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Advice on gold standard treatment for Type I Salter harris Fracture

Discussion in 'Biomechanics, Sports and Foot orthoses' started by LCG, Mar 12, 2009.

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  1. LCG

    LCG Active Member


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    I am treating a 12 year old girl who suffered a inversion sprain 4/52 ago.

    She presented 4 weeks post injury. Imaging confirms partial ATF rupture, peroneal tenosynovitis, and an avulsion fracture of the distal fibula with associated widening of the epiphyseal plate.

    I was wondering if there is a gold practice standard for Salter Harris Fractures given their potential for long term complications.

    I plan to follow a 6 week weight bearing cam walker immobilisation with anti inflammatory modalities followed by rehab strengthening etc

    Any advice would be greatly appreciated

    Luke
     
  2. Luke:

    She is already 4 weeks post injury so she should be pretty well healed by now at the age of 12 unless she has been running on it the last 4 weeks without being immobilized.

    Normally, I would put someone at that age with a Salter type I fracture into a cam walker brace for 4-6 weeks after the injury, having her use an ace wrap (elastic wrap) inside the brace and daily icing out of the brace for the first 2-3 weeks for swelling. I would also have her start early non-weightbearing range of motions after about 2 weeks post injury to prevent immobilization stiffness and maintain muscle strength. I tend to avoid NSAID use in this age group and use ice only, unless they are in significant pain to avoid gastic issues. Gradual weightbearing strenthening can generally be started 6 weeks after the injury, assuming the above treatment protocol.

    Any reason to give 6 weeks of immobilization therapy now a full four weeks post injury? Is she still tender at the growth plate? It is unlikely that a Salter type I fracture will cause any long term issues at that age.
     
  3. LCG

    LCG Active Member

    Thanks for your reply Kevin.
    She was poorly managed post injury by her coach and GP. She has been training and trialling for rep netball for the last 3 weeks, ie she only had 1 week of icing and rest. She has been able to run however she has developed significant swelling and pain at the epiphysis site following activity. My main reason for the cam walker immobilisation at this late stage was her failure to have any real treatment following the injury and her high level of activity following the injury.
     
  4. Luke, use the force!! Sorry, Luke, I just couldn't resist.

    Seriously now, I would put this young lady in a weightbearing cam walker brace for 4 weeks, get her icing and doing non-weightbearing range of motions/strengthening exercises for this 4 week period, have her start walking, biking and light joggin out of the brace for 2 weeks and would expect her back to full running activities in 6 weeks from now.

    Hope this helps.
     
  5. Ashley Mahoney

    Ashley Mahoney Welcome New Poster

    With respect to her rehabilitation she will need to complete a pretty comprehenisve re-strengthening program.

    I agree with Kevins suggestion below;
    .


    Following on from this I would use an approach like I have listed below;

    Stage 1 Non-Weightbearing - Start sagital plane ROM only and progress to more 3 D as is tolerated by patient - I use Plantar Flexion/Dorsi-Flexion then progress to alphabets etc

    Stage 2 Non-Weightbearing with theraband (elastic tubing) - eg plantar flexion plus Plantar flexion and External rotation to target Peroneals.

    Stage 3 Partial Weightbearing - Heel to Toe Shuffles and peroneal catches

    Stage 4 Weight Bearing -Heel to Toe Shuffles and peroneal catches

    Stage 5 Advanced Weightbearing - Peroneal Specific ArchCOACH strengthening


    Also she will need to start proprioception/balance work in as soon as she can..

    Hope this helps
     
  6. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    What on earth for? Its a Type 1 injury.

    LL
     
  7. Ashley Mahoney

    Ashley Mahoney Welcome New Poster

    LL

    I understand your questioning of exercise rehabilitation to this extent,
    but this is my clinics "Gold Standard" for exercise rehabilitation.. and the aim of the post was to help LCG with the patient whose "imaging confirms partial ATF rupture, peroneal tenosynovitis, and an avulsion fracture of the distal fibula"

    Cheers
     
  8. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Ashley

    I appreciate the efforts within your clinic to develop a 'gold standard', and this should be commended, and I doubt it would do any harm at all.

    However if we consider ATF attenutation and a touch of peroneal tenosynovitis is what you are aiming to deal with through your rehab program, then I guess the point is to reduce the risk of recurrent ankle sprain?

    Unfortunately (at this time), my understanding is that physical rehab and proprioception exercises have been shown to have little or no benefit in the preventing recurrent ankle instability issues (work done by the Cochrane Bone, Joint and Muscle Trauma Group). Unsurprisingly, if the ATF is attenuated, no exercises will resolve an instability situation. Just like recurrent ACL problems that require surgical repair.

    But, I guess it couldn't hurt. I personally feel a child this age will heal uneventfully with little or no rehab beyond some simple stretching after coming out of immobilisation, and a gradual return to full activity + addressing any mechanical issues which promote a varus hindfoot. Getting kids to comply with a wide range of rehab activities is also challenging (like getting them to brush their teeth).

    All the best,

    LL
     
  9. LCG

    LCG Active Member

    Thankyou for all your valuable feedback. I cant say I am familiar with the archCOACH though. Is this an evidence based adjunct to her rehab???? Any info out there on the arch coach?
     
  10. You should cast it, Toes 30% down
    Pedicus Bavariae
     
  11. trophikas

    trophikas Active Member

    Dear LL

    You
    Are you saying that proprioceptive training post inversion injury is pointless and that the only treatment should be RICE and temporary immobilisation. I would love to get my hands on any evidence that suggests this so I can fire up the physios as work and modify my treatment regime accordingly. Do you not do proprioceptive retraining?
     
  12. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Personally, no. Why do we treat a damaged ankle ligament so much so differently than any other ligament in the body?

    I find it hard to accept that the proprioceptive fibres within ligaments such as the ATF (that physio's and others are so focussed on) are not damaged just as much as the collagen within the deep fascia and ligament tissue itself.

    If a ligament or connective tissue fibre is stretched to the point of permanent stretch or tear (eg think plantar plate, cruciate ligament, rotator cuff) - how does inordinate effort to build strength have any significant effect on joint stability. That is why evolution developed ligaments (to stabilise joints) and muscles (to move bones through a range of motion across a joint). Muscles, particularly in a weight-bearing situation, cannot act as a strut. That's why chronically unstable ligamentous injuries typically do best with delayed primary repair (ie Modified Brostrom procedure for the ATF - we can argue about wether this then 'helps' proprioception post-operatively by assisting in nerve fibre repair within the deep fascia ;)).

    However, I would direct you to the more learned 'evidence-based' Cochrane Collaboration to see their thoughts on this issue: http://www.cochrane.org/reviews/en/ab002938.html , and more importantly here http://www.cochrane.org/reviews/en/ab000018.html.

    Bare in mind, this is not to say that a wobble board or whatever might not be helpful, but my interpretation of these meta-analyses is that there are better options that have more evidence to support their use.

    LL
     
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