i bc27f85be50b71b1 (52 page)

anatomically complex joints, such as the pelvis, sacrum, spine, or

shoulder.' CT is commonly used to define and localize spinal stenosis,

disc protrusion or herniation, nerve entrapment, bone tumor, and

osseous or articular bone infection or abscess.4

Magnetic Resonance Imaging

Magnetic resonance imaging (MRJ) is superior to x-ray or CT for the

evaluation of soft tissue. MRI detects partial or complete tendon, ligament, or meniscal tears. MRI has also been used to (1) detect patellar tracking abnormalities, rOtator cuff rcars, and arthritis; (2) detect and

localize soft tissue masses, such as hematoma, cyst, abscess, or lipoma;

and (3) evaluate bone marrow. Finally, the high resolution of MRJ reveals

stress fractures and bone bruises that could be unobserved on x-ray.'

Bone Scan

A bone scan is the radiograpllic picture of the uptake in bone of a radio

onuclide tracer. Scans of a portion of or the whole body may be taken

at the instant rhe tracer is injected or 5-1 0 minutes or 2-4 hours postinjection. Bone scan reAects the metabolic sratus of the skeleton at the time of the scan and is extremely helpful in detecting metabolic abnor·

malities of bone before the appearance of structural changes on x-ray.s

It is therefore used to detect skeletal metastases, especially in the base of

the skull, sternum, scapula, and anterior ribs.s Other uses of bone scan

include the diagnosis of stress fractures and other nondisplaced fractures, early osteomyelitis, inAammatory or degenerative arthritis, avascular necrosis (AVN), and myositis ossificans.

Arthrography

An arthrogram is a radiograph of a joint with air or dye cOntrast. Performed primarily on the knee, shoulder, and hip, arthrography allows examination for internal joint derangements or soft tissue disruption.

Arrhrograms may diagnose meniscal and cruciate ligament tears or

articular cartilage abnormalities of the knee, adhesive capsulitis or

rotator cuff tears of the shoulder, and arthritis or intra-articular neoplasm of the hip.'

Myelography

A myelogram is a radiograph or CT of the spinal cord, nerve root,

and dura mater with dye contrast. A myelogram can demonstrate spi-

MUSCULOSKEU-rAL SYSTEM 169

nal stenosis, cord compression, intervertebral disc rupture, or nerve

root injury.1

Clinical Tip

• X-rays may be ordered after any new event, such as an

in-hospital fall, abnormal angulation of an extremity, possible loss of fixation or reduction, or for a dramatic

inctease in pain. Regatdless of the situation, defer physical

therapy intervention until results are reported or the situation is managed.

• Physical therapy intervention is typically deferted for

the patient POSt myelography secondary to specific postprocedure positioning and bed test restrictions. (Refer to Myelography in Chaptet 4.)

• As with any test that includes contrast media, contrastrelated reactions post arthrogram or myelogram may

occur. Check with the nutse or physician befote physical

therapy intervention.

Fracture Management

Types of Fracture

The analysis and classification of fracture reveal the amount of energy

impacted on bone and the potential for secondary injury, and direct

fracture management. Fractures can be described according to the

followings:

1. The maintenance of skin integrity:

a. A closed fractllre is a bony fracture withour disruption of the skin.

b. An opel! fractllre is a bony fracture with open laceration of the skin or protrusion of the bone through the

skin.

2. The site of the fracture:

170 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

a. At the proximal third, distal third, or at the shaft of

long bones.

b. An intra-articular fracture involves the articular surface. Intra-articular fractures are furrher described as linear, comminuted, impacted, or with bone loss. An extraarticular fracture does not involve the arricular surface.

c.

An epiphyseal {racture involves the growth plate.

3. The configuration of the fracture (Figure 3-1):

a.

A linear fracture can be transverse (fracture is perpendicular to the long axis of the bone), oblique (fracture is on a diagonal to the long axis of the bone), or spiral

(fracture is similar to oblique with a greater surface area

of shaft involvement secondary to a circular pattern).

b. A comminuted {racture has two or more fragments.

A burterfly (wedge-shaped) fragment may or may not be

present.

e.

A segmental fractllre has two or more fracture lines

at different levels of the bone.

2

3

4

Fig'ure 3-1. Orientation of a fracture pattern. (1 = transverse; 2 = oblique; 3 =

segmental; 4 = comminuted.) (With permission from A Unwin, K Jones reds/.

Emergency Orthopaedics and Trauma. Boston: Butterworth-Heinemann,

1995;22.)

MUSCULOSKELETAL SYSTEM 171

4.

The extent of the fracture:

a. An incomplete fracture, in which one portion of the

cortex is interrupted.

b. A complete (ractllre, in which all cortices of bone are

interrupted.

5. The relative position of the fragments:

a. A flofldisplaced (rac/llre is characterized by anatomic

alignment of fracture fragments.

b. A displaced fracture is characterized by abnormal

anatomic alignmem of fracture fragments.

Cliflical Goal o( Frac/llre Management

The goal of fracrure management is bony union of the fracture without further bone or soft tissue damage that enables early testoration of maximal function.9 Early restoration of function minimizes cardiopulmonary compromise, muscle atrophy, and the loss of functional ROM. It also minimizes impairments associated with limited skeletal weight bearing (e.g., osteoporosis).

Fractures are managed either nonoperatively or operatively on an

elective, urgent, or emergent basis depending on the location and type

of fracture, presence of secondary injuries, and hemodynamic stabiliry. Elective or floflllrgellt management (days to weeks) applies to stable fractures with an intact neurovascular system or fracture previously managed with conservative measures that have failed.

Urgeflt management (24-72 hours) applies ro closed, unstable fractures, dislocations, or long bone stabilization with an intact neurovascular system. Emergent management applies to open fractures, fractures/dislocations with an impaired neurovascular system or compartment syndrome, and spinal injuries with deteriorating neurologic deficits.'

Fracture redllctiofl is the process of aligning and approximating

fracture fragments. Reduction may be achieved by either closed or

open methods. Closed redllction is noninvasive and is achieved by

manual manipulation or traction. Open reduction internal fixation

(ORIF) techniques require surgery and fixation devices (Figure 3-2),

commonly referred to as hardtl/are. ORIF is the treatment of choice