セッティング 多施設(507施設)。28ヵ国。

    期間 登録期間は2000年12月-2002年4月。追跡期間は18ヵ月。追跡完了は2003年10月。

    対象患者 7599例。40歳以上で過去3ヵ月以内に虚血性脳卒中あるいはTIA発症歴があり,過去3年以内に次のリスク因子を1つ以上有する患者:虚血性脳卒中,MI,狭心症,糖尿病,症候性末梢血管疾患。虚血性脳卒中はTOAST(Trial of Org 10172 in Acute Stroke)分類によるものとした。
    【除外基準】重度の合併症,出血リスクが高い,大手術あるいは血管手術の予定など。

    方法 脳卒中患者のADL自立達成度をmodified Rankin Scale (mRS):下表 を用いて分類 、ADL自立達成の有無、達成時期を18か月間追跡調査 
    (ADL非自立をmRS 3以上 ADL自立をmRS2以下 と定義)
    各Scale症例のADL自立達成時期をコックス比例ハザード比モデルで検証した。

    追跡完了率 追跡完了率は96%

    結果
    mrs


    mRS 3以上の脳卒中1662例; 内訳
    moderate mRS 3 in 931
    severe (mRS 4) in 691
    very severe (mRS 5) in 40 について、

    18ヶ月後、877名の患者(52.8%)がADL自立達成 内訳
    moderate mRS 3 in 589 (63%)  平均3か月で達成
    severe (mRS 4) in 281 (40.6%) 
    very severe (mRS 5) in 7 (17%)  


    末梢動脈疾患(閉塞性動脈硬化症)、DM、脳卒中既往が無ければ有意に回復が見込める


    Rate, degree, and predictors of recovery from disability following ischemic stroke

    Objective: To determine the rate, degree, and predictors of recovery from disabling ischemic stroke.

    Methods: Patients with ischemic stroke enrolled in the Management of Atherothrombosis With Clopidogrel in High-Risk Patients (MATCH) study underwent long-term prospective assessment of their modified Rankin Scale (mRS) score. Disability (functionally dependent state) was defined as mRS ≥ 3, and recovery (functionally independent state) was defined as mRS < 3. The timing and the independent predictors of recovery were determined using a Cox proportional hazards multiple regression analysis.

    Results: Of 7,599 patients enrolled with ischemic stroke or TIA, 1,662 (21.8%) were disabled (mRS ≥ 3) at baseline (median of 14 [0 to 96] days after stroke onset). Disability was moderate (mRS 3) in 931 (56%) patients, severe (mRS 4) in 691 (42%), and very severe (mRS 5) in 40 (2%). By 18 months, 877 (52.8%, 95% CI 50% to 55%) patients had recovered, 589 (63%, 60% to 66%) with moderate disability, 281 (41%, 37% to 44%) with severe disability, and 7 (17%, 7 to 33%) with very severe disability. Median time to recovery was 3 months for patients with moderate disability and 18 months for severe disability; 82.5% of severely disabled patients remained so at 18 months. Predictors of recovery were moderate disability (mRS 3) at baseline compared with severe (mRS 4: hazard ratio [HR] 2.13, 1.86 to 2.44) or very severe disabling stroke (HR 5.88, 2.86 to 12.5); younger women (aged <65 years, compared with ≥75 years; HR 1.85, 1.47 to 2.33); decreasing time (days) between the qualifying event and the baseline assessment (HR 1.01, 1.01 to 1.02); and the absence of previous ischemic stroke (HR 1.61, 1.35 to 1.92), concurrent peripheral artery disease (HR 1.61, 1.23 to 2.13), or diabetes (HR 1.30, 1.10 to 1.54).

    Conclusions: Half of patients with disabling ischemic stroke recovered within 18 months, and recovery was greatest within 6 months. Significant predictors of recovery included the severity of the index stroke and no history of ischemic stroke, peripheral artery disease, or diabetes.

    55277d8a-1660-41f1-a2e6-69736dcb7170


    1 The fractures of the greater tuberosity of the proximal humerus

    treated nonoperatively

    0-10days immobilization using a Gilchrist bandage until pain relief was achieved, followed by oscillating movements of the arm.
    3–4 weeks active ROM
    6-8 weeks bear weight on their arms

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3247891/

    Nonoperative treatment for a nondisplaced greater tuberosity fracture has been reported to include

    1 week passive range of motion (PROM)
    6 weeks active range of motion (AROM) followed by gradually progressed strengthening once full PROM is reached.

    http://www.jospt.org/doi/pdf/10.2519/jospt.2005.35.8.521


    minimally displaced (<3 mm) fractures of the greater tuberosity
    0-3weeks patients were immobilized in a sling
    3 to 6 weeks pendular and active assisted exercises
    6weeks active exercises

    https://www.ncbi.nlm.nih.gov/pubmed/23639834

    60歳以上・脱臼を合併した症例は特に受傷後2週以内に骨片の転位が進行する可能性があるため早期手
    術を考慮する必要がある.
    「上腕骨大結節骨折における骨片転位の予測因子」


    Neerは10mm未満の転位を,仲川は大結節の前方部であれば5mm,大結節後方部のみの骨片は10mm以内を保存療法の適応と述べた

    治療は3週間体幹固定がおこなわれ,3週経過後より可動域訓練,6週から腱板強化訓練おこなわれた.
    「当科における上腕骨大結節骨折の治療指針」


    2 Shoulder dislocation

    immobilization in 10° of external rotation for three weeks reduces the relative risk of recurrence of a
    first-time traumatic anterior shoulder dislocation when compared with the risk associated with conventional immobilization in internal rotation.
    Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007; 89:2124-2131
    http://medicine.tums.ac.ir:803/Users/ramin_espandar/Journal%20Club%20Articles/=Immobilization%20in%20External%20Rotation%20After%20Shoulder%20Dislocation%20Reduces.pdf


    The recognition and treatment of first-time shoulder dislocation in active individuals. JOSPT. 2009;39(2):118-123

    Decisions are made based on the age, activity level of the patient. Generally those that are involved in contact sports and ages 15 to 25 years acute repair may be a viable option based on the high risk of reacurrance, apprehension, impact on sports participation and quality of life, they favour arthroscopic instability repair for athletes in this age group.
    Patients who are age 25-40 have a much lower recurrence rate of dislocation in general and conservative treatment is generally the best RX.

    Older patients over 40, who sustain a Anterior dislocation have lower recurrence rates again but can residual disability from associated soft tissue injuries such as a rotator cuff tear, nerve injury or vascular injury.

    Traditional no-operative treatment has included a period of immobilisation with the arm in internal rotation for 6 weeks, this has not reduced the recurrence rate. Degenerative joint disease was found in both surgical and non-surgical cases.
    A short term clinical study revealed decreased recurrence rates in patients that were immobilised in ER. After 3 weeks of immobilisation they had a recurrence rate of 26% while those who were in IR had a 42% reccurance rate and 46% in patients that were younger than 30 years old.
    Athletes who sustain a first time dislocation at the end of the season or spring practice, one option is early mobilisation, rehabilitation and return to full activity. Another option is to immobilise for 3-4weeks, proceed with rehab, and return the athlete to sport after 6-8 weeks.
    In the young, contact athlete, modern operative stabilisation (open and arthoscopic) which reduces the recurance rate from the 80%-90% range-3-15% range. This is preferred with first time dislocation as the reccurane rate is decreased and it improves a better quality of life.
    The first 2 weeks after the injury occurs is the best time to operate, taking advantage of the good condition of the capsulolabral tissue. Focus of surgery is to repair the capsulolabral avulsion with suture anchors.


    Shoulder Dislocation Original Editor - Haley Stevenson and Sherin Mathew as part of the Temple University EBP Project

    Phase 1 (up to 6 weeks)[1]: Goal is to maintain anterior-inferior stability

    Immobilization
    It has traditionally been thought to be immobilized with internal rotation, but according to Miller, immobilization has been beneficial in external rotation because there is more contact force between the glenoid labrum and the glenoid.[3] Research by Itoi[4] suggests immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal rotation.[4] There is currently no consensus on the duration of immobilization in a sling.[5] But, typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40.[4] During the immobilization period, the focus is on AROM of the elbow, wrist and hand and reduction of pain. Isometrics can be incorporated for the rotator cuff and biceps musculature.

    Codman Exercises
    AAROM for external rotation (0-30º) and forward elevation (0-90º)







    Phase 2 (6-12 weeks)[1]: Goal is to restore adequate motion, specifically in external rotation

    AAROM to achieve full range of motion
    When stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching.
    No strengthening or repetitive exercises should start until achievement of full range of motion

    Phase 3 (12-24 weeks)[1]: Successful return to sports or physical activities of daily living

    Begin strengthening exercise
    Strengthening exercises should be impairment-based. Typically begin strengthening exercise in a pain-free motion with exercises for stability. A possible progression could begin by focusing on the rotator cuff musculature and scapular stabilizers, which include trapezius, serratus, levator scapulae, and rhomboids. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals.
    Start focusing on functional exercises
    Include proprioceptive training
    Tailor to promote patient's activities and participation in society

    http://www.physio-pedia.com/Shoulder_Dislocation

    Epidemiology

    約12%に橈骨神経麻痺が合併する  Anglen JO, Archdeacon MT, Cannada LK, et al.
    Avoiding complications in the treatment of humeral fractures. Instr Course Lect 2009;58:3-11.

    肘関節より末梢で障害された場合
    ◦手関節の伸展は可能だが,伸展時に手関節は橈屈する.
    ◦母指と他指の MP(metacarpophalangeal:中手指節)関節の伸展不良.

    肘関節より中枢で障害された場合
    ◦下垂手(手掌を地面に向けると手関節と MP 関節が下垂し背屈できない〔drop hand〕
    ◦「肘関節より末梢で障害された場合」と同じ症状も出る.

    整形外科看護 2013 vol.18 no.4 (361)

    上腕骨骨幹部骨折に対する髄内釘治療について,過去の報告では偽関節発症率は0~19%であり,合併症や追加手術が必要となることがプレート固定と比較して多いと報告されている
    上腕骨骨幹部骨折髄内釘固定法の結果、40歳以上の症例では肩関節機能障害が高頻度に生じた. 骨折第31巻No.32009

    1) Lin J, Shen PW, Hou SM. Complications of locked nailing in humeral shaft fractures. J Trauma 2003 ; 54 : 943-949,
    2) McCormack RG, Brien D, Buckley RE, et al.Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial. J Bone Joint Surg Br 2000 ; 82 : 336-339.
    3) Ajmal M, O’Sullivan M, McCabe J, et al.Antegrade locked intramedullary nailing in humeral shaft fractures. lnjury 2001 ; 32 : 692-694.
    4) Habernek H, Orthner E. A locking nail for fractures of the humerus. J Bone Joint Surg Br 1991 ; 73 : 651-653.
    5) Bhandari M, Devereaux PJ, McKee MD, et aL Compression plating versus intramedullary nailing of humeral shaft fractures一一a meta-analysis. Acta Orthop 2006 ; 77 : 279-284,


    achot_2011_3_185_a



    Humeral shaft fractures account for 1 to 3% of all fractures in adults [1, 2] and for 20% of all humeral fractures
    https://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-14-246

    Bone union period
    AO分類のA, B, Cの順に骨癒合期間が長くなる傾向があり
    type Aで平均53日,type Bで平均102日, type Cで平均120日

    「上腕骨骨幹部骨折に対するInterlocking nailの治療経験」


    Rehabilitation protocol
    Postoperative Protocol For Intramedullary Nailing of Humerus Fractureshttps://www.advancedorthopedicspecialists.com/sites/advancedorthopedicspecialistsV2.com/files/(P)%20Humerus%20Fracture%20IMN.pdf

    Postoperative Days 0-14
    Goals:
    1. Protect fracture repair
    2. Minimize swelling and pain.
    3. Optimize independence while accomplishing the above.

    Review postoperative precautions with patient and care-partner.
    o No shoulder AROM.
    o No lifting of objects
    o When reclining or lying supine, the patient is encouraged to keep a pillow or blanket behind their elbow, preventing extension through the shoulder, to reduce stress on the anterior repair site. As a rule of thumb, the patient should always be able to see their elbow.
    o No excessive shoulder motion beyond side pocket, especially into internal rotation(IR)
    o No excessive stretching or sudden movements (particularly external rotation (ER))
    o No supporting of body weight by hand or elbow on involved side
    o May shower at 4 days postop, letting water run over the skin and patting dry with a clean towel. No standing in a pool or bathtub for 3 weeks. No swimming for at least 10 weeks.
    o No driving for 6 weeks

    Home education therapy:
    · Instruct in scapular elevation, depression, retraction, and protraction (clock exercises)
    · Preview safety and ADLs for life in a sling. Emphasize donning and doffing of shirts.
    · Patient may remove sling for short periods of time and allow elbow to extend fully.
    · Instruct patient and family in 6-pack exercises for upper extremity:

    1. Clockwise shoulder pendulum
    2. Counterclockwise shoulder pendulums
    3. Tight fist-- patient makes a tight fist then fully extends fingers
    4. Thumb to shoulder-- the patient flexes the elbow to touch the anterior shoulder with the tip of their thumb and then extends the elbow fully.
    5. Front-assisted forward elevation: using either a cane or dowel (broomstick), the patient grasps the device with hands 6 inches apart. They then use their uninjured extremity to slowly lift the injured arm. The deltoid of the injured arm should not contract actively. The arm is lifted to the point of mild discomfort, then gently lowered back to the resting position.
    6. Side-assisted lift: the same dowel is used but hands are placed shoulder-width apart.The uninjured arm pushes the dowel to the injured side, abducting the injured structure with no active muscle contraction of its own.


    2 weeks--

    ❏ 3-views of proximal humerus for comparison with intraoperative x-rays.
    ❏ Assess pain control/ refill or adjust pain medications as needed.
    ❏ Formal therapy requirement:
    ❏ if forward elevation>90⁰: continue with HEP alone.
    ❏ If forward elevation<90⁰ or if elbow, wrist, or hand have any noticeable limitation: start formal therapy.
    ❏ Review postoperative precautions and activity limitations.
    ❏ Work Limitations: No use of operative arm for other than typing or writing. No lifting, pushing, or pulling. Full-time sling use at job site. No driving/ operation of medium+ machinery.
    ❏ Expected return to work:
    ❏ Cognitive work: 1-2 weeks
    ❏ Light manual (retail/ light personal service): 8 weeks
    ❏ Manual labor: 12-14 weeks
    ❏ Overhead lifting intensive manual work: 4-6 months
    ❏ Follow-up visit in 4 weeks.

    Therapy Rx Weeks 2-6:
    ● 1-2x/week x 4 weeks
    ● PROM of shoulder in plane of scapula. No IR/ ER> 30degrees.
    ● AROM/ PROM of elbow, wrist, and hand.
    ● Scapular isometrics in protraction, retraction, elevation, and depression.
    ● Modalities prn for muscle relaxation
    ● HEP


    2nd postoperative visit at 6 weeks--
    ❏ 3-views of proximal humerus for comparison with intraoperative x-rays.
    ❏ Assess pain control/ refill or adjust pain medications as needed.
    ❏ Review postoperative precautions and activity limitations.
    ❏ Therapy Rx:
    ❏ If patient shows bridging bone at three+/four cortices on AP and axillary views,
    advance to formal therapy.
    ❏ Paucity of callus (<3 cortices bridged) or focal tenderness persisting at shoulder
    results in continuing sling and AROM restrictions for another 2 weeks, then
    reassessing in office.
    ❏ Work Limitations: Limit 20# weight. No pushing or pulling. No overhead activity. May
    drive.
    ❏ Return to work:
    ❏ Cognitive work: 1-2 weeks
    ❏ Light manual (retail/ light personal service): 8 weeks
    ❏ Manual labor: 12-14 weeks
    ❏ Overhead lifting intensive manual work: 4-6 months


    Therapy Weeks 6-12:
    ● 1-2 x/ week for 6 weeks
    ● AROM/ AAROM/ gentle PROM of shoulder, elbow, wrist, and hand. Emphasize ER and pec minor stretching early to minimize scapular protraction with forward elevation.
    Scapular mechanics are critical to early progress with active range of motion.
    ● Okay to start light glides and mobilization maneuvers at 8 weeks postoperative.
    ● May start light strengthening for the rotator cuff at 10 weeks.
    ● General upper extremity strengthening at 12 weeks.


    上腕骨骨幹部骨折に対する髄内固定法について、後療法は

    術後3日目 振り子運動と他動運動を開始
    2週目 自動運動を開始 ,アームスリングを併用

    上腕骨骨幹部骨折における順行性髄内釘は逆行性髄内釘より肩関節の挙上・外旋運動に可動域制限を残す.
    この理由として順行性髄内釘の挿入時に棘下筋腱の線維を切離している可能性と腱板のfootprintに挿入口がかかっている可能性が示唆された.

    「上腕骨骨幹部骨折に対する順行性・逆行性髄内固定法における肩関節への影響」骨折 第31巻No.12009  


    後療法については,骨折型,骨折レベルにかかわらず,

    手術翌日 三角布固定のみとして,三角布内での振り子運動,肘関節の自動運動を開始
    術後3週目 肩関節屈曲90度以上の関節可動域の拡大へと訓練を進めた.

    「上腕骨骨幹部骨折に対して横止め式髄内釘固定を用い,早期に生活基本動作を獲得・有用であった症例」


    Operative vs Non-operative
    Standard treatment for most humeral shaft fractures is nonoperative functional bracing; however, certain clinical scenarios necessitate operative intervention. There have been few studies in the literature comparing nonoperative and operative fixation of humeral shaft fractures. Two-hundred thirteen adult patients with a humeral shaft fracture who satisfied inclusion criteria were treated at 2 level 1 trauma centers with either a functional brace (nonoperative treatment group) or compression plating (operative treatment group). Main outcome measures were evaluated retrospectively and included time to union, nonunion, malunion, infection, incidence of radial nerve palsy, and elbow range of motion (ROM). The occurrence of nonunion (20.6% vs 8.7%; P=.0128) and malunion (12.7% vs 1.3%; P=.0011) was statistically significant and more common in the nonoperative group. There was no significant difference in infection rate between nonoperative and operative treatment (3.2% vs 4.7%; P=1.0000). Radial nerve palsy presented after fracture treatment in 9.5% of patients in the nonoperative group and in 2.7% of patients managed operatively (P=.0678). No difference in time to union or ultimate ROM was found between the 2 groups. Closed treatment of humerus fractures had a significantly higher rate of nonunion and malunion while operative intervention demonstrated no significant differences in time to union, infection, or iatrogenic radial nerve palsy. Nonoperative management has historically been the treatment of choice for many humeral shaft fractures, however, in certain clinical scenarios these fractures may be well served by compression plating.
    http://www.healio.com/orthopedics/journals/ortho/2010-8-33-8/%7B5c428edd-6106-4957-a77b-746144fd943c%7D/outcome-of-nonoperative-vs-operative-treatment-of-humeral-shaft-fractures-a-retrospective-study-of-213-patients

    Non-operative protocol
    0-14days U-splint
    14days- functional brace
    For allowing the patients to move their shoulder and elbow freely to exercises and rehabilitation. This brace will be kept until fracture consolidation, determined on radiography by two previously-assigned assessors.
    21days- pendulum exercises with the elbow in extension were begun.
    When roentgenographic and clinical evidence of good callus formation was demonstrated, the splint was removed for periods of time.
    https://smhs.gwu.edu/orthopaedic-surgery/sites/orthopaedic-surgery/files/Sarmiento%20Humerus.pdf

    7-8weeks functional brace was removed
    (median of 8.5 weeks and a mode of seven weeks)

    When I am in charge of frozen shoulder patients,I always do Posterior Glide Joint Mobilization such as the following videos. But recently I learned End-Range Mobilization Techniques for the first time.

    The Effect of Anterior Versus Posterior Glide Joint Mobilization on External Rotation Range of Motion
    in Patients With Shoulder Adhesive Capsulitis

    http://www.jospt.org/doi/pdf/10.2519/jospt.2007.2307
    A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis




    End-Range Mobilization Techniques in Adhesive Capsulitis of the Shoulder Joint: A Multiple-Subject Case Report

    At the start of each intervention session, the physical therapist examined the patient's ROM in all directions to obtain information about the end-range position and the end-feel of the glenohumeral joint. Intervention started with a few minutes of warm up consisting of rhythmic mid-range mobilizations with the patient in a supine position.
    Thereafter, the therapist's hands were placed close to the glenohumeral joint, and the humerus was brought into a position of maximal flexion in the sagittal plane. After 10 to 15 repetitions of intensive mobilization techniques in this end-range position, the direction of mobilization was altered by varying the plane of elevation or by varying the degree of rotation. In addition, as an alternative to varying the direction of mobilization, other movements such as gliding techniques and distraction in that joint position were used. In each direction of mobilization, 10 to 15 repetitions were performed, and the mobilization grade (3 or 4) and the duration of prolonged stress varied according to the patient's tolerance.
    http://ptjournal.apta.org/content/80/12/1204

    Figure 1. 

    The treatment of joints by passive movement

    http://www.maisfisio.com.br/biblioteca/AustJPhysiotherv19i2Maitland.pdf

    Mobilization Techniques in Subjects With Frozen Shoulder Syndrome
    http://ptjournal.apta.org/content/ptjournal/87/10/1307.full.pdf?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=frozen%20shoulder&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT
    . At the start of each intervention session, the physical therapist examined the subject’s ROM to obtain information about the endrange position and the end-feel of the glenohumeral joint. Then, the therapist’s hands were placed close to the glenohumeral joint, and the humerus was brought into a position of maximal range in different directions. Ten to 15 repetitions of intensive mobilization techniques, varying the plane of elevation or varying the degree of rotation in the endrange position, were applied


    These Techniques, End-Range Mobilization Techniques and Posterior Glide Joint Mobilization are recommended in Second Phase.
    http://www.physio-pedia.com/Adhesive_Capsulitis

    Fracture Healing Time Period
    These are the Fracture Healing Time Period ,also I included Rehab protocol, if you want to know about more details of Rehab menu,click these links below.

    骨折部による骨癒合日数

    以下の目安は正常過程の経過で最小の値であり、小児ではこれより20~30%早く、逆に高齢者では遅れる傾向にある。

    中手骨       2週

    肋骨        3週

    鎖骨        4週

    前腕骨       5週

    上腕骨体部     6週

    脛骨、上腕骨頚部  7週

    下腿骨       8週

    大腿骨体部     8週

    大腿骨頚部     12週

    http://medical-care.augking-lab.info/%C2%B4%E2%88%80%EF%BD%80%E9%AA%A8%E7%99%92%E5%90%88%E3%81%AE%E8%A9%B1/


     一般に整形外科分野では、骨折の骨癒合に関しての目安がある。海綿骨は骨折後6週間、皮質骨(緻密骨)は9~16週で骨癒合する。部位別にみると、脛骨骨幹部骨折は16週、上腕骨骨幹部骨折は10~12週、
    また中足骨や中手骨は骨性架橋形成が良好なため4~5週で骨強度が回復することが期待される。

    phalanges: 3 weeks
    non 3week immobilization


    closed reduction

    0- protected AROM
    4weeks AROM
    6weeks PROM
    8weeks Light resistance

    rigid fixation

    0- protected AROM
    1week AROM
    4weeks PROM
    6weeks Light resistance

    file:///C:/Users/Ishioka1/Downloads/29Hand-MPFractures.pdf
    http://www.jospt.org/doi/pdfplus/10.2519/jospt.2004.34.12.781
    principles of Metacarpal and Phalangeal fracture Management: A review of
    Rehabilitation Concept .J Orthop Sports Phys Ther 2004; 34:781-779


    metacarpals: 4-6 weeks

    closed reduction

    0- protected AROM
    4weeks AROM
    5weeks PROM
    6weeks Light resistance

    rigid fixation

    0- protected AROM
    2week AROM
    4weeks PROM
    6weeks Light resistance


    http://www.handconsult.com/images/downloads/Hand_Therapy_Management_of_Metacarpal_Fractures.pdf



    distal radius: 4-6 weeks

    http://www.handrehabsection.com/docs/Distal_Radius_Fractures.pdf



    lower arm: 8-10 weeks

    file:///C:/Users/Ishioka1/Downloads/17Elbow-RadialHeadFracture%20(1).pdf



    humerus: 6-8 weeks

    http://www.drcoyner.com/shoulder-rehabilitation-protocols-katherine-j-coyner-orthopaedic-surgeon.html


    femoral neck: 12 weeks

    ・術直後からROM、電気刺激による疼痛緩和、歩行を始めて効果があるかは不明
    ・同様に術後2週vs12週から筋トレを始めて効果があるかは不明
    ・方法について トレッドミルvs平地歩行 どちらも効果は変わらず

    http://www.ncbi.nlm.nih.gov/pubmed?term=21412873[uid]%20AND%20CD001704[pg]&


    femoral shaft: 12 weeks


    tibia: 10 weeks


    hone_2

    http://jikitiryou.net/category/1261571.html


    If you want know more information about healing process of fracture, I added articles below↓

    Healing Process of Bone Fracture

    day1-7
    Inflammation

    After fracture, the inflammatory process starts rapidly and lasts until fi brous tissue, cartilage, or bone formation begins (1–7 days postfracture). Initially, there is hematoma formation and inflammatory exudation from ruptured blood vessels. Bone necrosis is seen at the ends of the fracture fragments. Injury to the soft tissues and degranulation of platelets results in the release of powerful cytokines that produce a typical inflammatory response, ie, vasodilatation and hyperemia, migration and proliferation of polymorphonuclear neutrophils, macrophages, etc.

    骨折により骨細胞は変性、壊死 骨折部に血管損傷が起き血腫形成→凝集した血小板からTNFαやIL-1,6などの炎症性サイトカイン放出→骨髄,筋肉、骨膜、循環血液中にある未分化幹細胞(間葉系幹細胞)の骨芽細胞化を促す

    *どの組織由来の細胞の貢献度が最も高いかについては,議論の余地があるものの,これまでの臨床的知見や研究成果からは,やはり骨膜に存在する前駆細胞であるといえる.
    しかしながら,近年には筋肉由来のMSCが骨折治癒を促進することが報告されていることから’,脛骨遠位1/3部などの偽関節リスクが高い部分では,血流が乏しいだけでなく,周囲に筋肉があまり存在しないという2つの解剖学的特徴が合わさることで骨折治癒に負の影響を及ぼすことが考えられる.
    今井祐記 「骨折治癒の分子メカニズム」 日本臨;72巻10号(2014-10)

    ↓骨髄由来の前駆細胞の方が骨折治癒への貢献度が高い、という見解も
    *Both MSCs and EPCs have demonstrated effectiveness in preclinical models of fracture healing
    • There is emerging evidence to suggest that EPCs may be superior to MSCs, due to their combined
    effects on osteogenesis and angiogenesis
    • The best strategy may be combined administration of both cell populations
    http://ota.org/media/81057/28-Nauth-Stem-Cell.pdf


    1-2week
    reparative phase

    Within the hematoma, there is a network of fibrin and reticulin fibrils; collagen fibrils are also present. The fracture hematoma is gradually replaced by granulation tissue. Osteoclasts in this environment remove necrotic bone at the fragment ends.
    The inflammation stage. Formation of hematoma resolving into granulation tissue with the typical inflammatory cascade.

    *炎症細胞の浸潤の後に血腫が未分化結合組織に転換される。次にその結合組織で間葉系細胞が増殖・凝集し,軟骨細胞に分化する。その軟骨細胞は増殖し細胞外基質を産生し,さらに肥大軟骨細胞に最終分化して基質の石灰化を誘導する。そして,石灰化した軟骨が新生骨に置換される。この一連の現象にTGFβ1とbFGFが関与していることが示唆されている 

    大山 正割「骨折治癒におけるBasic Fibroblast Growth Factor Transforming Growth Factorβ1の 発現およびTypeIとTypeIICollagenの局在 」

    *FGFについて
    ■繊維芽細胞成長因子
    繊維芽細胞成長因子(FGF)は繊維芽細胞や内皮細胞の増殖を促進する分子量約16000~20000のペプチドでファミリーを形成しています。FGF-1,FGF-2はサテライト細胞や筋芽細胞の増殖を促す、また分化を抑制することが知られています。
    このFGFは骨格筋損傷時や筋肥大時に筋細胞から自己分泌され細胞間隙に出現し、骨格筋細胞の肥大と増殖に関与していると考えられています。
    http://www.yyokota.net/training-site/muscle-stress.html


    2-4week
    Soft callus formation

    Eventually, pain and swelling decrease and soft callus is formed. This corresponds roughly to the time when the fragments are no longer moving freely, approximately 2–3 weeks postfracture.
    At the end of soft callus formation, stability is adequate to prevent shortening, although angulation at the fracture site may still occur.
    The soft callus stage is characterized by the growth of callus. The progenitor cells in the cambial layer of the periosteum and endosteum are stimulated to become osteoblasts. Intramembraneous,appositional bone growth starts on these surfaces away from the fracture gap, forming a cuff of woven bone periosteally, and filling the intramedullary canal. Ingrowth of capillaries into the callus and increased vascularity follows. Closer to the fracture gap, mesenchymal progenitor cells proliferate and migrate through the callus, differentiating into fibroblasts or chondrocytes, each producing their characteristic extracellular matrix and slowly replacing the hematoma

    *bFGFとTGFβ1の発現が未分化間葉系細胞から軟骨芽細胞への分化と軟骨細胞の増殖促進作用に重要な役割を果たしている

    大山 正割「骨折治癒におけるBasic Fibroblast Growth Factor Transforming Growth Factorβ1の 発現およびTypeIとTypeIICollagenの局在 」


    4-24week
    Hard callus formation

    When the fracture ends are linked together by soft callus, the hard callus stage starts and lasts until the fragments are firmly united by new bone (3–4 months). As intramembraneous bone formation continues, the soft tissue within the gap undergoes endochondral ossification and the callus is converted into rigid calcified tissue (woven bone). Bone callus growth begins at the periphery of the fracture site, where the strain is lowest. The production of this bone reduces the strain more centrally, which in turn forms bony callus. Thus, hard callus formation starts peripherally and progressively moves towards the center of the fracture and the fracture gap. The initial bony bridge is formed externally or within the medullary canal, away from the original cortex. Then, by endochondral ossification, the soft tissue in the gap is replaced by woven bone that eventually joins the original cortex.


    hone6


    皮質骨:
    硬くて緻密な骨で骨の表面を覆っています。

    海綿骨:
    細い骨がハニカム(蜂の巣)のように組み合わさった構造をしています。
    腕や大腿・下腿などの長い骨(長管骨)は皮質骨が厚く、背骨などは海綿骨の割合が大きく、骨代謝の影響をうけやすい構造をしています。


    large


    骨細胞(osteocyte)
    骨細胞は、骨小腔と呼ばれる洞穴のなかに1個ずつ孤立して存在するが、無数の長い細胞突起を伸ばして骨細胞同士あるいは骨表面の骨芽細胞とギャップジャンクションを介してネットワークを形成している 
    骨細胞は骨表面の破骨細胞や骨芽細胞に司令を送り、骨代謝を骨の内部から制御するという重要な生理機能を担っている
    また、すべての血液細胞の元となる造血幹細胞の動員を制御するhttps://www.astellas.com/jp/byoutai/other/reports_h21/pdf/08_ikeda_k.pdf
    http://first.lifesciencedb.jp/archives/7316#more-7316


    破骨細胞(osteoblast)と骨芽細胞(osteoclast)
    骨代謝の実行細胞  
    破骨細胞(osteoblast)は造血幹細胞(ぞうけつかんさいぼう; hematopoietic stem cell - HSC)から 
    骨芽細胞(osteoclast)、骨細胞(osteocyte)は間葉系幹細胞(かんようけいかんさいぼう、英: Mesenchymal stem cell)から分化


    一次性骨性仮骨
    炎症部位から放出される局所ホルモンの一つは、周囲の細い血管にもはたらきかけ、新血管をつくって骨芽細胞のかたまりす線維性仮骨に栄養や酸素が行きわたるようにする。そして、十分に栄養や酸素が行きわたった部位では、骨芽細胞が線維に沿ってカルシウムを沈着させて、不完全ながらも骨をつくりはしめる。一方、栄養す酸素のとどかない骨折中では、細胞が豊富な素材を必要とする骨をつくらずに、ひとまず大きな軟骨(軟骨性仮骨)をつくりだす。そして、つくられた軟骨のかたまりが今度はけずられて一挙に弱い骨に置きかわるといったぐあいに、骨折部全体は骨形成となる。長管骨の骨折治癒過程では、骨折部の中心部のような新生血管の侵入の不十分な部位でも、軟骨のかたまりを用いて間断なく骨形成がおこなわれることが特徴であり、この軟骨性骨化が骨折の修復を迅速にさせる機構となっている。
    線維性仮骨や軟骨性仮骨から弱い骨ができるが、これを一次性骨性仮骨という。


    二次性骨性仮骨
    次いで、これらの仮骨が溶かされ、順次成熟した骨に入れかわるが、この骨折部をつなげる成熟骨を二次性骨性仮骨という。この頃に骨折部のレントゲン写真を撮ると、仮骨部は骨折りない部位の骨よりもむしろ厚く、カルシウムの多い骨のように見え、この場合はもう体重をかけたり、普通に動かしても大丈夫な骨となっている。一次性骨性仮骨の状態では、骨折部をそっと動かすぐらいであればずれたりはしないが、全体重をかけたり、強く力を入れたりすると骨折部が動いてしまうので、慎重にあっかう必要がある。一次性骨性仮骨の部分はレントゲン像でより厚く、濃く写っているので、骨は普通以上に強くなっているのではないか、と患者さんに聞かれることがある。この点について、骨を折ってみるなどをして研究した結果がないので、正確には答えられないが、仮骨である以上は強度が劣ると考えられ、仮骨の存在する期間は無理な使い方をしない方がよい。骨折後一年すれば、肥厚した仮骨が平坦となり、レントゲン像でも健常々骨と大差がなくなるが、この特にはじめて骨は元どおりの強さに戻ったとみるべきである。
    http://ejtrans.hateblo.jp/entry/2014/08/18/233934

    fxcallus



    The first x-ray was taken right after a fracture. The second was 2 months later, showing some callus. Notice that the leg is now in a cast, so the entire bone looks a little more dense and fuzzy. The last x-ray was 4 months after the fracture, showing a good callus. The bone now can bear weight, but it will take many months to remodel the area and complete the repair.
    https://depts.washington.edu/bonebio/ASBMRed/growth.html


    骨折の治癒過程について
    骨折あるいは骨欠損部にこれを修復する機転が働くとき,局所に生ずる骨の前段階の組織を仮骨という.骨折部には出血が起こり骨折部を包み込むように血腫が形成され,この中に細胞浸潤,血管新生が起こり肉芽組織が形成される.また骨折の刺激により骨髄の多能間葉細胞から線維芽細胞への分化が起こり,これらの細胞および組織球が肉芽組織内へ侵入し肉芽組織は次第に吸収され線維性組織に置換される.このような組織を線維性仮骨fibrous callusと呼ぶ.またこれらの組織には多少なりとも軟骨形成が認められることが普通であり,これを軟骨性仮骨cartilaginous callusと呼ぶ.線維性仮骨は次第に骨塩の沈着が起こり骨性仮骨となり,これに質的,量的に再造形remodeling機転が働いて正常な骨へと変化する.軟骨性仮骨は内軟骨性骨化機転により骨が形成される.仮骨はその形成される部位により,外仮骨,内仮骨,中間仮骨と呼ばれたり,あるいは外骨膜性仮骨,内骨膜性仮骨と呼ばれたりするが,Weinmannは仮骨の機能的役割を重視して係留仮骨anchoring callus(つなぎとめ仮骨),架橋仮骨(橋わたし仮骨),結合仮骨,髄腔仮骨に分類することを提唱している
    http://www.seadict.com/ja/ja/%E4%BB%AE%E9%AA%A8


    Optimal mechanical environment of the healing bone fracture/osteotomy
    International Orthopaedics (SICOT) (2012) 36:689–695
    https://www.mf.uni-lj.si/dokumenti/98d458af35655313a8dbbf02418a4b3a.pdf

    骨折治癒のための最適な環境とは何か、を論文レビューにより検証した 
    原則として骨折後はギプスやプレート等で3週間固定し、その後に間歇的な圧力を加える。
    骨癒合のための理想的な機械刺激は1000-2000 microstrain, (年齢、骨折部位、ホルモンの分泌多寡を問わず)



    健康運動プログラムの基礎: 陸上運動と水中運動からの科学的アプローチ
    北川薫 編集
    On our age-related bone loss: insights from a new paradigm.
    http://onlinelibrary.wiley.com/doi/10.1359/jbmr.1997.12.10.1539/full

      
                活動       代謝様式      骨の増減

              不動、宇宙飛行    骨吸収亢進       減少
    50μストレイン  
              日常生活       骨吸収亢進=骨形成   変わらず
    1000μストレイン
              生理的過重負荷    骨形成亢進       増加

    3000μストレイン              病的変化
              過負荷          
    25000μストレイン              骨折

    骨の長さが0.1%変形したとき + 最少モデリング閾値=1000μストレイン
    最少偽骨折閾値=3000μストレイン

    日常生活では骨吸収亢進と骨形成が等しく骨量は変化しない 


    Why High-Impact Exercise Is Good for Your Bones
    http://well.blogs.nytimes.com/2014/03/07/why-high-impact-exercise-is-good-for-your-bones/?partner=rss&emc=rss&_r=0

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3465797/

    平均年齢17.1歳 14541人について
    15 inches=38.1cm の高さからdrop jump 5G以上、 または1マイル=1.6㎞を10分のペースでランニングする(マラソンでいうと42.195㎞を4時間20分で走るペース または5㎞を30分 実際に走るのは500m/day でいい )と4.2G以上の負荷を大腿骨に与えることができ、大腿骨の骨量が増加する

    drop jump


    ↑高齢者には無理、代わりにアエロビ、速歩、踏み台昇降運動では2.1G となり4.2Gを下回る 骨形成の効果はわずか

    Effect of two jumping programs on hip bone mineral density in premenopausal women: a randomized controlled trial.
    Am J Health Promot. 2015 Jan-Feb;29(3):158-64. doi: 10.4278/ajhp.130430-QUAN-200.
    http://www.ncbi.nlm.nih.gov/pubmed/24460005
    http://scholarsarchive.byu.edu/cgi/viewcontent.cgi?article=1666&context=etd

    女性、25-60歳、60名について 対照群:ストレッチするだけ 介入群①:裸足でカーペットの上でジャンプ 10回×2セット インターバル30秒  介入群②:同様にジャンプをする 20回×2セット

    結果:介入群②、介入群①の順で大腿骨の骨量増加した

    Optimum Force Magnitude for Orthodontic Tooth Movement: A Systematic Literature Review
    The Angle Orthodontist: February 2003, Vol. 73, No. 1, pp. 86-92.
    http://www.angle.org/doi/full/10.1043/0003-3219(2003)073%3C0086%3AOFMFOT%3E2.0.CO%3B2

    骨細胞の力学刺激感知およびカルシウム応答伝播のバイオメカニクス
    http://repository.kulib.kyoto-u.ac.jp/dspace/bitstream/2433/120809/3/D_Aonuma_Yuki.pdf

    https://books.google.co.jp/books?id=WyvFLjVTxS4C&pg=PA52&lpg=PA52&dq=%E3%81%B2%E3%81%9A%E3%81%BF%E5%8D%98%E4%BD%8Dstrain%E3%80%80%E9%AA%A8%E6%8A%98&source=bl&ots=1KH4uVp04Y&sig=icP88mNfEO65JOSD1RPHOHrxPlA&hl=ja&sa=X&ved=0ahUKEwjG17Dr4q3MAhUJsJQKHSKNAXQQ6AEIIjAB#v=onepage&q=%E3%81%B2%E3%81%9A%E3%81%BF%E5%8D%98%E4%BD%8Dstrain%E3%80%80%E9%AA%A8%E6%8A%98&f=false



    The influence of mechanical stimulation on osteocyte apoptosis and bone viability in human trabecular bone
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847464/

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