PENANGANAN FRAKTUR (Hoppenfeld)

1
PENANGANAN FRAKTUR KLAVIKULA

4 6 Weeks With bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% &racture line is less distinct +imit abduction 6 8 Weeks With bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is more apparent% &racture line is less distinct None% ,void contact sports ,ctive to active# assistive -. in all planes esistive ex to the shoulder girdle muscles 6 12 Weeks Stable
0 1 Week Bone Heal n! "#a$ l #% None
2 Weeks None to minimal
"#a!e &'Ra%
Inflammatory phase !allus "#$
Beginning of reparative phase None to early callus; fracture line is visible Shoulder is held in add ' int rotation% (lbow is held at )* of flexion /entle pendulum ex to the shoulder in the sling as pain permits No strengthening ex to the shoulder% Start gentle isometric ex to the deltoid 4he uninvolved extremity is used in self#care ' personal hygiene None
emodeling phase Bridging callus is very visible% &racture line becomes even less distinct None
P(es) ( *# o n
P(e)a+# ons R,-
Shoulder is held in add ' int rotation% (lbow is maintained at )* of flexion No -. to the shoulder
-+s)le "#(en!#.
No strengthening ex to the shoulder
F+n)# on al A)#/
4he uninvolved extremity is used in self#care ' personal hygiene None
,t the end of 0 wee1s, gentle active -. to the shoulder is allowed% ,bd is limited to 2*% 3endulum ex are prescribed to the shouler w/ gravity elimination% Start isometric ex to the rotator cuff ' deltoids 4he patient uses the affected extremity for some self#care ' personal hygiene None
,ctive, active#assistive -. shoulder Isometric ' isotonic ex are prescribed to the shoulder girdle muscles% esistive ex are prescribed 4he involved extremity is used in self#care ' functional activities &WB
We !.# Bea( n!
4he patient uses the involved extremity for self#care, personal hygiene, stabili5ation ' light activity /radual WB is allowed
3enanganan &ra1tur "di1utip dari 4reatment '
ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana
PENANGANAN FRAKTUR HU-ERU" PR,K"I-AL

4 6 Weeks With bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% With increased rigidity of the fixation, less bridging callus is noted, ' healing w/ endosteal callus predominates% (xpect less callus in end#of#bone fractures than in midshaft fractures 8o not apply force in attempting to regain the full -. Shoulder 9 limited range &lexion/abd up to 6**#66* Int/ext rotation 9 limited 3endulum ex against gravity (lbow 9 full -. in flexion, extension, supination ' pronation Surgically treated patients may continue w/ passive# assistive -. ex Shoulder 9 avoid ex to the deltoid if it is incised during surgery (lbow 9 isometric ' isotonic ex 6 8 Weeks With bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% With increased rigidity, less bridging callus is noted, ' healing w/ endosteal callus predominates% 4he fractures line is less distinct ,void forced -. ,ctive, active#assistive ' passive -. to the shoulder ' elbow in all planes, to tolerance 8 12 Weeks Stable
Bone Heal n!
"#a$ l #%
0 1 Week None
2 ' 4 Weeks None to minimal
"#a!e &'Ra%
Inflammatory phase !allus "#$% 4he fracture line is visible
Beginning of reparative phase No callus; fracture line is still visible
emodeling phase ,bundant callus; fracture line begins to disappear% With the time, there will be reconstitution of the medullary canal None ,ctive ' passive -. to the shoulder ' elbow in all planes
P(es) ( *# o n
P(e)a+# ons R,-
,void shoulder motion None at the shoulder ' elbow% /entle pendulum ex w/ elimination of gravity are allowed for nondisplaced fractures ' hemiarthroplasty
,void int/ext rotation of the shoulder 3atients treated conservatively with a sling can continue w/ pendulum ex% ,ctive to gentle passive#assistive ex to the shoulder% 3atient treated surgically should start passive# assistive -. in supine position% No active -. to the shoulder Isometric shoulder ex in patients treated w/ sling only% No strengthening ex for patients treated w/ surgical intervention
-+s)le "#(en!#.
No strengthening ex to the elbow or shoulder are permitted
!ontinue isometric ex to the shoulder% !ontinue w/ isometric ' isotonic ex to the elbow% Start progressive resistive ex for patients
esistive ex to the shoulder w/ gradual increases in weights% Iso1inetic ex using appropriate
treated w/ a sling F+n)# on al A)#/ -ne#handed activities w/ the uninvolved extremity% 4he patient needs assistance in dressing, grooming ' preparing meals None on affected extremity 3atient continues w/ one# handed activities ' needs assistance in dressing, grooming ' preparing meals% None on affected extremity Involved extremity used for dressing ' grooming as tolerated% 3atient still needs assistance in house cleaning ' preparing meals None o affected extremity 4he involved extremity is used for self#care ' feeding% 4he patient may still need to use the uninvolved extremity for some self# care activities WB as tolerated
e;uipment to improve strength ' endurance 3atient should be able to use the affected extremity w/o significant limitations in ,8+ ' self#care &WB
We !.# Bea( n!
PENANGANAN FRAKTUR 1IAPH2"I" ATAU -I1"HAFT HU-ERU"

2 Weeks None to minimal Beginning of reparative phase None to very early callus 4 6 Weeks Bridging callus ' moderate stability eparative phase Bridging callus is visible 8 12 Weeks Stable callus emodeling phase ,bundant callus, fracture line begins disappear, reconstitution of medullary canal% Non union is clearly evident No contact sports ,ctive, active#assistive ' passive -. tp the shoulder ' elbow
0 1 Week Bone Heal n! "#a$ l #% "#a!e &'Ra% None Inflammatory phase !allus "#$
P(es)( * # on
P(e)a+# ons R,-
-+s)le "#(en!# . F+n)# o nal A)# 3 # e s
No +ifting w/ the affected extremity Brace / Splint < No -. to the shoulder ' elbow - I& / external fixator < gentle active ' active#assistive -. to the shoulder ' elbow if fixation is stable% 3endulum ex% w/ gravity "#$ to the shoulder No strengthening exc% to the elbow or shoulder >ninvolved extremity may be used for self#care ' ,8+
No +ifting w/ the affected extremity ,ctive ' active#assistive -. to the shoulder ' elbow% W/ splint or brace, no abd shoulder = 0*
No heavy lifting w/ the affected extremity ,ctive ' active#assistive -. to the shoulder ' elbow
/entle pendulum exercise to the shoulder% No strengthening exercise to shoulder ' elbow ,8+ w/ uninvolved extremity% In - I& ' external fixation, involved extremity used for feeding, light grooming, writing
Isometric ' isotonic exc% 4o the forearm muscles% ,fter 0 wee1s, isometric exc% 4o biceps ' triceps Involved extremity may be used for basic self#care ' personal hygiene
3rogressive resistive exc% to the shoulder ' elbow Involved extremity may be used in ,8+% +ight lifting is allowed w/ the affected extremity
We !.# Bea( n!
NWB on affected extremity
NWB on affected extremity% +imited WB w/ rodding
(arly WB is allowed w/ int% fixation
&WB is allowed
PENANGANAN FRAKTUR HU-ERU" 1I"TAL

2 Weeks None to minimal 4 6 Weeks -nce calus is observed bridging the fracture site, the fracture is usually stable% 4his should be confirmed by physical examination% 4he strength of this callus is significantly lower than of normal bone, especially w/ torsional load eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates ,void rotational stresses across the elbow ,ctive / active#assistive flexion ' extension to the elbow 8 12 Weeks Stable
Bone Heal n!
"#a$ l #%
0 1 Week No bony stability% Some stability may be afforded ba an intact periosteum ' ligaments
"#a!e &'Ra%
Beginning of reparative phase None to early callus
P(es)( * # on
P(e)a+# ons R,-
No int or ext rotation of the shoulder% No passive -. to the elbow /entle active elbow flexion ' extension allowed for stable fractures treated w/ - I&% No -. to the elbow if treated by other methods
No int or ext rotation of the shoulder% No passive -. to the elbow /entle active flexion ' extension exc% to the elbow for fractures only when treated w/ - I&% /entle assistive supervised active flexion ' extension for nondisplaced stable fractures
emodeling phase !allus is present but less than in midshaft% 4he fracture line begins to disappear% econstitution of medullary canal occurs w/ time% ,void heavy lifting or pushing ,ctive ' passive elbow -. to the
-+s)le "#(en!# . F+n)# o nal A)# 3 # e s We !.# Bea( n!
No strengthening exc% to the elbow 4he uninvolved extremity is used for self#care ' ,8+ NWB on affected extremity
3rogressive resistive exc% to the elbow musculature 4he involved extremity used for self#care ' personal hygiene &WB by 6: wee1s
PENANGANAN FRAKTUR ,LEKRAN,N

4 6 Weeks W/ bridging callus, the fracture line is usually stable eparative phase Bridging callus is visible% &racture line is less distinct% (ndosteal callus formation will predominate 6 8 Weeks Stable eparative phase Bridging callus is more apparent, especially w/ less#rigid fixation% &racture line is less distinct% 4here is less callus formation if the fracture site is at the end of the ulna than in a midshaft fracture%% None &ull active to active# assitive -. in all planes to the elbow ' wrist 8 12 Weeks Stable emodeling phase .ore callus is seen A fracture line becomes even less distinct
2 Weeks None to minimal Beginning of reparative phase None to early callus% &racture line is visible
P(es)( * # on
P(e)a+# ons R,-
,void premature elbow motion No -. to the elbow or wrist in a cast or splint% /entle active elbow
!ast or splint < no extension to the elbow B )* No -. to the elbow or wrist in a cast or splint% ,ctive elbow flexion '
,ctive to active#assitive -. to the elbow ' wrist (ncourage active -. to the elbow in flexion ' extension
None &ull active ' active# assisted -. in all planes to the elbow
-+s)le "#(en!# .
flexion ' active -. to the wrist if treated surgically No strengthening exc% to the elbow% 4hree or @ days after fracture, isometric exc% to the wrist within the cast -ne#handed activities% 4he patient uses the uninvolved extremity for personal hygiene ' self#care None
active -. to the wrist if treated surgically No strengthening exc% to the elbow in extension% Isometric exc% to the elbow in flexion in a cast% Isometric exc% to the wrist 4he patient uses the uninvolved extremity for personal hygiene ' self# care None Isometric exc% to the elbow ' wrist in flexion ' extension esistive exc% to the elbow ' wrist
' wrist esistive exc% to the elbow ' wrist
F+n)# o nal A)# 3 # e s We !.# Bea( n!
4he patient uses the affected extremity for stability ' light self#care NWB
4he patient uses the affected extremity for personal hygiene ' self# care /radual WB is allowed
4he patient uses the affected extremity for personal hygiene ' self#care &WB is allowed
PENANGANAN FRAKTUR RA1IAL HEA1

4 6 Weeks W/ bridging callus, the fracture line is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates% 4he amount of callus formation is less 8 12 Weeks Stable
"#a!e &'Ra%
Beginning of reparative phase !allus "#$
emodeling phase Disible bridging callus in nonoperative patients% 4here is less callus with int fixation
P(es)( * # on
P(e)a+# ons R,-
No passive elbow
-. to the
No passive elbow ,ctive
-. to the
/entle, active -. to the elbow in flexion ' pronation
-. to the elbow
No strengthening exc% to the elbow% 4he uninvolved extremity is used for ,8+ None
No strengthening exc% to the elbow% Start isometric exc% to the deltoid, biceps ' triceps 4he uninvolved extremity is used for self#care None
at the ends of the long bones, compared to midshaft fractures ,void valgus stresses to the elbow to avoid stress on the radial head ,ctive, active#assistive ' passive -. to the elbow for nonoperative cases% ,ctive ' active#assistive -. for patients w/ int% fixation Isometric exc% to the biceps, triceps ' deltoid 4he uninvolved extremity is used in self#care% 4he involved extremity is used to assist in gentle activities 3WB for patients w/ nonoperative fixation% NWB for patients w/ int fixation
No pushing or lifting heavy obEects ,ctive ' passive to the elbow -.
3rogressive resistive exc% are given to the elbow flexor, extensors, supinators ' pronators 4he affected extremity is used in self#care WB allowed for self# care ' light#duty activities
PENANGANAN FRAKTUR F,REAR4 6 Weeks -nce callus is observed bridging the fracture site, the fracture is usually stable% 4his should be confirmed w/ physical examination% 4he strength of this callus is significantly lower than that of normal bone% 8 12 Weeks Stable
"#a!e
Inflammatory phase
Beginning of reparative phase
eparative phase
&'Ra%
!allus "#$
None to early callus
Bridging callus is visible in patient w/ a cast% 3atient who have had anatomic rigid int fixation show little or no callus, because primary bone healing predominates% 4he fracture line becomes less visible%
P(es)( * # on
P(e)a+# ons R,-
No passive
-.
No passive
-.
-+s)le "#(en!# .
If there is ade;uate fixation ' the forearm is not in a cast, gentle active -. exc% are prescribed to the elbow ' wrist, including supination ' pronation exc% Isometric exc% to the deltoid, biceps ' triceps if the fracture is rigidly fixed% No strengthening exc% to the forearm if treated w/ cast only 4he uninvolved extremity is used for self#care NWB on the affected extremity
/entle active -. to the elbow ' wrist if there is ade;uate fixation ' the forearm is not in a cast
No passive -. to the forearm ,ctive to active#assistive -. to the elbow ' wrist, including supination ' pronation if the patient is out of cast%
Woven bone is replaced by lamellar bone% 4he process of remodeling ta1es months to years% 3atients whose treatment is w/ rigid fixation have direct bridging osteomes% ,bundant callus is present if cast treatment was used% 4he fracture line begins disappear ' reconstitution of the medullary canal occurs w/ time% 3atient who have had anatomic rigid int fixation show little or no callus; rather, the fracture line disappear as primary bone healing progresses% 4he amount of callus is inversely proportional to the stability% No heavy lifting or sports activities &ull active ' passive -. to the elbow ' wrist% Stress supination ' pronation of the forearm
No strengthening exc% to the forearm if treated w/ cast only% Isometric exc% to the deltoid, biceps ' triceps w/ rigid fixation 4he uninvolved extremity is used for self#care NWB on the affected extremity
If fixation is ade;uate at end of 0 wee1s, start gentle iso1inetic exc% to the forearm muscles w/ B C lb of resistance 4he involved extremity is used for light self#care activities% NWB on the affected extremity
3rogressive resistive exc% are prescribed for the forearm muscles% >se free weights of C lb ' more
4he affected extremity is used for self#care &WB as tolerated
PENANGANAN FRAKTUR 6,LLE"

4 6 Weeks 6 8 Weeks 8 12 Weeks
0 1 Week
2
2 Weeks
Bone Heal n!
"#a$ l #%
None
None to minimal
"#a!e &'Ra%
Inflammatory phase !allus "#$; fracture line is visible
Beginning of reparative phase None to early callus; fracture line is visible
W/ bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted, ' healing w/ endosteal callus predominates% 4he fracture line is less distinct% No passive forearm -. to the
W/ bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted, ' healing w/ endosteal callus predominates% 4he fracture line is less distinct% None, unless pseudoarthrosis or nonunion is suspected &ull -. of all Eoints of upper extremity% Stress supination ' ulnar deviation% ,ctive assistive to passive -. attempted or initiated% /entle resistive exc% to the digits ' wrist% Improve power grip
Satble
emodeling phase !allus is seen% 4he fracture line begins to disappear; w/ time, the contour of the bone is being restored% .etaphyseal areas do not produce as much callus as diaphyseal regions None
P(es)( * # on
P(e)a+# ons R,-
No supination ' pronation No -. to wrist &ull active -. of digits of .!3 Eoint% &ull opposition of thumb
No supination ' pronation if treated w/ cast ' - I& No passive -. &ull -. of .!3 ' I3 Eoint% ,ttempt gentle active -. of wrist if treated by - I& ' fixation is rigid% Isometric exc% given to the intrinsic muscles of the hand ' wrist flexor ' extensor%
&ull active -. of wrist, .!3 ' I3 Eoints% Supination ' pronation encouraged% ,ctive ulnar ' radial deviation% /entle resistive exc% given to the digits of the hand% I7*(o3e *o8e( !( * Isometric exc% to wrist flexors, extensors ' radial and ulnar deviators% /entle resistive exc% given to the wrist if treated by - I& 4he involved extremity may be used as a stabili5er in two#handed activities% 4he patient may attempt self#care w/ involved extremity% ,void WB until the end of 0 wee1s
&ull -., active ' passive in all planes to the wrist ' digits% Stress supination ' ulnar deviation 3rogressive resistive exc% to the wrist ' digits ' to all the groups of muscles
-+s)le "#(en!# .
,ttempt isometric exc% to the intrinsic muscles of the hand
>se the uninvolved extremity for self# care ' ,8+
>ninvolved extremity is used for self#care ' ,8+
4he affected extremity is used for self#care ' ,8+
4he patient may use the involved extremity in self#care ' ,8+
NWB on the affected extremity
NWB on the affected extremity
WB as tolerated, because the fracture
&WB as tolerated on the involved extremity
is stable
PENANGANAN FRAKTUR "6APH,I1 :NAVI6ULAR;

2 Weeks None to minimal 4 6 Weeks Bridging callus indicates stability eparative phase !allus is not seen because there is no periosteum% 4his is a membranous bone% 4rabecular bone may be visible ,void passive -. to the thumb ' wrist Thumb 9 If short arm cast is removed "- I&$, gentle active -. to the wrist ' thumb in flexion, extension ' thumb opposition% 7ydrotherapy to improve the -. Elbow 9 /entle active -. in flexion extension "long arm cast$ ' short arm cast applied% No supination/pronation Shoulder, Digits 9 ,ctive ' passive -. Elbow 9 Isotonic exc% in flexion Shoulder # (xtension, shoulder add/abd 8 12 Weeks Stable 12 16 Weeks Stable
Bone Heal n!
"#a$ l #%
"#a!e &'Ra%
0 1 Week No bony stability, although ligamentous stability may be present Inflammatory phase !allus "#$; fracture line is visible
Beginning of reparative phase !allus "#$% esorption at fracture site may be seen
emodeling phase &racture line begins to disappear w/ reconstitution of trabecular bone pattern ,void heavy lifting
emodeling phase &racture line begins to disappear% 4here is reconstitution of the trabecular bone pattern None if fracture is healed ,ctive#resistive, passive -. of wrist ' thumb%
P(es)( * # on
P(e)a+# ons R,-
,void supination ' pronation of the elbow Thumb, Wrist 9 none "immobili5ed$ Elbow 9 none if immobili5ed in a long arm cast% If in a short arm cast, gentle active elbow flexion ' extension Digits 9 /entle active -. Shoulder 9 gentle active ' active# assistive -. Thumb, Wrist, Elbow 9 no strengthening exc% Shoulder 9 Isometric exc% to deltoid, biceps ' triceps
,void supination ' pronation at the elbow Thumb, Wrist 9 none "immobili5ed$ Elbow 9 none if immobili5ed in a long arm cast% If in a short arm cast, gentle active elbow flexion ' extension Digits 9 ,ctive ' passive -. Shoulder 9 ,ctive ' active#assistive -. Thumb, Wrist, Elbow 9 no strengthening exc% Shoulder 9 Isometric exc% to deltoid, biceps ' triceps
!ast is removed after 6: wee1s% /entle active -. to wrist ' digits ' .!3 ' I3 Eoints of thumb% W/ - i&, active, active#assistive ' passive -. to the wrist ' thumb to maximi5e full -.
-+s)le "#(en!# .
Wrist 9 ,fter 6: wee1s, active resistive exc% to long flexors ' extensors of thumb ' wrist
,ctive#resistive to progressive#resistive exc% to the wrist ' thumb
-ne#handed activities% >ninvolved extremity used in self#care ' dressing NWB on the affected extremity
4he patient uses the uninvolved extremity for personal 9hygiene ' self#care NWB on the affected extremity
4he patient needs assistance in self#care ' dressing ' uses the uninvolved extremity for self#care ' personal hygiene NWB on the affected extremity
Elbow 9 esistive exc% to elbow flexors, extensors, supinators ' pronators 3atient uses the involved extremity for stabili5ation purposes ' certain self#care activities WB is allowed after 6: wee1s
Involved extremity is used for all self#care activities
&WB is allowed
10
PENANGANAN FRAKTUR -ETA6ARPAL

4 6 Weeks W/ bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less distinct 6 8 Weeks W/ bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less distinct 8 12 Weeks Stable
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Beginning of reparative phase !allus "#$
emodeling phase ,bundant callus is seen ' the fracture line begins to disappear; w/ time, there will be reconstitution of the medullary canal% .etaphyseal areas do not produce as much callus as diaphyseal regions None &ull active ' passive -. to all digits
P(es)( * # on
P(e)a+# ons R,-
No passive
-.
No passive -. to the affected digit 6% If rigid fixation is achieved, active -. to the affected digit :% ,ctive, active#
No passive -. to the affected digit 6% &ull active -. to all digits ' wrist :% ,ctive pronation ' supination of wrist ' ulnar ' radial deviation
None ,ctive, active#assistive ' passive -. to all digits
,ctive -. to non# splinted digits
6*
-+s)le "#(en!# .
Isometric exc% prescribed within the cast of the non# splinted fingers >ninvolved extremity used in self#care ' personal hygiene None
assistive ' passive -. to non#splinted digits Isometric exc% to the intrinsic muscles of non#splinted digits
of the wrist 6% /entle ball# s;uee5ing ' Silly 3utty exc% :% /entle add ' abd resistive exc% of the digits Bimanual activities are encouraged at 0 wee1s None ,ctive#resistive exc% to all digits ' wrist 3rogressive resistive exc% to the all digits w/ increasing weights
>ninvolved extremity used in self#care ' personal hygiene None
4he patient uses affected extremity for self#care ' personal hygiene &WB as tolerated
4he affected extremity used for self#care &WB
11
PENANGANAN FRAKTUR PHALANG

4 6 Weeks W/ bridging callus, the fracture is usually stable; confirm w/ physical examination 6 8 Weeks W/ bridging callus, the fracture is usually stable% 7owever, the strength of this callus, especially w/ torsional load, is significantly lower than that of normal lamellar bone% !onfirm w/ physical examination eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less distinct 8 12 Weeks Stable
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Inflammatory phase !allus "#$; fracture line is visible
Beginning of reparative phase None to early callus; fracture line is visible
eparative phase Bridging callus is visible% W/ increased rigidity, less bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less distinct
emodeling phase ,bundant callus is seen ' the fracture line begins to disappear; there is reconstitution of the medullary canal% .etaphyseal areas do
66
P(es)( * # on
P(e)a+# ons R,-
No -. to the digit if the fracture is unstable ,ctive -. to the unaffected digits ' to the fractured digit if the fracture is stable Isometric exc% to the intrinsic muscles of the non#splinted fingers 4he uninvolved extremity used for self#care ' personal hygiene None
No -. to the splinted Eoint ,ctive -. to all non# splinted Eoints ' digits
No passive -. to the affected Eoint &ull active ' active# assistive -. to all digits Isometric ' isotonic exc% to the flexors, extensors, abd ' add of the digit Bimanual activities using the involved extremity are encouraged for self#care WB as tolerated by the patient
Night splint is used if necessary ,ctive, active#assistive ' passive -. to all digits /entle resistive exc% to all digits 4he involved extremity is used for self#care &WB
not produce as much callus as diaphyseal regions None
&ull active ' passive -. to all digits ' wrist% 3rogressive resistive exc% to the digits ' wrist 4he involved extremity is used in all activities to tolerance &WB
Isometric strengthening exc% to the intrinsic muscles 4he uninvolved extremity used for self#care None
12
PENANGANAN FRAKTUR 6,LLU- < NE6K FE-UR

2 Weeks -nly minimal stability% Impacted femoral nec1 fracture < partial bony stability 4reated w/ screws, except severe osteopenia < immediate mechanical stability 4reated w/ hemiarthroplasty < full mechanical stability Beginning of reparative phase No callus is visible 4 6 Weeks .oderate stability from bone healing is present as endosteal callus bridges the fracture; correlate w/ physical examination% .echanical stability from hardware or endoprosthesis is unchanged 8 12 Weeks .oderate stability from bone healing is present as endosteal callus bridges the fracture; correlate w/ physical examination% .echanical stability from hardware or endoprosthesis is unchanged +ate reparative, early remodeling phase No external callus is 12 16 Weeks Significant stability is now present from bone healing as endosteal callus bridges the fracture; correlate w/ physical examination% .echanical stability from hardware or endoprosthesis is unchanged emodelling phase No external callus is
Bone Heal n!
"#a$ l # %
"#a!e &'Ra%
0 1 Week No stability is present from bone healing% Impacted femoral nec1 fracture < partial bony stability 4reated w/ screw, except severe osteopenia < immediate mechanical stability 4reated w/ hemiarthroplasty < full mechanical stability Inflammatory phase !allus "#$, fracture line is
eparative phase No external callus is
6:
clearly visible% No periosteum, all healing is endosteal
"healing is endosteal/intenal$ &racture line is visible
visible because healing is endosteal "internal$ ' composed of cartilage ' fibrous tissue; this gradually becomes visible as it undergoes endochondral ossification
visible because healing is endosteal "internal$ ' composed of cartilage ' fibrous tissue; this gradually becomes visible as it undergoes endochondral ossification ,void excessive add ' int rotation if use endoprosthesis
P(es) ( *# o n
P(e)a+' # ons
,void passive -.% 3atient treated w/ endoprotheses avoid int% rotation ' add past midline
,void passive -. on fractures that have been reduced% 4reated w/ endoprotheses < avoid int% rotation ' add past midline ,ctive, active#assistive -. to hip ' 1nee Isometric gluteal ' ;uadriceps exc% Stand#pivot transfers ' ambulation w/ assistive devices Stable impacted fracture or endoprotheses < WB as tolerated >nstable fracture that re;uire reduction < NWB
R,-+s)le "#(en!# . F+n)# o nal A)#/ We !.# Bea( n !
,ctive
-. hip ' 1nee
No passive -. on fractures that have been reduced% 4reated w/ hemiarthroplasty < avoid int rotation ' add past midline ,ctive, active#assistive -. to hip ' 1nee Isometric ' isotonic exc% to hip ' 1nee Stand#pivot transfers ' ambulation w/ assistive devices Stable impacted fracture or endoprotheses < WB as tolerated >nstable fracture that re;uire reduction < NWB
visible because healing is endosteal "internal$ ' composed of cartilage ' fibrous tissue; this gradually becomes visible as it undergoes endochondral ossification% &racture line is obliterated ,void excessive add if use endoprosthesis
Isometric gluteal ' ;uadriceps exc% Isotonic exc% to an1le Stand#pivot transfers ' ambulation w/ assistive devices; raised toilet seat ' chair Stable impacted fracture or endoprotheses < WB as tolerated >nstable fracture that re;uire reduction < NWB
10
,ctive, active#assitive ' passive -. to hip ' 1nee Isotonic ' iso1inetic exc% to hip ' 1nee% 3rogressive resistive exc% instituted WB transfers ' ambulation w/ assistive devices &WB to WB as tolerated
&ull active ' passive -. to hip ' 1nee Iso1inetic ' isotonic exc% ' progressive resistive exc% Independent in transfers ' ambulation w/o assistive devices &WB
PENANGANAN FRAKTUR INTERTR,6HANTER FE-UR

2 Weeks None to minimal 4 6 Weeks With a bridging callus, the fracture is usually stable; confirm w/ physical examination eparative phase 8 12 Weeks Stable
"#a!e
Inflammatory phase
Beginning of reparative phase
(arly remodeling phase
6?
&'Ra%
!allus "#$, fracture line is visible%
None to very early callus; fracture line is visible% Bone in the metaphyseal region has very thin periosteum ' does not form an abundant external callus ,void standing on the affected leg w/o support% ,void passive -. ,ctive -. to hip ' 1nee% ,chieved )* flexion at hip
Bridging callus is beginning to be visible% (ndosteal callus may predominate in the metaphyseal region ' the fracture line should become less visible ,void torsion or twisting at the fracture site ,ctive, active#assistive to hip ' 1nee -.
P(es) ( *# o n
P(e)a+# ons R,-
,void passive
-.
,bundant callus has formed ' fracture line begins to disappear% 4he medullary canal ' metaphyseal region begin to be reconstituted% None !ontinue active, active#assistive -.% Start passive -. ' stretching to hip ' 1nee 3rogessive resistive exc% to hip ' 1nee
/entle active -. exc% to hip ' 1nee in flexion, extension, abd ' add Isometric exc% to ;uadriceps ' glutei
-+s)le "#(en!#.
Isometric exc% to glutei, ;uadriceps ' hamstrings
F+n)# on al A)#/
We !.# Bea( n!
Stand#pivot transfers if NWB% If WB, the affected extremity is used during transfers% , raised toilet seat is used to decrease hip flexion% &or ambulation, use a two# or three#point gait depending on WB status, using ,8 Stable fractures < WB as tolerated >nstable fractures < toe# touch to partial or NWB
8epending on WB, the patient performs stand# pivot transfers or uses the affected extremity during transfers% &or ambulation, use two# or three#point gait w/ ,8 8epending on procedure, WB as tolerated% NWB to 3WB, to toe#touch for unstable fractures
Isometric exc% to glutei, ;uadriceps ' hamstrings% ,ctive#resistive exc% to ;uadriceps, glutei ' hamstrings, if motion is well tolerated 8epending on WB, stand# pivot transfers or WB as tolerated on the affected extremity during transfers% ,mbulation w/ ,8
4he patient uses involved extremity w/ WB as tolerated or &WB during transfers ' ambulation% Weaning from ,8 &ull
>nstable fractures < 3artial to NWB to toe#touch Stable fracture < WB as tolerated
14
PENANGANAN FRAKTUR "UBTR,6HANTER FE-UR
6@
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Inflammatory phase !allus "#$, fracture line is clearly visible%
P(es) ( *# o n
P(e)a+' # ons R,-
No add ' abd to hip% No isometric exc% to ;uads ' hamstrings ,ctive -. to hip ' 1nee in flexion ' extension Isometric exc% to glutei WB as tolerated or toe#touch WB during transfers w/ ,8 ' ?# point gait w/ ,8 Stable fractures treated w/
Beginning of reparative phase None to very early callus in the region below the lesser trochanter% !allus "#$ in the intertrochanteric region where periosteum is thin ' healing is predominately endosteal% &racture line is visible ,void torsional forces on fracture% ,void excessive abd or add ,ctive, active#assistive to gentle passive -. to hip in flexion ' extension Isometric exc% to glutei, ;uadriceps ' hamstrings 4oe#touch WB or WB as tolerated during transfers ' ?#point gait; WB as tolerated or toe# touch WB w/ ,8 Stable fractures treated w/ intramedullary nails<
4 6 Weeks !allus is beginning to bridge fracture fragments in the femoral region "thic1 periosteum$ ' endosteal healing is bridging the metaphyseal region "thin periosteum but rich intramedullary blood supply$% >nless bone loss or severe comminution is present, the fracture is usually stable; confirm w/ physical examination eparative phase Bridging callus is beginning to be visible% W/ increased rigidity of fixation, less bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less visible in both the shaft ' metaphyseal regions ,void torsional forces on fracture site% ,ctive, active#assistive, passive -. to hip in flexion ' extension% ,ctive -. to hip in abd ' add Isometric exc% to glutei, ;uadriceps ' hamstrings% 4oe#touch WB or WB as tolerated during transfers ' ambulation w/ ,8 Stable fractures treated w/ intramedullary nails< WB as
8 12 Weeks Stable
12 16 Weeks Stable
(arly remodeling phase ,bundant callus in fracture w/ intact periosteum% &racture line begins disappear
emodeling phase ,bundant callus is present ' fracture line begins to disappear
None &ull -. in all planes to hip ' 1nee /radual resistive exc% to hip ' 1nee WB as tolerated or &WB during transfers ' ambulation w/ ,8 ,lmost all fractures have sufficient bone
None &ull -. in all planes to hip ' 1nee 3rgressive resistive exc% to hip ' 1nee &WB during transfer ' ambulation
-+s)le "#(en!# . F+n)# o nal A)#/
We !.# Bea( n!
,lmost all fractures have sufficient bone
intramedullary nails< WB as tolerated on affected extremity >nstable fractures or those treated by - I& < toe#touch WB
WB as tolerated on affected extremity >nstable fractures or those treated by - I& < toe#touch WB
tolerated on affected extremity >nstable fractures or those treated by - I& < toe#touch WB
healing ' callus to be &WB as tolerated% +imited WB should be necessary only for fractures w/ no callus present that are being considered for bone grafting
healing ' callus to be &WB as tolerated% +imited WB should be necessary only for fractures w/ no callus present that are being considered for bone grafting
14
PENANGANAN FRAKTUR "HAFT FE-UR

4 6 Weeks With bridging callus, the fracture is usually stable; confirm w/ 3( eparative phase Bridging callus is beginning to be visible% W/ increased rigidity of fixation, less bridging callus will be noted, ' healing w/ endosteal callus will predominate% 4he amount of callus formation is greater for diaphyseal than metaphyseal fractures% &racture line is less visible ,void rotation on the affected extremity w/ foot planted ,ctive/passive 1nee -. to hip ' 8 12 Weeks Stable (arly remodeling phase ,bundant callus in fractures not rigidly fixed by plates% &racture line begins to disappear; with time, there will be reconstitution of the medullary canal, except w/ an intramedullary nail ,void torsion loading of the femur ,ctive/passive to hip ' 1nee -. 12 16 Weeks Stable emodeling phase ,bundant callus in fractures not rigidly fixed by plates% &racture line begins to disappear; w/ time, there will be reconstitution of the medullary canal, except w/ an intramedullary nail None
0 1 Week Bone Heal n! "#a$ l #% "#a!e &'Ra% None Inflammatory phase !allus "#$, fracture line is clearly visible%
2 ' 4 Weeks None to minimal Beginning of reparative phase None to very early callus; fracture line is visible
P(es) ( *# o n
P(e)a+# ons R,-
No passive -. to hip ' 1nee No rotation on planted foot ,ctive -. to hip ' 1nee
,void rotation on the affected extremity w/ the foot planted ,ctive, active#assistive -. to hip ' 1nee, passive -. closer to @ wee1s Isometric ex% to ;uads ' glutei; straight leg raising
,ctive/passive to hip ' 1nee
-.
-+s)le "#(en!#.
Isometric exc% to ;uads ' glutei
esistive isotonic exc% ' isometric exc% to ;uads, hamstrings ' glutei
3rogessive resistive exc% to ;uads, hamstrings ' glutei
F+n)# on
,mbulatory stand#pivot
,mbulatory stand#pivot
Stand/pivot transfers '
egular transfers%
3rogressive resistive exc% to ;uads, hamstrings ' glutei% Iso1inetic exc% to ;uadriceps ' hamstrings egular transfers%
6C
al A)#/ We !.# Bea( n!
transfers ' ambulation w/ crutches >nstable fractures or those treated by plating or external fixator < toe# touch or NWB Stable fracture < progress to &WB as tolerated
transfers w/ crutches ' ambulation w/ crutches >nstable fractures or those treated by plating or external fixator < toe# touch or NWB Stable fracture < WB as tolerated
ambulation w/ crutches >nstable fractures ' those treated w/ plating or external fixator < 3WB Stable fracture < &WB
.ay need crutches for ambulation Stable fracture < &WB or WB as tolerated >nstable fracture < 3WB
.ay need crutches for ambulation &WB
16
PENANGANAN FRAKTUR "UPRA6,N12LAR FE-UR

2 Weeks None to minimal Beginning of reparative phase None to early callus; fracture line is visible 4 8 Weeks With bridging callus, the fracture is usually stable; confirm w/ 3( eparative phase Bridging callus is beginning to be visible% W/ increased rigidity of fixation, less bridging callus will be noted, ' healing w/ endosteal callus will predominates% 4he fracture line is less visible% , large amount of callus formation w/ a rigid fixation device indicates a lac1 of rigid fixation No passive -. Fnee < ,ctive -. = )*; active, active#assistive -. in flexion ' extension, if the 8 12 Weeks Stable (arly remodeling phase ,bundant callus in fractures not rigidly fixed by plates% &racture line begins to disappear% W/ time, there will be reconstitution of the medullary canal, except w/ an intramedullary nail No aggressive passive -. Fnee < ,ctive, active#assistive -.; gentle passive 12 16 Weeks Stable emodeling phase ,bundant callus, fracture line begins to disappear% W/ time, there will be resorption of the callus
P(es) ( *# o n
P(e)a+# ons R,-
,void passive
-.
,void passive
-.
,ctive -.% ,ttempt full extension ' 0* # )* of flexion to the 1nee% ,void
,ctive -. 0* # )* in flexion ' full extension to the 1nee%
8o not be aggressive in passive -. Fnee < ,ctive ' passive -.; emphasi5e terminal
60
passive -+s)le "#(en!#.
-. Isometric exc% to ;uadriceps in supine position ' 1nee in full extension
fracture is stable Fnee < Isometric exc% to ;uadriceps ' hamstrings
-. Fnee < Isometric ' isotonic exc% to ;uadriceps ' hamstrings
No strengthening exc% prescribed to the 1nee
F+n)# on al A)#/ We !.# Bea( n!
NWB stand/pivot transfers ' NWB ambulation None
NWB ambulation ' stand/pivot transfers None
extension to reduce extension lag Fnee < Isometric, isotonic ' iso1inetic exc% to ;uadriceps ' hamstrings% /entle progressive resistive exc% .uscle strength @G or C 3WB w/ crutches, progressing to &WB during ambulation ' transfers 4oe#touch to 3WB progressing to &WB
15
PENANGANAN FRAKTUR PATELLA

4 6 Weeks None to minimal eparative phase No callus; fracture line is less visible% Sesamoid bones produce minimal callus 8 12 Weeks Stable emodeling phase Small amount of callus noted% &racture line begins to disappear w/ time% ,mount of callus formed is small, because this is a sesamoid bone Fnee < ,ctive ' passive -.% 3atient
0 1 Week Bone Heal n! "#a$ l #% "#a!e &'Ra% None Inflammatory phase &racture line is visible; no callus formation
2 Weeks None to minimal Beginning of reparative phase !allus "#$; fracture line is visible
P(es) ( *# o n
P(e)a+# ons R,-
,void passive
-.
,void passive
-.
Fnee < None if in a cast% If open reduction '
Fnee < None If treated w/ open
.aintain 1nee immobili5er if tenderness is present Fnee < ,ctive -. in flexion/extension
6A
-+s)le "#(en!#.
stable internal fixation is achieved, active -. of the 1nee in a sitting position w/o WB No strengthening exc% prescribed to the 1nee
reduction ' stable internal fixation, active 1nee flexion w/ no WB Fnee < None Fnee < Isometric exc% to ;uadriceps ' hamstrings% ,t 0 wee1s, isotonic exc% to ;uadriceps w/ active 1nee extension< @C to * ' then from )* to * where * is full extension &WB during ambulation ' transfers% emove immobili5er for level ground wal1ing if fracture is stable
F+n)# on al A)#/
&WB during transfers ' ambulation using ,8
&WB during ambulation ' transfers
may have extension lag secondary to ;uad wea1ness ' immobili5ation Fnee < 3rogressive resistive exc% to ;uadriceps ' hamstrings w/ weights; iso1inetic exc% using !ybex machine; pylometric closed chain exc% &WB during ambulation A transfers w/o ,8
18
PENANGANAN FRAKTUR TIBIAL PLATEAU

4 6 Weeks W/ bridging callus, the fracture is usually stable; confirm w/ 3( eparative phase Bridging callus is beginning to be visible% W/ increased rigidity of fixation, less bridging callus is noted ' healing w/ endosteal callus predominates% 4he fracture line is less visible No varus or valgus stress 8 12 Weeks Stable (arly emodeling phase ,bundant callus in fracture not rigidly fixed by plates% &racture line begins to disappear, w/ time the medullary canal will be reconstituted No varus or valgus 12 16 Weeks Stable emodeling phase &racture line has disappeared
0 1 Week Bone Heal n! "#a$ l #% "#a!e &'Ra% None Inflammatory phase No callus
2 Weeks None to minimal Beginning of reparative phase None to early callus; fracture line is visible
P(es)
62
P(e)a+#
No varus or valgus stress
No varus or valgus
None
( *# o n
ons R,-
on 1nee; no passive
-.
-+s)le "#(en!#. F+n)# on al A)#/ We !.# Bea( n!
,ctive ' active#assistive flexion/extension< @* to 0* of flexion allowed initially, increasingly to )* of flexion after 6 wee1 No strengthening exc% to 1nee NWB stand/pivot transfers ' ambulation w/ crutches NWB on the affected extremity
stress on 1nee; no passive -. ,ctive ' active# assistive flexion/extension up to )* Isometric exc% to the ;uadriceps NWB stand/pivot transfers ' ambulation w/ crutches NWB on affected extremity
on 1nee; no passive
-.
stress ,ctive, active# assistive ' passive -. to the 1nee &ull active ' passive -. to the 1nee
,ctive ' active#assistive -. to the 1nee
No strengthening exc% to the 1nee NWB transfers ' ambulation w/ crutches NWB on affected extremity
/entle resistive exc% to the ;uadriceps ' hamstrings WB transfers ' ambulation at the end of 6: wee1s 3artial to &WB at the end of 6: wee1s
3rogressive resistive exc% to the 1nee &WB transfers ' ambulation &WB
19
PENANGANAN FRAKTUR "HAFT TIBIA

4 6 Weeks W/ advancing callus, the fracture becomes stable for axial loading but must still be protected from torsional loading 8 12 Weeks &ractures having minimal to no comminution are increasingly stable to completely stable% &ractures that have significant bone loss or have re;uired bone grafting for bone loss have limited stability until the bone graft begins consolidate ' the
6)
"#a!e &'Ra%
Beginning of reparative phase No callus; fracture line is visible
eparative phase (arly callus may be visible in the posterolateral aspect of the tibia where blood supply is best% If the fracture is rigidly fixed, little callus is seen
callus is visible (arly remodeling phase Bony consolidation is progressing, ' the callus should be visible at the posterolateral surface of the tibia in extending around to the other surfaces% 4he fracture line should become cloudy ' begin to disappear% If bone grafting was re;uired, consolidation of this bone graft should begin to be seen ,ctive, active#assistive ' passive -. to 1nee ' an1le /entle progressive resistive exc% prescribed to ;uadriceps, dorsiflexors ' plantar flexors% If fracture site is still tender, patient may still need ,8 for transfers ' ambulation
P(es) ( *# o n
P(e)a+# ons R,-+s)le "#(en!#. F+n)# on al A)#/
,void rotary motion w/ the foot on the floor ,ctive -. an1le ' 1nee if not in a cast Isometric ex to ;uadriceps, tibialis anterior ' gastroc# soleus >nstable fractures < stand# pivot transfers ' NWB ambulation w/ ,8 Stable fracture < WB as tolerated to 3WB transfers w/ ,8 Stable fracture patterns "restoration of cortical contact, no comminution, no segmental bone loss$ < WB as tolerated >nstable fracture "minimal cortical contact, comminution, segmental bone loss$ < NWB to toe# touch
,void rotary movements w/ the foot planted ,ctive -. an1le ' 1nee if not in a cast Isometric exc% to ;uadriceps, tibialis anterior ' gastroc#soleus >nstable fractures < stand/pivot transfers ' NWB ambulation w/ ,8 Stable fracture < WB as tolerated or 3WB w/ ,8, depending on the method of treatment Stable fracture patterns "restoration of cortical contact, no comminution, no segmental bone loss$ < WB as tolerated >nstable fracture "minimal cortical contact, comminution, bone loss$ < NWB to toe#touch
,void rotation of the extremity on a fixed foot ,ctive -. to an1le ' 1nee if not in a cast Isometric ' isotonic exc% to 1nee ' an1le >nstable fractures < stand/pivot transfers ' NWB ambulation w/ ,8 Stable fracture < WB as tolerated or 3WB, to &WB transfers ' ambulation w/ ,8, depending on the method of treatment Stable fracture patterns "restoration of cortical contact, no comminution, no segmental bone loss$ < WB as tolerated >nstable fracture "minimal cortical contact, comminution, bone loss$ < NWB to toe#touch
We !.# Bea( n!
,s tolerated
20
PENANGANAN FRAKTUR TIBIAL PLAF,N1

4 6 Weeks 6 8 Weeks 8 12 Weeks
0 1 Week
:*
2 Weeks
Bone Heal n!
"#a$ l #%
None
None to minimal
"#a!e &'Ra%
Inflammatory phase !allus "#$% &racture lines are visible%
Beginning of reparative phase None to very early callus
>sually stable% &ractures should be showing bridging callus ' are stable% 7owever, the strength of this callus, especially w/ torsional load, is significantly less than that of normal bone% !onfirm this w/ 3( ' x# rays eparative phase Bridging callus is visible as a small amount of fluffy material on the periosteal surface of cortical bone% &ractures rigidly fixed w/ screws ' plates < callus may not be visible, because there is primary bone healing% &ractures treated in a cast, expect more callus formation% 4here is a consolidation of the fracture ' filling in of lucent lines >nstable fractures or those w/ limited fixation are still in a cast igidly fixed fractures < active -. to an1le, .43 Eoints ' 1nee Nonrigidly fixed fractures < active -. to the .43 Eoints, an1le ' 1nee as immobili5ation devices allow
W/ bridging callus, the fracture is usually stable% 7owever, the strength of this callus, especially w/ torsional load, is significantly less than that of normal lamellar bone% !onfirm w/ 3( eparative phase Bridging callus is visible ' indicates increasing rigidity% W/rigid fixation, less callus is seen ' fracture lines are less distinct% +ess bridging callus is noted ' healing w/ endosteal bone predominates
Stable% Bridging callus is being reorgani5ed as lamellar bone% 4here is increased rigidity% +igamentous healing across the an1le Eoint is well established
eparative phase / early remodeling phase Bridging callus is visible across the fracture% W/ fracture consolidation, fracture lines are less visible% 7ealing w/ endosteal callus predominates% 4here is evidence of incorporation of bone graft%
P(es) ( *# o n
P(e)a +' # ons R,-
,n1le ' leg are immobili5ed in either a cast, splint, fixation or traction igidly fixed fractures < active -. at .43 ' 1nee Eoints; gentle active -. to the an1le while in a compressive dressing% Nonrigidly fixed fractures < -. at the .43 Eoints%
3atients in a long cast or external fixator do not have stable fractures igidly fixed fractures < active -. at .43 ' 1nee Eoints; active -. to the an1le out of splint or bivalve cast% Nonrigidly fixed fractures < active -. at the .43 Eoints%
3atients undergoing conservative treatment may not yet have stable fractures igidly fixed fractures < begin active -. in all planes of the an1le ' subtalar Eoint% Nonrigidly fixed fractures < range the an1le ' 1nee as the immobili5ation device allows% !ontinue active -. to .43 Eoints
,void heavy pounding activities igidly fixed fractures < begin more aggressive resistive exc% in all planes of the an1le ' subtalar Eoint% Nonrigidly fixed fractures < begin active ' active#assistive as well as passive -. of the an1le ' subtalar Eoints% 3atients in a cast may actively range the .43 Eoints ' perform isometric exc% of the
-+s)l e "#(en! #.
No strengthening exc% to the an1le or foot% Huadriceps isometric exc% as tolerated
igidly fixed fractures < isometric exc% to dorsiflexors ' plantarflexors of the an1le ' toes; no resistive exc%; isometric ;uadriceps exc% Nonrigidly fixed fractures < no strengthening or resistive exc%
igidly fixed fractures < isometric exc% to dorsiflexors ' plantarflexors of the an1le% No resistive exc% to long flexors ' extensors of the toes% Huadriceps strengthening continues Nonrigidly fixed fractures < gentle isometric exc% to dorsiflexors ' plantarflexors within a cast% No resistive exc% to the long flexors ' extensors of the toes% Huadriceps strengthening continues% NWB stand/pivot transfers ' ambulation w/ ,8
F+n)# onal A)#/
NWB stand/pivot transfers ' ambulation w/ ,8
NWB stand/pivot transfers; ambulation w/ ,8
igidly fixed fractures < continue isometric exc% to dorsiflexors ' plantarflexors of the an1le; no resistive exc% to long flexors ' extensors of the toes; continue ;uadriceps isotonic strengthening Nonrigidly fixed fractures < continue gentle isometric exc% to dorsiflexors ' plantarflexors within a cast; no resistive exc% to the long flexors ' extensors of the toes% Huadriceps strengthening continues% igidly fixed fractures < begin 3WB w/ ?#point stance% &or fractures w/ evidence of healing, ambulation w/ ,8
an1le ' subtalar Eoints within their cast% igidly fixed fractures < begin more aggressive resistive exc% to dorsiflexors ' plantarflexors, as well as the invertors ' evertors% Nonrigidly fixed fractures < begin gentle patient controlled resistive exc%
We !. # Bea( n !
None
None
None
None for fractures that have not shown evidence of healing% 3WB for fractures that are nontender to palpation ' appear stable on radiograph
igidly fixed fractures < progress from partial to &WB as tolerated for transfers ' ambulation using ,8 as necessary% Non rigidly fixed fractures < begin 3WB using ,8 4oe#touch to &WB
21
PENANGANAN FRAKTUR ANKLE

4 6 Weeks ,cute fractures should be showing bridging callus ' are stable% 7owever, the strength of this callus, especially w/ torsional load, is significantly less than that of normal bone% eparative phase Bridging callus is visible as a small amount of fluffy material on the periosteal surface of cortical bone% &ractures rigidly fixed w/ screws ' plates < callus may not be visible, because there is a consolidation of the fracture ' filling in of lucent lines% ,mount of callus deposition is less than that at a midshaft fracture Feep unstable fractures or those w/ limited fixation in a cast or cam wal1er% Stable fractures are out of a cast% igidly fixed fractures < active -. to an1le, .43 6 8 Weeks W/ bridging callus, the fracture is usually stable% 7owever, the strength of this callus, especially w/ torsional load, is significantly less than that of normal bone% !onfirm w/ 3( eparative phase Bridging callus is visible ' indicates increased rigidity% W/rigid fixation, less callus is seen ' fracture lines are less distinct% 7ealing w/ endosteal bone predominates 8 12 Weeks Stable, except for the most comminuted fractures
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Beginning of reparative phase No changes noted% &racture lines are visible; no callus present
emodeling phase igidly fixed bones should show a disappearance of the fracture line% &ractures treated in a cast show a small amount of fluffy callus at the medial malleolus ' along the shaft of the distal fibula%
P(es) ( *# o n
P(e)a +' # ons R,igidly fixed fractures < active -. at .43
3atients treated in long leg cast or external fixation do not have stable fractures igidly fixed fractures < active -. at .43 '
Feep unstable fractures or those w/ limited fixation in a cast or cam wal1er% Stable fractures are out of a cast% igidly fixed fractures < active, active#assistive
(ssentially none
igidly fixed fractures < active, active#assistive
:6
' 1nee Eoints% No an1le -.% Nonrigidly fixed fractures < -. at the .43 Eoints% No -. at an1le or 1nee
1nee Eoints% No an1le -.% Nonrigidly fixed fractures < active -. at the .43 Eoints% No -. at an1le or 1nee
Eoints ' 1nee Nonrigidly fixed fractures < active -. to the .43 Eoints% ange the an1le ' 1nee as immobili5ation devices allow
-+s)l e "#(en! #.
No strengthening exc% to an1le or foot% Huadriceps isometric exc% as tolerated
igidly fixed fractures < isometric exc% to dorsiflexors ' plantarflexors of toes ' an1le% No resistive exc% Nonrigidly fixed fractures < no strengthening exc%
F+n)# onal A)#/
NWB stand/pivot transfers; ambulation w/ ,8
igidly fixed fractures < isometric ' isotonic exc% to dorsiflexors ' plantarflexors of the an1le, evertors ' invertors of the an1le ' foot% No resistive exc% prescribed% Huadriceps strengthening continued% Nonrigidly fixed fractures < gentle isometric exc% to dorsiflexors ' plantarflexors within a cast% No resistive exc% prescribed% Huadriceps strengthening continued% NWB stand/pivot transfers ' ambulation w/ ,8 for fractures w/ little evidence of healing% 4oe# touch to 3WB w/ ,8 for fractures showing evidence of healing% None for fractures showing little evidence of healing% 3WB for fractures that are nontender to palpation ' appear stable
' passive -. in all planes of the an1le ' subtalar Eoint% Nonrigidly fixed fractures < begin active ' active#assistive -. to the an1le ' subtalar Eoint% 3atients still in a cast may actively range the .43 Eoints ' try to actively range the an1le in their casts &or rigidly ' nonrigidly fixed fractures, begin resistive exc% to dorsiflexors ' plantarflexors as well as invertors ' evertors of the an1le%
' passive -. in all planes of the an1le ' subtalar Eoint% Nonrigidly fixed fractures < begin active ' active#assistive -. to the an1le ' subtalar Eoint% 3atients still in a cast may actively range the .43 Eoints ' try to actively range the an1le in their casts igidly fixed fractures < begin progressive resistive exc% to dorsiflexors ' plantarflexors, as well as the invertors ' evertors% Nonrigidly fixed fractures < continue gentle resistive exc%
We !. # Bea( n !
None, except WB as tolerated for nondisplaced distal fibula fractures
None, except for stable fractures of the distal fibula% 4oe#touch WB for rigidly fixed fractures
igidly fixed fractures < 3WB to &WB w/ ,8 for fractures showing evidence of healing% >se ,8 as necessary% Nonrigidly fixed fractures < toe#touch to 3WB using ,8 for transfers ' ambulation 3WB to &WB
igidly fixed fractures < 3WB to &WB as tolerated for transfers ' ambulation, using ,8 as necessary% Nonrigidly fixed fractures < begin 3WB% ,8 re;uired for transfers ' ambulation 3WB to &WB
on radiography% WB as tolerated for nondisplaced distal fibula fractures%
22
PENANGANAN FRAKTUR TALAR

4 6 Weeks Some stability at fracture site% 4here is some callus formation, but the strength of this callus, especially w/ torsional load, is significantly lower than that of normal bone% 4he foot re;uires further protection to avoid refractures% !onfirm w/ 3( ' radiography% eparative phase 4he tarsal bone, which mainly cancellous in composition, w/ minimal 6 8 Weeks Increasing stability% 4here is callus formation, but the strength of this callus, especially w/ torsional load, is significantly lower than that of normal lamellar bone% 4he foot re;uires further protection to avoid refracture% !onfirm w/ 3( ' radiography eparative phase 4he fracture lines is less distinct% In the tarsal bones, which are mainly 8 12 Weeks &ractures treated w/ internal fixation are stable% 4alar nec1 fractures that are not rigidly fixed may not be stable
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Inflammatory phase !allus "#$; visible fracture lines%
Beginning of reparative phase No changes noted% &racture lines are visible; no callus
eparative / early remodeling phase 4arsal bones show that fracture lines are disappearing% 4his is
::
formation
periosteum, begin to show consolidation of the fracture ' filling in of lucent lines% W/ increased rigidity, lucency disappears ' healing w/ endosteal callus predominates because there is little periosteum
cancellous, no appreciable amount of callus is visible because the periosteum is thin%
P(es) ( *# o n
P(e)a +' # ons R,-
&ixation is not rigid unless the patient has had - I&% ,void passive -. ,ctive -. of the toes ' .43 Eoints as well as the 1nee% Before casting, do not move the an1le ' subtalar Eoint unless rigidly fixed%
&ixation is not rigid unless the patient has had - I&% ,void passive -. igidly fixed fractures of the talus may begin active an1le ' subtalar -.% !ontinue .43 Eoints exc% 3atients who have not had internal fixation may range the .43 Eoints only
No passive
-.
-+s)l e "#(en! #.
No strengthening exc% to an1le ' foot%
igidly fixed fractures may begin isometric exc% in dorsiflexion ' plantarflexion as well as inversion ' eversion out of the bivalve cast or cam wal1er
F+n)# onal A)#/
4oe#touch WB transfers w/ ,8 for rigidly fixed talar fractures
igidly fixed fractures < begin active, active# assistive -. in dorsiflexion ' plantarflexion as well as inversion ' eversion at the an1le ' subtalar Eoint, out of the cast% Nonrigidly fixed fractures < actively range the .43 Eoints as well as an1le ' subtalar Eoints within or w/o a cast% igidly fixed fractures < begin isometric exc% out of the cast% Nonrigidly fixed fractures < continue isometric exc% at the an1le ' subtalar Eoint in the cast% !ontinue ;uadriceps strengthening igidly fixed fractures < 3WB for transfers ' ambulation w/ ,8% Nonrigidly fixed fractures < continue
more obvious w/ fracture that have had internal fixation% 4he amount of callus formation is significantly less than in midshaft long bone fractures because the periosteum is ;uite thin in this region Nonrigidly fixed fractures may need to limit the amount of WB ' the performance of resistive exc% igidly fixed fractures < active, active#assistive ' passive -. at the an1le ' subtalar Eoints% Nonrigidly fixed fractures < allow active -. at the .43 Eoints ' isometric exc% of the an1le ' subtalar Eoints out of the casts
igidly fixed fractures < begin gentle resistive exc% to dorsiflexors ' plantarflexors, invertors ' evertors ' flexor ' extensor of the toes% Nonrigidly fixed fractures < no resistive exc% igidly fixed fractures < progress to &WB as tolerated for transfers ' ambulation, using ,8 as necessary%
NWB transfers ' mobili5ation
We !. # Bea( n !
None
4alar fractures that have been rigidly fixed may begin toe#touch WB
igidly fixed fractures < begin 3WB as tolerated in a cast Nonrigidly fixed fractures < must remain NWB
Nonrigidly fixed fractures < NWB or 3WB% 4hey re;uire the use of ,8 for transfers ' ambulation igidly fixed fractures < 3WB to &WB Nonrigidly fixed fractures < NWB to 3WB
20
PENANGANAN FRAKTUR 6AL6ANEAL

4 6 Weeks Some stability at fracture site% 4here is some callus 6 8 Weeks Increasing stability% 4here is callus 8 12 Weeks &ractures treated w/ internal fixation are
Bone Heal
:?
"#a$ l #%
0 1 Week None
n!
formation, but the strength of this callus, especially w/ torsional load, is significantly lower than that of normal bone% 4he foot re;uires further protection to avoid refractures% !onfirm w/ 3( ' radiography% "#a!e &'Ra% Inflammatory phase !allus "#$; visible fracture lines% Beginning of reparative phase No changes noted% &racture lines are visible; no callus formation eparative phase 4he tarsal bone, which mainly cancellous in composition, w/ minimal periosteum, begin to show consolidation of the fracture ' filling in of lucent lines% W/ increased rigidity, lucency disappears ' healing w/ endosteal callus predominates because there is little periosteum ,ll calcaneus fractures are still in NWB short leg cast igidly fixed fractures < still casted% !ontinue active -. to the .43 Eoints as well as isometric exc% of the an1le, plantarflexion ' dorsiflexion, inversion ' eversion in the cast% Nonrigidly fixed fractures < continue active -. at .43 Eoints only% 4he patient is still in a cast% igidly fixed fractures <
formation, but the strength of this callus, especially w/ torsional load, is significantly lower than that of normal lamellar bone% 4he foot re;uires further protection to avoid refracture% !onfirm w/ 3( ' radiography eparative phase 4he fracture lines is less distinct% In the tarsal bones, which are mainly cancellous, no appreciable amount of callus is visible because the periosteum is thin%
stable%
emodeling phase 4arsal bones show that fracture lines are disappearing% 4his is more obvious w/ fracture that have had internal fixation% 4he amount of callus formation is significantly less than in midshaft long bone fractures because the periosteum is ;uite thin in this region Nonrigidly fixed fractures may need to limit the amount of WB ' the ability to perform resistive exc% igidly fixed fractures < active ' active#assistive as well as passive -. at the an1le ' subtalar Eoints% Nonrigidly fixed fractures < actively range the .43 Eoints ' perform isometric exc% of the an1le ' subtalar Eoints within their casts igidly fixed fractures <
P(es) ( *# o n
P(e)a +' # ons R,-
&ixation is not rigid unless the patient has had - I&% ,void passive -. ,ctive -. of the toes ' .43 Eoints ' 1nee% Before casting, do not move the an1le ' subtalar Eoint unless rigidly fixed%
&ixation is not rigid unless the patient has had - I&% ,void passive -. igidly ' nonrigidly fixed fractures may range the .43 Eoints only%
No passive
-.
igidly fixed fractures < begin active -. in dorsiflexion ' plantarflexion as well as inversion ' eversion to the an1le ' subtalar Eoint, out of the cast% Nonrigidly fixed fractures < actively range the .43 Eoints as well as an1le ' subtalar Eoints in or out of a cast% igidly fixed fractures <
-+s)l
No strengthening
igidly fixed calcaneal
e "#(en! #.
exc% to an1le ' foot%
fractures may begin isometric exc% in dorsiflexion ' plantarflexion as well as inversion ' eversion in the cast only
begin isometric exc% to the dorsiflexors ' plantarflexion of the an1le ' the invertors ' evertors in the cast% Nonrigidly fixed fractures < o strengthening exc% igidly fixed fractures of the calcaneus ' talus may continue 3WB stand/pivot transfers ' a ?#point gait
F+n)# onal A)#/
NWB stand/pivot transfers for calcaneus fractures
begin isometric exc% out of the cast% Nonrigidly fixed fractures < continue isometric exc% at the an1le ' subtalar Eoint in the cast% !ontinue ;uadriceps strengthening igidly fixed fractures < 3WB for transfers ' ambulation w/ ,8% Nonrigidly fixed fractures < continue NWB transfers
We !. # Bea( n !
None
!alcaneus fractures are NWB
igidly fixed fractures < continue toe#touch to 3WB% Nonrigidly fixed fractures < NWB in a short leg cast%
igidly fixed fractures < begin 3WB as tolerated in a cast Nonrigidly fixed fractures < must remain NWB
begin gentle resistive exc% to the dorsiflexors ' plantarflexors, invertors ' evertors ' flexor ' extensor of the toes% Nonrigidly fixed fractures < no resistive exc% igidly fixed fractures < progress to &WB as tolerated for transfers ' ambulation, using ,8 as necessary% Nonrigidly fixed fractures < NWB or 3WB ' re;uire the use of ,8 for transfers ' ambulation igidly fixed fractures < 3WB to &WB Nonrigidly fixed fractures < NWB to 3WB
24
PENANGANAN FRAKTUR -I1F,,T

4 6 Weeks >sually stable% ,cute fractures should show bridging callus% !onfirm w/ 3( ' radiography/ W/ ligamentous inEuries that occurs in +isfranc fracture/dislocations ' tarsal bone avulsions, the reconstruction may not yet be stable secondary to the slower healing of ligaments% eparative phase Bridging callus is visible as a fluffy material on the periosteal surface of cortical bone% 4he tarsal bones, which are mainly cancellous in composition, begin to show consolidation ' filling in of lucent fracture lines% W/ increased rigidity, less bridging callus ' lucency are noticed, ' healing w/ endosteal callus predominates% In stress fractures ' nonunions of the tarsal navicular, a fibrous nonunion w/ a smooth fracture edge may be observed 6 8 Weeks W/ bridging callus, the fracture is usually stable% !onfirm w/ 3( 8 12 Weeks Stable%
Bone Heal n!
"#a$ l #%
0 1 Week None, except stress fracture of the navicular
"#a!e &'Ra%
Beginning of reparative phase No changes to early callus noted in the periosteal aspects of the bone%
eparative phase Bridging callus is visible in cortical bone, indicating increased rigidity% 7ealing w/ endosteal bone oredominates% In the region of the tarsal bone, which are mainly cancellous, an appreciable amount of callus is not seen because the cortex is ;uite thin, but the fracture line is less distinct
emodeling phase !allus is seen in all fractures in cortical regions of bone% 4arsal bones show fracture lines beginning to disappear% 4rabeculae reform ' strengthen over time
:@
P(es) ( *# o n
P(e)a +' # ons
&ixation is not rigid unless the patient has had - I&% No -. to the midfoot%
&ixation is rigid ' stable only for treated w/ - I&%
R,-
,ctive -. to the toes ' .43 Eoints%
,ctive -. to the toes ' .43 Eoints
4he fracture/dislocation is not fully stable unless the rigid fixation device is in place% 7owever, the fractures is still not fully healed ' cannot bear weight% ,ctive -. to toes ' .43 Eoints% If out of cast, gentle active -. to the an1le ' subtalar Eoint% Isometric exc% to the dorsiflexors ' plantarflexors of the an1le% No resistive exc% to the long flexors or extensors of the toes%
,void passive -. to the midfoot% Stability of fracture/dislocations not full unless rigid fixation devices in place% /entle active to active# assistive to gentle passive -. as tolerated to the an1le ' subtalar Eoint if not in a cast Isometric exc% ' isotonic exc% to the an1le ' subtalar Eoint if not in a cast
, rigid shoe or cam wal1er can be used as necessary
,ctive, active#assistive ' passive -. to the an1le ' subtalar Eoints
-+s)l e "#(en! #.
No strengthening exc% to an1le ' foot%
F+n)# onal A)#/
NWB stand/pivot transfers ' ambulation w/ ,8% 3WB transfers ' ambulation w/ ,8 for some fractures of the navicular ' cuboid 3WB for cortical avulsion ' tuberosity fractures of navicular, as well as avulsion or nondisplaced fractures of cuboid% emainder are NWB%
We !. # Bea( n !
No resistive exc% to the long flexor ' extensors of the toes ' .43 Eoints% Isometric exc% to the dorsiflexors ' plantarflexors ' invertors ' evertors of the an1le are performed in the cast% NWB stand/pivot transfers ' ambulation w/ ,8, depending on type of fracture% 3WB to WB as tolerated w/ ,8 for stable fractures of the navicular ' cuboid% None except for stable fractures of the tarsal navicular ' cuboid%
/entle resistive exc% to the dorsiflexors ' plantarflexors, evertors, invertors, long flexors ' extensors of the toes
3WB or NWB stand/pivot transfers ' ambulation w/ ,8, depending on type of fracture
3WB is permitted during transfers except in fractures treated w/ - I&
3artially to &WB transfers ' ambulation w/ ,8 or independently, as healing dictates
None for patients w/ - I&, or multiple cuneiform fractures ' displaced stress fractures of the tarsal navicular% 3WB as tolerated for all other fractures, including percutaneous pinning after hardware removal%
8epending on tenderness at fracture site ' callus formation, WB is partial or full, w/ the exception of any fracture w/ - I&
3WB to &WB
24
PENANGANAN FRAKTUR F,REF,,T

4 6 Weeks ,cute fracture should be showing bridging callus ' the fracture is usually stable% 4his is confirmed by 3( ' radiography% 7owever, the strength of this callus, especially w/ torsional load, is significantly lower than that of normal bone% eparative phase Bridging callus is visible as a fluffy material on the periosteal surface of the bone% W/ increased rigidity, less bridging callus is noted, ' healing w/ endosteal callus predominates% &or stress fractures ' nonunions of the sesamoids ' Cth metatarsal, a fibrous nonunion w/ smooth 6 8 Weeks W/ bridging callus, the fracture is usually stable% !onfirm w/ 3( 8 12 Weeks Stable%
Bone Heal n!
"#a$ l #%
0 1 Week None
"#a!e &'Ra%
Beginning of reparative phase No changes to early callus noted in the periosteal aspects of the bone%
eparative phase Bridging callus is visible w/ increased rigidity% +ess bridging callus is noted ' healing w/ endosteal callus predominates% &racture line is less distinct% Sesamoid fractures do not show callus but the fracture line is less distinct%
emodeling phase ,bundant callus is seen in all fractures w/ the exception of the sesamoids% 4he fracture line begin to disappear% W/ time, there is reconstitution of the medullary canal% ,pophyseal areas do not produce as much callus as diaphyseal regions%
:C
P(es) ( *# o n
P(e)a +' # ons R,-
No passive
-.
No passive
-.
fracture edges may be observed No passive -. Stable phalangeal fractures < full active -. to the metatarsal Eoints .etatarsal fractures out of cast< active -. to metatarsal Eoints% ,ctive to active#assistive -. to the an1le% &ractures of the 6st ' Cth metatarsal "Iones fracture$, sesamoids ' 6st phalanx < immobili5ed, no -. Stable phalangeal fractures < isotonic exc% to the long flexors ' extensors of the toes% .etatarsal fractures < isometric ' isotonic strengthening exc% to the an1le plantarflexors, dorsiflexors, evertors ' invertors% WB transfers ' ambulation w/ ,8 as needed% 3WB to NWB transfers ' ambulation for 6st phalanx, 6st ' Cth metatarsals ' sesamoids%
No repetitive impact exc% ,ctive ' active#assistive to gentle passive -. to all phalangeal, metatarsal ' an1le Eoints% ,ctive, active#assistive ' passive -. to the .43, I3 ' an1le Eoints
&or stable phalangeal fractures, active -. to .43 Eoints% &or fractures of the sesamoids, 6st phalanx ' 6st metatarsal, no -.
-+s)l e "#(en! #.
No strengthening exc%
F+n)# onal A)#/
We !. # Bea( n
NWB stand/pivot transfers ' ambulation w/ ,8 for fractures of sesamoi, 6st phalanx ' 6st ' Cth metatarsals% NWB as tolerated, transfers ' ambulation for stable fractures of metatarsals, lesser phalanges ' lesser metatarsal WB to tolerance for stable fractures of phalanges ' lesser
Stable phalangeal fractures < active -. to the .43 Eoints &ractures of 6st metatarsal ' Iones fracture < no -. Sesamoids ' 6st phalanx < immobili5ed, no -. &ractures of the :nd 9 Cth metatarsal < active -. to the .43 ' I3 Eoints Stable phalangeal fractures < no strengthening exc% to the long flexors ' extensors of the toes% .etatarsal fractures < no exc% however, isometric strengthening exc% to all the an1le musculature NWB stand/pivot transfers ' ambulation w/ ,8 for fractures of the 6st phalanx, sesamoids, 6st ' Cth metatarsals% WB as tolerated transfers A ambulation for single lesser phalangeal fractures
Isometric ' isotonic exc% w/ resistance to an1le dorsiflexors, plantarflexors, evertors ' invertors% Isometric ' isotonic strengthening exc% to longflexors ' extensors of the toes
3rogressive resistive exc% to the longflexors, extensors of the toes, dorsiflexors, plantarflexors, evertors ' invertors of the an1le
Stable fractures < &WB transfers ' ambulation &ractures of sesamoids, 6st ' Cth metatarsal ' 6st phalanx < 3WB to &WB transfers ' ambulation
&WB transfers ' ambulation
+esser phalangeal ' stable metatarsal fractures < WB as
Stable fractures, lesser phalangeal fractures ' metatarsal fractures < WB
&WB for phalangeal ' metatarsal fractures% 3WB to &WB for
&WB
metatarsals% NWB for fractures of the sesamoid, 6st phalanx ' 6st ' Cth metatarsals%
tolerated% Sesamoid, 6st ' Cth metatarsal fractures < NWB
as tolerated &ractures of the 6st phalanx, 6st ' Cth metatarsal "Iones fracture$ ' sesamoids < NWB to 3WB
fractures of sesamoids, 6st ' Cth metatarsal ' 6st phalanx
26
PENANGANAN FRAKTUR 61 :=e>>e(son F(a)#+(e;

4 8 Weeks (arly healing at the fracture site ' early graft consolidation give added stability% 8 12 Weeks Bone stability achieved but ligamentous instability may persist 12 16 Weeks Stable%
Bone Heal n!
"#a$ l #%
0 1 Week >nstable% 4he degree of instability is dependent upon intact bony ' ligamentous structures, internal fixation ' external immobili5ation Inflammatory phase
2 4 Weeks >nstable% Stability continues to be a function of intact bony ' ligamentous elements, internal fixation ' external immobili5ation eparative phase
"#a!e o> $one

:0
eparative phase
emodeling phase
emodeling phase
.eal n ! "#a!e o> a(#.(o ?es s &'Ra%
&ibrovascular stroma arises &racture lines ' bone graft, if used, are visible &racture lines ' graft remain visible% (arly callus formation occurs but is usually not seen &racture lines are less obvious; bone graft is consolidating% !allus is observed ' it may be minimal in cervical spine fractures because of the small si5e of the bones% .aintain immobili5ation
4rabeculation of fusion mass is occurring% emodeling is an ongoing process &racture lines begin to disappear% 4rabeculation of bone graft is at varying stages% Be aware of ligamentous instability /entle active -. to the cervical spine if the fracture has healed at 6* to 6: wee1s% /entle passive -. may begin if the fracture has healed at 6: wee1s% Isometric strengthening exc% to the cervical spine as tolerated%
emodeling phase
7ealed fractures; maturation of bone graft
P(es) ( *# o n
P(e)a +' # ons R,-
!ervical spine is immobili5ed% ,void overhead -. of upper extremities% No -. is allowed to the cervical spine% /entle active -. to upper ' lower extremities
.aintain cervical spine immobili5ation No -. to the cervical spine% ,ctive -. to the upper ' lower extremities
No contact sports
,void -. to the cervical spine% ,ctive -. to the upper ' lower extremities%
,ctive, gentle passive -. to the cervical spine
-+s)l e "#(en! #.
F+n)# onal A)#/ We !. # Bea( n
No strengthening exc% allowed to the cervical spine% Isometric exc% to the abdominal, gluteal ' ;uadriceps muscles% If the cervical spine is immobili5ed, gentle strengthening exc% to both upper extremities% Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8 ' w/ assistance% WB w/ ,8%
No strengthening exc% to the cervical spine% Isometric exc% to the abdominal, gluteal ' ;uadriceps%
Isometric strengthening exc% to the cervical spine muscles
Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8 ' w/ assistance% WB as tolerated w/ ,8
Bed mobility < log#rolling Transfers & ambulation < w/ ,8 as needed% &WB
Independent in bed mobility, transfers ' ambulation &WB
Independent in transfers ' ambulation
&WB
25
PENANGANAN 6ERVI6AL "PINE 6,-PRE""I,N @ BUR"T FRA6TURE"

2 4 Weeks Stability continues to be a function of intact 4 8 Weeks (arly healing at the fracture site ' early graft 8 12 Weeks Bone stability achieved but ligamentous 12 16 Weeks Stable%
Bone Heal
:A
"#a$ l #%
0 1 Week 8ependent upon intact bony '
n!
ligamentous elements, internal fixation ' external immobili5ation "#a!e o> $one .eal n ! "#a!e o> a(#.(o ?es s &'Ra% Inflammatory phase
bony ' ligamentous elements, internal fixation ' external immobili5ation eparative phase
consolidation give added stability%
instability may persist
eparative phase
emodeling phase
emodeling phase
Bone graft is at a similar phase &racture lines ' bone graft are visible
&ibrovascular stroma arises &racture lines ' graft remain visible% (arly callus may be seen !ervical spine immobili5ed No -. is allowed to the cervical spine% ,ctive -. to the upper ' lower extremities No strengthening exc% to the cervical spine% Isometric exc% to the abdominal, gluteal ' ;uadriceps% +ight isotonic exc% to the upper extremities &racture lines become obscured; bone graft is consolidating% No passive -.% .aintain immobili5ation in patients w/ unstable inEuries ,void -. to the cervical spine%
P(es) ( *# o n
P(e)a +' # ons R,-
!ervical spine is immobili5ed% ,void overhead -. of upper extremities% No -. is allowed to the cervical spine% /entle active -. to upper ' lower extremities No strengthening exc% allowed to the cervical spine% Isometric exc% to the abdominal, gluteal ' ;uadriceps muscles% If the cervical spine is immobili5ed, gentle strengthening exc% to both upper extremities% Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8 '
4rabeculation of fusion mass is occurring% emodeling is an ongoing process &racture lines begin to disappear% 4rabeculation of bone graft is at varying stages% Be aware of ligamentous instability /entle active -. to the cervical spine, if the fracture has healed at 6* to 6: wee1s% 3assive -. is allowed at 6: wee1s if the fracture has healed% Isometric strengthening exc% to the cervical spine as tolerated%
emodeling phase
7ealed fractures; maturation of bone graft
No contact sports
,ctive, gentle passive -. to the cervical spine
-+s)l e "#(en! #.
Isometric strengthening exc% to the cervical spine muscles
F+n)# onal A)#/
Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8
Bed mobility < log#rolling Transfers & ambulation < w/ ,8 as needed%
Independent in bed mobility, transfers ' ambulation
Independent in transfers ' ambulation
We !. #
w/ assistance% WB w/ ,8%
28
WB w/ ,8
&WB
&WB
&WB
PENANGANAN 6ERVI6AL "PINE UNILATERAL @ BILATERAL FA6ET 1I"L,6ATI,N

2 4 Weeks Stability continues to be a function of intact bony ' ligamentous elements, internal fixation ' external immobili5ation eparative phase 4 8 Weeks (arly healing at the fracture site ' early graft consolidation give added stability% 8 12 Weeks Bone stability achieved but ligamentous instability may persist 12 16 Weeks Stable%
Bone Heal n!
"#a$ l #%
0 1 Week !omplex, depending on intact bony ' ligamentous elements, internal fixation ' external immobili5ation Inflammatory phase
"#a!e o> $one .eal n ! "#a!e o> a(#.(o ?es s &'Ra%
eparative phase
emodeling phase
emodeling phase
Bone graft is at a similar phase If an associated fracture was present, a fracture line is visible ' if a fusion was performed, the bone graft is visible% &acets should appear reduced ' spinous processes aligned !ervical spine is immobili5ed% No -. is allowed to the cervical spine% /entle active -. to upper ' lower extremities No strengthening exc% allowed to the
&ibrovascular stroma arises &racture lines ' graft remain visible% (arly callus may be seen &racture lines become obscured; bone graft is consolidating%
4rabeculation of fusion mass is occurring% emodeling is an ongoing process &racture lines begin to disappear% 4rabeculation of bone graft is at varying stages%
emodeling phase
P(es) ( *# o n
P(e)a +' # ons R,-
.aintain cervical spine immobili5ation No -. to the cervical spine% ,ctive -. to the upper ' lower extremities No strengthening exc% to the cervical spine%
.aintain cervical spine immobili5ation No -. to the cervical spine% ,ctive -. to the upper ' lower extremities No strengthening exc% to the cervical spine%
Be aware of persistent ligamentous instability /entle active ' passive -. to the cervical spine if the fracture has healed% Isometric strengthening exc% to the cervical
,ny fractures that were present should be healed% 4here is maturation of bone graft in surgically treated patients% +igamentous instability may still be present as evidenced by motion on dynamic active flexion/extension radiographs No contact sports ,ctive, gentle, passive -. to the cervical spine Isometric strengthening exc% to the cervical
-+s)l e
:2
"#(en! #.
F+n)# onal A)#/ We !. # Bea( n !
cervical spine% Isometric exc% to the abdominal, gluteal ' ;uadriceps in neurologically intact patients% If the cervical spine is immobili5ed, gentle strengthening exc% to both upper extremities in intact patients% 3assive -. in neurologically impaired patients to prevent contractures Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8 ' w/ assistance% &WB w/ ,8 in neurologically intact patients%
Isometric exc% to the abdominal, gluteal ' ;uadriceps in neurologically intact patients% If the cervical spine is immobili5ed, gentle strengthening exc% to both upper extremities in intact patients% 3assive -. in neurologically impaired patients to prevent contractures Bed mobility < log# rolling w/ assistance% Transfers & ambulation < w/ ,8 ' w/ assistance% &WB w/ ,8 as needed
Isometric exc% to the abdominal, gluteal ' ;uadriceps in neurologically intact patients% If the cervical spine is immobili5ed, gentle strengthening exc% to both upper ' lower extremities in intact patients% 3assive -. in neurologically impaired patients to prevent contractures Bed mobility < log#rolling w/ assistance% Transfers & ambulation < w/ ,8 ' w/ assistance% &WB w/ ,8 as needed
spine as tolerated%
spine muscles
Independent in bed mobility, transfers ' ambulation in neurologically intact patients &WB in neurologically intact patients
Neurologically intact patients are independent in transfers ' ambulation &WB for neurologically intact patients
29
PENANGANAN TH,RA6,LU-BAR "PINE FRA6TURE"

4 8 Weeks (arly healing at the fracture site ' early graft consolidation provides some stability% 8 12 Weeks Bone stability is established but ligamentous instability may persist 12 16 Weeks Stable%
Bone Heal n!
"#a$ l #%
0 1 Week !omplex, depending on intact bony ' ligamentous elements, internal fixation ' external immobili5ation Inflammatory phase
2 Weeks Stability continues to be a function of intact bony ' ligamentous elements, internal fixation ' external immobili5ation (arly reparative phase
"#a!e o> $one .eal n ! "#a!e o> a(#.(o ?es s &'Ra%
eparative phase
emodeling phase
emodeling phase
Bone graft is at a similar phase &racture line is visible ' not incorporated
&ibrovascular stroma arises &racture lines ' bone graft remain visible% (arly callus may be seen% 4he amount of callus formation is minimal compared to the long bones ,void spinal flexion, torsion ' sit#ups &racture lines become obscured; bone graft is consolidating%
(arly trabeculation of the fusion mass seen at 6: wee1% emodeling is an ongoing process &racture lines begin to disappear% 4rabeculation of bone graft is at varying stages% No passive -. to the thoracolumbar spine%
emodeling phase
P(es) ( *# o n
P(e)a +' # ons R,-
,void flexion, sit#ups ' spinal rotation
,ctive -. to the upper ' lower
No -. to the thoracolumbar spine%
No passive -. to the thoracolumbar spine% ,void rotator ' flexion movements to the thoracolumbar spine% ,t the end of 0 wee1s, active extension is
7ealed fractures; maturation of fusion mass% Bone fragments in spinal canal associated w/ a burst fracture may show signs of resorption ,void extreme -.
,ctive flexion, extension, lateral
,ctive, active#assistive, gentle passive -. to
:)
extremities% No -. of the thoracolumbar spine allowed% -+s)l e "#(en! #. ,bdominal isometrics ' gluteal ' ;uadriceps sets% No strengthening exc% to the spinal muscles Bed mobility < log# rolling% ,void lying prone Transfers & ambulation < to a chair using ,8% WB as tolerated w/ ,8
,ctive -. to the upper ' lower extremities ,bdominal isometrics exc% Isotonic exc% w/ light weights to the upper ' lower extremities% No strengthening exc% to the spinal muscles Bed mobility < log# rolling% ,void lying prone Transfers & ambulation < w/ ,8% WB w/ ,8
allowed to the thoracolumbar spine for stable compression fractures No strengthening exc% to paraspinal muscles% Isotonic exc% w/ weights to the upper ' lower extremities% Bed mobility < log#rolling encouraged% Transfers & ambulation < w/ ,8% WB w/ ,8
bending ' rotary movement allowed to the thoracolumbar spine 4run1 strengthening ' paraspinal strengthening exc% once the fusion is solid or the fracture is healed% Bed mobility < patients can be prone by 6: wee1s postoperatively% Transfers & ambulation < independent &WB
the thoracolumbar spine
3rogressive resistive exc% to the paraspinal muscles
F+n)# onal A)#/
Independent transfers ' ambulation
We !. # Bea( n !
&WB
PE A 3hysical (xamination W< A with W<, A without ,RIF A -pen reduction and Internal &ixation WB A Weight Bearing NWB A Non Weight Bearing PWB A 3artial Weight Bearing FWB A &ull Weight Bearing A1 A ,ssistive 8evices -6P A .etacarpophalangeal -TP A .etatarsophalangeal
In>la77a#o(% *.ase A 4he fracture hematoma is coloni5ed by inflammatory cells, ' debridement of the fracture begins% Be! nn n! o> (e*a(a# 3e *.ase A -steoprogenitor cell differentiate into osteoblasts, which lay down woven bone% Re*a(a# 3e *.ase A 4here is further organi5ation of the callus, and formation of lamellar bone begins% -nce callus is observed bridging the fracture site, the fracture is usually stable% 7owever, the strength of the callus, especially with torsional load, is significantly lower than that of normal bone% &urther protection of bone "if not further immobili5ation$ is re;uired to avoid refracture% Re7o?el n! *.ase A 4here is further organi5ation of the callus, ' formation of lamellar bone continues% Woven bone is replaced w/ lamellar bone% 4he process of remodeling ta1es month to years for completion "years for radial head$%

PENANGANAN FRAKTUR (Hoppenfeld)

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PENANGANAN FRAKTUR (Hoppenfeld)

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PENANGANAN FRAKTUR KLAVIKULA

0 1 Week Bone Heal n! "#a$ l #% None

2 Weeks None to minimal

Inflammatory phase !allus "#$

P(e)a+# ons R,-

No strengthening ex to the shoulder

4he uninvolved extremity is used in self#care ' personal hygiene None

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

PENANGANAN FRAKTUR HU-ERU" PR,K"I-AL

2 ' 4 Weeks None to minimal

Inflammatory phase !allus "#$% 4he fracture line is visible

Beginning of reparative phase No callus; fracture line is still visible

P(e)a+# ons R,-

No strengthening ex to the elbow or shoulder are permitted

esistive ex to the shoulder w/ gradual increases in weights% Iso1inetic ex using appropriate

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

PENANGANAN FRAKTUR 1IAPH2"I" ATAU -I1"HAFT HU-ERU"

P(e)a+# ons R,-

-+s)le "#(en!# . F+n)# o nal A)# 3 # e s

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

NWB on affected extremity

NWB on affected extremity% +imited WB w/ rodding

(arly WB is allowed w/ int% fixation

PENANGANAN FRAKTUR HU-ERU" 1I"TAL

Inflammatory phase !allus "#$

Beginning of reparative phase None to early callus

P(e)a+# ons R,-

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

-+s)le "#(en!# . F+n)# o nal A)# 3 # e s We !.# Bea( n!

PENANGANAN FRAKTUR ,LEKRAN,N

P(e)a+# ons R,-

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

' wrist esistive exc% to the elbow ' wrist

F+n)# o nal A)# 3 # e s We !.# Bea( n!

PENANGANAN FRAKTUR RA1IAL HEA1

0 1 Week Bone Heal n! "#a$ l #% None

2 Weeks None to minimal

Inflammatory phase !allus "#$

Beginning of reparative phase !allus "#$

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

P(e)a+# ons R,-

No passive elbow ,ctive

/entle, active -. to the elbow in flexion ' pronation

-+s)le "#(en!# . F+n)# o nal A)# 3 # e s We !.# Bea( n!

No pushing or lifting heavy obEects ,ctive ' passive to the elbow -.

0 1 Week Bone Heal n! "#a$ l #% None

2 Weeks None to minimal

3enanganan &ra1tur "di1utip dari 4reatment '

ehabilitation of &ractures; 7oppenfeld$ by &anny !hristina; 3rinted by Indriana

Beginning of reparative phase

None to early callus

P(e)a+# ons R,-

F+n)# o nal A)# 3 # e s We !.# Bea( n!

4he affected extremity is used for self#care &WB as tolerated

PENANGANAN FRAKTUR 6,LLE"

3enanganan &ra1tur "di1utip dari 4reatment '