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Stasia Blyskal, DO, PGY-3; Hugh Ettlinger, DO, FAAO NMM/OMM Department, St. Barnabas Hospital, Bronx, NY INTRODUCTION Tibial fractures are the most common long-bone fracture, and are associated with significant short- and long-term morbidities, including malunion or nonunion, persistent pain, and decreased bone density even decades later. However, the role of osteopathic manipulative treatment in the management of acute fracture is scarcely mentioned in the literature. This case demonstrates that osteopathic manipulation can address acute, even severe, trauma in ways that are effective and well-tolerated and that may even promote bone healing. CASE DESCRIPTION History of Present Illness The inpatient Osteopathic Manipulative Medicine (OMM) Service was consulted to see a 45-year-old female who was post-operative day one status post (s/p) closed reduction and external fixation of fractures of her right tibia and fibula. The patient had been a passenger in a bus accident; radiographs performed in the Emergency Department revealed severely comminuted fractures of the distal tibial and fibular shafts; multiple bone fragments; and diffuse soft-tissue swelling. At the time of consultation, the patient reported significant ankle swelling and ankle pain that was well-controlled with morphine. She denied motor and sensory loss of the right foot and ankle, but reported difficulty shifting position due to the swelling and external fixation hardware. She denied fever, chest pain, shortness of breath, abdominal pain, nausea, vomiting, and and pain with urination. Past Medical/Surgical History Ovarian cancer, s/p total abdominal hysterectomy and bilateral salpingo-oophorectomy and chemotherapy; in remission since 2009. Post-chemotherapy osteoporosis. Right tibial and fibular fractures due to a fall at age 14; she was casted at that time. Physical Exam Vital signs within normal limits. Alert, oriented, in no acute distress. Head, neck, heart, lungs, and abdomen all unremarkable. External fixation hardware in place to the right lower extremity; significant edema and tenderness present; motor function intact at all five toes; capillary refill <3 seconds; peripheral pulses intact. 2cm x 2cm area of decreased sensation to light touch on the dorsum of her right foot at the location of one of the fixation rods; otherwise sensation intact. Osteopathic Structural Exam Head: OA ES R R L Cervical spine: Cervicothoracic junction rotated right Thoracic spine: T4-5 NS L R R ; thoracolumbar junction sidebent and rotated right Lumbar spine: L5 ESR L ; L1-5 right paravertebral muscle hypertonicity; right psoas hypertonicity Ribs: Right rib 12 inferior Abdomen: Right hemidiaphragm inhalation dysfunction Sacrum: Right upper and lower pole restrictions; sacral base unleveled with right side inferior Pelvis: Superior shear of right innominate Lower extremity: Severe fluid congestion, as well as osseous and fascial strains, of right leg and thigh; right hip externally rotated with fascial strain Assessment and Plan A 45-year-old female, with a history of Ovarian Cancer (in remission), osteoporosis and old fractures of the right tibia and fibula, now s/p closed reduction and external fixation of severely comminuted fractures of the right distal tibia and fibula, with the above-noted moderate- to-severe somatic dysfunction due to acute trauma. As part of her post-operative management, plan was for treatment with OMM to decrease fascial strains, promote fluid drainage, and palliate pain. Optimizing lymphatic function was the priority of her first treatment: balanced ligamentous techniques were employed to address the strains through her cervicothoracic, thoracolumbar and lumbopelvic regions as well as her diaphragmatic restriction. In addition, a gentle, oscillatory fluid fluctuation was performed at the right knee for several minutes. She tolerated the treatment without complication and with good response. Hospital Course The day after her first OMM treatment, the patient reported significant decreases in both pain and swelling of her right ankle. Physical exam confirmed a marked decrease in edema of the right distal lower extremity. She was treated with OMM daily throughout the remainder of her admission. Subsequent treatments continued to focus on fluid drainage and decreasing the severity of fascial strains. All treatments were well-tolerated and resulted in significant symptomatic and clinical improvement. Compact bone. Accessed at http://commons.wikimedia.org/wiki/File:Compact_bone.png on 2/22/15. File made available under Creative Commons CC0 1.0 Universal Public Domain Dedication DISCUSSION Although Julius Wolff first argued in 1892 that bone responds to the forces placed upon it, current research has elucidated at the cellular level the ways in which bone adapts to mechanical forces. Interstitial fluid flow within the lacuno-canalicular system activates osteocytes, likely via stretch-activated ion channels, thereby converting a mechanical signal to a chemical one. Mechanical activation of osteocytes leads to production of numerous signaling molecules, including bone morphogenic proteins, which are critical mediators of fracture healing. This ever-ongoing process of remodeling in response to its external environment is at the core of bone’s structure and function, its architecture and its self - healing. This case brings into stark relief the dynamic responsiveness of bone: a history of prior fractures, post- chemotherapy osteoporosis, then a second trauma resulting in an extraordinary degree of damage. That this responsiveness is mediated by mechanotransduction would seem to make the topic of fracture healing prime for the application of osteopathic principles and practices. Yet acute orthopedic injury is rarely discussed in the literature and, when mentioned, typically involves injuries of lesser severity. This case serves as evidence that the use of OMM in the setting of acute trauma may offer significant benefits. While inflammation is a necessary phase of healing, if the capacity of the lymphatic system is overwhelmed, edema persists. This contributes to localized ischemia, nutritional deprivation of involved tissues, and pain. Addressing lymphatic function has been a focus of osteopathic medicine since its inception. Based on the osteopathic assessment of this patient, the goals of her treatment included removing obstacles to lymphatic drainage and promoting lymph formation. A respiratory-circulatory approach aptly addresses the first goal; the restrictions and fascial strains of the patient’s cervicothoracic junction, diaphragm and lumbopelvic regions were all addressed. Another osteopathic approach is to stimulate lymph generation, i.e., to facilitate the movement of fluid from the interstitium into lymphatic vessels. It is interstitial fluid flow – whether due to inherent motions associated with pulse and respiration, or due to therapeutic motions designed to create a fluid fluctuation – that drives the process of lymph formation. Thus, the fluid fluctuation performed at the patient’s knee was a vital component of her initial treatment. As discussed, osteocytes are also responsive to interstitial fluid flow, and recent evidence supports the use of various mechanotransducing modalities to stimulate bone healing. This raises the intriguing question of whether an osteopathically induced fluid fluctuation may also have a stimulatory, but as yet unstudied, effect on bone healing. Osteopathic Manipulative Medicine offers a range of treatment approaches; all of the ones utilized in this case were gentle enough to be easily tolerated. The fields of orthopedic and osteopathic medicine are in agreement that somatic alterations due to fracture may persist for years. This patient’s clinical and symptomatic improvement are indicative of the pivotal role OMM might play in acute, even severe, trauma. Current research in the fields of manual lymph drainage, mechano- transduction, and bone physiology support the claim that the acute setting is precisely where OMM may have its most potent effects. SBH IRB Approved 2015.11 FRACTURES, FASCIAL STRAINS AND FLUID FLOW– OMM IN THE SETTING OF ACUTE TRAUMA: A CASE REPORT
