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From PEKN 1P93 Winter 2014: Group 09: Treatment Rehab, Hand Tendon Repair

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[edit] Background

Understanding treatments and rehabilitation for injuries is very important in any active person's life. Injuries are an unfortunate consequence of being physically active, but they benefit you in the sense of better understanding the body. One injury that is becoming increasingly more common is an ankle fracture, which can prevent people from putting weight on the ankle for up to several months and thus interfere with day-to-day life and daily physical activity. The ankle, being a complex formation of three bones, can suffer from many different types of fractures, including lateral malleolus fractures, medial malleolus fractures, bimalleolar fractures and posterior malleolus fractures. The importance of providing proper treatment and rehabilitation ensures a more successful healing process and targets developmental healing. This ensures that mobility issues are limited, and the patient can return to normal function and physical activity as soon as possible.

Images of Different Types of Fractures

Lateral Malleolus Fracture
[1] Lateral Malleolus Fracture[2]Bimalleolar Fracture
Bimalleolar Fracture


Medial Malleolus Fracture

[3]Medial Malleolus Fracture[4]Posterior Malleolus Fracture

Posterior Malleolar Fracture

[edit] History

Ankle fractures are one of the most common injuries, consisting of a break in the bone(s) of the ankle, and could be cause by many reasons, including physical activity. This injury is important to understand since there is a great chance that the injury will occur again if not treated at the right time and with proper recovery methods. Ankle fractures can be difficult to handle as it can be mistaken with a sprain or strain. This can prevent a longer absence of physical activity, not just with sports, but one's daily activities. Treatments for a fracture can be different from a sprain, where sprains are dealing with torn ligaments and fractures are with broken bones. The ankle is made of three major bones, tibia, talus, and fibula which are placed into four different sections of the ankle. These sections are the lateral, medial, anterior, and posterior where the movements of the ankle can perform. According to Haddad (2013) ankle fractures have accounted for about 9% of all fractures throughout the body. This limits the number of opportunities of being physically active due to ankle injuries having a crucial impact on mobility. Throughout history treatments were improved and revolutionized into appropriate diagnose for patients with an ankle fracture. Great work has been done in the medical field to provide information about the physiology and anatomy of the ankle to further enhance our knowledge about treatments for such injuries. Internal fixation is an example where it is an operational treatment for ankle fractures which started in mid-19th century. By the 20th century internal fixations are still being used such as metal plates and bone screws to keep the ankle stable. Over time, new technology has advanced to further reduce the duration of the healing process to engage in physical activities as soon as possible. These medical improvements were introduced as ankle fractures were becoming more frequent since there was a major increase in physical activity in the population, also with the population of the baby-boomers. Now, there is a higher participation of physical activity and sports are reaching higher levels that can increase the number of injuries, such as ankle fractures. It is important to understand ankle fractures because they will only increase in occurrence over time and the ways to treat or even prevent ankle injuries are significant.

[edit] Target Audience

People of all ages are susceptible to ankle fractures, therefore it is important for everyone to understand the injury and its treatment in order to continue to be physically active. Children and adolescents are prone to common injuries, including fractures, due to weaker bones that have not yet fully developed. Ankle fractures in children can disrupt bone development, which can cause long-term physical disabilities and limit their future involvement in physical activity. Children and adolescents are also most actively involved in daily sport or physical activities, which increases their chances of injury. Rapid recovery from an ankle fracture is important so that the child can continue being physically active. Children who are not physically active continue with these habits and grow up to live unhealthier lifestyles. Athletes/ physically active individuals are also put at greater risk than most because of the repeated movements and stress on the muscles, bones and joints, and an increased likelihood of collision impacts. Even as athletes age and decrease the intensity of physical activity or stop altogether, they continue to be at risk of injuries due to the stress they have put on their ankle joints over the years. Proper treatment and rehabilitation are important so that the patient can return to sport or physical activity without being at risk of causing furhter damage. In the elderly population, ankle fractures are also becoming more frequent due to general health issues brought on by old age (for example, osteoporosis). Since the elderly population are already limited in mobility, it is especially important for them to be able to deal with the injury without interfering too much with their daily lives and to make sure the bone heals properly to allow them to continue being physically active. Since ankle injuries can affect such a wide range of individuals, it is important to understand the proper treatments for different age groups in order to return to regular routine and physical activity.

[edit] Research

Before any treatment or rehabilitation happens, it is important to take note of the classifications of what level of injury one may have. This article provides the reader with information about classifying ankle injuries. According to Smithius (2012), being able to classify ankle fractures is important because it will help guide rehabilitation treatment correctly. The Weber & Launge-Hansen classification system is the most well known system used today. The Weber classification system looks at the integrity of the syndesmosis. It breaks bone fractures down into three main categories; type A, type B and type C. The Lauge-Hansen classification focuses on the trauma mechanism. It breaks down the mechanism of the injury in two simplistic terms. The first term describes the position of the foot at the time of injury. The second term describes the direction or force of the talus in regards to where the tibia moves. By utilizing both these classifications together, people will be able to predict ligamentous injury, instability and bone fractures. By using this system to classify ankle fractures, professionals are further able to create the most appropriate treatment. The appropriate treatment reduces the time of being injured which is crucial in most patients situations so they are able to get back to their daily routine, especially athletes who lead very physically demanding and active lifestyles.

Another study describes patients that have had an ankle fracture in the past and have been treated with monitoring for a duration of thirty years. According to Bauer, Jonsson, & Nilsson (1985), this study consisted of finding out if these patients developed signs of arthrosis during the years of their treatment. Results showed that the hypothesis, stating that ankle fractures must be perfectly reduced, is not supported. This relates back to physical activity as patients going through treatment with an ankle fracture cannot be doing any physical activity as they are nursing their injury for many years. Arthrosis or joint disease can arise when a person ages and overuse their ankle joint which can be dangerous towards a person’s physical activity, as they are stopping their activity, which can cause major damage to a person’s mobility, in turn, affecting that person’s health (Bauer et al., 1985).

Over a 20 year time span, another study viewed the outcomes of treated ankle fractures from 19 patients. Donken, Goorden, Verhofstad, Edwards & Laarhoven's (2011) research shows the outcome of these patients who all had an isolated fracture of the posterior malleolus. Multiple assessments of various approaches, such as questionnaires and measurements differentiated the individual's situation. Donken et al. (2011), concluded that there was no correlation between the size of the fracture gap and the proportion of the tibiotalar contact area. This conclusion was shown throughout all of the individuals who participated and all had very positive and efficient results. With the combination of proper treatment and healing shows that no matter the size or severity of the injury, there are the same possibilities of outcomes for each person. Physically being able to return to a regular lifestyle and have positive outcomes in the future is the ideal treatment for anyone.

Determining a patient’s plan to care for the injury depends on their ability to go through operative surgery and the ability to rearrange the bones to original placement and overall, recreating the same function of the tendons and ligaments surrounding the injury is displayed in a different article. According to Hsu & Bariteau (2013), management of an ankle fracture ranges from immediate weight-bearing to up to 12 weeks of non-weight bearing, and may or may not require an operation, depending on the severity of the fracture. Most often, treatment begins by immobilizing the ankle for stability; ice and elevation also helps to decrease swelling. This also includes an examination, which looks for factors of skin changes and bleeding, appropriate imaging, which displays a variety of views of the foot to further assess an accurate result, and having a technical fixation and immobilization. Once healed, rehabilitation works to restore motion, strength, and function to the ankle, and the plan must be tailored to the patient’s medical history and severity of their individual injury. This can then help the patient regain strength and allow them to start participating in less strenuous physical activity. Rehabilitation plans often include weight bearing and range of motion exercises, which should increase in intensity as healing progresses, but should not include heavy lifting or running (Hsu & Bariteau, 2013).

A research study by Zaghloul, Haddad, Barksfield & Davis (2014), conducted that people sixty years of age or older who have undergone operative treatment, such as open reduction or internal fixation for ankle fractures are more prone to experience complications in the future, which then affects their physical activity levels tremendously. The average age for the participants was seventy years old. There is a need for the revision of surgery after treatment of ankle fractures. Postoperative wound infections are the most common complications found. Some other complications found were hardware failure, wound debridement, and removal of metal hardware. As these complications occur, it is even harder for elders to get back into their daily routines of physical activity and they have a much more delayed recovery time. Based on statistical analysis, it is important to bear specific factors while deciding whether surgical treatment should be used in elders, such as smoking, diabetes, age, sex, fracture type, and Charlson score (Zaghloul et al., 2014).

[edit] Existing Physical Activity Programs

After the ankle bone heals, the patient is able to begin rehabilitation of the injury. Physiotherapy is a type of rehab and is a common exercise approach to aid the healing of an ankle fracture as well as to help patients progress into simple movements. These simple movements further allow the patient to work towards getting back into physical activity. This primary care, client focused health profession is dedicated to improving the quality of life by helping the patient fully recover from the injury and return the ankle to its full potential. People who experience ankle fractures focus on rehabilitating their injury through these therapeutic exercise programs and learn how to prevent future injury in the process. Physiotherapy is a commonly used practice upon injury. Physiotherapists can use their modern day technology, such as ultra sounds, muscle stimulation and IFC machines, to further superficially stimulate around the injury and promote faster healing. Therapists are also helpful in aiding with future prevention of an injury through instructions on proper prevention tactics, such as tensor bandage usage (Hawson, 2011).

Sports Medicine Clinics around communities help and support people who need a progressing and developing program to ensure proper care and recovery. They cover patients with sport or exercise related injuries, while usually having a larger staff that includes professionals that focus on different aspects such as athletic therapists, sports massage therapists, sports physicians and many more. Facilities such as the The Fowler Kennedy Clinic provide many services to meet each client's needs such as injury prevention, diagnosis, treatment, rehabilitation, research, education and advocacy. Having planned strategies to diagnose and treat the injury can usually result in a more successful recovery. Regaining muscle strength slowly and carefully to recover after a break prevents further breaks, can help prevent other injuries, and can promote healing. Simple exercises, which can be done either in a physiotherapy clinic or at home are designed to progressively strengthen the ankle after the injury. Programs should be specially designed to ensure optimum healing of the ankle, depending on the exact injury of that specific patient. The program could be primarily made up of light ankle exercises, but may also incorporate some exercises to strengthen the knee and hip, which may have been weakened during the immobilization and non-weight bearing stages of treatment. An existing program that treats ankle fractures is the Summit Medical Group, which provides a variety of exercises dealing with not just how to rehabilitate the ankle itself, but includes other parts of the body as a whole within these exercises (White, 2012). Practitioners are available within this program to help the patient treat their injury as quickly as possible with any assistance needed.

These fitness programs are a way to help patients with an ankle fracture to recover and get back into their previous fitness state. Fitness programs help regain strength and sustain stability in the ankle by the use of enhanced mobility exercises and different movements. Programs such as any YMCA health and fitness are available to the public to assist in physical activity through the rest of the body as muscle atrophy may develop from large amounts of resting time with an ankle fracture. Any physical activity that keeps your body healthy, your muscles and bones strong can act as prevention for ankle fractures. Proper stretching and warming up before exercise decreases the risk of injury and helps maintain proper muscle function.

[edit] Best Practice Activity Suggestions

There are many existing activities that can help rehabilitate the ankle following an injury without causing further damage. Any physical activity that keeps your body healthy and your muscles and bones strong can act as prevention for ankle fractures. For example, swimming is a common exercise used for any leg or ankle injury and in some cases even partly paraplegic people, thus making it an ideal exercise activity for anyone who has suffered an ankle fracture or wishes to prevent one. Swimming is a non-weighted, resistant exercise that can be used to rehabilitate the surrounding muscles of the ankle for a quicker return to full health, as well as to prevent further injury.

Another great practice for ankles and joints is yoga. Strong ankles are very important to athletes, however most ignore that particular area. Yoga improves joint positions while strengthening the muscles around the ankle, which creates better stability for anyone who is engaging in physical activity. The major problem with ankles is that they tend to be tight at the front, and yoga is a practice that promotes better flexibility in that particular area where the injury can occur. Yoga is also great for relaxing before or after physical activity. This program is used all over the world to help athletes recover from any pain.

Stretching is an important practice for the prevention, rehabilitation and treatment of an ankle injury. Stretching allows full range of motion to return quicker. By focusing the stretching on the two main muscle groups surrounding the ankle, which include the gastrocnemius and soleus, the range of the motion of the ankle joint can be increased. By stretching these muscle groups, an increase in muscle elasticity and durability will occur and help relieve tension in the ankle and prevent future injuries from occurring.

Massage therapy is a beneficial practice to returning to normal after an ankle injury. Whether it is performed as an at home application or performed by a professional massage therapist, massage therapy can help relieve the built up tension in the ankle. After an injury, the body responds by forming scar tissue around the damaged tissue as a safety mechanism. This scar tissue is important for the healing of the body, but it also prevents future range of motion and mobility. Massage therapy breaks down these tissues and allows for them to be removed by your body, post-injury.

Prior to returning to sport, it is highly encouraged to engage in some strength and conditioning activities, with the potential of some weight bearing exercises. These include, but are not limited to, skipping, around the clock-lunges to engage all angles of the ankle, calf raises, one legged balances and so on. These exercises will help enhance the surrounding muscles' overall strength and support the ankle for future vigorous activity.

Balance Board
Balance Board
Skipping
Skipping
Icing & Wrapping
Icing & Wrapping
One Foot Balance
One Foot Balance

[edit] Future Directions

Following treatment and rehab of an ankle injury, a good future practice that can be incorporated into one's daily routine would be to return to small amounts of physical activity. Once the injury is fully healed, maintaining a physically active lifestyle that does not put strain on the injury can lead to a healthier body and prevent future injury.

Some patients who recover from an ankle injury may feel slight discomfort or pain even after the healing and rehabilitation process. This can be solved by changing the types of shoes worn. Wearing shoes with proper support that targets the area, or inserting insoles into the shoes worn throughout most of the day gives extra support to the ankle and reduces the feelings of discomfort.

An action that can be taken by the patient to maintain maximum treatment and health of the bones fractured from the injury would be to incorporate daily doses of supplements such as calcium and vitamin D. Vitamin D deficiency, low calcium intake, physical inactivity lead to decreased bone density. This decrease leads to increased chances of fractures, not only in the ankle, but other bones throughout the body that may impact an individual's ability to lead a physically active lifestyle (Bachrach & Sills, 2010).

[edit] External Links

For more information regarding ankle fractures and their treatment and rehabilitation, please visit the links below:

Cluett, J. (2014). Broken Ankle: All About Ankle Fractures. Retrieved from "http://orthopedics.about.com/cs/ankleproblems/a/anklefracture.htm" http://orthopedics.about.com/cs/ankleproblems/a/anklefracture.htm

Sears, B. (2012). Physical Therapy After Ankle Fracture. Retrieved from "http://physicaltherapy.about.com/od/sportsinjuries/a/Ankle-Fracture.htm" http://physicaltherapy.about.com/od/sportsinjuries/a/Ankle-Fracture.htm

http://emedicine.medscape.com/article/309106-treatment

http://fowlerkennedy.com/patient-care-education/physiotherapy/

http://orthoinfo.aaos.org/topic.cfm?topic=a00391

http://orthopedics.about.com/cs/ankleproblems/a/anklefracture.htm

http://physicaltherapy.about.com/od/sportsinjuries/a/Ankle-Fracture.htm

http://emedicine.medscape.com/article/92095-overview

[edit] Notes and References

  1. Michealson, J. D. (2003). Ankle Fractures resulting from rotational ankle injuries. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=a00391
  2. Clough, J. F. (2001). Glossary of broken Leg terms. Retrieved from http://www.mybrokenleg.com/faq/glossary.html
  3. Anderson, T. Carr, P.C. (2014). Full Service Georgia Law Firm. Retrieved from http://www.atclawfirm.com/resources/success-stories/lori-breaks-leg-on-painted-handicapped-ramp-350000-settlement/
  4. Medical Multimedia Group, L. L. C. (2011). Orthopod: Types. Retrieved from http://www.eorthopod.com/content/adult-ankle-fractures-types

Bachrach, L.K., Sills, I.N. (2010). Bone densitometry in children and adolescents. American Academy of Pediatrics, 127(1), 189-194.

Bauer, M., Jonsson, K., & Nilsson, B. (1985). Thirty-year follow-up of ankle fractures. Lund University Departments of Orthopedics, 56(2), 103-106.

Broos, P.L.O., Sermon, A. (2004). From unstable internal fixation to biological Osteosynthesis a historical overview of operative fracture treatment. Acta Chirurgica Belgica, 104(4), 396-400.

Colberg, S. (2012). Why the physical inactivity of youth is a growing problem. Retrieved from http://www.diabetesincontrol.com/articles/64-/13359-why-the-physical-inactivity-of-youth-is-a-growing-problem

Donken, C., Goorden, A., Verhofstad, M., Edwards, M., & van Laarhoven, C. (2011). The outcome at 20 years of conservatively treated 'isolated' posterior malleolar fractures of the ankle: A case series. Journal Of Bone & Joint Surgery, British Volume, 93(12), 1621-1625.

Haddad, L. S. (2013). Ankle fractures (broken ankle). American Academy of Orthopaedic Surgeons.

Hawson, S.T. (2011). Physical Therapy and Rehabilitation of the foot and ankle in the athlete. Clinics in Podiatric Medicine and Surgery.

Hsu, R. Y., & Bariteau, J. (2013). Management of ankle fractures. Rhode Island Medical Journal, 96(5), 23-7.

Shin, L. (2014). Step Lively. Retrieved from http://www.yogajournal.com/practice/1014

Smithuis, R. (2012). Weber & Lauge Classification. Radiology Assistant.

White, T. (2012). Ankle fracture exercises. Retrieved from http://www.summitmedicalgroup.com/library/adult_health/aha-ankle_fracture_exercises/

Zaghloul, A., Haddad, B., Barksfield, R., & Davis, B. (2014). Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases. ScienceDirect, 45(4), 780-783.

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