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1. Locomotor Dysfunction Capt. Myat Bhone Aung Assistant Lecturer M.B.,B.S, M.Med.Sc , Dr.Med.Sc (Rehabilitation Medicine) Department of Physical Medicine and Rehabilitation, DSMA 1

2. Rheumatoid Arthritis 2 Capt. Myat Bhone Aung

3. Definition Rheumatoid arthritis is an autoimmune disease causing a chronic symmetrical polyarthritis with systemic involvement. Its course is extremely variable and it is associated with nonarticular features. 3

4. There are three types of joints – fibrous, fibrocartilaginous and synovial. Fibrous and fibrocartilaginous joints the intervertebral discs, the sacroiliac joints, the pubic symphysis and the costochondral joints. Skull sutures are fibrous joints. Synovial joints the ball-and-socket joints (e.g. hip) and the hinge joints (e.g. interphalangeal ). 4

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6. Pathophysiology RA has an unknown cause. Although an infectious etiology has been speculated ( eg , Mycoplasma organisms, Epstein-Barr virus, parvovirus, rubella), RA is associated with a number of autoimmune responses, but whether autoimmunity is a secondary or primary event is still unknown. 6

7. The joints most commonly involved first the finger (40 %) a shoulder (20 %) a foot joint (20 %) a wrist (15%). The knee joint - first involvement only 3 % Asymmetrical onset is common 7

8. Common hand deformities Swan-neck deformity Boutonnier deformity MP jt.volar subluxation and ulnar deviation Thumb deformity 8

9. Swan neck deformity Although characteristic in RA, swan-neck deformity has several causes, including untreated mallet finger, laxity of the ligaments of the volar aspect of the PIP joint in old age or a normal variant. True swan-neck deformity does not affect the thumb, which has only one interphalangeal joint. 9

10. Multiple Joints Deformities 10

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12. ACR Criteria for Assessing Functional Status in Rheumatoid Arthritis 12

13. Risk Factors for Increased Morbidity and Mortality in RA Social factors Low socioeconomic status Lack of formal education Psychosocial stress Low HAQ scores Physical factors Extra-articular manifestations Elevated CRP and ESR High titers of RF Erosions on x-ray Duration of disease 13

14. American College of Rheumatology criteria for rheumatoid arthritis 1. Morning stiffness of at least 1 h 2. Arthritis of three or more joint areas 3. Arthritis of hand joints 4. Symmetric arthritis 5. Rheumatoid nodules 6. Serum rheumatoid factor positive 7. Typical radiographic changes in the hand and wrist Criteria 1-4 must have been for at least 6 weeks. 14

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16. Patients with a score of <6/10 are not classifiable as having RA, their status – reassessed and the criteria might be fulfilled cumulatively over time. 16

17. Joint involvement Any swollen or tender joint on examination- -Indicative of active synovitis -may be confirmed by imaging (MRI or USG) -any joint with known recent injury contribute to swelling or tenderness should not be considered - DIP Joint, first CMC joints , and first MTP joints excluded (often affected by osteoarthritis) 17

18. Large joints -- shoulders, elbows, hips, knees, and ankles. “ Small joints ” -- MCP joints, PIP joints, second through fifth MTP joints, thumb interphalangeal joints, and wrists 18

19. Definition of the serologic categories negative - < or = to the ULN for the laboratory test and assay low-level positive - higher than the ULN but < 3 times the ULN for the laboratory test high-level positive- >3 times the ULN for the laboratory test and assay 19

20. Rheumatoid factor RF is present in approximately 60-80% of patients with RA over the course of their disease but is present in fewer than 40% of patients with early RA. RF values fluctuate somewhat with disease activity, although high- titered RF generally remains present even in patients with drug-induced remissions. 20

21. Conditions in which rheumatoid factor is found in the serum 21

22. Antinuclear antibodies: These are present in approximately 40% of patients with RA, but test results for antibodies to most nuclear antibody subsets are negative. Newer antibodies ( eg , anti-RA33, anti-CCP): Recent studies of anti-CCP antibodies suggest a sensitivity and specificity equal to or better than those of RF, with an increased frequency of positive results in early RA. The presence of both anti-CCP antibodies and RF is highly specific for RA. Additionally, anti-CCP antibodies, as do RF, indicate a worse prognosis. 22

23. INVESTIGATIONS AND MONITORING OF RHEUMATOID ARTHRITIS To establish diagnosis Clinical criteria Acute phase response Serological tests X-rays To monitor disease activity and drug efficacy Pain (visual analogue scale) Early morning stiffness (minutes) Joint tenderness (number of inflamed joints, articular index) Acute phase response 23

24. To monitor disease damage X-rays Functional assessment To monitor drug safety Urinalysis Biochemistry Haematology 24

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26. Management Multidisciplinary Approach 26

27. Goals of Treatment (1) relief of pain, (2) reduction of inflammation, (3) protection of articular structures, (4) maintenance of function, and (5) control of systemic involvement 27

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29. Rehabilitative Treatment of Impairment, Functional Deficits, and Disabilities in RA 29

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31. Pharmacological Treatment 31

32. The New Treatment Paradigm Orthopedic surgery Higher dose steroids for flares or extraarticular disease Occupational therapy Physical therapy HE Intraarticular steroids Simple analgesic 32

33. Non pharmacological treatment 33

34. Non-Pharmacological Management of Rheumatoid Arthritis Rest Exercise Flexibility/stretching Muscle conditioning Cardiovascular/aerobic Diet/weight control Physical/occupational therapy 34

35. REHABILITATION INTERVENTIONS Rehabilitation treatment plans must be individualized for the patient's needs; they should be practical, economical, and valued by the patient to enhance compliance. Treatment should begin early in the disease process to help prevent impairment and functional decline and so that the patient identifies this as part of the overall management plan. REST Three forms of rest have been used by persons with arthritis: complete bed rest, local rest of a joint or joints with splints or casts, and short rest periods of 15 to 30 minutes dispersed throughout the day. 35

36. Systemic Rest Systemic rest has many adverse effects, including muscle weakness and bone loss. Currently, the approach to the management of RA has changed. Much more adequate pharmacologic management of disease activity exists, such as early treatment with DMARDS. Depending on disease severity, shorter periods of complete bed rest than formerly used may be needed. Several days of bed rest may be indicated for severe new-onset RA. 36

37. 37 Local Rest Local rest of acutely or subacutely inflamed joints at night with nonfunctional resting splints and during the day with functional splints reduces inflammation and pain, and may help prevent contracture. Immobilization of the wrist for painful periarticular syndromes (e.g., de Quervain's syndrome and carpal tunnel syndrome) is useful to relieve pain.

38. Short Rest Periods Provision of short rest periods during the day of 20 to 30 minutes along with appropriate local splinting is considered the appropriate way to manage patients with inflammatory arthritis to help control joint inflammation and fatigue. 38

39. TREATMENT WITH HEAT AND COLD MODALITIES Therapeutic heat can be applied with a number of devices and techniques. The effect on the tissue, location, surface area, depth of the tissue, and acuteness or chronicity of the arthritis must be considered in the selection of modalities. Patients report that warm baths, heated pools, hot packs, and warm mineral springs provide relief of joint pain and stiffness. Both superficial and deep heat can raise the threshold for pain, producing sedation and analgesia by acting on free nerve endings of both peripheral nerves and gamma fibers of muscle spindles. 39

40. Steps Application of moist heat to the joints. Followed by ROM active stretching exercises helping to reduce the contracture. Severe cases - protective splints. Joint mobilization - gentle manipulation of joints past the range normally reached by active ROM exercises. 40

41. Cold Cold modalities such as air or ice decrease skin, muscle, and joint temperature in arthritis patients . The application of cold to rheumatoid joints may therefore inhibit collagenase activity in the synovium . Some clinical studies have shown greater and more prolonged relief of pain with ice than deep or superficial heat in patients with RA . Cold decreases muscle spasticity by direct action on the muscle spindle activity and raises the pain threshold. Cold should not be used in patients with Raynaud's phenomenon, cold hypersensitivity, cryoglobulinemia . 41

42. ORTHOTICS Splints and orthotics are used to unweight joints, stabilize joints, decrease joint motion, support joints in a position of maximal function, and increase joint motion (i.e., dynamic splint). Splints may be prefabricated but are best when molded to fit the individual patient. Used to – Unweight joints Stabilize joints Decrease joint motion (static) Increase joint motion (dynamic) Support joint in position of maximal function 42

43. Splint for MP jt.volar subluxation and ulnar deviation 43

44. Effect of Exercise programs for patients with arthritis Increase and maintain ROM Reeducate and strengthen muscles Increase static and dynamic endurance Decrease the number of swollen joints Enable joints to function better biomechanically Increase locomotor ability Increase bone density Decrease pain Increase the patient's overall function and well-being Decrease inflammation Increase aerobic capacity Reduce body weight Limit rheumatoid cachexia 44

45. EXERCISE Arthritis commonly produces decreased biomechanical integrity of joints and their surrounding structures, which results in decreased joint motion, muscle atrophy, weakness, joint effusion, pain, instability, energy-inefficient gait patterns, and altered joint-loading responses Exercise programs for patients with arthritis have been shown to produce a variety of benefits: Increase and maintain ROM Reeducate and strengthen muscles Increase static and dynamic endurance Decrease the number of swollen joints 45

46. Enable joints to function better biomechanically Increase locomotor ability Increase bone density Decrease pain Increase the patient's overall function and well-being Decrease inflammation Increase aerobic capacity Reduce body weight Limit rheumatoid cachexia Exercise should be performed with proper joint support, after reduction of joint effusion is accomplished, and attention should be given to level of aerobic capacity. 46

47. Occupational therapy In everyday practice, the substantial impact of skilled occupational therapy (OT) intervention on quality of life for patients with RA is clear. Unfortunately, relatively few studies have been carried out and evidence from RCTs is often lacking. The OT approach is multifaceted and includes: 47

48. Occupational Therapy 48

49. Assisstive & adaptive devices 49

50. Thank You 50

51. ANKYLOSING SPONDYLITIS 51 Capt. Myat Bhone Aung

52. Ankylosing spondylitis Diagnosis is usually made on the basis of inflammatory back pain with radiological evidence of sacro-ilitis in the absence of evidence of microbial infection. 52

53. Ankylosing Spondylitis Features Chronic & progressive form of seronegative arthritis with axial skeleton predominance Affects 0.1-0.2% of the population 90-95% of patients are HLA-B27 positive 7% of general population is positive, only 1% of positives will develop ankylosing spondylitis Male : female 4-10:1 53

54. Age of onset 15-35 years old juvenile onset associated with more frequent & severe hip & peripheral joint involvement Life expectancy unaffected, although 20% morbidity most patients able to maintain a normal lifestyle Starts with sacroiliac joints begins with sclerosis, eventually get ankylosis Progresses to include facet joints, spine, iliac crest, ischial tuberosity, greater trochanter, hips, patella, calcaneus, glenohumeral joints peripheral joint involvement in 30% 54

55. Enthesopathy - calcification & ossification of ligaments, tendons, joint capsules at insertion into bone Erosion of subligamentous bone due to inflammatory response Fusion of interspinous ligament Dagger sign 55

56. Physical Findings Patients usually present with low back pain and stiffness, which improves with activity Decreased range of motion in lumbar spine Thoraco-cervical kyphosis (late) One-third of patients will have acute, unilateral uveitis 56

57. 57 Clinical Features of AS Skeletal Axial arthritis ( eg , sacroiliitis and spondylitis) Arthritis of ‘girdle joints’ (hips and shoulders) Peripheral arthritis uncommon Others: enthesitis , osteoporosis, vertebral, fractures, spondylodiscitis, pseudoarthrosis Extraskeletal Acute anterior uveitis Cardiovascular involvement Pulmonary involvement Cauda equina syndrome Enteric mucosal lesions Amyloidosis, miscellaneous

58. 58 Modified New York Criteria for the Diagnosis of AS Clinical Criteria Low back pain, > 3 months, improved by exercise, not relieved by rest Limitation of lumbar spine motion, sagittal and frontal planes Limitation of chest expansion relative to normal values for age and sex Radiologic Criteria Sacroiliitis grade  2 bilaterally or grade 3 – 4 unilaterally Grading Definite AS if radiologic criterion present plus at least one clinical criteria Probable AS if: Three clinical criterion Radiologic criterion present, but no signs or symptoms satisfy clinical criteria

59. Differential Diagnosis Ankylosing spondylitis Diffuse idiopathic skeletal hyperostosis Gout Psoriatic arthritis Rieter syndrome Rheumatoid arthritis Spondylodiskitis 59

60. During acute inflammatory periods, AS patients will sometimes show an increase in the blood concentration of C-reactive protein (CRP) and an increase in the erythrocyte sedimentation rate (ESR), but there are many with AS whose CRP and ESR rates do not increase so normal CRP and ESR results do not always correspond with the amount of inflammation a person actually has. Sometimes people with AS have normal level results, yet are experiencing a significant amount of inflammation in their bodies. Lab Findings 60

61. • (+) HLA-B27 in 90% of patients – Clinically, the test to evaluate for HLA-B27 factor is expensive. • Increased ESR and C-reactive protein (CRP) • Anemia—normochromic/normocytic • RF (–) and ANA (–) 61

62. HLA B27 Positive Diseases • Ankylosing Spondylitis • Reiter’s Syndrome • Psoriatic Arthritis—HLA Cw6 • Enteropathic Arthropathy • Pauciarticular JRA 62

63. Diagnostic Criteria 63

64. ESR. raised in about 70% of patients (inflammatory activity) . HLA-B27 test -positive in about 95% of patients. Hb- Normochromic or normocytic anaemia Synovial Fluid - a moderate no of mononuclear leucocytes Rheumatoid Factor are absent. 64

65. Pulmonary Function Tests In patients with thoracic involvement - diminished vital and total lung capacity, increased residual volume and functional residual volume. Flow measurements are usually normal. Nuclear scans Technitium stannous pyrophosphate bone scans, can often detect areas of active inflammation in AS, before standard changes are present. 65

66. Treatment • Education – Prevent spine flexion contractures. – Good posture. – Firm mattress, sleep in position to keep spine straight/prevent spine flexion deformity — lie prone. 66

67. Medications – NSAIDs Control pain and inflammation Allow for physical therapy – Corticosteroids—tapering dose, PO, and injections – DMARDs Sulfasalazine Methotrexate Topical corticosteroid drops—uveitis 67

68. Rehab – Spine mobility—extension-based exercises. – Swimming is ideal. – Joint protection. • Pulmonary—maintain chest expansion: – Deep breathing exercises. – Smoking cessation. 68

69. AIMS OF Rehab MANAGEMENT IN A S Relieve pain. Maintain the mobility of joints affected like spine, hip, thorax, shoulder etc. Prevent and correct deformity. Increase chest expansion and vital capacity. Attention to posture. To maintain and improve physical endurance. Advice to patient. 69

70. Pain Relief Pain and muscle spasm are treated by the following modalities and the relaxation is advised- Infra red. Hot packs. Cryotherapy. Steam bath. Hydrotherapy. 70

71. Thank You 71

72. OSTEOARTHRITIS 72 Capt. Myat Bhone Aung

73. Definition Osteoarthritis is an abnormality of the synovial joints characterized by softening, splitting and fragmentation (fibrillation) of articular cartilage not attributable to direct contact with inflammatory tissue. 73

74. Also known as degenerative joint disease or “wear and tear arthritis”. Progressive loss of cartilage with remodeling of subchondral bone and progressive deformity of the joint (s). Cartilage destruction may be a result of variety of etiologies 74

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76. FACTORS THAT CAN ACCELERATE OSTEOARTHRITIS Age: Osteoarthritis is a disease that appears with age, due to wear and tear on the joint produced by use over the years, together with the fact that the tissue is less able to recover with age. Obesity: There is a clear relationship between obesity levels and the probability of developing osteoarthritis. There is also a relationship between the level of obesity and the functional severity of the disease. Obesity precedes osteoarthritis; it is not a result of the disease. 76

77. Physical Activity: The continuous, persistent and repetitive use of a joint (especially by top-level athletes) can lead to osteoarthritis in a specific joint, given that such activity increases the risk of early joint degeneration. Work Activity: The development of osteoarthritis has been linked to certain jobs that call for the continuous use of certain anatomical areas over long periods of time. Eg ..This is the case of lumbar and knee osteoarthritis among miners, and osteoarthritis of the elbow and wrist among pneumatic-drill operators, among others. 77

78. History of Injury: Eg ..A major injury is a common cause of knee osteoarthritis, especially in the case of cruciate-ligament injuries and meniscal tears. A tear can alter the mechanical function of the joint and make the patient predisposed to osteoarthritis in any other joint. Bone Mineral Density: It has been observed that patients with a higher bone mineral density are at greater risk of suffering from osteoarthritis. This may be caused by increased biomechanical stress on the cartilage, which leads to its degradation. 78

79. Genetics: Heredity is believed to be a factor in osteoarthritis in that patients may be predisposed to getting the disease but do not necessarily inherit it. Systemic Diseases: Endocrine disorders such as hypothyroidism and diabetes often occur in conjunction with osteoarthritis. Other risk factors appear to be menopause, muscle fatigue, joint instability and osteoporosis, etc., while some drugs, such as non-steroid anti-inflammatory drugs (NSAIDs), can accelerate the process. 79

80. Different developmental stages of osteoarthritis have been identified: I. DESTRUCTION OF THE CARTILAGE : proteolytic damage to the cartilage matrix. II. INFLAMMATION OF THE SYNOVIAL MEMBRANE : fibrillation and erosion of the cartilage surface. Release of degradation products from the synovial fluid. III. REMODELING OF SUBCHONDRAL BONE : the synovial cells consume the degradation products. Production of inflammatory proteases 80

81. The evolution of the disease Edema of the cartilage: There are no clinical or radiological signs. The edema can only be perceived under an electron microscope. 2. Fibrillation: Cartilage begins to wear down. 3. Fissuring: Presence of deep cracks in the cartilage. 4. Ulceration-Eburnation: The subchondral bone of the joint surface is exposed. 81

82. The evolution of the disease is clearly shown in the following images 82

83. SIGNS AND SYMPTOMS OF OA • Symptoms – Dull aching pain increased with activity, relieved by rest. – Later pain occurs at rest. – Joint stiffness < 30 minutes, becomes worse as the day goes on. – Joint giving away. – Articular gelling A stiffness after immobility lasting short periods and dissipating after brief period of movement. – Crepitus on ROM 83

84. Signs – Monoarticular , shows no obvious joint pattern. – Localized tenderness of joints – Pain and crepitus of involved joints – Enlargement of the joint A changes in the cartilage and bone secondary to proliferation of synovial fluid and synovitis . 84

85. Involved joints DIP, PIP 1 st carpometacarpal cervical/lumbar facet joints 1 st metatarsophalangeal Hips Knees Uncommon Wrist, elbows, shoulders, ankles 85

86. Osteoarthritis of the knee This is a very common complaint. It usually appears together with osteoarthritis of the hands within the context of primary polyarthritis , particularly among middle-aged and elderly women, and is associated with obesity. When it appears in younger patients, it is associated with biomechanical disorders, previous knee injuries or meniscus surgery. 86

87. The main symptom is mechanical pain with stiffness and functional impairment, which become more severe as the disease progresses. In initial stages, pain is felt only when the knee is completely flexed. As the degenerative process advances, the symptoms become more evident, flexion is more limited, joint swelling appears and is sometimes accompanied by joint effusion and cysts. Joint atrophy and deformity are observed in advanced cases, together with joint-ligament instability. 87

88. Osteoarthritis of distal interphalangeal joints This is one of the most frequent and typical kinds of osteoarthritis. Patients complain of slow, gradual swelling of these joints until so-called Heberden nodes are formed . Single nodes appear initially, but become multiple as time goes by. They are more common in women than men. 88

89. These nodes may begin with just a little or no pain; or they may appear suddenly, as an acute inflammatory reaction with pain, reddening, swelling and functional impairment. Although the deformity remains, discomfort disappears or becomes tolerable over time and the joints are only painful when certain movements and exertions are made. Small gelatinous cysts are sometimes observed in the joints. 89

90. Osteoarthritis of proximal interphalangeal joints This ailment is generally associated with distal interphalangeal osteoarthritis, and frequently also with rhizoarthritis and osteoarthritis of the thumb. It usually begins after the signs and symptoms of distal interphalangeal osteoarthritis have appeared, but the clinical symptoms are similar, with pain and characteristic deformity and swelling of the bone, in this case caused by so-called Bouchard nodes 90

91. Osteoarthritis of the trapeziometacarpal joints ( rhizoarthritis or osteoarthritis of the thumb) Osteoarthritis of the trapeziometacarpal joints is a very frequent form of osteoarthritis of the hand. It sometimes appears by itself, but is usually associated with the presence of Heberden nodes. It is found more frequently in women. Clinical manifestations include deformity and local joint pain that varies in intensity; with asymptomatic forms and others involving joint effusion accompanied by pain and marked functional impairment. This is the form of osteoarthritis that most restricts the movements of the hand. 91

92. Classification Criteria for Osteoarthritis of the Hand Hand pain, aching or stiffness plus Hard tissue enlargement of two or more of 10 selected joints* -- plus Fewer than three swollen metacarpophalangeal joints plus Hard tissue enlargement of two or more distal interphalangeal joints or Deformity of two or more of 10 selected joints* 92

93. INVESTIGATION 93

94. Blood tests —are performed to look for general signs of inflammation, to help eliminate the possibility of other types of arthritis such as rheumatoid or Lyme's disease, and to check for possible markers of OA such as hyaluronic acid, a substance that normally provides lubrication for joints but breaks down in the case of OA. 94

95. SYNOVIAL FLUID FINDINGS IN NORMAL AND PRIMARY OSTEOARTHRITIC JOINTS Normal OA 95

96. Joint aspiration – if fluid is present, it can be withdrawn from the joint for evaluation using a needle and syringe; normally with OA, there is not an adequate amount of fluid in the joint space to aspirate; therefore, evaluation of fluid may reveal another cause of arthritis such as gout or an infection. 96

97. 97 MANAGEMENT OF OSTEOARTHRITIS Objectives in management of osteoarthritis Education The patient, relatives and carers should understand the condition and know what they themselves can do to help Relieve Symptoms Pain, stiffness and other symptoms of the condition should be controlled as well as possible with minimum risk to the patient Minimize handicap any consequences on function, and any disability or handicap, should be minimized through appropriate rehabilitative techniques Limit progression Any factors known to be likely to worsen the condition should be avoided, and any practices likely to reduce the risk of progression instituted, with minimum risk, if they do not conflict with the other objectives

98. 98 1. NSAIDs are widely used. Analgesics such as acetaminophen may also be used effectively. PHARMACOLOGICAL TREATMENT

99. Intra-Articular Steroids in Osteoarthritis Indications For Intrasynovial Corticosteroids To provide pain relief and suppress the inflammation of synovitis . To provide adjunctive therapy for one or two joints not responsive to other systemic therapy. To facilitate a rehabilitative and physical therapy program or orthopedic corrective procedures. To prevent capsular and ligamentous laxity (large knee effusion). To bring about a Medical synovectomy . To treat patients unresponsive to or intolerant of oral systemic therapy. To treat acute effusions occurring with associated crystal deposition disease. 99

100. 100 NON PHARMACOLOGICAL Corner stone Maintained throughout the treatment period 1. Patient education ADL (walking, dressing, bathing, use of toilet, performing household shores ) limited. Self management programs-joint pain and improve quality of life Avoid activities that cause impact-shoes Activity modifications Weight reduction

101. 101 NON PHARMACOLOGICAl

102. 102 2. Rehab therapy Exercise program to improve ROM and muscle strength Weak muscle increases risk of OA & /S To decrease joint loading, improve function Provides assisted devices such as brace, canes, crutches, walkers to - reduce joint loading, - improve function and - decrease pain Physical therapy such as heat, cold, SWD, U/S etc.

103. TYPICAL Rehab THERAPY PROGRAM CONTENT 103

104. ThankYou 104

105. FRACTURE REHABILITATION 105 Capt. Myat Bhone Aung

106. 1.DEFINITION A fracture is a break in the structural continuity of bone. A bone fracture can be the result of high force impact or stress , or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis , bone cancer , or osteogenesis imperfecta , where the fracture is then properly termed a pathologic fracture . 106

107. Causes Falls Crush injuries Motor vehicle accidents Bicycle accidents Sports injuries Fights Repetitive stress or fatigue Spontaneous / idiopathic 107

108. Type of fracture Complete - Transverse Spiral Impacted fracture Comminuated fracture Incomplete - Greenstick fracture Compresssion fracture 108

109. 5. How fractures heal Healing by callus ( Apley’s ) Tissue destruction and haematoma formation Inflammation and cellular proliferation – within 8 hours of fracture Callus formation – at about 4 weeks after injury the fracture 'unites'. Consolidation Remodelling 109

110. 110 23 4 Fracture healing Five stages of healing : (a) Haematoma : there is tissue damage and bleeding at the fracture site; the bone ends die back for a few millimetres . (b Inflammation: inflammatory cells appear in the haematoma . (c) Callus: the cell population changes to osteoblasts and osteoclasts; dead bone is mopped up and woven bone appears in the fracture callus. (d) Consolidation: woven bone is replaced by lamellar bone and the fracture is solidly united. (e) Remodelling : the newly formed bone is remodelled to resemble the normal structure

111. How does a fracture heal? Stage 1: Inflammation bleeding and oedema lasts about 2 - 3 weeks Stage 2: Soft callus Healing process begins and bridge the fracture. lasts until 4 - 8 weeks after the injury No evidence on X rays. 111

112. Stage 3: Hard callus or calcification Visible on x rays. last 8 - 12 weeks after the injury Stage 4: Bone remodeling last up to several years (mostly 1 year) The rate of healing and the ability of remodelling vary for each person and depend on age, general well being, the type of fracture, and the bone involved. 112

113. Union of fractures Type of bone Cancellous bone > compact bone Depend on size of bone Upper limbs (3 – 12 weeks) Lower limbs (12 – 18 weeks) (femur takes 4 – 5 months) Classification of fracture Good apposition Initial position of the fragments b/f reduction Effect of m/s on fragments 113

114. Diagnosis A bone fracture can be diagnosed clinically based on the history given and the physical examination performed. Imaging by x-ray is often performed to view the bone suspected of being fractured. In situations where x-ray alone is insufficient, a computed tomograph ( ct scan) or MRI may be performed. 114

115. 8.Principles for rehabilitation management of fracture Goals of fracture treatment Restore the patient to optimal functional state. Prevent fracture and soft-tissue complications. Get the fracture to heal, and in a position which will produce optimal functional recovery. Rehabilitate the patient as early as possible. 115

116. Rehabilitation After Fracture The broad concept of rehabilitation is the restoration of the individual to his fullest physical, mental, social, vocational, or economic capacity. Rehabilitation is important in management of fracture. Goals of rehabilitation are To preserve the function so far as possible while the fracture is uniting To restore function to normal when the fracture is united 116

117. When to start? As soon as possible , recover from anaesthesia or pre-operative stage. When to stop? -Up to complete recovery of normal function or as nearly as normal function. -To find out the suitable work and training when residual impairment. By which way or how? With active muscular exercise 117

118. Rehabilitation emphasizes restoring full range of motion, strength, proprioception, and endurance, while maintaining independence in all activities of daily living. Modalities can be used in controlling pain and edema. The individual should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Depending on the stability of the fracture, range of motion exercises of the adjacent joints may be started immediately and progressed to strengthening exercises as indicated. 118

119. Elevation and support of the injured limb The limb is either placed on a cushion or elevated in a bag   Flexion of the elbow should not exceed 75° Medial epicondyle of the elbow (ulnar nerve), and the head of the fibula (fibular nerve) must be well padded. 119

120. In fractures close to the hip , the affected extremity is placed in moderate abduction and held in that position between cushions or in a padded splint In distal and midshaft femur fractures, the lower leg is supported with the hip and knee joints each in 90° of flexion An operated lower leg is similarly supported, but it is sufficient to flex the knee and hip to 45°   Articular fractures in the knee are best managed by continuous passive motion (CPM) 120

121. Thoraco -lumbar spine without paraplegia 121

122. Stable # s/a wedge compression and appendages #s, which cause back pain are best treated with immobilization. After an initial bed rest of two weeks (good bed position with good body alignment), trunk extension exercises should be taught within limits of pain in supine position 122

123. Weight bearing 123 Weight bearing status % of body weight None 0% Toe Touch 20% Partial weight bearing 20%-50% Weight bearing as tolerated 50%-100% Full weight bearing 100%

124. COMPLICATIONS OF FRACTURES Early Late General Other injuries Chest infection PE UTI FES/ARDS Bed sores Bone Infection Non-union Malunion AVN Soft-tissues Plaster sores/WI Tendon rupture N/V injury Nerve compression Compartment syn. Volkmann contracture 124

125. Thank You 125

126. LOWER LIMB AMPUTATION 126 Capt. Myat Bhone Aung

127. Indications of amputation Colloquially speaking , the indications are 3 Ds : Dead , Dangerous and Damn nuisance. 1. Dead or Dying peripheral vascular disease accounts for almost 90% of all amputations. other causes of bone death are severe trauma , burn and frostbite. 2. Dangerous dangerous disorder are malignant tumors , lethal sepsis and crush injury 3. Damn nuisance retaining the limb may be worsen than having no limb at all this may be because of pain , gross malformation , recurrent sepsis , or severe loss of function 127

128. Level of amputation in lower limb 128

129. Lower limb . Transmetatarsal - difficult in healing but no prosthesis required , only adapted shoes . Symes (through ankle) - rarely use in vascular patient though in trauma and infection - can walk without prosthesis . Below knee - ideal (12 to 15.5 cm from knee joint) - retain knee joint , need low energy in mobility . Knee disarticulation - stump is strong with no muscle imbalance - unsuitable in arthritis knee, hip flexion deformity 129

130. Gritti -Stokes (femoral condyles ) - good healing but unsightly prosthesis Midthigh (above knee) - good healing but mobility reduced due to Knee joint loss - need higher energy for mobility - knee joint prothesis clearance 12cm above knee joint Hip disarticulation - use in trauma or malignancy - not in peripheral vascular disease . Hemiplevectomy - removing lower limb and half of pelvis with muscle flap covering internal organs - mainly use in malignancy 130

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133. PRE-OPERATIVE PREPARATION When the decision to amputate has been taken, the patient should be approached with the following information: ● an explanation of why the operation is necessary ● an explanation of what the operation entails ● a prediction of how the patient can expect to feel after the operation, including a description of phantom reactions and residual limb pain ● instructions concerning what to do about the pain (e.g. telling staff and relaxation) ● reassurance that the pain will pass ● introduction to, and explanation of, the local prosthetic service (provided the preoperative assessment indicates a likelihood of prosthetic rehabilitation) ● realistic information regarding the possible effect of the operation on the patient’s lifestyle ● an opportunity to talk over the patient’s feelings about loss of the limb. 133

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136. Optimal (or) Standard Stump Requirement Optimal functional length that is 5-6" below the medial tibial articular margin measured with the knee flexed 90°. - In growing children amputation should be done with the stump as long as possible. - Longer stump (>6") will not materially affect the leverage on function power, depend, not so much on the length of the bone but more on the site of insertion of the muscles i.e. Quadriceps, Ham strings. - Long stump do not maintain their vascularity - Nutrition of skin poor, and be come discolored and painful, infected, reamputation sometimes required. - Shorter stump less than 5 can be fitted with suitable suspension system. 136

137. 2. Surgical scar should be linear, nonadherent and be transversely across the end of the stump or just proximal to it 3. The bone end should be rounded off and free from spurs 4. Overlying skin s/b freely movable and fit without redundancy and fascia covering the bone end s/b normal tone and sensation. 5. The muscle and fascia covering the bone end and should be just enough to form a band of scar 6. The stump should be a normal smooth , even contour and activated by well balanced powerful muscles 7. The joint proximal to the stump should be normal range of motion 137

138. Amputees demonstrate significantly reduced average walking speed (0.85 vs. 1.44 m/s), have longer stance duration (0.85 vs. 0.67 s), and have significantly reduced horizontal ground reaction forces (GRF). These effects are seen on the prosthetic side in the fore direction in the vascular group, and in the fore and aft directions in the trauma group (Skinner and Effeney 1985). 138

139. Amputation Management - Amputee management is a dynamic continuous process which begins at the time of injury or disease and continues until the patient has achieved maximum function use of his prosthesis and is able to perform the activities essential for daily living and gainful employment. - It is a multidisciplinary approach. - It will include three phase ; 1.preprothetic phase 2.prosthetic phase and 3.postprosthetic phase 139

140. Rehabilitation team . Physiatrist . Psychiatrist . Surgeon . Physician . Physiotherapist . Family member . Nurses . Occupational therapist . Prosthetist . Orthotist . Social worker 140

141. To achieve comprehensive rehabilitation for an amputee Interdisciplinary approach that communicate between interrelated Medical and ancillary specialist in other word, a coordinated program and procedure drawn within a suitable period. Coordinated program for amputee rehabilitation revealed various stages and pattern of treatment for the same goal I interdisciplinary approaches Communication between interrelated medical and ancillary specialist. Aiming for producing reasonably , efficiently functioning prosthesis for an individual to meet the challenge of life. 141

142. Comprehensive Management of Amputee Includes Proper and timely surgical intervention Psychological preparation Physical and after care treatment of Amputation Careful selection and prescription of most suitable prosthesis for individual. Fitting and approvement of the prosthesis. Adequate training in use including maintenance of the prosthesis. Vocational assessment and training after prosthetic rehabilitation. Placement of Job. Follow up. 142

143. Patient Education 143

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149. Four Periods in Pre Prosthetic Phase 1. Recovery Period 2. Bed Rest Period 3. Pre ambulatory Period 4. Gymnasium Period 149

150. Important for amputee patient Must achieve safe stable and secure crutch Walking gait with the remaining leg. Develop strength for crutch walking muscles Suitable method i.e. Swing to, Swing through gait. Crutch Walking & Training 150

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156. Prosthetic Rehabilitation is a systemic procedures of the prosthesis with regards to Characteristic and biomechanics of the stump. The ability to use the fitted prosthesis with reasonable efficiency and function Follow up care for periodic adjustment Employment ability. Prosthetic Rehabilitation is concerned with producing reasonably efficiently functioning Prosthesis which will meet the Medical Physical Psychological Social Educational Vocational needs of the amputee. Well coordinated program of prosthetic rehabilitation among team members is important and essential support for maximal achievement and functional outcome of the amputee. Conclusion 156

157. THANK YOU 157