Rehabilitasi Fraktur.

Presentasi berjudul: "Rehabilitasi Fraktur."— Transcript presentasi:

1 Rehabilitasi Fraktur

2 Rehabilitasi Fraktur AGA

3 Fraktur Humerus Proximal Midshaft Distal

4 Fraktur Humerus Proximal
 head humerus, anatomic neck humerus, dan surgical neck humerus Rehabilitation goals: Mengembalikan full ROM bahu Mengembalikan kekuatan otot-otot bahu Fungsional: Meningkatkan atau mengembalikan fungsi bahu untuk ADL. Bone healing: 6 – 8 minggu Rehabilitasi: 12 minggu – 1 tahun

5 Rehabilitation Fraktur Humerus Proximal
Weeks Nonoperative Fixation Operative Fixation Endoprosthesis 0 - 1 Pendulum exercises to shoulder No range of motion to the shoulder 2-4 Gentle active ROM exercise shoulder (flexion, extention, abduction, adduction) Gravity eliminated pendullum exercise Avoid internal and external rotation No active ROM to the shoulder Gentle passive-assistive ROM exercise to the shoulder in supine position Begin passive-assistive shoulder ROM (avoiding internal and external rotation) 4-6 Advance isometric exercises Continue with passive-assistive ROM

6 Rehabilitation Fraktur Humerus Proximal
Weeks Nonoperative Fixation Operative Fixation Endoprosthesis 6-8 Begin active ROM with terminal stretching, emphasizing elevation and external rotation Begin active ROM shoulder, emphasizing elevation and external rotation Advance isometric shoulder exercises in all planes 8-12 Begin resistive shoulder exercises and continue terminal capsular stretching >12 Continue resistive exercises with increasing resistance Continue capsular stretching Continue resistive exercises

7 Fraktur Midshaft Humerus
Bagian diafisis humerus Rehabilitation Goals Mengembalikan ROM bahu dan siku Meningkatkan kekuatan m.pectoralis major, deltoid, biceps, dan triceps Fungsional: Meningkatkan atau mengembalikan fungsi bahu untuk ADL. Bone healing: 8 – 12 minggu Rehabilitasi: 12 minggu – 16 minggu

8 Rehabilitasi Fraktur Midshaft Humerus
Weeks Cast Rod Plate 0 - 1 Move digits to diminish hand swelling No strengthening or ranging to elbow or shoulder If stable fixation, the patient may begin moving the shoulder and elbow as pain allows If stable fixation, the patient may range the shoulder and elbow as pain allows If unstable, no ROM 2-4 Begin gentle ROM to elbow and shoulder No strengthening Progress with ROM to shoulder and elbow Pendulum exercises to the shoulder Limited weight bearing is allowed No weight bearing 4-6 Aggresive ROM to shoulder and elbow Strengtehning with isometric and isotonic exercise Light weight bearing to extremity Use extremity for ADL If callus is evident, weight bearing is to be progressed Isotonic and isometric strengthening, and ranging to elbow and shoulder Lightweight bearing allowed Aggresive ranging and light strengthening to shoulder and elbow 8-12 Full weight bearing, ranging, andprogressive resistive exercises for strengthening Full activities

9 Fraktur Humerus Distal
 distal humerus melibatkan metafisis, bisa sampai ke permukaan intraartikuler Rehabilitation goals: Mengembalikan full ROM elbow dan shoulder, melindungi sudut normal carrying dari elbow. Meningkatkan kekuatan dari otot-otot: triceps, biceps, forearm supinators & pronators, wrist extensors, wrist flexors, dan deltoid 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

10 Rehabilitation Fraktur Humerus Distal
Weeks Cast/Splint Percutaneous Pinning ORIF 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 Active & passive ROM exercises to the digits Isometric exercises to biceps, triceps, & deltoid 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 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 Isometric exercises to biceps, triceps, deltoid, & forearm muscles Continue gentle active ROM exercises to the entire extremity, including elbow, wrist, fingers, and shoulder

11 Rehabilitation Fraktur Humerus Distal
Weeks Cast/Splint Percutaneous Pinning ORIF 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 Continue active & active-assistive ROM exercises to the entire extrimity including elbow, wrist, fingers, and shoulder 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 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

12 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

13 Rehabilitation Fraktur Forearm
Weeks Cast ORIF of Both Bone Fractures ORIF of Galeazzi & Monteggia Fractures 0-1 Long arm cast  AROM & PROM shoulder Short arm cast  AROM & PROM digits; AROM & AAROM elbow and shoulder No cast with stable fixation: gentle active ROM exercises for the entire extremity, including fingers, wrist, elbow, and shoulder Long arm cast: active and passive ROM exercises to the digits. Active & active assistive ROM exercises to the shoulder Isometric exercises to the biceps, triceps, & deltoid 2 Long arm cast  AROM & PROM digits; AROM & AAROM shoulder Short arm cast  AROM & PROIM digits; AROM & AAROM elbow and shoulder

14 Rehabilitation Fraktur Forearm
Weeks Cast ORIF of Both Bone Fractures ORIF of Galeazzi & Monteggia Fractures 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 No cast with stable fixation: gentle active ROM exercises for the entire extremity, including fingers, wrist, elbow, and shoulder At 6 weeks, gentle active resistive exercises can be started No lifting or weight bearing allowed, although patient may use extremity to eat or write Long arm cast: active and passive ROM exercises to the digits. Active & active assistive ROM exercises to the shoulder Isometric exercises to the biceps, triceps, & deltoid 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

15 Fraktur Colles Definisi:
Rehabilitation goals: 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. 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.

16 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 2 Active ROM to the wrist if fixation is rigid 4-6 Begin active ROM of wrist if cast removed 6-8 Active & passive ROM to wrist Gentle resistive exercises to the wrist Active & passive ROM to wrist as tolerated 8-12 Active & passive ROM and progressive resistive exercises

17 Rehabilitasi Fraktur AGB

18 Fraktur Femur Fraktur neck femur Fraktur shaft femur

19 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

20 Rehabilitasi Fraktur Neck Femur
Internal Fixation Hemiarthroplasty ROM AROM exc AAROM exc PROM exc Minggu ke-1 Minggu ke-2 Minggu ke-8 (hindari add & Int Rot) Strengthening Isometric exc Isotonic exc Minggu ke-4 Weight Bearing Partial WB Full WB Minggu ke-12 Minggu ke-1 (~toleransi)

21 Fraktur Shaft Femur 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 Definisi: Fraktur pada diafise femur yang tidak meluas ke daerah artikuler atau metafise

22 Rehabilitasi Fraktur Shaft Femur
Intramedullary Rod ROM AROM exc AAROM exc PROM exc Minggu ke-1 Minggu ke-2 Minggu ke-4 Strengthening Isometric exc Isotonic exc Weight Bearing Partial WB Full WB Minggu ke- Minggu ke-12

23 Fraktur Shaft Tibia 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 Definisi: Fraktur diafise tibia yang biasanya tidak melibatkan daerah artikuler atau metafise

24 Rehabilitasi Fraktur Shaft Tibia
Cast ORIF External Fixation ROM AROM exc AAROM exc PROM exc Minggu ke-1 Minggu ke-8 Strengthening Isometric exc Isotonic exc Minggu ke-4 Weight Bearing Partial WB Full WB Minggu ke- Minggu ke-12 (~ toleransi)

25 Fraktur Ankle 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 Definisi: Fraktur ankle meliputi fraktur dari maleolus lateral dan medial, juga permukaan artikuler dari tibia dan fibula

26 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

27 Rehabilitasi Fraktur Ankle
Cast ORIF ROM AROM exc AAROM exc PROM exc Minggu ke-1 Minggu ke-8 Strengthening Isometric exc Isotonic exc Minggu ke-2 Minggu ke-6 Weight Bearing Partial WB Full WB Minggu ke-4 (~toleransi) Minggu ke-8 (~ toleransi)

28 Terima Kasih

29 Komplikasi Fraktur Komplikasi dini Komplikasi lanjut

30 Komplikasi Dini Lokal Kulit : nekrosis, trombosis vena Sendi : infeksi
Tulang : osteomyelitis, nekrosis avaskular Jauh Emboli lemak Emboli paru tetanus

31 Komplikasi lanjut Lokal Sendi : kaku, degenerasi sendi Tulang:
malunion, delayed union, non union, gangguan pertumbuhan Otot : posttraumatic myositis ossificans Jauh Renal kalkuli

32 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

33 80% ossifications arise in the thigh or arm
Other sites include intercostal spaces,erector spinae ,pectoralis muscles, glutei, and the chest

34 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.

35 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

36 X-ray soft tissue ossification not attached to bone is common x-rays show round mass w/ distinct peripheral margin of mature ossification & a radiolucent center of immature osteoid & primitive mesenchymal tissue this peripheral maturation, reverse of that seen in a malignant tumor, is characteristic of myositis CT Scan calcification of the heterotopic ossification proceeds from the outer margin and progresses centrally Bone Scan active myositis appears as intense para-osseous accumulation of tracer activity in acutely damaged muscle on delayed images;

37 Treatment Rest Immobilization Anti-inflammatory drugs
physiotherapy management surgical debridement

38 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

39 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.

40 TERIMA KASIH