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INTRODUCTION

Supracondylar region extends from the femoral condyles to the junction of metaphysic with femoral shaft.

The distal fragment is displaced and angulated posteriorly due to the pull of gastrocnemius muscle.

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The sharp edge of the fracture fragment can injure the popliteal artery.

Supracondylar fractures of the femur although uncommon, are very challenging injuries to treat.

The fracture is often comminuted depending upon the severity of the force.

These fractures occur in two different age groups due to different types of injuries.

In young adults these fracture occurs due to high energy injury, usually seen in road traffic accidents, sport injuries.

In elderly patients due to low velocity injury like fall during walking, it may be an osteoporotic fracture.

Treatment of these fractures has been a controversial subject over the past 20 years.

Early surgical stabilization can facilitate care of the soft issue, permit early mobility and reduces the complexity of nursing care.

Open reduction and internal fixation has been advocated, using implants, including angle blade plate, fickle devices, Rush roads, Endernails and interlocking nails.

These implants can be used in various circumstances like simple fractures and complicated cases eg. in fracture after total knee arthroplasty.

Fixation of supracondylar fracture of femur with dynamic condylar screws.

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AIM OF THE PROJECT

To evaluate the effectiveness of various physiotherapeutic techniques in a

patient with Supracondylar fracture of femur. To know the condition to

preserve maximum function of the femur and muscles strength even after

femur fracture using the various exercises, proper measures to preserve

maximum range of motion(ROM) of the knee joint and maintain good

posture and gait.

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ANATOMY

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Femur is the bone of the thigh. The femur is the longest and

strongest bone in the body.

Above it involves in the hip joint and below involves in the knee

joint.

The femur transmits body weight from pelvis to the tibia,

The femur consists of upper end, lower end and shaft.

1. Upper end : It is facing upwards, it consists of :

a. Head : It is facing upwards, medially and slightly forwards, it is articulates

with the acetabulum of the hip bone. Its surface is smooth and is marked a little below and behind its

centre by a small roughened pit.

b. Neck : It is a larger narrow constricted portion in between head and shaft.

The length is about 5cm. Anterior surface is completely covered by joint capsule, whereas medial half of posterior surface is covered by joint capsule.

c. Greater trochanter : It is a large quadrangular prominence, which projects upward from

the junction of the neck. It consists of three surfaces- anterior, lateral and medial surface. It is also consists one prominent border on the superior aspect.

d. Lesser trochanter : It is blunt conical projection at inferio-medial part of junction

between neck and shaft.

e. Inter trochanteric line : It is a rough oblique ridge at the junction of anterior surface of neck

with shaft, below it is continued with spiral line.

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f. Inter trochanteric crest : It is smooth rounded ridge on the posterior aspect at the junction of

neck with shaft.

g. Quadrate tuberosity : It is rounded small elevation on the middle of inter trochanteric crest.

2. Lower end :

It is expanded and consists of bony masses, known as condyles. The medial condyle is larger whereas lateral condyle is smaller but

stronger than medial condyle. The condyles are smooth convex consists of articular surfaces-

anterior, inferior and posterior.

a. Anterior articular surface : It is known as patellar surface, as it articulates with posterior surface

of patella.

b. The inferior and posterior surface: The condyle articulates with the superior surface condyles of tibia to

forms the knee joint.

c. Inter condylar fossa : It is a large depression at posterio-inferior aspect between the two

condyles.

d. Popliteal surface : It is a triangular area on posterior aspect above the condyles. It forms

floor of the popliteal fossa.

3. Shaft :

The medial portion is narrow and both upper and lower parts become expanded. The middle one by third of the shaft consists of three borders- lateral, medial and posterior, three surfaces- anterior, medial and lateral.

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Three borders:

a. Lateral border : It is rounded and not well defined, separates anterior surface from

lateral surface.

b. Medial border : It is also rounded and not well defined; it is separates anterior

surface from medial surface.

c. Posterior border : It is also known as linea aspera. It is formed by a broad rough

ridge, consists of lateral and medial lips.

The medial above becomes spiral line and below becomes medial lip of aspera.

The lateral above becomes gluteal tuberosity and below becomes lateral Supracondylar ridge.

Three surfaces:

a. Anterior surface : It is smooth rounded and convex lies in between medial and

lateral borders.

b. Medial surface : Facing medially and posteriorly lies in between medial border

and linea aspera.

c. Lateral surface : Facing laterally and posteriorly lies in between lateral border and

linea aspera.

Upper posterior surface is an area between spiral line and gluteal tuberosity.

Lower posterior surface lies between lateral and medial supracondylar ridges (popliteal surface).

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MUSCLE ATTACHMENTS:

I. ADDUCTOR GROUP :

Adductor Magnus:

Origin : Inferior ramus of the Pubis, ramus of ischium, ischial tuberosity.

Insertion: Linea aspera and adductor tubercle.

Actions: Adduct hip, medially rotate hip, assist hip flexion posterior fibers also extend the hip.

Adductor Longus:

Origin: Pubic tubercle.

Insertion: Medial lip of linea aspera.

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Actions: Adduct hip, medially rotate hip, and assist hip flexion.

Adductor Brevis:

Origin: Inferior ramus of pubis.

Insertion: Pectineal line and medial lip of linea aspera.


Pectineus:

Origin: Superior ramus of pubis.

Insertion: Pectineal line of femur.


Gracilis:

Origin: Inferior ramus of pubis and ramus of ischium.

Insertion: Proximal, medial shaft of tibia at pes anserius tendon.

Actions: Adduct hip, medially rotate hip, assist hip flexion also flexes and medially rotates the knee.

II. GLUTEAL GROUP:

Gluteus Maximus:

Origin: Coccyx, posterior sacrum, posterior iliac crest, sacrotuberus and sacroiliac ligaments.

Insertion: Gluteal tuberosity (Upper fibers), iliotibial tract (Lower fibers).

Actions: Extends, laterally rotates, and abducts the hip; lower fibers, adduct the hip.

Gluteus Medius:

Origin: External surface of the ilium between the iliac crest and posterior and anterior gluteal lines.

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Insertion: Greater trochanter.

Actions: Abducts, flexes, extends and laterally and medially, rotates hip.

Gluteus Minimus:

Origin: External surface of the ilium between anterior and inferior gluteal lines .

Insertion: Anterior border of greater trochanter.

Actions: Abducts, flexes, and medially rotates hip.

III. HAMSTRINGS :

Biceps Femoris:

Origin:

Long head: Ischial tuberosity .

Short head: Lateral lip of linea aspera.

Insertion: Head of the fibula .

Actions: Flex knee, extend hip, tilt pelvis posteriorly, also laterally rotate hip and flexed knee.

Semitendinosus:

Origin: Ischial tuberosity .

Insertion: Proximal, medial shaft of the tibia.

Actions: Flex knee, extend hip, tilt pelvis posteriorly, also medially rotate hip and flexed knee.

Semimembranosus:

Origin: Ischial tuberosity .

Insertion: Posterior aspect of medial condyle of tibia.

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Actions: Flex knee, extend hip, tilt pelvis posteriorly, also medially rotate hip and flexed knee.

IV. ILIOPSOAS :

Psoas Major:

Origin: Bodies and transverse processes of lumbar vertebrae.

Insertion: Lesser trochanter of femur.

Actions; Flexes, adducts and laterally rotates hip.

Iliacus :

Origin: Iliac fossa.

Insertion: Lesser trochanter of femur.

Actions: Flexes, adducts and laterally rotates hip.

V. LATERAL ROTATORS OF THE HIP :

Piriformis:

Origin: Anterior surface of sacrum.

Insertion: Greater trochanter.

Actions: Laterally rotate hip, abduct thigh when hip is flexed.

Quadratus Femoris:

Origin: Lateral border of ischial tuberosity.

Insertion: Posterior surface of femur between greater and lesser trochanter.

Actions: Laterally rotates hip.

Obdurator Internus:

Origin: Obdurator membrane and pelvic surface.

Insertion: Medial surface of greater trochanter.

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Obdurator Externus:

Origin: Superior and inferior rami of pubis.

Insertion: Trochanteric fossa of femur.


Gemellus Inferior:

Origin: Ischial tuberosity.

Insertion: Upper border of greater trochanter.


Gemellus Superior:

Origin: Spine of the ischium.

Insertion: Upper border of greater trochanter.


VI. QUADRICEPS FEMORIS GROUP :

Rectus Femoris:

Origin: Anterior inferior iliac spine (AIIS).

Insertion: Tibial tuberosity.

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Actions: Extend knee, flex hip.

Vastus Medialis:

Origin: Medial lip of linea aspera.


Actions: Extend knee.

Vastus Lateralis:

Origin: Lateral lip of linea aspera, gluteal tuberosity.



Vastus Intermedius:

Origin: Anterior and lateral shaft of femur.



Sartorius:

Origin: Anterior superior iliac spine (ASIS).

Insertion: Proximal, medial shaft of tibia.

Actions: Flex, abduct and laterally rotate hip, flex knee, medially rotate flexed knee.

Tensor Fascia Latae:

Origin: Iliac crest, posterior to ASIS.

Insertion: Iliotibial tract.

Actions: Flex, abduct and medially rotate hip.

NERVE AND BLOOD SUPPLY

Anterior compartment:

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This contains the flexors of the hip, and extensors of the knee, such as the quadriceps femoris. These muscles are supplied by the femoral nerve and the femoral artery.

Medial compartment:

The obturator nerve supplies the hip adductors in this compartment. Muscles include adductor longus, adductor brevis and gracilis.

Posterior compartment:

The muscles here are the hamstrings. These muscles flex the knee, and extend the hip. This compartment is sciatic nerve territory.

MODE OF INJURY

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The knee joint is subjected to a variety of forces during day to day

activities and sport. The nature of the forces may be direct or indirect.

An indirect on the knee may be:

a. Hyper extension

b. Twisting

c. Valgus

d. Varus.

A direct force may be:

a. Road traffic accidents.

b. Direct trauma to the lower end of the femur.

CLASSIFICATION

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I. NEER’S CLASSIFICATION :

1. Undisplaced fracture :

This fracture is impacted, linear, or slightly displaced, but

stable after closed reduction.

2. Displaced fractures:

a. Medial displaced fractures:

A more violent force applied to the antero-lateral side of the

flexed knee produces an oblique fracture extending from just

proximal to the lateral epicondyle to well above the medial

epicondyle. This displacement is augmented by the pull of the

lower part of the adductor magnus.

b. Lateral displaced fractures:

Severe force applied to the lateral side of the extended limb, as

when the limb struck by an automobile, produces this fracture

which tends to be transverse and usually produces a condylar

segment which is longer on the lateral side.

3. Comminuted fracture:

Extreme violence applied to the anterior aspect of the flexed

knee, as in a fall from a height or in a motorcycle accident

produces this lesion.

Comminuted fractures are associated with maximum damage

to the quadriceps tendons

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II. SEINSHEIMER CLASSIFICATION:

Seinsheimer in 1980 published a classification of fractures of

the distal 3 1/2 inches of the femur based on his experience.

His classification divided the fractures into groups based on

location and degree of comminution.

Type I represented any fracture of less than 2 mm

displacement.

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Type II fractures by the Seinsheimer classification involved a

distal metaphysis without intercondylar extension. Type IIA

was a two part fracture and Type IIB had greater

comminution.

Type III Seinsheimer fractures were any condylar injuries

extending into the intercondylar notch. In Type A, the medial

condyle was separated. TypeB - the lateral condyle was

separated and with TypeC, both condyles separated from the

shaft and each other.

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The Seinsheimer IV was articular fractures that went outside

of the intercondylar notch through the articular surface either

medially or laterally. A Type IV C was a comminuted,

complex intercondylar injury.

III. AO CLASSIFICATION:

The AO/OTA classification originally developed by Maurice Muller in the 1960's, divided supracondylar fractures into three main types.

It has been adopted by the OTA as a classification of choice and is included in the OTA compendium of all fracture and dislocation classifications for the entire musculoskeletal system as published in a Supplement to the Journal of Orthopaedic Trauma in 1996.

As seen in below Image, the AO/OTA classification numbers the major bones. The femur is bone number 3. Bone number 3 is divided into proximal, middle and distal components which are designated by a second digit (1, 2, and 3 respectively).

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The distal supracondylar area is designated by the number 33.

It is divided into three articular injuries. They are :

Extra-articular injuries (33A).

Partial articular (33B)

Intra-articular injuries (33C)

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CLINICAL FEATURES

Patient usually presented with history of trauma and complains of typical

symptoms of fracture:

Pain.

Swelling.

Tenderness.

Restriction of joint movement.

Decreasing joint ROM.

Bruising around the knee.

Flexion deformity caused by the pull of gastrocnemius.

Haemarthrosis is commonly seen especially with fractures extending

in to the joint.

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COMPLICATIONS

A. KNEE STIFFNESS : Occurs due to prolonged immobilization, particularly in older

patients.

The causes are:

a. Adhesions inside the joint. (tibio femoral)

b. Adhesion of patella to the femur.

c. Adhesion of quadriceps muscle to the fracture site more particularly in cases treated by open reduction.

B. MALUNION: A mal-union may result in varus or valgus deformities,

sometimes requiring a corrective osteotomy.

C. NON-UNION : Is usually due the interposition of soft tissues between the

fragments. This will need operative reduction and internal fixation with intra-medullary nailing, supplemented with bone grafting.

D. DEEP VEIN THROMBOSIS : It is a common complication associated with lower limb

injuries. Immobilization following trauma leads to venous stasis which results in thrombosis of vein treated by the elevation of the limb, elastic bandage and anticoagulant therapy.

E. INFECTION : Infection of the bone is an early complication of fractures. It

occurs more commonly in open fractures, it is treated by proper care of an open fracture can prevent osteomyelitis.

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F. ISCHAEMIC CONTRACTURES: Medial and lateral popliteal nerves and vessels may be

involved due to compression. Posterior tibial nerve and vessel canals are involved. Therefore a careful watch is necessary to detect the signs of compression early to prevent ischia.

G. Injury to the popliteal vessels and common peroneal nerves.

H. Joint stiffness as a result of immobilization of the knee joint during holding of reductionemic contractures.

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INVESTIGATIONS

Radiological features:

In supracondylar fractures, a fracture line is seen just above the

condyles, or in severe cases, it may be comminuted.

Anteroposterior, lateral, and two 45-degree oblique radiographs of

the distal femur should be obtained.

Radiographic evaluation should include the entire femur.

Traction views may be helpful to better determine the fracture

pattern.

Contralateral views may be helpful for comparison and serve as a

template for preoperative planning.

Complex intra-articular fractures and osteochondral lesions may

require additional imaging with computed tomography to assist in

completing the diagnostic assessment and preoperative planning.

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Magnetic resonance imaging (MRI)may be of value in evaluating

associated injuries to ligamentous or meniscal structures.

Arteriography may be indicated with dislocation of the knee,

because 40% of dislocations are associated with vascular disruption.

The reason is that the popliteal vascular bundle is tethered

proximally at the adductor hiatus and distally at the soleus arch. By

contrast, the incidence of vascular disruption with isolated

supracondylar fractures is between 2% and 3%.

CT-Scans are not necessary, however if there is any question

regarding the inter pretation of the x-rays or if the involves the joint

surface.

CT with sagittal and coronal reconstruction is useful.

CT better delineates fracture patterns and articular involvement.

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MANAGEMENT

ORTHOPAEDIC TREATMENT

A. Conservative method

B. Traction method

C. Operative method

A. CONSERVATIVE METHODS:

This has a limited role and is usually useful in impacted and undisplaced fractures.

In the former, a long leg or spica cast is sufficient and in the latter a long above knee cast after an intial period of skin or skeletal traction is all that I required.

B. TRACTION METHODS:

a. Upper tibial traction

b. Two-pin traction

a. Upper tibial traction: Here the skeletal traction is applied through the upper end of

tibia.

Intial weight used is around 15 to 20 lbs and is subsequently reduced.

The traction is given for a period of 8 to 12 weeks and the patient is put on cast braces.

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To prevent the knee stiffness from developing the patient is encouraged to carry out the knee movements during the traction itself.

b. Two-pin traction method :

In this method traction is added through the distal femur apart from the traction given through the upper end of the tibia.

This helps in accurate reduction of the fracture and also maintains the reduction so obtained.

The disadvantage of this technique is that it is cumbersome and may cause neuro vascular compressions in around the knee.

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C. OPERATIVE METHOD: Surgical therapy requires reduction followed by fixation to

maintain alignment. Options include external fixation or internal fixation. Internal fixation is with intramedullary devices (eg, flexible rods, more rigid retrograde or antegrade rods) or extramedullary plates and screws.

PREOPERATIVE MANAGEMENT AND PLANING:

Immediate surgery is indicated;

Place the injured limb in balanced suspension with tibial pin traction.

Perform surgery immediately or within 24 to 48 hours after the injury.

A radiograph of the opposite normal femur is helpful for preoperative planning.

A tunnel view of the intercondylar notch is helpful in judging the displacement of vertical fractures into the joint.

Use templates to draw the outlines of the femur and fracture lines.

Determine the type, size, and position of the implants and the need for a bone graft.

Select all necessary instruments, implants, and back-up devices.

The chief surgeon must review and discuss the procedure step by step with the assistant surgeons and surgical staff.

INDICATIONS FOR SURGERY Extra-articular fractures in which acceptable reduction cannot be

obtained or maintained. Displaced intra-articular fractures. Distal femoral fractures combined

with ipsilateral (floating knee) or contra-lateral fractures to begin

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early mobilization of the knee and to facilitate control of the limb. Fix bilateral femoral fractures internally to facilitate general care.

Supracondylar femur fractures in patients with multiple system injuries.

Obesity. Extremely obese patients are best managed by internal fixation because of the difficulty in treating them with skeletal traction or a cast-brace.

Vascular repair. A distal femur fracture associated with vascular damage should be stabilized to protect the vascular repair.

CONTRAINDICATIONS

Patients with massive.

Severe comminution.

Severe osteopenia.

Presence of infection.

Severely contaminated soft tissues that cannot be adequately debrided.

PRINCIPLES OF TREATMENT Good pre-operative planning.

Gentle handling of soft tissue.

Accurate anatomical reduction.

Rigid, stable internal fixation.

Bone grafting of any defects.

Early, active rehabilitation of the limb and the patient. This type of careful preoperative planning is important to smooth

surgical technique and a successful outcome.

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Surgical techniniques:

Open reduction and internal and external fixation:

1. Screws: In most cases, they are used in addition to other fixation devices. In

noncomminuted, unicondylar fractures in young adults with good bone stock, interfragmentary screws alone can provide adequate fixation.

2. Plates: To control alignment (particularly varus and valgus) of the relatively

short distal articular segment, a fixed angle implant is frequently necessary.

A 95-degree condylar blade plate: This provides excellent fracture control but is technically demanding.

3. Dynamic condylar screw (DCS): This is technically easier to insert than a condylar blade plate, and

interfragmentary compression is also possible through its lag screw design.

Disadvantages of the DCS are the bulkiness of the device and the poorer rotational control than with the blade plate.

4. Non-locking peri-articular plates (condylar buttress plates):

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These are used with extensive comminution or multiple intra-articular fractures.

Screws may toggle within the plate holes; therefore, these plates have no inherent varus or valgus stability.

This stability must therefore be provided by additional fixation devices such as a second medial plate or by the inherent stability of the bone after fixation of the fracture.

5. Locking plates (with fixed angle screws): The development of locking plates made the nonlockingperiarticular

plate relatively obsolete.

Locking plates are an alternative to the DCS and blade plate. Like the DCS and the blade plate, locking plates are fixed-angle devices.

The screws lock to the plate and therefore provide angular stability to the construct.

Disadvantages of the DCS are the bulkiness of the device and the poorer rotational control than with the blade plate.

6. Intramedullary (IM) nails:

A. Antegrade inserted IM nail: It has limited use owing to the distal nature of the fracture. It is best

used in supracondylar type fractures with a large distal segment.

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Because at least 10 cm of intact bone above the intercondylar notch is normally required. Essential to success is the ability to secure the two distal screws into intact bone.

B. Retrograde inserted IM nail: It has the advantage of improved distal fixation. The disadvantages

are the further insult to the knee joint and the potential of knee sepsis if the nailing is complicated by infection.

7. External fixation: In patients whose medical condition requires rapid fracture

stabilization or in patients with major soft tissue lesions, spanning external fixation allows for rapid fracture stabilization while still allowing access to the limb and patient mobilization.

Definitive external fixation, although rarely used, can be in the form of a unilateral half-pin fixator or a hybrid frame.

Problems include pin tract infection, quadriceps scarring, delayed or nonunion, and loss of reduction after device removal.

POST-OPERATIVE TREATMENT:

During fixation of supracondylar femur fractures, the surgeon must assess the stability of fixation and quality of the bone.

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As soon as the drains are removed, begin knee rehabilitation. Continuous passive emotion (CPM) is helpful to regain knee motion in the immediate postoperative period.

The AO group advocates positioning the limb on a frame, with the hip and knee flexed 90Â°. This position, combined with CPM, prevents quadriceps contraction, helps decrease swelling, and enhances knee motion if the patient can tolerate it.

Continue CPM full-time until gait training is initiated and then intermittently after gait training is started. If CPM is unavailable, maintain the limb in the 90Â°/90Â° position for 4 to 6 days.

The suction drain is removed when the drainage fluid decreases which usually can be done after 48 hours.During this period, active and passive movements of the toes are encouraged.

If the fixation is solid and bone quality good, some patients can be allowed early weight bearing and motion, especially when intramedullary fixation is used.

If bone quality is good but not enough to allow early weight bearing, the patient may be placed in a hinged knee brace to allow early motion but kept off full weight bearing until radiographs show bone healing (at about 12 week).

If bone quality is poor, more rigid splinting may be required for about 6 weeks and then switched to a hinged brace.

Postoperative physical therapy is usually required.

ASSOCIATED VASCULAR INJURY

The incidence is estimated to be about 2%.

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If arterial reconstruction is necessary, it should be done before definitive skeletal stabilization.

Reduction of the fracture and temporary fixation with an external fixator or femoral distractor before vascular repair should be considered.

Definitive fracture management can proceed after the vascular procedure if the patient’s condition allows.

Fasciotomy of the lower leg should be performed in all cases

PHYSIOTHERAPY MANAGEMENT

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ORTHOPAEDIC GOALS:

To restore alignment and keep the articular step off in the knee joint to less than 1-2mm.

REHABILITATION GOALS:

To restore the hip, knee [normal flexion-135˚, functional-110˚] and ankle movements to normal.

To restore the strength of quadriceps, hamstrings, hip adductors and gastrocnemius muscles.

FUNCTIONAL GOALS:

To achieve a knee flexion of 90˚ for proper sitting and to restore back the normal gait.

I. CONSERVATIVE MANAGEMENT:

A. IMMOBILIZATION PERIOD:

During first 10-days:

a. General measures: Foot end elevation to prevent limb swelling.

Inspection of wound for erythema and infection.

Check the distal neuro vascular status.

Keep a watch for evidence for compartment syndrome of the leg.

b. Movements: For the hip, knee and ankle gentle active range of movement

exercises are commenced. At the knee joint, the goal is to achieve 60˚-90˚of flexion and full extension.

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No passive range of movement exercises at this stage.

c. Exercises: No muscle strengthening exercises are allowed at this stage.

d. Functional activities: The patient is advised non weight bearing for atleast3-months.

The patient can stand or transfer weight by using a walker or crutches.

A 2-point gait using a crutch or walker with no weight bearing on the extremity.

The patient is instructed to climb with the unaffected leg first and descend with the affected leg first.

For wearing trousers, patient is instructed to do with the affected extremity first and removing it from unaffected leg first.

After 10-days: Gradual knee mobilization is started.

It may begin as a relaxed passive movement preceeded by thermotherapy or cryotherapy.

Self-controlled mobilization by CPM is very effective.

Early mobilization improves and maintains the tone and strength of the quadriceps besides facilitating gliding plains of quadriceps mechanism.

Self assisted relaxed knee swinging, the patient, sitting at the edge of the bed and supporting the operated leg by the good one, is ideal technique of mobilization.

II. MOBILIZATION PERIOD:

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During 4-6 weeks:

Active knee flexion of more than 90˚ can be aimed at and active assistive knee movements are prescribed.

All the programmes should be made vigorous to gain further range and strength.

Partial weight bearing is intiated by 9 weeks following surgery and the patient is given proper education in walking.

During 8-12 weeks:

Partial weight bearing is permitted by 8-12 weeks. Proper gait training, ambulation and functional training are intiated.

Gentle passive movements to assist knee flexion can be commenced.

Isometric and isotonic exercises to the quadriceps and hamstrings can be intiated.

During 12-16 weeks:

Weight bearing can be progressed from partial to full.

Isometric, isotonic and isokinetic resistive exercises to the hip, knee and ankle and gentle progressive exercises are continued.

OPERATIVE MANAGEMENT

a. PREOPERATIVE

b. POSTOPERATIVE

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a. PREOPERATIVE

Give the psychological support to the patient.

Explain to patient about the post operative management.

Check the cast maintain properly.

Strengthening the un-involved muscles.

Active movements to the uninvolved joints.

b. POSTOPERATIVE

During first 10-days:

Foot end elevation to prevent limb swelling.

Inspection of wound for erythema and infection.

Check the distal neuro vascular status.

Keep a watch for evidence for compartment syndrome of the leg.

For the hip,knee and ankle gentle active range of movement exercises are commanced.At the knee joint,the goal is to achieve 60˚-90˚of flexion and full extension.

No passive range of movement exercises at this stage.

No muscle strengthening exercises are allowed at this stage. The patient is advised non weight bearing for atleast3-months.

The patient can stand or transfer weight by using a walker or crutches.

A 2-point gait using a crutch or walker with no weight bearing on the extremity.

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The patient is instructed to climb with the unaffected leg first and descend with the affected leg first.

For wearing trousers, patient is instructed to do with the affected extremity first and removing it from unaffected leg first.

After 10-days:

Gradual knee mobilization is started.

It may begin as a relaxed passive movement preceded by thermotherapy or cryotherapy.

Self-controlled mobilization by CPM is very effective.

Early mobilization improves and maintains the tone and strength of the quadriceps besides facilitating gliding plains of quadriceps mechanism.

Self assisted relaxed knee swinging, the patient, sitting at the edge of the bed and supporting the operated leg by the good one, is ideal technique of mobilization.

During 4-6 weeks:

Active knee flexion of more than 90˚ can be aimed at and active assistive knee movements are prescribed.

All the programmes should be made vigorous to gain further range and strength.

Partial weight bearing is intiated by 9 weeks following surgery and the patient is given proper education in walking.

During 8-12 weeks:

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Partial weight bearing is permitted by 8-12 weeks. Proper gait training, ambulation and functional training are intiated.

Gentle passive movements to assist knee flexion can be commenced.

Isometric and isotonic exercises to the quadriceps and hamstrings can be intiated.

During 12-16 weeks:

Weight bearing can be progressed from partial to full.

Isometric, isotonic and isokinetic resistive exercises to the hip, knee and ankle and gentle progressive exercises are continued.

STRENGTHENING EXERCISES FOR QUADRICEPS:

1. Isometric strengthening:

Indirect: Lie flat on back, face up. Contract quadriceps and imagine “pushing

knee down” into mattress with maximal force.These should be virtually no motion at the knee joint. This used in intial stages of quadriceps muscle strengthening exercise.

Direct strengthening: These conventional quadriceps exercises where the patient makes

voluntary contractions of the quadriceps muscle in standing or sitting positions.

2. Isometric straight leg raising:

Lie flat on back weight on ankle. Lift foot approximately 12inches of bed keeping knee completely straight, hold for 3-5 sec count out land. Lower leg to bend again slowly. Repeat 15 times, 3sets. The amount of weight on the ankle should be increased slowly from 0-20 lbs.

3. Isotonic strengthening:

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Once isometric exercises done with 15-20 lbs comfortably, limited range isotonic strengthening should be begun.

4. Terminal extension: Sitting upon a table or a high chair, with feet dangling, weight

around ankle, straighten (extend) the knee to full extension.

The knee should than be bent up to 30 of flexion slowly and

straightened again. Each flexion-extension arc is one repetition. Perform 15 repetitions, 3 sets.

This exercise should be begun with approximately 5-10 lbs and gradually increased to 20 lbs over several days to weeks.

5. Multiple small are isometrics or isotonic: If feasible, multiple similar contractures should be performed at

different angles of flexion. These should be begun isometrically and progressed to small arcs of isotonic flexion or extension.

Once terminal extension and multiple small are isometrics or isotonics done, comfortably, gradually increase to full range isotonic strengthening. This means sitting with leg extended and flexing all the way and extending all the way.

6. Isokinetic strengthening: People with more strenuous activities, typically athletes, sometimes

need to go beyond isotonic strengthening to isokinetic strengthening. This involves usage of isokinetic machinery such as BIODEX,

where not only the strength of the muscle contraction is trained but the speed of contractions as well.

The rate of development of force in muscle is known as “torque” training to recruit the fullest possible force in the muscles in the shortest time results in reduced.

41

STRENGTHENING EXERCISES FOR HAMSTRING MUSCLES:

1. Hamstring-setting (Hamstring set): Supine or long-sitting, with the knee in extension or slight flexion

with a towel roll under the knee.

Have the patient isometrically contract the knee flexors just enough to feel tension developing in the muscle group by gently pushing the heel into the treatment table and holding the contraction.

Have the patient relax and then repeat the contraction.

2. Multiple-Angle isometric exercises: Supine or long sitting, apply either manual or mechanical resistance

to a static hamstring muscles contraction with the knee flexed to several positions in the ROM.

Place the tibia in internal or external rotation prior to resting knee flexion to emphasize the medial or lateral hamstring muscles, respectively.

Teach the patient to apply self-resistance at multiple points in the ROM by placing the opposite foot behind the ankle of the leg to be resisted.

3. Hamstring curls: Standing, holding on to a solid object for balance. Have the patient

pickup the foot and flex the knee.

Maximum resistance from gravity occurs when the knee is at 90

flexion. If the patient flexes the hip, stabilize it by having the patient

place anterior thigh against a wall or solid object.

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In prone position with a cuff around the ankle, have a patient flex the

knee to only 90 . Maximum resistance from gravity occurs when the

knee first starts to flex it 0 .

If hamstring curls are performed in the prone position using manual resistance, a weight-pulley system or isokinetic resistance to the knee flexors can be applied throughout the range of knee flexion.

To avoid the patella compressions using that towel roll between the treatment table and femur.

4. Closed chain isometric exercises: Closed chain isometric exercises are done to facilitate co-contraction

of the quadriceps and hamstrings-

a. Setting exercises: Sitting on a chair, with the knee extended or slightly flexed and the

heel on the floor and the thigh against the seat of the chair and concentrate on contracting the quadriceps and hamstrings simultaneously to facilitate co-contraction around the knee joint.

b. Stabilization exercises: In standing, with weight equally distributed through both lower

extremities. Apply manual resistance to the pelvis in alternately directions as the patient holds the position.

This facilitates isometric contractions of muscles in ankles, knees and hips.

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Hamstring curl exercise Isotonic terminal extension

Quadriceps isometric Short arc quad

Long arc quad Hamstring isometric

Isometric straight leg raising Isometric for gluteal set

CONCLUSION

Supracondylar fracture due to direct or indirect forces.

44

Physiotherapy treatment is very important to restoring the joint function.

Supracondylar nailing is useful for fixation of Supracondylar and less comminuted intercondylar fractures. With minimal disruption to soft tissue, and good purchase of the distal bone fragment, this approach provides stable fracture fixation, allowing early joint mobilisation.

The rate of union is high, with a low incidence of complications. The simplicity of the procedure also facilitates fracture fixation in patients with multiple trauma, including those with multiple fractures.

Dynamic condylar screw fixation for distal femoral fractures achieves better functional outcomes and lower complication rates.

The excellent or good outcomes of femoral supracondylar fracture could be obtained through the operative treatment. The fixations of the retrograde locking and condylar buttress plate have their own advantages in biomechanical properties.

Assessment Chart

Name:

Age:

45

Sex:

Occupation:

Address:

1. Chief complaints:

2. History:

a. Present history :

b. Past medical history:

c. Personal history :

d. Family history :

3. Vital signs:

a. Blood pressure :

b. Pulse rate :

c. Heart rate :

d. Respiratory rate :

i. Type of breathing :

ii. Rhythm of breathing :

4. On Observation:

a. General built :

b. Posture :

i. Anterior :

46

ii. Posterior :

iii. Lateral :

c. Gait :

d. Deformities :

5. On palpation:

a. Warmth :

b. Tenderness :

c. Nodules :

d. Swelling, Oedema, Effusion :

6. Pain assessment:

a. Site :

b. Type :

c. Quantity: Vas scale.

d. On set of pain :

0_____________5_____________10

7. On Examination:

Sensory examination :

a. Superficial :

i. Light :

47

ii. Touch :

iii. Pain :

iv. Temperature :

b. Deep :

i. Pressure :

ii. Vibration :

iii. Cruel touch :

iv. Kinesthesia :

v. Proprioception :

c. Dermatomes :

d. Myo-tomes :

8. Motor assessment:

a. Tone :

i. Hyper tonicity :

ii. Hypo tonicity :

b. Power :

MMT :

c. Muscle bulk :

d. ROM :

e. Equilibrium :

48

f. Balance :

g. Gait description :

9. Investigation:

a. X-ray :

b. MRI :

c. Ct-scan :

10. Special test:

11. Diagnosis:

12. Treatment:

a. Problem list :

13. Aims of treatment:

a. Long term goals :

b. Short term goals :

14. Modalities required:

15. Exercise prescription:

16. Prognosis:

CASE STUDY- 1

Name: CH. NARASIMHA CHARY

Age: 55 years

49

Sex: Male

Occupation: Goldsmith

Address: Karimnagar

1. Chief complaints: Pain, abnormal mobility of the joint, swelling.

2. History:

a. Present history: Supracondylar nail fixation, antibiotics.

b. Past medical history: Hyper extension of knee in RTA.

c. Personal history: Alcoholic.

d. Family history : Well economic status

3. Vital signs:

a. Blood pressure : Normal (130/80mmhg)

b. Pulse rate : Normal (72/min.)

c. Heart rate : Normal (72/min.)

d. Respiratory rate : 15 breaths/min.

4. On Observation:

a. General built : Measomorphic.

b. Gait :

c. Deformities : Extension of knee.

5. On palpation:

a. Warmth : Present

50

b. Tenderness : Present

c. Nodules : Absent.

d. Swelling, Oedema, Effusion : Present

6. Pain assessment:

a. Site : Around the knee joint.

b. Type : Muscular.


d. On set of pain : 6 (moderate) 0_____________5_____________10

7. On Examination:


a. Superficial :

i. Light : Present.

ii. Touch : Present.

iii. Pain : Present.

iv. Temperature : Present.

b. Deep :

i. Pressure : Present.

ii. Vibration : Absent.

iii. Cruel touch : Present.

51

iv. Kinesthesia : Present.

v. Proprioception : Present.

c. Dermatomes : Normal.

d. Myo-tomes : Normal.


a. Tone : Hypotonicity.

b. Power :

MMT : 3

c. Muscle bulk : Atrophy (specially quadriceps).

d. ROM : Loss of ROM (active 30 , passive 45 )

e. Equilibrium :

f. Balance :


9. Investigation:

a. X-ray : Comminuted fracture of right and left Supracondylar femur

b. MRI :c. Ct-scan :

10. Special test:

11. Diagnosis:

12. Treatment:

52

a. Problem list :


To reduce the pain

To reduce the joint stiffness

To improve the joint ROM

14. Modalities required: CPM, ULTRA SOUND, IFT.


Stretching of calf muscle.

Isometric strengthening exercises for quadriceps and hamstring muscles.

16. Prognosis: GOOD

CASE STUDY- 2

Name: Manemma.

Age: 48 years.

Sex: Female

53

Occupation: House wife

Address: Karimnagar.

1. Chief complaints: Pain, inability to move the joint.

2. History:

a. Present history : Plate fixation, antibiotics.

b. Past medical history: Fall in bothroom with hyper extension of the knee.

c. Personal history : No.

d. Family history : Low Economic Status.

3. Vital signs:

a. Blood pressure : Normal (120/80mmhg)

b. Pulse rate : 70/min.

c. Heart rate : 72/min.

d. Respiratory rate : 12 breaths/min.

4. On Observation:

a. General built : Ectomorphic.

b. Gait :

c. Deformities : Deformity of knee.

5. On palpation:

a. Warmth : Present.

b. Tenderness : Present.

54


d. Swelling, Oedema, Effusion : Present.

6. Pain assessment:

a. Site : Above knee joint.

b. Type : Muscular pain.


d. On set of pain : 7 (moderate). 0_____________5_____________10

7. On Examination:


a. Superficial :

i. Light : Present.




b. Deep :


ii. Vibration :

iii. Cruel touch :

iv. Kinesthesia :

55

v. Proprioception :




i. Tone : Hypotonicity.

b. Power :

MMT : 2

c. Muscle bulk : wasting of quadriceps.

d. ROM : Active 30 , Passive40 of knee.

e. Equilibrium :

f. Balance :


9. Investigation:

a. X-ray : Supracondylar fracture of femur.

b. MRI :

c. Ct-scan :

10. Special test:

11. Diagnosis:

12. Treatment:

56

a. Problem list :


To restoring the knee function. To reducing the pain. To restore the strength of quadriceps, hamstrings.

To achieve a knee flexion of 90 for proper sitting and

To restore back the normal gait.

14. Modalities required: CPM, IFT, ULTRASOUND and TENS.


Isometrics of quadriceps and hamstrings. Active movements of uninvolved joints. Stretching of calf muscle.

16. Prognosis: Good.

CASE STUDY- 3

Name: Geetha. J

Age: 28 years.

Sex: Female

57

Occupation: Accountant.

Address: Mukarampura, Karimnagar.

1. Chief complaints: Pain, loss of mobility and swelling.

2. History:

a. Present history : Screw fixation, antibiotics.

b. Past medical history: RTA with hyper extension of knee.

c. Personal history : No.

d. Family history : Well Economic Status.

3. Vital signs:

a. Blood pressure : Normal (120/80 mmhg)

b. Pulse rate : 72/min.

c. Heart rate : 72/min.

d. Respiratory rate : 15 breaths/ min.

4. On Observation:

a. General built : Mesomorphic.

b. Deformities : Extension deformity of knee.

5. On palpation:

a. Warmth : Present.

b. Tenderness : Present.

58


d. Swelling, Oedema, Effusion : Present, pitting oedema.

6. Pain assessment:

a. Site : Around the knee joint.

b. Type : Muscular pain.


d. On set of pain : 10 (severe) 0_____________5_____________10

7. On Examination:


a. Superficial :

i. Light : Present.




b. Deep :


ii. Vibration : Absent.

59

iii. Cruel touch :

iv. Kinesthesia :

v. Proprioception :




a. Tone : Hypotonicity.b. Power :

MMT : 3

c. Muscle bulk : Reduced

d. ROM : Active 20 , Passive 30 of knee.

e. Equilibrium :

f. Balance :


9. Investigation:

a. X-ray : Comminuted supracondylar fracture of femur.

b. MRI :

c. Ct-scan :

60

10. Special test:

11. Diagnosis:

12. Treatment:

a. Problem list :


To restoring the knee function. To reducing the pain. To restore the strength of quadriceps, hamstrings.

To achieve a knee flexion of 90 for proper sitting and

To restore back the normal gait.

14. Modalities required: CPM, ULTRASOUND, IFT and TENS.


Isometrics of quadriceps and hamstrings. Active movements of uninvolved joints. Stretching of calf muscle.

16. Prognosis: Good.

BIBLIOGRAPHY

1. HUMAN ANATOMY- B.D. Chaurasia’s (4th edition).

2. GRAY’S ANATOMY- F. Davies (33rd edition).

61

3. ESSENTIAL ORTHOPAEDICS- J. Maheshwari (3dr edition).

4. TEXT BOOK OF ORTHOPAEDICS AND TRAUMATOLOGY- M. Natarajan (6th edition).

5. NOTES ON MUSCLES- S. Poddar.

6. ESSENTIALS OF ORTHOPAEDICS AND APPLIED PHYSIOTH -ERAPY- Jayant Joshi.

7. ESSENTIALS OF ORTHOPAEDICS FOR PHYSIOTHERAPISTS- John Ebnezar (1st edition).

8. TIDY’S PHYSIOTHERAPY- Stuart Porter (14th edition).

9. HAND BOOK OF FRACTURES- Kenneth J. Koval (3rd edition).

10. THERAPEUTIC EXERCISE FOUNDATIONS AND TECHNIQ- UES - Carolyn Kisner, PT, MS (5th edition).

11. CAMBELL’S OPERATIVE ORTHOPAEDICS- S. Terry Canale (11th

edition).

12. CHAPMANS ORTHOPAEDIC SURGERY- Michael w. Chapman (3rd edition).

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nani project work

Documents

facilitating

road traffic

poorer rotational

gentle progressive

tilt pelvis

early mobilization

past medical

inter trochanteric