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Occupational Therapy Perspective on Rehabilitation for Patient with Forearm Fracture
Ken WongOccupational Therapist (PWH)
14/3/10
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OT treatment goals in forearm fracture
1. Maximize elbow / forearm / wrist range of motion and strength
2. Minimize complications related to forearm fractures
3. Resume premorbid functional status in ADL, Work and Leisure
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Common problems encountered with forearm fracture
1. Post traumatic swelling2. Need of immobilization and controlled mobilization3. Diminished range of motion and strength4. Joint stiffness5. Uninvolved joints stiffness 6. Complications associated with forearm fracture7. Hypertrophic scar 8. ADL deficits9. Impaired work capacity
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(1) Post traumatic swelling
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Edema control
• Elevation of hand above the level of heart– Use sling with caution as it promote elbow and
shoulder stiffness– Use sling for short period only in crowded, public
situation
• Active finger mobilization– In conjunction with
elevation reduce edema by the pumping action
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Edema controlPressure garment
Finger stall Glove
Arm tube
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(2) Immobilization and controlled mobilization
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Indication for immobilization by splintage
1. Conservative treatment2. Post operative management
• Prevent displacement or angulations• Maintain correct alignment• Prevent excessive limb motion• Control direction of movement• Protect the healing fragments • Pain relief
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Tips on early controlled motion
• Approximately 80% of elbow contracture occurred within the first 3 weeks (Morrey, 2009)
• Elbow exhibits a marked tendency to develop articular adhesions, therefore early controlled motion is desirable (Talyor, 2003)
• Early motion can enhance bone healing and decrease recovery time after injury or surgery (Thompson ST, Wehbe MA. 1996)
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Controlled motion with LAB
LockLimit the elbow ROM
Neutral Supination
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Distal radius fractureForearm shaft fractureRadial head fractureOlecranon fracture
Monteggia fractureGaleazzi fracture
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Distal radius fracture
• Distal radius fracture occur as a result of a fall on the outstretched hand (Laseter, 2002)
• Cast for ~ 5 weeks• Start controlled active mobilization
– Colles’ fracture with dorsal displacement of fracture fragment
– Allow free wrist flexion with zero extension
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Short arm brace with dorsal block
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Controlled active mobilization
• Stable non-displaced fracture or post-operation
• Wrist resting splint– As a bridge between total
immobilization and no support (Georgiann F. Laseter, 2002)
• Encourage mobilization out of splint and put on splint for resting
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Forearm fracture• Conservative treatment of forearm shaft fractures
usually results in:– poor functional outcome – exception of undisplaced & simple fracture – resort to operative management
(Charnley, 1961)
• Functional bracing apply to: – non-displaced fractures– protective bracing in post operation
(Sarmiento, 1975)
• Interosseous membrane strain – immobilization provide opportunity for healing
(Charnley, 1961)
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Forearm fracture• Diaphyseal radial & ulnar fracture
• Result of a fall with axial loading on hand
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Forearm shaft fracture
• Isolated ulna shaft fracture (nightstick #)
• Results of a direct blow on ulna in a self- defense position
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• 3-4/52 – elbow cast in 90 with forearm in neutral position
• Then depending on # condition:– Hinge brace free elbow but keep
forearm in neutral – Circumferential forearm brace– Forearm cast– Free mobilization
Immobilization & controlled mobilization
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Radial head fracture
• Outstretched hand with elbow flexed and pronated• Most radial head fracture is crack # without
displacement
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** Forearm rotation lead to radial head fragment instability– limit forearm rotation
** Radial head is one of the anatomical restraints to valgus stress at elbow (Robbin et al, 1986)
– avoid valgus stress
• Long arm hinged brace with 30 to 100 elbow ROM and forearm in supination ~5/52
Immobilization & controlled mobilization
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Olecranon fracture• Fall on the olecranon process• Undisplaced stable fracture
conservative Rx• Displaced fracture
operative Mx
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Immobilization & controlled mobilization
** Elbow in 90, bone fragments are held together by surrounding aponeurosis
** Too much elbow flexion lead to increased tension over # site by tricep muscle
1-3/52– LAB with elbow keep in 90 and
forearm in full supination / neutral
3-7/52 onward– LAB hinge brace with elbow 0-90
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Monteggia / Galeazzi fractureMonteggia fractureUlnar shaft fracture associated with dislocation of radial head /PRUJ
Galeazzi fracture Radial shaft fracture associated with dislocation at DRUJ
• Fracture dislocation of the forearm results in an extremely unstable skeletal dissociation poor result• Fell with outstretched hand with hyperpronated forearm / direct blow• Need operative management
Monteggia Galeazzi
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** Reduction of fracture dislocation– Difficult to maintain– Prone to malunion
• Radioulnar joint incongruence – Severe loss of forearm rotation
(Reckling, 1982)
• 4-6/52– Long arm cast
(elbow in 90, forearm in supination)• 6/52 onward
– Long arm hinge brace (free elbow, forearm in supination)
Immobilization & controlled mobilization
Rehab. is guided by the stability of PRUJ / DRUJ reduction
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(3) Diminished ROM and strength
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Compare with contralateral sideMotion Normal
ROMFunctional
ROM
ElbowExtension 0 30
Flexion 145 130
ForearmSupination 85 50
Pronation 80 50
WristExtension 60 40
Flexion 60 40(O’Neill et al, 1992)
Functional ROM (Braddom R., 1996)
The joint movement required for functional use in daily living tasks
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Loss of forearm rotation is extremely disabling (Duncan, 1992)
• Forearm fracture usually results in loss of forearm rotation – complicated dual intra-articular structures of the PRUJ / DRUJ
• Forearm rotation is one of the important features that differentiate human as the most highly developed hominids / mammals (Almquist, 1992)
– Forearm rotation– Increase in brain size– Prehensile thumb
• Regaining forearm rotation is one of our treatment focus
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Forearm rotation trainingS
SS
P P P
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Elbow & wrist mobilization Hand function training
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• Wrist extensor weakness is due to a period of immobilization in a flexed position (Stanley. B & Tribuzi M, 1992)
• Wrist extension with a substitution pattern by long finger extensor (Terri M. Skirren, 2002)
• Reestablish independent wrist extension is critical to the development of power grip and hand function (Werremeyer MM et al. 1997)
Wrist extensor weakness x fracture DR
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Wrist extension / flexion training
• Re-establish normal muscular balance
• Synergistic relationship
– Wrist ext. with finger in flexion
– Wrist flexion with finger in either extension
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Progressive resistive strengthening activities
Strengthening Start only when
Fracture is clinically stable
Healing in progress
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Strengthening with computer machinery
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(4) Joint stiffness
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Corrective splintage
When to start corrective splintage?
• Joint ROM plateaus before reaching the acceptable functional ROM
• Corrective splintage applied for loss of motion related to:
soft tissue tightness
bony blockage or joint incongruence
(Richard, 1995)
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Basic principles
• Excessive / aggressive passive stretching lead to reactive inflammation (Richard, 1995)
• Low-load prolonged stress (LLPS) is more effective than high load brief stress (HLBS) (Flower KR & Michloritz SL, 1988)
– 20-25 minutes alternative stretching, 5-6 times a day
• Stretch are followed by AROM to re-establish neuromuscular control within the newly obtained motion arcs (Smidt, 2002)
Corrective splintage
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Forearm rotation brace
Provides progressive stretch to the joint capsule and soft tissues
Circumferential short arm splint can prevent torque at the wrist
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Supination
Pronation
Follow the axis of radioulnar joints radial head proximally to the fovea of the ulnar head distally
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Turn buckle brace for wrist E/F
Turn buckle bracing provides progressive stretch to joint capsule and soft tissues by a serial adjustment of the buckle
- Buckle -
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Wrist Extension
8 cm 5 cm
Circulation
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Wrist Flexion
8 cm 5 cm
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Passive stretching device for wrist E/F
OPD training – alternative wrist E/F stretching
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Turn buckle brace for elbow E/F
Turn buckle bracing provides progressive stretch to joint capsule and soft tissues by a serial adjustment of the buckle
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JAS device for elbow E/F
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(5) Uninvolved joints stiffness
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Mobilization of uninvolved jointsMobilization of shoulder, elbow, wrist, fingers & thumb
Prevent soft tissue adhesion Maintain joint mobility
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(6) Complication associated with
forearm fracture
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Neuropathy
PIN (forearm shaft #) Dynamic outrigger splint
Radial n. (monteggia #)Dynamic wrist and finger outrigger splint
Sensory branch of radial n. (Galeazzi #) sensory charting + sensory reeducation
Ulnar n. (olecranon #) anti claw hand
Medial n. (DR #) wrist neutral splint
Anti claw.
Transient TardivePermanent
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Delay- / non- / mal- union
– Common1. Complicated forearm anatomical structure2. Imperfect immobilization
• rotatory shearing movement between fragments
** Improve compliance with immobilization and controlled mobilization program
** Operative management
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Ulnar wrist pain• Common in DR#• DRUJ instability, ulnar variance• Wrist arthroscopy• Conservative Rx or post op rehab. program
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Osteoarthritis
• Post traumatic• Irregularity of a joint surface will accelerate
the OA changes
** Avoid heavy weight bearing
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Reflex Sympathetic Dystrophy (RSD)
Close monitoringStart with gentle mobilization as toleratedPressure garmentResting splint for pain reliefEncourage active use of hand in ADL tasks
•Persistent pain•Persistent swelling•Joint stiffness•Trophic skin changes•etc…(Procacci P, 1987)
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(7) Hypertrophic scar
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Scar management
PG +/- Padding Silicon gel
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(8) ADL deficits
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Encourage early involvement of affected limb in
ADL tasks
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ADL training and aid prescription
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(9) Diminished work capacity
Return to work?
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Stage Model of Industrial Rehabilitation
Goal of Work Rehabilitation Transition of Patient to Worker
Work Capacity Evaluation
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Work Complexity / DiversityWork Complexity / Diversity
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Job AnalysisJob Analysis•• Identify a patientIdentify a patient’’s Job Demand to match with s Job Demand to match with
the patientthe patient’’s Work Capacity to determine s Work Capacity to determine treatment goals.treatment goals.
Job DemandPhysical demandBreakdown of tasksTools and machines handlingPhysical Work environment
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Taste & Feel
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Work Capacity Evaluation To measure patient’s work capacity
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Job demand vs pt’s work capacity
• Pt’s work capacity > job demand– Return to work
• Job demand > pt’s work capacity– Start work hardening program
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Work hardening programIntensive job-specific training to improve pts’ work capacity
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Work hardening Structured work simulation
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Work hardening Work Simulators
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Conclusion• Forearm fracture is a common but difficult
orthopaedic condition
• Ultimate goal is to restore premorbid functional status
• Require team work in the hospital settings– Orthopaedic specialists– Nurses– Occupational / Physical Therapists
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~ Thank you~
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