Rehabilitasi Fraktur

Rehabilitasi Fraktur AGA

Fraktur Humerus
• Proximal
• Midshaft
• Distal
Fraktur Humerus Proximal
•  head humerus, anatomic
neck humerus, dan surgical neck
humerus
• Rehabilitation goals:
1. Mengembalikan full ROM
bahu
2. Mengembalikan kekuatan
otot-otot bahu
3. Fungsional: Meningkatkan
atau mengembalikan fungsi
bahu untuk ADL.
• Bone healing: 6 – 8 minggu
• Rehabilitasi: 12 minggu – 1
tahun
Rehabilitation Fraktur Humerus Proximal
Weeks Nonoperative Fixation Operative Fixation Endoprosthesis

0-1 Pendulum exercises to No range of motion to the Pendulum exercises to shoulder

shoulder shoulder
2-4 •Gentle active ROM exercise •No active ROM to the shoulder Begin passive-assistive shoulder
shoulder (flexion, extention, •Gentle passive-assistive ROM ROM (avoiding internal and
abduction, adduction) exercise to the shoulder in supine external rotation)
•Gravity eliminated pendullum
position
exercise
•Avoid internal and external
rotation
4-6 Advance isometric exercises Continue with passive-assistive Continue with passive-assistive
ROM ROM
Rehabilitation Fraktur Humerus Proximal
Weeks Nonoperative Fixation Operative Fixation Endoprosthesis

6-8 Begin active ROM with Begin active ROM with terminal •Begin active ROM shoulder,
terminal stretching, stretching, emphasizing elevation emphasizing elevation and external
emphasizing elevation and and external rotation rotation
•Advance isometric shoulder
external rotation
exercises in all planes
8-12 Begin resistive shoulder Begin resistive shoulder exercises Begin resistive shoulder
exercises and continue and continue terminal capsular exercises and continue terminal
terminal capsular stretching stretching capsular stretching

>12 •Continue resistive exercises •Continue resistive exercises with •Continue resistive exercises
with increasing resistance increasing resistance •Continue capsular stretching
•Continue capsular stretching •Continue capsular stretching
Fraktur Midshaft Humerus
• Bagian diafisis humerus • Rehabilitation Goals
1. Mengembalikan ROM bahu
dan siku
2. Meningkatkan kekuatan
m.pectoralis major, deltoid,
biceps, dan triceps
3. Fungsional: Meningkatkan
atau mengembalikan fungsi
bahu untuk ADL.
• Bone healing: 8 – 12 minggu
• Rehabilitasi: 12 minggu – 16
minggu
Rehabilitasi Fraktur Midshaft Humerus
Weeks Cast Rod Plate
0-1 •Move digits to diminish hand If stable fixation, the patient may •If stable fixation, the patient may
swelling begin moving the shoulder and range the shoulder and elbow as
•No strengthening or ranging to elbow as pain allows pain allows
elbow or shoulder •If unstable, no ROM
2-4 •Begin gentle ROM to elbow •Progress with ROM to shoulder •Progress with ROM to shoulder
and shoulder and elbow and elbow
•No strengthening •Pendulum exercises to the •Pendulum exercises to the
shoulder shoulder
•Limited weight bearing is allowed •No weight bearing
4-6 •Aggresive ROM to shoulder and •If callus is evident, weight bearing •Lightweight bearing allowed
elbow is to be progressed •Aggresive ranging and light
•Strengtehning with isometric and •Isotonic and isometric strengthening to shoulder and
isotonic exercise
strengthening, and ranging to elbow
•Light weight bearing to
extremity elbow and shoulder
•Use extremity for ADL
8-12 Full weight bearing, ranging, Full activities Full activities
andprogressive resistive
exercises for strengthening
Fraktur Humerus Distal
•  distal humerus melibatkan
metafisis, bisa sampai ke permukaan
intraartikuler
• Rehabilitation goals:
1. Mengembalikan full ROM elbow
dan shoulder, melindungi sudut
normal carrying dari elbow.
2. Meningkatkan kekuatan dari
otot-otot: triceps, biceps,
forearm supinators & pronators,
wrist extensors, wrist flexors,
dan deltoid
3. Mengembalikan aktivitas yang
membutuhkan fleksi/ekstensi
dan pronasi/supinasi, misalnya
makan, pesrsonal hygiene,
dressing, dan grooming.
• Bone healing: 8 – 12 minggu
• Rehabilitasi: 12 – 24 minggu
Rehabilitation Fraktur Humerus Distal
Weeks Cast/Splint
0-1 •Active ROM exercises to the
digits
•Active & Active-assistive ROM
exercises to the shoulder
•Avoid elbow motion
•No shoulder internal/external
rotation exercises
2-4 • AROM exercises to the digits
• AROM & AAROM exercises shoulder
• Isometric exercises to biceps, triceps,
deltoid, and forearm muscles
• Begin grip strengthening exercises with
ball or putty
• No pronation/supination or shoulder
internal/external rotation exercises
• For extension type supracondylar
humerus fractures, may add supervised
elbow flexion from 90° up with posterior
splint immobilization between sessions
Percutaneous Pinning
• Active & passive ROM exercises to the
digits
• Active & Active-assistive ROM exercises to
the shoulder
• Isometric exercises to biceps, triceps, &
deltoid
• Avoid elbow motion
• No shoulder internal/external rotation
exercises
•Active & passive ROM exercises to the
digits
•Active & Active-assistive ROM
exercises to the shoulder
•Isometric exercises to biceps, triceps,
deltoid, & forearm muscles
•Begin grip strengthening exercises
with ball or putty
•No pronation/supination or shoulder
internal/external rotation exercises
ORIF
• Assuming a stable construct, begin
gentle active ROM exercises to the
entire extremity, including elbow,
fingers, wrist, and shoulder within 3 to 5
days as soft tissues allow
• Avoid passive ROM exercises to the
elbow to reduce the risk of myositis
ossificans
•Continue gentle active ROM
exercises to the entire extremity,
including elbow, wrist, fingers, and
shoulder
•Begin grip strengthening exercises
with ball or putty
•Avoid passive ROM exercises to
the elbow to reduce the risk of
myositis ossificans
Rehabilitation Fraktur Humerus Distal
Weeks Cast/Splint
4-6 • Once clinical stability and radiographic
healing are present, begin supervised
active elbow ROM. Usually a home
program may be added by 6 weeks.
Between sessions the patient should be
protected
• Continue grip strengthening exercises
with ball or putty
• Avoid passive ROM exercises to the
elbow to reduce the risk of myositis
ossificans
8-12 • Continue active and add passive ROM
to all joints of the extremity while
focusing on flexion/extension of the
elbow and pronation/supination of the
forearm
• Continue grip strengthening exercises
with ball or putty
• Introduce resistive exercises using
weights in gradation, starting with 1 to
2 punds
• The risk of myositis ossificans related to
Percutaneous Pinning
• Once clinical stability and radiographic
healing are present, begin supervised active
elbow ROM. Usually a home program may be
added by 6 weeks. Between sessions the
patient should be protected
• Continue grip strengthening exercises with
ball or putty
• Avoid passive ROM exercises to the elbow to
reduce the risk of myositis ossificans
• Continue active and add passive ROM to all
joints of the extremity while focusing on
flexion/extension of the elbow and
pronation/supination of the forearm
• Continue grip strengthening exercises with
ball or putty
• Introduce resistive exercises using weights in
gradation, starting with 1 to 2 punds
• The risk of myositis ossificans related to
passive ROM of the elbow has significantly
decreased
ORIF
•Continue active & active-assistive
ROM exercises to the entire extrimity
including elbow, wrist, fingers, and
shoulder
•Continue grip strengthening
exercises with ball or putty
•Avoid passive ROM exercises to the
elbow to reduce the risk of myositis
ossificans
• Continue active and add passive ROM to
all joints of the extremity while focusing
on flexion/extension of the elbow and
pronation/supination of the forearm
• Continue grip strengthening exercises with
ball or putty
• Introduce resistive exercises using weights
in gradation, starting with 1 to 2 punds
• The risk of myositis ossificans related to
passive ROM of the elbow has significantly
decreased
Fraktur Forearm
• Definisi:
 Fraktur yang terjadi pada
shaft dari radius, ulna, atau
keduanya.
 Monteggia: dislokasi caput
radius akibat fraktur ulna
 Galeazzi: dislokasi sendi
radioulnar distal akibat
fraktur radius
Rehabilitation Fraktur Forearm
Weeks Cast ORIF of Both Bone Fractures ORIF of Galeazzi & Monteggia
Fractures

0-1 •Long arm cast  AROM & No cast with stable fixation: gentle •Long arm cast: active and passive
PROM shoulder active ROM exercises for the entire ROM exercises to the digits.
•Short arm cast  AROM & extremity, including fingers, wrist, • Active & active assistive ROM
exercises to the shoulder
PROM digits; AROM & elbow, and shoulder
•Isometric exercises to the biceps,
AAROM elbow and shoulder triceps, & deltoid
2 •Long arm cast  AROM & No cast with stable fixation: gentle •Long arm cast: active and
PROM digits; AROM & active ROM exercises for the entire passive ROM exercises to the
AAROM shoulder extremity, including fingers, wrist, digits.
•Short arm cast  AROM & elbow, and shoulder • Active & active assistive ROM
PROIM digits; AROM & exercises to the shoulder
AAROM elbow and shoulder •Isometric exercises to the
biceps, triceps, & deltoid
Rehabilitation Fraktur Forearm
Weeks Cast
4-6 • short arm cast: AROM & PROM digits;
AROm & AAROM shoulder; gentle
AROM elbow in all planes,; ball
squeezing exercises; isometrics
exercises to biceps, triceps, and
deltoid
• When casting of isolated ulnar
fracture discontinued: gentle AROM
fingers, wrist, elbow, & shoulder;
gentle resistive exercises can be
started
8-12 • When immobilization discontinued:
full active and passive ROM exercises
to all joints of the extremity while
focusing on pronation and supination
of the forearm
• Putty and ball squeezing exercises
improve grip strength
• Introduce resistive exercises using
weights in gradation
ORIF of Both Bone Fractures ORIF of Galeazzi & Monteggia
Fractures
•No cast with stable fixation: gentle •Long arm cast: active and
active ROM exercises for the entire
passive ROM exercises to the
extremity, including fingers, wrist, digits.
elbow, and shoulder
• Active & active assistive ROM
•At 6 weeks, gentle active resistive
exercises can be started exercises to the shoulder
•No lifting or weight bearing allowed, •Isometric exercises to the
although patient may use extremity to biceps, triceps, & deltoid
eat or write
• When immobilization discontinued: full • When immobilization discontinued: full
active and passive ROM exercises to all active and passive ROM exercises to all
joints of the extremity while focusing on joints of the extremity while focusing on
pronation and supination of the forearm pronation and supination of the forearm
• Putty and ball squeezing exercises improve • Putty and ball squeezing exercises
grip strength improve grip strength
• Introduce resistive exercises using weights • Introduce resistive exercises using
in gradation weights in gradation
Fraktur Colles
Rehabilitation goals:
• Definisi:
Fraktur distal metaphyseal
radius, disertai dengan angulasi
volar dari apex fraktur (silver
fork deformity), displacement
ke arah dorsal dari fragmen
distal, dan pemendekan radius.
• Mengembalikan full ROM dari wrist dan
fingers
• Memperbaiki kekuatan otot-otot
hipotenar dan tenar, lumbrical, interossei.
• Memperbaiki kekuatan otot-otot yang
melalui wrist: extensor digits, flexor digits,
abductor pollicis longus, flexor carpi
radialis, flexor carpi radialis, extensor carpi
radialis longus & brevis, extensor carpi
ulnaris.
• Functional goals: mengembalikan
kekuatan grip, grasp, dan pincer grip.
Rehabilitation Fraktur Colles
Weeks Cast ORIF of Both Bone Fractures ORIF of Galeazzi & Monteggia
Fractures

0-1 ROM of shoulder and digits ROM of shoulder, elbow, and digits ROM of shoulder, elbow, and digits
2 ROM of shoulder and digits ROM of shoulder, elbow, and digits •ROM of shoulder, elbow, and
digits
•Active ROM to the wrist if fixation
is rigid
4-6 Begin active ROM of wrist if Begin active ROM of wrist if cast Begin active ROM of wrist if cast
cast removed removed removed
6-8 •Active & passive ROM to •Active & passive ROM to wrist as •Active & passive ROM to wrist
wrist tolerated •Gentle resistive exercises to the
•Gentle resistive exercises to •Gentle resistive exercises to the wrist
the wrist wrist
8-12 Active & passive ROM and Active & passive ROM and Active & passive ROM and
progressive resistive progressive resistive exercises progressive resistive exercises
exercises
Rehabilitasi Fraktur AGB
Fraktur Femur
• Fraktur neck femur
• Fraktur shaft femur
Fraktur Neck Femur
 proximal dari garis intertrochanter di dalam
daerah interkapsular dari hip
Rehabilitation goals:
• Memperbaiki ROM lutut dan hip
• Memperbaiki kekuatan otot-otot:
 Gluteus medius
 Iliopsoas
 Gluteus maximus
 Adductor magnus, longus, dan brevis
 Quadriceps
 Hamstrings
• Fungsional: menormalkan pola gait pasien, fleksi
hip 90° untuk posisi duduk yang baik
• Bone healing: 12 – 16 minggu
• Rehabilitasi: 15 – 30 minggu
Rehabilitasi Fraktur Neck Femur
Internal Fixation Hemiarthroplasty

ROM (hindari add & Int Rot)

• AROM exc Minggu ke-1 Minggu ke-1
• AAROM exc Minggu ke-2 Minggu ke-2
• PROM exc Minggu ke-8 Minggu ke-8
Strengthening
• Isometric exc Minggu ke-1 Minggu ke-1
• Isotonic exc Minggu ke-4 Minggu ke-4
Weight Bearing
• Partial WB Minggu ke-8 Minggu ke-1 (~toleransi)
• Full WB Minggu ke-12 Minggu ke-8
Fraktur Shaft Femur
Definisi: Fraktur pada diafise femur
yang tidak meluas ke daerah
artikuler atau metafise
Rehabilitation goals:
• Memperbaiki ROM lutut dan hip
• Memperbaiki kekuatan otot-otot:
 Quadriceps
 Hamstring
• Fungsional: menormalkan pola
gait pasien
• Bone healing: 4 – 6 minggu fraktur
menjadi lekat dan menunjukkan
stabilitas awal, 12 – 16 minggu
daerah fraktur sudah menyatu
• Rehabilitasi: 12 – 16 minggu
Rehabilitasi Fraktur Shaft Femur
Intramedullary Rod

ROM
• AROM exc Minggu ke-1
• AAROM exc Minggu ke-2
• PROM exc Minggu ke-4
Strengthening
• Isometric exc Minggu ke-1
• Isotonic exc Minggu ke-4
Weight Bearing
• Partial WB Minggu ke-
• Full WB Minggu ke-12
Fraktur Shaft Tibia
Definisi: Fraktur diafise tibia yang biasanya
tidak melibatkan daerah artikuler atau
metafise
Rehabilitation goals:
• Memperbaiki ROM lutut dan ankle
• Memperbaiki kekuatan otot-otot:
 Dorsiflexors: tibialis anterior,
extensor hallucis longus, extensor
digitorum longus
 Plantarflexors: gastrocnemius, soleus,
flexor digitorum, flexor hallucis
longus
 Inverters: tibialis posterior, tibialis
anterior
 Everters: peroneus longus & brevis
• Fungsional: menormalkan pola gait
pasien
• Bone healing: 10 – 12 minggu
• Rehabilitasi: 12 – 24 minggu
Rehabilitasi Fraktur Shaft Tibia
Cast ORIF External Fixation

ROM
• AROM exc Minggu ke-1 Minggu ke-1 Minggu ke-1
• AAROM exc Minggu ke-8 Minggu ke-8 Minggu ke-8
• PROM exc Minggu ke-8 Minggu ke-8 Minggu ke-8
Strengthening
• Isometric exc Minggu ke-1 Minggu ke-1 Minggu ke-1
• Isotonic exc Minggu ke-4 Minggu ke-4 Minggu ke-4
Weight Bearing
• Partial WB Minggu ke- Minggu ke-1 Minggu ke-1
• Full WB Minggu ke-12 Minggu ke-8 Minggu ke-8
(~ toleransi)
Fraktur Ankle
• Definisi: Fraktur ankle meliputi fraktur dari
maleolus lateral dan medial, juga permukaan
artikuler dari tibia dan fibula
Rehabilitation goals:
• Memperbaiki ROM ankle pada semua arah
• Memperbaiki kekuatan otot-otot:
 Plantar fleksor ankle & foot:
gastrocnemius, soleus, tibialis posterior,
flexor digitorum longus, flexor hallucis
longus
 Dorsifleksor ankle & foot : tibialis
anterior, extensor digitorum longus,
extensor hallucis longus
 Evertor foot: Peroneus longus, peroneus
brevis
 Invertor foot: tibialis posterior, tibialis
anterior
• Fungsional: menormalkan pola gait pasien
• Bone healing:
Extraarticular (isolated lateral malleolar): 6 – 10
minggu
Intraarticular (bimalleolar, trimalleolar, bimalleolar
equivalent, medial malleolar): 8 – 12 minggu
• Rehabilitasi:
Extraarticular malleolar: 12 – 16 minggu
Intraarticular malleolar: 16 – 24 minggu
Rehabilitasi Fraktur Ankle
Cast ORIF

ROM
• AROM exc Minggu ke-1 Minggu ke-1
• AAROM exc Minggu ke-8 Minggu ke-8
• PROM exc Minggu ke-8 Minggu ke-8
Strengthening
• Isometric exc Minggu ke-2 Minggu ke-2
• Isotonic exc Minggu ke-6 Minggu ke-6
Weight Bearing
• Partial WB Minggu ke-4 (~toleransi) Minggu ke-4 (~toleransi)
• Full WB Minggu ke-8 (~ toleransi) Minggu ke-6
Terima Kasih
Komplikasi Fraktur
• Komplikasi dini
• Komplikasi lanjut
Komplikasi Dini
Lokal Jauh
• Kulit : nekrosis, trombosis vena • Emboli lemak
• Sendi : infeksi • Emboli paru
• Tulang : osteomyelitis, nekrosis • tetanus
avaskular
Komplikasi lanjut
Lokal Jauh
• Sendi : kaku, degenerasi sendi • Renal kalkuli
• Tulang:
malunion, delayed union, non
union, gangguan pertumbuhan
• Otot : posttraumatic myositis
ossificans
Myositis Ossificans
• extra-skeletal ossification that
occurs in muscles & other soft
tissues
• As a result of impact which
causes damage to the sheath
that surrounds a bone
(periosteum) as well as to the
muscle
• 80% ossifications arise in the
thigh or arm
• Other sites include intercostal
spaces,erector spinae ,pectoralis
muscles, glutei, and the chest
Cause
• Not applying cold therapy and compression immediately after the
injury.
• Having intensive physiotherapy or massage too soon after the injury.
• Returning too soon to training after exercise.
Symptom
• Restricted range of movement
• Pain in the muscle when it is used
• A hard lump in the muscle
• An X-ray can show bone growth
X-ray CT Scan
• soft tissue ossification not • calcification of the heterotopic
attached to bone is common ossification proceeds from the
• x-rays show round mass w/ outer margin and progresses
distinct peripheral margin of centrally
mature ossification & a
radiolucent center of immature Bone Scan
osteoid & primitive
• active myositis appears as
mesenchymal tissue
intense para-osseous
• this peripheral maturation, accumulation of tracer activity in
reverse of that seen in a acutely damaged muscle on
malignant tumor, is delayed images;
characteristic of myositis
Treatment
• Rest
• Immobilization
• Anti-inflammatory drugs
• physiotherapy management
• surgical debridement
Physiotherapy management
• Rest
• Immobilization
• pulsed Ultra sound and phonophoresis
• Maintain available range of motion but avoid stretching and massage,
until maturation.
• iontophoresis with 2 % acetic acid solution.
• extra corporeal shock wave therapy
Surgical treatment
• Growth should not be removed in premature stage as it will likely
reoccur.
• The ossification becomes exuberant, infiltrates beyond the original
site, and compresses the soft tissues around beyond hope of repair.
• When after serial x-rays the mass is dense, well delineated, and at a
stand still, it may be safely removed.
• It may be possible to prevent myositis by aspirating the original
haematoma.
TERIMA KASIH