Brian G. Simpson M.C.S.P.   Registered with the Health Professions Council
Home Physiotherapist Equipment & Treatments Case Studies

A random selection of case studies

Fracture of Left Humerus

Thomas Holbrook aged 36 fractured his left humerus in an off road buggy accident on the 4th September 2005. The fracture extended over the distal and middle thirds and was comminuted (in many pieces). X-rays (shown below) taken over three months later, on the 9th December 2005 showed delayed union with no callus. Tom could feel the fracture moving. He was fitted with a mid-shaft plastic brace.

Tom first came to see us on the 19th December 2005 and was given MFT and Pulsed Scanning Laser. He had two more treatment sessions before further X-rays showed early milky callus high on the fracture. It was decided to boost his treatment by giving Tom Hyperbaric Oxygen Treatment along with the MFT and Laser and the first session was given on the 17th January 2006. Tom went on to have a further five treatment sessions and when he had further X-rays on 10th February there was extensive callus - or in Tom's words "there was callus just everywhere!"

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Collar Bone Fractures

Case Study "A" ( PMFT & LASER TREATMENT) Above - Fractured clavicle in motorcycle racing accident. The clavicle is in four separate pieces Top Right - Following 1st treatment one day after fracture Right - This picture was taken following treatment - 4 days after fracture (although we do not recommend doing this) - He raced the same day! Virtually all our racing motor cyclist patients with a classic clavicle fracture race within 14 days and many have won Championship races on their return.

Case Study "B"

John Reynolds fractured his left clavicle (collar bone) in a British Superbike race at Thruxton on June 6th 2004. He was knocked off in an incident with his stand-in team mate Gregorio Lavilla. John came for PMFT and Laser treatment on June 7th, 8th and 11th and raced, 14 days after fracture, at Brands Hatch where he not only competed but won the first race with little or no pain from the fracture. John went on to win the British Championship that season.

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Fracture of Distal Tibia and Fibula

Steve Boyes is a young man who was involved in a road traffic accident in December 2002. He suffered a fractured distal tibia and fibula. He had surgery four days following the accident to plate both tibia and fibula and was put in a BKPOP.

The POP was removed three months later.

Four months after fracture infection was found in the bone plus exiting screw. The screw was removed.

At Six to eight months the fracture started deviating and he was referred to St. George's Hospital, Tooting in January 2004.

He had surgery in May 2005 where an osteotomy was performed and he was fitted with a Taylor Spacial frame with micrometer adjustment for correction of the deviation.

In August 2005 the Taylor Spacial frame was removed and replaced with an ex-fix with 2 superior and 3 inferior bolts. He was full weight bearing from the 15th September 2005 but with the ex-fix not dynamised. Nearly six months after surgery the X-rays still showed non-union.

Steve approached the clinic early November 2005 and came for consultation and treatment on the 10th November 2005. His treatment involved pulsed magnetic field therapy at a frequency of 200 Hz pulsed at 50 Hz for 20 minutes at an intensity of 100 gauss followed by a 3 watt pulsed scanning Laser at a wave length of 850 Nm for 14 minutes. He then had one session of Hyperbaric Oxygen Therapy at a pressure of 2 ATA's for a period of one hour. Following a lunch break he returned and continued with one further treatment of Magnetic Field Therapy and one session of pulsed Laser.

He returned for further treatment eleven days later on the 21st November and stated he had had X-rays at the hospital four days earlier which appeared to show early signs of bridging callus. The ex-fix was removed and replaced with a functional brace. He was full weight bearing and off of NSAID's. He received the same treatment modalities as previously.

Young Steve returned for further treatments on the 30th November and the 7th December 2005.

He returned on the 10th January 2006 whereby X-rays showed extensive callus visible all around the fracture. Steve is now well on the way to a full recovery.

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Achilles Tendon

Two professional footballers both having surgery on their Achilles tendons by the same surgeon with outcomes as follows:

Prognosis for Recovery 9-10 weeks

Without HBO:

Patient trained for the first time 64 days after surgery. Earlier training was impossible due to pain and oedema when cast was removed and was unable to weight-bear until 3 weeks after cast removal.

With HBO:

Patient trained after 34 days following 13 one hour sessions of HBO while still in his cast. He was able to fully weight-bear immediately the cast was removed, had no swelling and had full ankle movements.

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Posterior Shoulder Dislocation

A National Hockey Player sustained this injury when he crashed into the boards and fell to the ice with left arm being pushed back

Prognosis for Recovery 4 – 6 weeks

Player commenced HBO 2 days after injury with virtually no range of motion in abduction or forward flexion and there was a constant ache. After four days of HBO patient had regained full range of movement and the pain was dramatically reduced. Played in game 21 days after injury.

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Fractured Jaw Bone

Prognosis for Recovery 6 – 8 weeks

Another Hockey player suffered this fracture during a game. He could not sleep or eat semi-solid food because of pain. After two sessions of HBO he was able to sleep through the night and began eating semi-solid foods. After his third treatment he found his jaw could be slapped without pain. X-rays confirmed greatly accelerated healing.

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Comminuted Fracture of the Humerus with detached
“butterfly” fragment

One of our patients, World Champion Speedway rider Mark Loram sustained this severe fracture while racing. He had surgery the same day where the humerus was plated.

Prognosis for Recovery 18 – 20 weeks minimum.

Mark came to see us four days after his injury and started with one treatment of pulsed laser and pulsed MFT. Two days later he commenced on a ten day course of HBO for 1 hour sessions plus pulsed 800 nM laser and pulsed MFT. Continued for a further 12 sessions of pulsed MFT and pulsed 800 nM laser and Mark rode again 12 weeks after fracture, and won the race.

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Severe Quadriceps Contusion

Prognosis for recovery 4 – 6 weeks (possibly longer)

Patient was treated within 40 minutes of injury with a 70 minute session of HBO. Following his treatment his thigh circumference was reduced by 3 cm from its pre-treatment measurement. He also reported reduction in pain. When patient reported for treatment the following day he had discarded his crutches he relied on the day before and had already regained about 50% of his flexion. Following a further five HBO’s he had regained 90% of his range of motion and was able to ride an exercise bike and stairmaster. He resumed his sporting activities at full fitness eight days after injury.

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Bone Fractures with Arterial Injuries

Blunt arterial injuries secondary to bone fractures are frequently associated with nerve, vein and soft tissue lesions. A delayed diagnosis or treatment is the main cause of high amputation rate. Porcellini et al (1977) described 34 patients who presented with acute arterial occlusion (15 cases), false aneurysms (13 cases) or arterio-venous fistulas (6 cases) of the extremity. Various procedures were performed to repair injured arteries associated venous lesions were treated. External fixation of long bone fractures was made in 29 patients before vascular reconstruction to prevent further injury during orthopaedic stabilisation. Fasciotomies were made to treat compartmental compression where necessary. Hyperbaric oxygen therapy was applied in 7 patients to control bacterial contamination and improve wound healing. The authors emphasised that a multidisciplinary diagnostic and management strategy is required to improve limb and patient survival. HBO is an important component of such multidisciplinary strategies.

Certain bones have an inherently poor blood supply such as scaphoid which has its blood supply from one end only as does the ankle bone called the talus. The junction between the lower and middle third of the tibia also has a poor blood supply and all three of these types of fracture frequently suffer delayed or non-union.

An example of lower/middle third tibial fracture suffered by patient Mr. Paul Bunn is as follows:

Paul suffered a severe fractured Tibia & Fibula in a Moto X accident on 16th November 2003 and first came to see us on the 3rd December 2003 with no sign of callus formation (see X-ray right). The whole middle segment of the fractured Tibia was displaced out of line making internal fixation with an intra-medullary nail impossible.

The double fracture of the tibia severely compromised the blood supply and healing ability of the middle segment. Because of the distinct possibility of necrosis (dying off) of the middle segment it was decided to treat with Hyperbaric Oxygen, Pulsed Laser and Magnetic Field Therapy.

At the end of December, following ten sessions of Hyperbaric Oxygen, laser and MFT Paul saw his consultant who removed the plaster and, after expressing surprise that the fracture appeared stable, X-rayed the leg and was further surprised at the remarkable callus formation. Another month later Paul was holidaying in America with no walking aids.

Note: Paul suffered a less severe fracture of his other Tibia and Fibula thirteen years ago and it took him seven months to heal!!

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HBO Clinical Experience

Strauss and Hart (1977) presented 20 patients with 24 long bone fractures treated by HBO. Primary healing occurred in 15 (75%) of the patients. The healing was 100% in cases where HBO was started within 10 days of the fracture. These are good results: the incidence of non-union can be as high as 75% in displaced tibial fractures. The authors recommended the use of HBO when there is a significant risk of delayed union or non-union.

Kolontai et al (1976) treated 295 patients with compound fractures of the long bones with a combination of local antibiotics, HBO (2-3 ATA), hypothermia, and surgery. They were able to reduce the complications such as infections and non-union considerably.

Pseudarthrosis is a fracture with inadequate healing and false joint formation, which requires surgery such as bone grafting to correct it. Oriani et al (1982) used HBO as a useful adjunct to surgery both preoperatively and postoperatively in such cases, as well as in other non-healing fractures.

Tkachenko et al (1988) found that use of HBO therapy in 33 patients with defects of the long tubular bones contributed to shortening the period of rehabilitation.

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HBO Considerations

Most bone fractures heal spontaneously, but 3%-5% of them have delayed union or non-union. This proportion may rise markedly in certain locations with compound comminuted fractures. The major cause of non-union is interruption of blood supply at the ends of the fractures.

Lack of oxygen is considered to be a limiting factor in the healing of fractures. Bassett and Hermann (1961) demonstrated that multipotential precursors of fibroblastic origin form bone when exposed to increased oxygen tensions and compressive forces. If, instead, oxygen tensions are low, cartilage is formed. Cartilage is a relatively avascular tissue and its presence is noted at fracture sites in cases of non-union. Brighton and Krebs ((1972) observed low oxygen tensions in healing fractures until the medullary canal is reformed. They postulated that this was secondary to increased oxygen utilization associated with the fracture repair process.

Yablon and Cruess (1968) studied healing of fractured femurs in rats treated with 100% oxygen at 3 ATA for 1 h twice a day. By the 40th day the fractures treated with HBO had completely remodelled, while healing was just completed in the control animals. Micro-radiography showed abundant medullary canal and sub-periosteal new bone in HBO-treated animals at a time when there was incomplete bony union in the control animals.

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Coulson et al (1966) showed that rats treated at 3 ATA oxygen displayed a greater calcium ion uptake and lower fragility than air-breathing controls.

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Niinikoski et al (1970) demonstrated that 100% oxygen at 2.5 ATA for 2 h twice daily produced an increased callus formation in experimental fractures. There was increases accumulation of calcium, magnesium, phosphorus, sodium, potassium and zinc as well as accelerated collagen production compared with air-breathing controls.

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Karapetian et al (1985) demonstrated that HBO at 2 ATA stimulates the repair of non-inflamed mandibular fractures in rats.

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Tkachenko et al (1988) have shown that, in rabbits with experimental defects of the radius, HBO therapy results in the greatest activation of bone repair in the early period after trauma with the formation of osseus matrix.

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Nilsson et al (1989) studied the effect of HBO on bone regeneration by inserting a bone harvest chamber in the rat tibia and rat mandible. Their results showed that HBO treatments caused a significant increase of bone mineralization in the implant, and that lamellar bone had invaded the implant as quantified by micro-radiography and micro densitometry.

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Experimental studies in rats have shown once daily HBO treatments (2 ATA for 90 min) appeared to accelerate bone repair with vessel ingrowth.

(Barth et al 1990)

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Ueng et al (1998) investigated the effect of intermittent hyperbaric oxygen (HBO) therapy on the bone healing of tibial lengthening in rabbits. Twelve male rabbits were divided into two groups of six animals each. The first group went through 2.5 atmospheres absolute of HBO for 2 hours daily and the second group did not receive HBO. Each animal’s right tibia was lengthened 5 mm using an uniplanar lengthening device. Bone mineral density (BMD) study was performed for all of the animals at 1 day before operation and at 3, 4, 5 and 6 weeks after operation. All of the animals were killed at 6 weeks postoperatively for biomechanical testing. Using the preoperative BMD as an internal control, the authors found that the BMD of the HBO group was increased significantly compared with the non HBO group. The mean %BMD at 3, 4, 5 and 6 weeks were 69.5%, 80.1%,87.8% and 96.9% respectively in HBO group, whereas the mean %BMD were 51.6%, 67.7%, 70.5% and 79.2% respectively in non-HBO group (two tailed t test,

< 0.01, p< 0.01, p <0.01 and p < 0.01 at 3, 4, 5 and 6 weeks respectively)

Using the contra-lateral non-operated tibia as an internal control, they found that torsional strength of lengthening tibia of the HBO group was increased significantly compared with the non-HBO group. The mean percent of maximal torque was 88.6% in HBO group at 6 weeks, whereas the mean percent of maximal torque was 76.0% in non-HBO group (two-tailed t test, p < 0.01). The results of this study suggest that the bone healing of tibial lengthening is enhanced by intermittent HBO therapy.

Clinical Papers by B.G. Simpson M.C.S.P.

pdf documents

Brachial Plexus Lesions

The Structure and Physiology of Bone and Physiothereapeutic Modalities to promote Fracture Healing