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MUSCULOSKELETAL SYSTEM

183

II

Figure 3-8. Odontoid peg (ractllres. Type I (raetllres o( the upper third o( the

peg. Type II (raetllres at the ;1I/letioll o( the peg with the body o( C2. Type III

(raetllres esselltially o( the body o( C2 at the base o( the peg. (With permission from A Unwin, K Jones /eds/. Emergency Orthopaedics and Trauma.

Boston: Buttertuorth-Heillemamt, 1 995;85.)

respectively. If surgical management is required, it is performed as

soon as the patient is medically stable. Secondary management of spinal fracture may also include the following:

• Examinarion and rrearmenr of associated extremity fracrure or

head or internal injuries

184

A� CARE HAND800K FOR PHYSICAL THERAPISTS

Figure 3-9. Burst fracture. (With permission from A Unwin, K jones /eds/.

Emergency Orthopaedics and Trauma. Boston: Butterworth-Heinemann,

1995;85.)

•

Very frequent (every 15-30 minutes) neurovascular assessment

by nursing

• Close monitoring of airway and brearhing with cervical spine

fractures

Clinical Tip

• Until the cervical, thoracic, and lumbar spines have

been ruled out or "cleared" for fracture, do not remove

temporary immobilization devices (e.g., cervical collar)

until ordered to do so by rhe physician.

• Logroll precautions may exist before spine fracture

clearance. This typically includes bed rest (with the head

of the bed at a 30 degree angle or less) and turning the

patient via logro/! (with rhe head and rorso as a unit).

• Refer to Physical Therapy Intervention after Spinal Surgery for additional tips on mobilizing a patient with back pain or after spinal stabilization.

MUSCULOSKELETAL SYSTE.M 185

Upper Extremity

Shoulder Girdle Fractures

Fracture of the scapula is rare and often requires little treatment

(other than pain management), because the surrounding musculature

serves to protect and immobilize the fracture. Scapular fractures

occur most commonly in 35- to 45-year-olds as a result of a xial loading on an outstretched arm or a direct blow or force from a fall onto the back or top of the shoulder.2• Injuries associated with scapular

fracture include rib fracture, pulmonary contusion, pneumothorax,

and spinal fracture.

Fractures of the distal, middle, or medial third of the clavicle result

from direct impact, such as falls or blows on the point of the shoulder.

Management is conservative (sling immobilization for comfort) for

nondisplaced fractures without ligamentous injury. ORIF is required

acutely if the clavicle fracture is associated with neurovascular compromise, coracoclavicular ligamenr tear, floating shoulder ( fracture of both the clavicle and surgical neck of the scapula), or for separation

of fractute fragments by the deltoid or trapezius muscle.27 Short-term

immobilization is typical after ORJE

Fractures involving the articulation of the glenohumeral joint or

coracoid process are more complicated than scapular body and clavicular fracrures. Intra-articular glenoid fractures may involve the spine of the scapula and are associated with shoulder dislocation or

acromioclavicular injury.28 Coracoid fractures occur at either the tip

or base and may also involve the spine of the scapula.2s Management

for stable nondisplaced fractures is conservative (sling immobilization) or ORIF for displaced fractures.

The vast majority of glenohumeral dislocation occurs anteriorly

as a result of forceful external rotation and extension while the arm

is abducted'> Glenohumeral dislocation should be treated with

immediate closed reduction CO minimize injury to the neurovascular

struc[Ures surrounding the joint. The need for strict dislocation precautions for the patient without risk factors for further dislocation is unlikely.>'

Proximal Humeral alld Humeral Shaft Fractures

Proximal humeral fractures occur when the humerus is subjected to

direct or indirect trauma and can be associated with glenohumeral

dislocation, rotator cuff injuries, and brachial plexus or peripheral

nerve damage. Fracture of the humeral head, ana comic neck, and

lesser tuberosity arc rare; however, fracture of the greater tuberosity is

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AClfn CARE HANDBOOK FOR PHYSICAL TIIERAPISTS

common.7 The majority of these fractures are nondisplaced or minimally displaced JO Complications of proximal humeral fractures include nonunion, AVN of the humeral head, abnormal posture, and

abnormal scapulothoracic rhythm.

Humeral shaft fractures are also the result of direct or indirect

trauma, usually a fall on an outstretched hand, MVA, or direct load

on the arm.JI Humeral shaft fractures may be associated with radial

nerve or brachial plexus injury. Chapter Appendix Table 3-A.14 summarizes proximal humerus and humeral shaft fracture management.

Clinical Tip

• When the patient is lying supine, placing a thin pillow

or folded sheet under the upper arm will help maintain

neutral alignment and reduce pain.

• Getting in and out of bed on the opposite side of an

upper arm fracture is usually more comfortable for the

patient.

Distal Humeral, Olecranon, and Radial Head Fractures

Distal humeral fractures are rare but complex fractures to manage

because of the bony configuration of the elbow joint, adjacent neurovascular structures (Figure 3-10), and minimal soft tissue surrounding the joint." The mOSt common distal humerus ftacture in the elderly is transcondylar (across the condyles of the olecranon fossa) as