UPPER LIMB FRACTURE ASSESSTMENT FORM

UPPER LIMB FRACTURE ASSESSTMENT FORM

Demographic Data:

Name :
Age:
Gender:
IP Number:
Occupation:
Address:

History relevant to present condition:

Mode of injury:
orthopedics management:
surgical management:

Investigation:

Lab reports
Radiology

Co-Morbidities:

Diabetes mellitus
Hypertension

Observation:

Position of comfort adapted by patient (if any):

Extent of cast/external fixator
Drain(if any)

Palpation:

Edema/Swelling
Capillary refill
Muscle spasm/guarding (if relevant)
Pulse

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 UPPER LIMB FRACTURE ASSESSTMENT FORM

Testing:

Sensory Examination:

*In area below the fracture (Present/Absent)

Pain Examination:

pain in area other than the fracture area (if relevant)

Screening of other limbs

Motor Examination:

Muscle Girth:

Right Left
Thigh
Leg
Arm
Forearm
Hand

Range of motion:

ROM of Joint proximal and distal to Active range

the fracture site

Muscle strength:

-Manual Muscle Testing of joints proximal and distal to fracture site.

Functional Evaluation:

Hand Function Evaluation

Wrist Extension range

MCP range
IP range
Web space

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 UPPER LIMB FRACTURE ASSESSTMENT FORM

Pinch grip

Kapandji opposite score

Expected Function (Prognosis)

Hand function
Proximal and distal joint mobility

Plan of Care: Pre-operative/Post-Operative

SMART GOALS

Treatment Plan:

*Treatment based on recent evidence /guidelines

Progress Note:

Functional range with assistance/without assistance

Basic hand function

Discharge Goals:

No swelling in ankle
Normal Scapular kinematics
Full ROM of Shoulder Joint (except in case of lateral 1/3rd of clavicle fracture.
fracture of proximal head of shoulder)

Home –exercise Program:

Exercise diagram No. of sets Repetition Do’s Don’t

Follow-Up:

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 UPPER LIMB FRACTURE ASSESSTMENT FORM

Clinical Reasoning

Clinical relevance /
contributing factors / Special
Important Information
Hypothesis / attention
Reasoning
Healing / degenerative
Age changes /osteoporosis/
strength / mobility
Reason for surgery
Surgical History –
Incision / type of
implant
HT/IHD/DM/ osteoporosis
Relevant medical
/ previous trauma
Surgical conditions
history and Presenting complaints
Previous Functional status
co- (list)
Activity Status
morbidities Relevant Past history (
Body Function status/
Assisted devices used for
Activity Status) /
supports, transfers and
contributing factors
mobility
that may influence the
exercise planning)
To get information on the
To correlate with the level infection,
Lab
present condition of inflammation and to test
investigation
the patient the level of calcium
precursors
To identify the type
Radiology
,extent of fracture

Surgical Incision, Healing

Swelling, (stages-inflammatory/
Presence of drain tubes remodelling etc.,)
Observation Scar (grading)

Position of comfort To understand which

adapted by patient (if position relieves pain and
any): also it would help in
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 UPPER LIMB FRACTURE ASSESSTMENT FORM

educating them regarding

the position of limb

Extent of To understand the mobility

cast/external fixator/ and stability of proximal
Surgical Incision and distal joint
Edema/Swelling
Palpation Sign of inflammation/Pain

Capillary refill To understand peripheral

perfusion(normal/decrease)

To understand if there is
Examination Sensory
any nerve involment
pain If pain
intensity is
more then
other motor
examination
should not
be
performed.
To identify flags, relate to Discuss
surgical with nurse
history,healing,mediction in charge
regarding
pain
medication
and patient
need to be
followed up
after pain
reduction.
Girth measurement
(differentiate between
Relate with observation
swelling / wasting)
- Limb Oedema
(identify possible
causes
Active Range of Movement pattern, Perform on
Motion of joints quantity, muscle activity, plinth not
proximal and distal to kinematics, protective on bed in
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 UPPER LIMB FRACTURE ASSESSTMENT FORM

fracture site. mechanism) supine and

Identify sitting to
- Lag evaluate the
- Muscle inhibition muscle
- Muscle power activity
(torque)
Strength of muscles
Strength (MMT) proximal and distal to
fracture site.
Total assist/
max/mod/min assist /
Independent
Functional Status

PT Plan of care

Pre- op / Prehabilitation

Mode Reasoning
Exercise counselling To Gain confidence
Unaffected limb exercise To train mobility and strength
-Finger movements
Affected limb exercise
-Isometrics exercise

Post operative

Treatment Reasoning / Progression Progress note

Gain confidence Exercise education
Decrease Pain Understand the underlying Pain rating (VAS /
causes of pain NPRS), quality and
- Cryotherapy - Inflammatory compliance at each
- Positioning - Chronic visit.
- Muscle activation ( - Structural
active exercise / - Muscle guarding
isometric exercises) - Cryotherapy ( once in
every 6 hours till 6th

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 UPPER LIMB FRACTURE ASSESSTMENT FORM

post op day)
Oedema control - Compression - Active exercises
- Elevation with elevation
- ST mobilization (If - Activity
required) modification
(elevation in
between with
active exercises)
Restore ROM

-Active exercises -Maintain Range of Slowly progress to

motion in joints proximal - Resisted exercises
and distal to fracture site

-Isometrics exercises -to active the muscles

around fracture site

Hand Function
-Wrist extension exercise
- MCP,IP ROM exercise -to restore the hand
-grip strengthening function
exercises

Safe transfers and No weight bearing on

ambulation affected side while
transfer or ambulation
Home exercise program
(HEP)

If goals are NOT achieved and patient is maximally dependent

Note for ADL then refer to Physical Medicine and Rehabilitation
centre (PMRC) -JSSH for further evaluation and rehabilitation.

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 UPPER LIMB FRACTURE ASSESSTMENT FORM

If Patient is moderately dependent for ADL refer to

Physotherapy OPD
If patient is not stable with co-morbidities and not willing to
stay inPMR/visit OPD,refer Home care physiotherpy

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