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TIDYS PHYSIOTHERAPY PDF

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𝗣𝗗𝗙 | On Jan 1, , Richards J and others published Biomechanics. In: Tidy's Physiotherapy 15th ed. Tidy's Physiotherapy has been a key text for physiotherapists over the years. Earlier editions whatis/pdfs/yazik.info, accessed October A classic textbook and a student favourite, Tidy's Physiotherapy aims to reflect contemporary practice of physiotherapy and can be used as a quick reference by .

Stiffness can also occur in the shoulder as it could be injured when the person falls but this might not be apparent at the time of the fracture. Occasionally there can be a rupture of the extensor pollicis longus and this occurs weeks after the fracture.

A late complication can be that of Sudecks atrophy. Median neuritis can also be a complication if displacement causes stretching or compression of the nerve. Fractures of the upper arm Fractures of the condyles of the humerus These fractures are found mainly in children as a result oi a fall.

A supracondylar fracture is - the commonest type and requires very careful management because of the possible complications. After reduction the arm may be immobilized in one of the following ways depending on the type of fracture: 1.

Plaster with the elbow at approximately or a little more and extending from below the shoulder down to the wrist or hand.. The plaster should be cut so that it is possible to feel the radial pulse at the wrist. A posterior slab plus a collar and cuff. A collar and cuff. Physiotherapy management During imrnobdization - The physiotherapist should see these patients as soon after reduction as possible. There is likely to be a considerable amount of swelling in the fingers and the patient may be reluctant to move them because of pain.

This swelling must be reduced and movement of the fingers and arm be encouraged otherwise adhesions may develop and the rehabilitation programme after the removal of the fixation will be prolonged. It is also important to see that movement of the shoulder is not limited as it is difficult to mobilize in the elderly and this would affect the use of the hand as well as other activities of the arm. The physiotherapist must assess the patient and continue treatment until the swelling has been reduced and the patient is using the arm as normally as possible within the limits of the fixation.

If the patient has understood the importance of the exercises and can carry on without supervision then there is no need to continue treatment. However, as many of the patients are elderly they may need to be monitored or treated over a longer period. After removal of fixation - If the fracture has healed normally and without any residual deformity, the swelling has been reduced, and the patient has been using the arm during the immobilization period, then recovery may occur very quickly.

However, there may be stiffness of the wrist and fingers and loss of supination at the radio-ulnar joints which, accompanied by weakness of muscles, requires a longer period of rehabilitation. With the elderly the emphasis must be on the restoration of function for the activities of daily living.

However, many elderly patients are very active and the physiotherapist must consider the needs of each patient whether it may be driving a car, gardening, playing golf or any other activity. Complications One of the most serious complications that can occur is damage to the brachial artery which could be severed or contused Figure 4.

Tidy's physiotherapy.

Therefore a very careful watch must be kept on the circulation and the patient will probably be kept in hospital for at least 24 hours. Impairment of the circulation requires emergency treatment as occlusion can lead to irreversible effects within a few hours. If the circulation is not restored Volkmanns ischaemic contracture may develop.

This affects the flexor muscles of the forearm which are replaced by fibrous tissue which contracts and produces flexion of the wrist and fingers Figure 4. The skin and nerves will also be affected by the diminished blood supply. In such cases it is not possible to regain normal function and it may be necessary to carry out some reconstructive surgery followed by a rehabilitation programme to regain optimum function.

If deformity develops at the elbow such as a cubitus valgus this may cause a stretch on the ulnar nerve which may require surgical intervention with a transposition of the nerve from the posterior to the anterior aspect of the elbow.

Fractures that extend onto the articular surfaces and cause disruption of the joint may cause a permanently stiff elbow, lead to the development of osteoarthritis, or both. Physiotherapy management Normally children mobilize quickly after the removal of fixation and treatment may not be necessary, particularly if the parents are aware of the care needed in regaining movement and do not attempt or allow any forced extension at the elbow.

However, sometimes it is helpful for the physiotherapist to teach the child simple free exercises with one or both of the parents present so that they can monitor and encourage the child and report back if necessary. If the child is very active it is sometimes helpful to keep the arm under the shirt or blouse for the first few days and allow the child to use that arm when the activity can be supervised.

When the parents are not able to understand what is required or cannot supervise the activity then it may be preferable for the child to attend for physiotherapy. Fractures of the shaft of the humerus These fractures usually occur in the middle third of the bone and may be due to direct or indirect violence Figure 4. Direct violence may give a transverse or oblique fracture which may or may not be displaced and sometimes presents as a comminuted fracture.

Displacement may also be effected by muscle pull, and if it is below the insertion of Deltoid the upper fragment will be moved laterally. Indirect violence tends to give a rotational force resulting in a spiral fracture and this usually heals more quickly than a transverse fracture. Fixation will depend on the stability of the fracture. In stable fractures the fixation can be minimal and consist of a sling alone or with a posterior slab from below the shoulder to the wrist with the elbow at If the fracture needs greater fixation a complete plaster from the shoulder to the wrist or hand may be applied.

The above methods do not fix the shoulder and in very unstable fractures it may be necessary to fix the shoulder with a plaster spica or by extending the Figure 4. If there is a severe injury some of the periosteum may be torn from the bone resulting in bleeding and the formation of a haematoma. Osteoblasts can invade this blood clot and new bone will develop. It can also occur as the result of forced extension of the elbow when movement is limited following a fracture.

First indications that this is developing may be pain and loss of movement.

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The elbow should be rested in a sling or collar and cuff for about 3 weeks to allow the haematoma to be absorbed. If this does ndt occur and bone is formed it may be necessary to remove the bone tissue surgically. In certain cases internal fixation is used with an intramedullary nail or plates and screws. Union of these fractures usually occurs in weeks or possiby earlier with a spiral fracture. Physiotherapy management During immobilization the treatment will depend on the type of fixation and whether shoulder movements are allowed.

Finger movements and static contractions for muscles working over the immobilized joints should be started at once and continued throughout this period. If the patient is able to do these on his or her own there is no need to attend the department until the fixation is removed. However, if shoulder movements are started early thepatient may need help from the physiotherapist. These may start with assisted active movements and change to free active when the patient has sufficient muscle power to do this and is not experiencing any pain.

The movements of abduction and rotation should be left till last.

After removal of fixation - Once the fracture has consolidated the patient should be reasssessed and treatment started to regain full range movement of the shoulder girdle, shoulder joint and elbow. Muscle power must be built up by progressive exercises although care must be taken at the beginning of this stage not to stress the fracture site.

The rehabilitation programme must take into account the work and other needs of the patient. Intensive daily treatment is ideal but if the patient is able to return to work before the programme is completed then attendances may need to be reduced.

Some patients are quite capable of continuing their own programme at home. Complications Because the fracture usually occurs in ihe middle part of the shztft the radial nerve may be affected as it winds through the sulcus. The injury may compress the nerve and give a neuropraxia or if it is stretched it may result in an axonotmesis.

Normally these will recover spontaneously although an axonotmesis will take longer as degeneration of the nerve has occurred within the sheath. In an open fracture the radial nerve may be severed resulting in a neurotmesis and this will have to be sutured. Delayed or non-union can be complications but are not very common. Fractures of the upper extremity of the humerus There are two fractures in this group which are of particular importance to the physiotherapist : fracture of the greater tuberosity and fracture of the surgical neck.

Fractures of the greater tuberosity are usually caused by a fall on the shoulder and can occur at any age. If there is no displacement fixation is unnecessary but the patient may be given a sling or a collar and cuff to relieve the pain. This should be discarded as soon as possible and normal movement encouraged. Fractures of the surgical neck usually occur in elderly people as the result of a fall on the outstretched hand.

There may or may not be displacement of the fragments but in a large number of cases the fragments are impacted. Displaced fractures, and particularly those occurring in the elderly, are not usually rdced for a number of reasons: 1. Lack of good alignment does not affect union. It is preferable to avoid sutgery in the elderly unless essential. Early movement is important to avoid a stiff shoulder.

Fractures in the foot The phalanges and metatarsals are most likely to be fractured by a heavy object falling on the foot.

This will also cause soft-tissue damage and consequently swelling is likely to be severe. These fractures do not as a rule require reduction or immobilization. However, a below knee walking plaster is usually applied for fractures of the metatarsals to relieve pain and enable the patient to walk. If swelling is severe the patient will need to rest in bed with the leg elevated for a few days. Another type of fracture that occurs in the metatarsals is a stress fracture often known as a March fracture.

It is caused by repeated minor trauma such as may arise from prolonged walking particularly on hard surfaces and usually in someone who is unaccustomed to walking long distances.

It is usually a crack fracture affecting the shaft or neck of the second or third metatarsal. No fixation is required hut a walking plaster may be applied if the pain is severe. Complications A stiff shoulder in the elderly can be a serious problem as it may require a long period of treatment and even then function may be impaired. A fractured greater tuberosity may lead to a painful arc syndrome particularly if there is a thickened area of bone on the greater tuberosity which interferes with abduction.

A complication of a fractured surgical neck may be damage to the axillary nerve resulting in a neuropraxia or axonotmesis. Physiotherapy management Early mobilization is the keynote to the treatment of these fractures to prevent the development of a stiff shoulder.

Movement should be started as soon as the pain has decreased enough to allow the patient to move. Treatment should always be geared to functional movements so that the patient may become independent as soon as possible.

Physiotherapy management During immobilization - If a below-knee walking plaster is applied the physiotherapist will teach the patient to walk correctly in the plaster.

When there is swelling the patient should be taught how to position the limb when sitting or lying down and which exercises to practise while in plaster. After removal of fixation - Treatment is not always necessary but the muscles supporting the arches of the foot are probably weak and the patient should be taught the appropiiate exercises. It is necessary to ensure that there is a correct walking pattern.

Fractures of the clavicle and scapula These fractures seldom require physiotherapy unless complications lead to a restricted range of movement in the shoulder girdle or shoulder joint and muscle weakness. Fractures of the lower extremity The bones of the lower limb are mostly weight-bearing and so fractures may cause a loss of mobility as the patient may be unable to walk or may need to use crutches, sticks or a frame. If an elderly person is unable to walk for any length of time this may seriously affect their chance of becoming independent again.

Independence should be regarded as a priority and this may affect the choice of methods of reduction and fixation. Similarly with young people mobility may be important because of their work but also it may be essential to regain full-range movement and muscle power in order to do their work whereas with the elderly this may not be necessary to gain functional independence. Fractures of the calcaneum Usually this fracture occurs as the result of a fall from a height onto the feet, fracturing the calcaneum on one, or sometimes both feet.

It may well be accompanied by a fracture of one of the lower thoracic or upper lumbar vertebrae. Minor crack fractures can be dealt with by applying a below-knee plaster to relieve pain and pressure on the calcaneum and retaining it for weeks. Severe compression fractures are a greater problem and there is some controversy about the best method of dealing with them.

The standard method is to elevate the limb on a Brauns frame Figure 4. Mobilization must be started during the above period. Some orthopaedic surgeons favour reduction of the fracture, but so far there does not seem to be any evidence to suggest that one method is more effective than the other. Physiotherapy management The emphasis is on the reduction of the oedema and mobilization. If the patient is kept in bed and the limb elevated as described above movements should start for the hip and knee and be followed by movement of the ankle and toes as soon as the pain has decreased sufficiently to allow this.

Movements of inversion and eversion will not be attempted at this stage. Once the patient is allowed to weight bear it is important to re-educate gait as well as concentrating on strengthening muscles and regaining range of movement in the ankle and foot. It may not be possible to regain any movement at the mid-tarsal joints and the patient will have to learn to adapt to this loss of movement.

The arches of the foot will probably have flattened and this may be the result of weak muscles, deformity of the foot, or both. In the former case the muscles can be stengthened but if the latter is the case the arches will not re-form. The patient may continue to have persistent pain and tenderness for a long time after the fracture has healed and it is difficult to relieve. The physiotherapist may help by advice on footwear and the use of mol foam pads to relieve pressure on a painful area.

Osteoarthritis may develop as a result of the disruption of the joint surfaces.

Fractures resulting from an adduction force: f fracture of medial malleolus; g avulsion fracture of lateral malleolus; h fractures of lateral and medial malleoli plus medial shift of talus. Fractures around the ankle The common fractures in this region affect the lower ends of the tibia and fibula and are often associated with dislocation of the ankle.

Usually they occur as the result of a twisting force or sometimes from a vertical comprestion force. The types of fractures can be described according to the nature of the injury causing them and seem to fall into five main categories as shown below Figure 4. In fractures without displacement a belowknee walking plaster may applied for weeks. When there is displacement it is important for the surgeon to try to ensure that reduction establishes the normal relationship at the ankle joint, and then a below-knee plaster is applied and retained for weeks.

If reduction cannot be attained by manipulation and plaster immobilization it may be necessary to have an open reduction and use a screw or screws to maintain a good position of the fragments followed by immobilization in a below-knee plaster. However, those that have had displacement and been immobilized for a longer period may present with a stiff ankle and foot. The physiotherapist must assess the range of movement in these joints and the strength of the muscles working over them and select the appropriate techniques for mobilizing and strengthening.

There may be flattening of the arches supporting the foot, and the muscles supporting them must be strengthened. Fractures around the ankle with soft-tissue damage can be unstable owing to loss of proprioception and this should be re-educated using a balance board. Fractures of the shafts of the tibia and fibula These fractures are common and can occur at all ages, either as a result of direct or indirect violence. Often they are open fractures either because of the direct violence or because the tibia is very close to the surface and the fragments may extrude through the skin.

Direct violence, commonly due to a road accident, is likely to give an oblique or transverse fracture with the fragments displaced. It may be comminuted and further complicated by soft-tissue damage. Fractures caused by a rotatory force, such as may occur in skiing, are usually spiral and the fractures of the two bones are at different levels.

In displaced fractures the tibia must be reduced and any soft-tissue damage attended to as a priority. Fixation will depend on the type of fracture and the amount of soft-tissue damage.

Tidy's Physiotherapy

In closed fractures or those where the fracture is stable after reduction the leg may be encased in a long plaster from the thigh to just above the toes with the knee slightly flexed and the ankle at a right angle. Usually the patient can start walking with crutches non-weight-bearing within a few days.

Later a rocker or plaster boot may be applied so that the patient can walk on the plaster but the time at which this occurs will depend on the surgeon. Alternatively a functional brace with a hinge at the ankle may be used and this has the advantage of allowing more movement and a better walking pattern.

15th Edition

If there is a lot of soft-tissue damage and consequent swelling a so jaster may be applied and the leg placed on a brans frame. This is replaced with a long leg plaster once the swelling has decreased. Another method that is used to immobilize this fracture is external splinting which may be used when there is a risk of infection Figure 4. Sometimes internal fixation is used with either an intramedullary nail or plate and screws. Union of these fractures normally takes months.

Complications Limitation of movement in the ankle joint and foot could result from peri-articular and intraarticular adhesions or from disruption of the articular surfaces. The latter may also lead to the later development of osteoarthritis. Physiotherapy management During immobilization - hitially the aim is to reduce the oedema and if the patient is not hospitalized he should be told to keep the limb elevated for most of the day.

Some movements can be started immediaiely, such as hip and knee movements in the lying position which will assist the reduction of the swelling as well as maintaining the movement at these joints. Toe movements and static contractions of the muscles working over the ankle joint should be started as soon as the pain will allow them.

The time at which weight bearing is allowed in the plaster is variable depending on the extent of the injury and the reduction of swelling. Sometimes the patient may start non-weight bearing with crutches progressing to partial and then full weight bearing. The physiotherapist must teach the patient how to use crutches if they are necessary and ensure that the other exercises are being carried out. After removal of fixation - Fractures with no displacement will mobilize quickly and need very little Fractures of the tibia or flbula alone are not very common.

The tibia can be the site of a stress fracture due to repeated minor trauma probably associated with sport. If the fibula is fractured it may be complicated by a rupture of the inferior tibio-fibular ligament. After the removal of fixation An intensive programme of treatment will probably be required to regain full function. Oedema may occur in the lower leg because of muscle weakness and this must be reduced quickly using techniques suitable for the particular patient and with emphasis on movement.

Initially the programme will include a larger number of non-weight-bearing exercises and then progressing to partial and full weight bearing as the patient gains range of movement and muscle power.

Ideally the patient should attend daily but if this is not possible because they are working or it is too long a distance to travel, or it is an elderly patient then it may be necessary to accept fewer attendances.

Implementing respiratory muscle training. Elsevier, Methods of respiratory muscle training. Tidy's Physiotherapy. Butterworth Heinemann publication. Larner E, Galey P. Active cycle of breathing technique. Young M. Dewse W. Fergusson J. Kolbe 8. Derliz Mereles et. Antonio R. Methods In total 40 patients hospitalised in Vlora Regional Hospital between January to June fulfilled the inclusion criteria: they were with pneumological problems, who did not suffer from other serious illness and had the capacity to perform the protocol evaluation tests properly.

Results Forty subjects completed the study. References 1. Larner, E. Eleanor, M. Stena, R. Duma, F. Topi, S. Page Count: View all volumes in this series: Physiotherapy Essentials.

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The responsibilities of being a physiotherapist 2. Collaborative health and social care, and the role of interprofessional education 3. Clinical leadership 4.

Pharmacology 5. Reflection 6. Management of respiratory diseases 7. Adult spontaneous and conventional mechanical ventilation 8. Cardiac rehabilitation 9. Physiotherapy in thoracic surgery Changing relationships for promoting health Musculoskeletal assessment Albert Einstein said 'Make everything as simple as possible, but not simpler.

Page Count: It is not always necessary to treat a patient throughout this stage provided that the patient can be taught to do his own exercises and is as independent as the circumstances will allow. Sports management Ideally the patient should attend daily but if this is not possible because they are working or it is too long a distance to travel, or it is an elderly patient then it may be necessary to accept fewer attendances.

Apart from this the patient should be kept as warm as possible until skilled medical help arrives. Physiotherapists should not be critical of each other except in extreme circumstances. Initially if the patient is in hospital the members of the team will include medical staff, nurses and radiographers.