silica gel which is encased in a canvas bag. This can be contoured to the various body regions.
Note Silica gel is able to maintain a heat of 40°C (104° of Fahrenheit) for a period of about 30-40 minutes.
The heat delivered by the hydro collator pack is a form of conductive heat.
Contraindications
- Open wounds
- Anesthetic skin
- Significant edema
- Skin diseases and infections.
Infrared Infrared heating is delivered through an artificial source called the infrared lamp. This heats structures only 10 mm beneath the skin.
Advantages
- It induces relaxation in the patient.
- It mobilizes the skin and subcutaneous tissues.
- It provides no pressure on the body.
- The area under treatment can easily be inspected without interrupting it.
- It is easy and simple to use even by the patient.
Optimum time Twenty minutes. It may cause burns, if allowed to heat for long.
Contraindications These are the same as for hydro collator packs.
Paraffin wax bath (Fig. 1.8) this consists of a mixture of one part of liquid petroleum to seven parts of paraffin.
It is most often indicated to treat small areas like hands and feet (as in rheumatoid arthritis, etc.).
Contraindications are the same as for hydro collator packs.
Other superficial heating methods These include hot packs, hot water bottle and a small electric heating pad. They are found to be equally effective as the other sophisticated methods described so far. They have the advantage of being simple, clean and easy to use even by the patients.
Caution Patient should be educated that too hot may be too bad and may cause burns.
Mode of action, indications, timing and contraindications are the same as for the other methods mentioned earlier.
DEEP HEATING AGENTS
These agents include microwave, shortwave, ultrasound etc and they act through the electromagnetic or mechanical waves. They heat the structures 30-50 mm beneath the skin surface.
Deep heating agents
- Diathermy This term denotes deep heating by electromagnetic or mechanical waves.
- Heating by electromagnetic waves, e.g. Microwave or short wave.
- Heating by mechanical waves, e.g. ultrasound.
Microwave
- This is more frequently used method than the short wave.
- It is known to selectively heat muscles.
- It is indicated in muscle shortening following fractures.
- It is contraindicated if there is an implanted metal or if the patient has a cardiac pacemaker.
Shortwave
- These waves though called short, have a greater wave length than the microwaves.
- It heats the subcutaneous tissue more effectively than the superficial heat modalities.
- It is indicated in post fracture contractures and subcutaneous adhesions.
- Its usage now has declined in favor of microwave.
- The contraindications are the same as for microwave.
Ultrasound (Figs 1.9A to C)
- Ultrasound waves are mechanical unlike shortwave and microwave.
- Ultrasonic waves are not faster than sound but have a greater frequency.
- It heats the bone muscle junction effectively.
- It is indicated in post-fracture muscle shortening and joint capsule contraction.
- Fractures fixed with implants are not suitable for ultrasound therapy.
Deep heat facts
- Microwave—selectively heats the muscle
- Shortwave—selectively heats the subcutaneous tissue
- Ultrasound—effectively heats the bone-muscle junction and the bones.
Note Both microwave and shortwave are not used frequently as it needs sophisticated equipment and greater technical expertise.
COLD THERAPY
This is usually given by an ice pack, ice cube or towels wrung in ice cold water. The following are some of the salient features of this therapy:
- The temperature is 0-2° centigrade or 28-32° F.
- It should be applied for a period of 10-15 minutes. After this patient has a feeling of numbness followed by local erythema.
- It effectively reduces pain, swelling, inflammation and spasticity when used immediately after an injury or fracture.
- It is less commonly used in the later stages of fracture rehabilitation. When used it reduces pain and spasm even in that stage.
HYDROTHERAPY
This includes whirlpool and therapeutic pools. When used along with heat and cold therapies, they act synergistically.
Whirlpool Therapy
- The whirling action of the water has a massaging effect on the body and improves the blood circulation.
- It is beneficial in post-fracture treatment and in disorders of wrists, ankles, knees, hands, etc.
- The temperature is 37-40°C (98-104° F).
Note If the temperature is more, it makes the patient delirious.
Caution The submission into whirlpool should not be more than 20 minutes.
Therapeutic Pool
- This pool has an inclining bottom with shallow and deep ends.
- The water is maintained at 37°C (98°F).
- Indicated in patients with lower limb disorders and also after hip, knee and back surgeries.
- The patient is instructed to float in the water, then stand in the deep end and gradually walk towards the shallow end. As he walks towards the shallow end, the weight on the lower limbs increase. This helps to increase the strength of lower limb muscles.
Advantages of pool therapy
- It improves circulation
- Improves ROM
- Enhances wound healing
- Strengthens the lower limb muscles.
Note The buoyancy of water in the pool therapy, gives a sense of freedom from the effects of gravity. The warmth of water relieves pain and muscle spasm.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)
- This is more useful in relieving intractable vertebral pains.
- It is applied by small electrodes attached to a portable stimulator (Fig. 1.10).
- The actual stimulation sites needs to be identified by trial and error methods.
- Similarly the intensity and duration of stimulation also is by trial and error.
MASSAGE
This is one of the age old methods of treatment. It is known to have the following beneficial effects:
- It increases the blood supply to the part.
- It helps in the drainage of fluid from the affected part.
- It provides muscular relaxation.
- It decreases the chances of muscle atrophy.
- It is helpful in the treatment of arthritis, sprains and contusions.
- It is also helpful in the treatment of backaches.
Types These are five different types of massage:
Effleurage
- This consists of a superficial stroking towards the body or heart by slow, gentle and rhythmic movements.
- The pressure exerted must be light and repeated in the same direction.Depending upon the types of stroking, the following types are described:
- Using tips of the fingers This is used to massage the joints.
- Using the thumb Used between two muscles, between a muscle and tendon, interossei of the hand and feet (Fig. 1.11B).
- Using one hand Used on the extremities, back of the head and neck.
- Using both hands Used over chest, back, double neck massage or the lower limbs (Fig. 1.11A).
- This technique involves striking in the same direction of flow of the lymph and venous blood.
- It is used to empty the contents of veins and lymph in their direction of flow.
- The muscles have to be relaxed while practicing this method.
Petrissage
- This consists of kneading, wringing, lifting or pressing a part to assist in the venous or lymphatic circulation.
- It helps in stretching the retracted muscles and tendons.
- It helps in stretching the adhesions.
Friction
- Here the part is pressed deeply in a circular direction with the hands.
- This loosens the deep adherent skin, scars or adhesions.
- It also helps in the absorption of effusions.
- It is used around hands, feet and face.
- It can also be given with the thumb, fingertips or hand.
Percussion (also called tapotement) This is a method of rapid massaging with the hand. Four types are described:
- Beating with a clenched fist.
- Tapping with tips of the fingers.
- Beating with ulnar borders of the hand.
- Clapping with the palms of your hands.
ASSISTIVE DEVICES
Various assistive devices are required to carry out acti-vities of daily living after the limb fractures. Upper limb fractures affect the activities of daily life whereas the lower limb fractures affect both functional activities and ambulation making the task of rehabilitation that more difficult.
What are the activities of daily living?
- Dressing
- Bathing
- Grooming
- Toileting
- Ambulating
These are also known as functional activities. The following are some of commonly used assistive devices:
Upper Limbs
For shoulder injuries Devices are required to extend the reach of the patient to enable to hold or pick an object at height or below:
- Reacher (Fig. 1.12)
- Grooming aidsThis eliminates the need for the shoulder to stretch or reach.
Elbow injuries here also reach is facilitated by grooming aids or reachers.
Forearm To decrease the torque while opening the doors, built in door handles are provided.
Wrist Again here built up door knobs and keys are provided to decrease the torque.
For the Spine
Following a spine injury, it is difficult to bend to carry out activities like wearing shoes, socks, etc. or to reach up. These activities now require certain aids:
For the Lower Limbs
In terms of rehabilitation lower limb fractures provide a greater challenge, for not only the functional activities are affected but even ambulation is disturbed.
Hip joint The toilet activities are severely affected after a hip injury. Ambulation is also rendered difficult. The following aids are now required to carry out the above functions:
| Raised toilet seats |
| Reacher |
| Walkers, crutches and cane |
Knee joint/leg/foot and ankle
| Crutches, walkers, canes |
| Sock aid |
| Shoe horns |
| Reachers |
Walking aids like crutches, walkers and canes are discussed in detail in appropriate sections.
ROLE OF BRACES AND SPLINTS
These include:
- Cast braces
- Spinal braces
- Cervical orthoses
- Splints.They are discussed in appropriate sections.
ROLE OF TRACTION
Traction occupies an important role in the conservative management of orthopedic disorders. These include:
- Spinal traction
- Cervical tractionThey are discussed in appropriate sections.
AMBULATION AFTER A LOWER LIMB FRACTURE
An active mobile person suddenly becomes immobile after a lower limb fracture. Immobility takes a heavy toll on the body and mind of the victim. The goals and responsibility of a physiotherapist is lower limb rehabilitation is as follows:
Goal To put the patient back on his feet again.
Responsibility To restore the normal ambulation.
Making Ambulation Possible
When the child first learns to walk, it suddenly does not do so. It first learns to actively use the joints of the upper and lower limbs, thereby strengthening them. Then it slowly tries to stand up on its feet with the help of the parents or some, external support and tries to balance it. After having learnt to balance itself properly, it now starts to ambulate with the parental or some external aid. It first learns how to walk on a level ground and only after having mastered; it attempts to learn how to climb the stairs, jump, run, etc. This is how; you and I learnt how to walk.
Now when we make an attempt to make the patient walk again, we have to necessarily put him through the same walking process a child goes through namely:
- To have a strong and mobile joints (preambulation phase).
- Learning how to balance with appropriate support (ambulatory devices).
- Learning how to walk first with support and later without support.’
- Lastly after regaining sufficient skill in normal walking, the patient is then taught climbing, running, squatting, etc.
Nature taught a child how to walk; now you as a therapist should ‘aid’ nature to enable an injured person to walk again. A systematic lower limb rehabilitation protocol helps you achieve the goal of ambulation. The stages are discussed below:
Preambulation Measures
Before a person actually walks, he needs mobile, strong stable joints free of deformities. So the preambulation measures precisely aims to achieve these prerequisites.
Measures to obtain joint mobility By active and passive movements, efforts are made to regain the near ‘normal’ or at least ‘functional’ range of movements of hip, knee and ankle joints so necessary for ambulation (Table 1.4).
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Measures to Strengthen the Muscles
By sustained isometric, resistive and stretching, efforts are made to strengthen the hip extensors and abductors, knee flexors and extensors, ankle dorsiflexors and plantar flexors. These muscles help in ambulation.
After attaining adequate joint mobility and regaining the muscle strengths required for ambulation, the patient needs to be re-educated on pre-walking controlled co-ordination. Supine cycling (Fig. 1.15A) helps to achieve this goal.
Measures to Prevent Contractures and Deformities
A malaligned joint places enormous stress on the muscles, ligaments, cartilages and joints. This leads to early stress and fatigue. Hence efforts are made to obtain a deformity free joint by observing the following:
- Obtain an anatomic reduction of the fractures by closed or open reduction.
- Secure the reduction by stable internal or external fixations.
- Splint the joints in functional positions to avoid contractures.
After having obtained deformity free, mobile and strong joints of the limbs, a perfect platform is set-up for the therapist to realize the objective of the patient to walk again.
Ambulation Phase
Patient needs assisted ambulation before he attains independent ambulation. Assisted ambulation becomes necessary in the initial stages for the following reasons:
- Due to the structural damage to the skeletal system, the patient has difficulty in bearing weight on the lower limbs.
- The muscles of the trunk and limbs are weak.
- Balance in the upright posture is poor.
For these reasons, assistive devices become necessary during the initial phase of ambulation. The commonly used assistive devices are:
- Parallel bars
- Walkers
- Crutches
- Canes.
After having made the patient fit by a good pre-ambulatory therapy mentioned earlier, a therapist mobilizes the patient with suitable assistive devices.
The following are some of the more frequently used assistive devices:
Parallel Bars (Fig. 1.15B)
This is the first choice ambulatory device. The reasons being:
- It assists the patient in initial standing and walking.
- It gives the patient a sense of security.
- It helps the patient to get accustomed to upright posture
- Other assistive aids can be fitted easily while the patient stands between the parallel bars.
Regime within a parallel bar
- Adjust the height of the parallel bar such that the elbows of the patient are bent at 25-30° while standing within it.
- To propel forwards, patient first uses the hands than his legs by gripping the parallel bar firmly.
- Gradually, the patient is trained to put the body weight on the lower limbs by just placing the hands on the bars and not gripping it.
Walkers (Fig. 1.16)
From parallel bars, the patient progresses to a ‘Walker’. Though it serves the same function as the parallel bars, it is less stable.
The Frame
- It is made up of aluminum
- There are four adjustable legs
- Rubber tips are provided to the legs to prevent sliding.
The functions
- Same as that of the parallel bar
- It can be used both at hospital and home
- It can also be transported.
Tips of usage
- Adjust the height of the walker such that the elbow is bent to 25-30° while the patient is standing holding it.
- During walking, lift it first with both the hands and place it towards by 25-30 cm.
- Step into the walker first with the stronger leg and then with the weaker leg.
Limitations
- It is less stable when compared to the parallel bar.
- It is useful only on the level ground
- It cannot be used on stair cases.
Advantages
- It is very useful in the initial stages of ambulation.
- It is easy to use.
- Can be used as a permanent walking aid in the elderly people.
- It is not very expensive.
Crutches
Crutches are the most popular walking aid used to ambulate a patient with lower limb fractures.
Types There are two types of crutches
- Axillary
- Forearm.
Axillary crutch
- This is made up of wood or aluminum.
- It is used in patients who require crutches for a short time.
- They are easier to use than forearm crutches.
Forearm crutch (Fig. 1.17)
- These are also called as lofstrand crutches.
- They are recommended in patients who need to use the crutches for a long time.
- They allow the patient greater freedom of movement.
- The demands on the patient's clothing are less.
Axillary Crutch Walking (Figs 1.18A and B)
The crutch structure
- It is made up of wood or aluminum.
- It is got two uprights.
- It has an adjustable bottom.
- The bottom is fixed to the uprights with the help of two screws.
- It has an adjustable hand grip.
- The bottom has rubber tips to prevent slippage.
Measurements and position
- Measurement for a suitable crutch is taken from the anterior fold of the axilla to the medial malleolus.Note This prevents crutch palsy.
- Measurement can also be taken from a point 2" below the axilla to a point in the foot 6" in front and two inches lateral.
- In a standard positions, the tips of the crutches should be 15-20 cm in front and 15-20 cm to the sides of the foot.This forms a tripod base.
Important considerations in crutch walking
- Patient shifts 50 per cent of his body weight from the legs to his arms through a 30° flexed elbow.
- The following muscles need to be strengthened:
- The upper limbs Shoulder muscles, triceps, wrist extensors and finger flexors.
- The lower limbs the glutei, quadriceps, ankle plantar and dorsiflexors and the toe flexors.
- The patient should look straight ahead in the direction of his walk and not down.
- He should not bear the weight on the axillary crossbar for fear of crutch palsy.
- Posture in the crutch should be correct with the head erect, shoulder level, pelvis level, and knee joint extended and straight, feet should be below the hip joints.
- A limb length discrepancy should be corrected first before the patient stands and walks on the crutch.
- The patient is first taught to balance himself on a single crutch. This is practiced by standing on one crutch with one or both legs and moving the crutch freely in all directions. This is repeated on the other side also.
- The patient should learn to take even and steps at equal length and stride.
- Gradually, the patient should learn to walk forwards, backwards, sideward, turning and walking on slopes and stairs.
Gait Patterns
There are two types of gait patterns described in crutch walking:
- Based on the type of step taken Here two types are described step-to or step-through.Now let us analyze each step in detail:
- Step-to-gait In this the crutch and the fractured limb are advanced first and then the normal limb is advanced to the same position. E.g. Partial weight bearing or toe touch weight bearing after a tibial shaft fracture.
- Swing through gait Here the intact leg is advanced first with the crutch and then the fractured leg is advanced towards it. E.g. oblique mid-shaft tibial fracture that is nonweight bearing practices this gait (see Figs 1.18A and B).
- Based on the number of contact points used to take a step Here three types are described 2 point, 3 point and 4 point gaits.
- A two point gait (Fig. 1.19A)
- One point is formed by the fractured leg and crutches.
- Second unit by the uninvolved leg.In this gait, the second unit is brought towards the first unit. E.g. a NWB fracture of femur.
- A three point gait
- First point—formed by the crutches.
- Second point—involved leg.
- Third point—uninvolved leg.In this, each crutch and the weight limb are advanced separately, with two of the three points touching the ground at any given point of time. E.g. In femoral neck fracture that are partially weight bearing. Here the crutches are advanced first, followed by the fractured and intact limb respectively (Fig. 1.19B).
- Four point gaitPoint No 1 This is the crutch on the involved side.Point No 2 This is the uninvolved leg.Point No 3 The involved leg.Point No 4 Crutch on the uninvolved side.Here the crutches and the limbs are advanced separately. With three of the four points touching the ground at any given time. E.g. a partially weight bearing fracture with an additional problem like muscle weakness, anxiety, etc. (Fig. 1.19C).
Crutch Walking in Special Situations
- Walking on uneven surfaces like staircases
- Ascend the staircase with the unaffected leg first.
- Then bring the fractured limb up to meet the first leg, either simultaneously with the crutches or by keeping the crutches on the step below until both the feet are level.
- While descending the stairs, the reverse is done and fractured limb is brought down first.
- Getting in and out of a chair the chair should be well supported to prevent it from slipping. Remove the crutches from under one arm thereby freeing it. Now with the freed hand, the patient pushes down on the chair set or armrest to support the body weight. Finally the patient gradually sits by flexing the elbow.The reverse technique is used while getting up from the chair.
- Climbing staircases with support (banister) Hold one or two crutches on the uninvolved side. Hold the banister with the hands on the side of fracture. Climb the staircase first with the uninvolved leg then pull the body up to bring the affected leg on the same point as the unaffected leg.The opposite is followed to descend down the staircase with banister.
Weight-bearing status in a lower limb fractures
- Non-weight-bearing (NWB)
- Toe-touch weight-bearing (TTWB)
- Partial weight-bearing (PWB)
- Weight-bearing as tolerated (WBAT)
- Full weight-bearing (FWB)
What is Shadow Walking?
This is a non-weight-bearing gait—here
- The crutch on the opposite side of NWB is put forward first.
- The non-weight bearing limb is advanced next.
- The second crutch is put forward next.
- This is followed by the advancement of the normal limb.
Ambulation with the Help of a Cane
Purpose of a cane To relieve one extremity of some weight bearing load. This also provides continuous stability to the patient (Fig. 1.20).
Types of cane
- Standard cane
- Axillary crutch can be used like a cane
- Three or four legged cane can be used by the elderly. This provides greater stability (Fig. 1.21)
- Hemi walker: Patient uses this walker like a cane by holding it on the opposite side.
Parts of a cane
- Hand grip
- An upright
- Bottom with a rubber tip.
- It is made up of either aluminum or wood.
Methods of walking with a cane
- The patient stands holding the wall or chair for support.
- The heel of the shoes should be about 1-1½”.
- The height of the cane should be such that, the elbow is flexed to 25-30°.
- The patient is instructed to hold the cane on the unaffected side.
- Patient is advised to take short steps.
Why should the patient, hold the cane on the unaffected side:
- In normal walking the leg and opposite arm move together.
- It increases stability by providing a wider base.
- The shifting of the centre of gravity is eliminated.
THERAPEUTIC EXERCISES
Goal The goal of any therapeutic exercise is to restore a symptom free movement and function.
Apart from this, efforts should also be made to restore strength, endurance, flexibility, relaxation, and mobility and coordination skill to the pre-injury levels.
Note An unused muscle loses strength at the rate of 5 per cent/day to 8 percent/week.
BASIC PRINCIPLES
Any therapeutic exercise, should aim to achieve the following basic principles:
- Determine at the beginning itself the purpose of the exercises, whether the general condition of the patient needs to be improved or whether the joint function or muscle strengthening.
- Determine the amount of stress the exercise places on the patient.
- Ensure that the type of stress imposed by the exer-cises should be relevant to that function that is to be increased.
- The intensity and duration of stress imposed on the joint or muscles should increase gradually to achieve increase in tolerance, endurance and strength.
- Last but not the least, the exercise regimen should not leave the patient exhausted and tired.
- Muscle strength This is the ability of the muscle to contract against resistance.
- Endurance This is the ability to do the same movement repeatedly.
COMPREHENSIVE EXERCISE PROGRAM
A comprehensive exercise programme should include the following set of exercises:
- Range of motion exercises (ROM) This includes the exercises mentioned below:
- Full range of motion
- Functional range of motion
- Active ROM
- Active assistive ROM
- Passive ROM
- Strengthening exercises This further includes:
- Basic strengthening exercises three types are described:
- Isometric exercises
- Isotonic exercises
- Isokinetic exercises.
- High performance strengthening exercises
- Closed chain exercise
- Open chain exercise
- Plyometric exercises
- Functional exercises
- Conditioning exercises
Now, let us analyze each exercise in detail:
Range of Motion Exercises
This is the most basic form of exercise indicated in all phases of fracture rehabilitation:
Benefits The ROM exercises provide the following benefits:
- It prevents contractures from developing.
- It prevents muscle shortening.
- It prevents adhesions in capsules, ligaments and tendons.
- It provides the patient with sensory stimulation.
Principles
- In ROM exercises, the joint should be moved only with respect to its actual movement.
- The length of the muscles exercised should actually cross the joint.
Types of ROM Exercises
- Full ROM this is the anatomically determined range of motion in a joint, e.g. knee joint (0-120°, i.e. 0° to extension and 120° flexion).
- Functional ROM this is the range of movement in a joint just required to carry out a specific function, e.g. A 90° flexion of the knee joint is enough to enable a patient sit on a chair.
- Active ROM This is performed by the patient himself by his own efforts he tries to move a joint through its partial or full range.Indications
- To prevent loss of available joint movements.
- When a patient needs support due to weakness, pain, decreased muscle tone or cardiopulmonary problems.
- In the early phase of bone healing when there is less stability at the fracture site.
- Active assistive ROM In this when the patient is performing an active ROM the therapist assists or provides additional force.Indications This is used where there is weakness, restriction of movements due to pain or fear, or, to increase the available ROM. To do this exercise, there should be some stability at the fracture site either in terms of bone healing or fracture fixation.
- Passive ROM exercises Here the joint movements are performed not by the patient but by the therapist.
Aim To maintain or increase the available range of motion at a joint.
Indications These are indicated when the active muscle contractions are not possible or strong enough to overcome the capsular contractures of a joint.
Contraindications If excessive joint movements affect the stability at the fracture site, these exercises are contraindicated.
Procedural Norms during ROM Exercises
- Support the part gently but firmly.
- Hold the part in such a way that the joint can be moved through its entire range.
- All the segments distal to the joint should be supported.
- The movements should be slow to moderate
- Each joint should be moved through its full range
- Stop the exercises if the patient complains of pain.
- Care should be taken not to damage the joints further.
Strengthening Exercises
These exercises aim to increase the strength of the muscles by increasing the amount of force a muscle can generate. These exercises not only make the muscle stronger but improve the coordination of the muscles.
Basic Exercises of Strengthening (Table 1.5)
- Isometric exercises (also called set exercises) In this type of exercise the muscle is contracted without bringing about any joint movement (Fig. 1.22).Advantages
- It can be used where active movements of the joints are either not possible or desirable.
- Since it does not disturb the stability at the fracture site, these exercises can be used at the earliest possible time of fracture rehabilitation.
TABLE 1.5 Basic exercises of strengthening Effects of exercisesMuscle lengthTension of musclesJoint motionGain of strengthROMIndications (fracture healing)IsometricNo change↑NilIn one jointNo changeEarly stageIsotonicShortens and lengthens↑+Maximal gain at ends of jointSame or ↑Intermediate stageIsokineticShortens and lengthens↑+ (constant rate)Equal gain throughout ROMSame or ↑Late stage - It alleviates the fear of pain and apprehension in the minds of the patient about exercises, e.g. quadriceps or biceps contraction in a long leg or long arm casts.
- Isotonic exercises Here the muscle contracts and relaxes bringing about joint motion. This is a dynamic exercise performed using a constant load or resistance. Here the speed of movement is uncontrolled (Fig. 1.23).Indications These exercises are used in the intermediate and late stages of fracture rehabilitation, e.g. Progressive resistive exercises like biceps curls using increasing dumbbell weights.These exercises result in greater strength and cannot be used when the cast is in place.
- Isokinetic exercises Here joint movements are performed at a constant rate and the resistance is varied according to the muscle force (Fig. 1.24).This exercise helps to optimally strengthen the joint through its entire range of motion.Indications Indicated during the late stages of fracture healing when the fracture has already united.Disadvantages To maintain a constant rate of motion and vary resistance, it requires the use of a machine called the cybex.
High Performance Strengthening Exercise
Closed chain exercise:
- This requires the proximal and distal portions of the body being moved to be fixed.
- They are indicated when multiple muscle groups need to be strengthened simultaneously, e.g. Wall slide exercises and squats (Here ankle, knee and hip muscles are strengthened).
Open chain exercise Here there is no fixation of the distal limb unlike the closed chain, e.g. leg or biceps curls.
Plyometric exercise After a quick stretch, these exercises are performed by maximal muscle contraction. Useful only in the late stages of fracture rehabilitation.
23The above three exercises are useful to achieve a specific task after the fracture has healed, e.g. returning a patient to athletic activity after the fracture has healed.
Functional exercises These exercises are aimed to improve the functional activity of a patient. They improve the agility, strength and neuromuscular coordination.
- Stair climbing after femoral fracture.
- Ball squeezing after removal of cast in Colles fracture.
Conditioning exercises These are aerobic exercises which aim to improve the overall cardiopulmonary function and overall endurance of the patient.
For example, Stationary bicycle, Treadmill, etc.
Types of Muscle Contraction during Exercise
Isometric This has already been explained. Here there is no change in muscle fiber length and no joint motion. It helps to stabilize a joint.
Concentric Here the muscle contracts to bring about a movement of the joint. This increases the joint movement.
Eccentric Here the muscle fibers lengthen and slows down the movement of a joint. They generate more force than the above two exercises. Useful only after the fracture has completely united, e.g. progressive knee flexion during squatting.