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<title>極める大腿骨骨折の理学療法 | 株式会社文光堂</title>


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<meta name="description" content="PART Iでは，骨折・術後理学療法の基礎知識として骨折時の大腿骨に作用する力学的特性や，細胞レベルでみた時の骨折の治癒過程，骨折部位の相異による病態特性，術後の回復過程（急性期，回復期，生活期）について，PART IIでは大腿骨頸部骨折（ハンソンピン，CCHS，人工骨頭置換術［前外側・外側・後方アプローチ］）について，PART　IIIでは大腿骨転子部・転子下骨折（CHS，PFN）について，PAR">

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		<h1 class="title">極める大腿骨骨折の理学療法<span class="version"></span></h1>
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					常任編集：斉藤秀之（医療法人社団筑波記念会）
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					<span class="transparent">常任編集</span>　加藤　浩（九州看護福祉大学大学院）
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		<div class="headers"><h3 class="current content">内容</h3><h3 class="preface">序文</h3><h3 class="indexes">主要目次</h3></div><section class="current content">PART Iでは，骨折・術後理学療法の基礎知識として骨折時の大腿骨に作用する力学的特性や，細胞レベルでみた時の骨折の治癒過程，骨折部位の相異による病態特性，術後の回復過程（急性期，回復期，生活期）について，PART IIでは大腿骨頸部骨折（ハンソンピン，CCHS，人工骨頭置換術［前外側・外側・後方アプローチ］）について，PART　IIIでは大腿骨転子部・転子下骨折（CHS，PFN）について，PART　IVでは大腿骨骨幹部骨折（順行性・逆行性髄内釘）について解説している．</section><section class="preface">序<br>「当たり前」はもうない！─ Disruption（断絶）の時代─<br><br>　2017年元旦の日本経済新聞（電子版）に次のような記事があった．『当たり前と考えていた常識が崩れ去る．速まる一方の技術の進歩やグローバリゼーションの奔流が，過去の経験則を猛スピードで書き換えているからだ．昨日までの延長線上にない「断絶（Disruption）」の時代が私たちに迫っている．』<br>　理学療法の世界も例外ではない．1965年（昭和40年）に「理学療法士及び作業療法士法」が制定されて今年で53年目となる．この半世紀の間で理学療法を取り巻く状況も大きく変化してきた．当時は理学療法士の数も希少で金の卵と称された時代もあったが，今では養成校急増による理学療法士過剰と言われる時代に突入しようとしている．このような背景のもと日本理学療法士協会は，10万人を超える組織に成長した．しかし，その一方で，一人ひとりの理学療法の質の差も拡大したように思える．また，超高齢社会を迎えたわが国においては，社会保障制度の見直しが迫られ，その一つとして毎年のように医療費削減，診療報酬の切り下げが国会で議論されている．国は我々に根拠のある理学療法，質の高い理学療法を強く求めてきている．皆さんは，自身が理学療法士として働いている職場，職域が10年後も同様に「当たり前」のように存在していると思っていないだろうか？　今の皆さんは，「当たり前」が通用しない時代の入り口に立っている．社会の理学療法に対するニーズも大きく変化しており，これから先は，誰もが経験したことのないスピードで日々の理学療法も置き換わっていくであろう．今日の延長線上に明日はない．正にDisruption（断絶）の時代である．いつまでも，今の理学療法という仕事が「当たり前」にあると思っている人，組織は10年後，生き残っていないかもしれない．常に新しい知識と技術を吸収し，一人ひとりの個人が質の高い医療を目指して変革していくことが，今の我々には求められている．<br>　そのような命題に答えるべく臨床で遭遇する頻度の高い大腿骨骨折に着目し，『極める大腿骨骨折の理学療法 医師と理学療法士の協働による術式別アプローチ』を企画した．今回のMOOKの最大の特徴は，術式別に医師と理学療法士がペアになりご執筆いただいた点である．骨折に対する質の高い理学療法を実践するためには，手術方法についての知識，情報は絶対不可欠である．どれだけ良い手術をしても，その後の理学療法が悪ければ心身機能や機能的制限，そしてADLの改善，向上は期待できない．逆も然りである．つまり，手術と理学療法は車でいう前輪と後輪にたとえることができるであろう．どちらが欠けても車は上手く走らない．そのような想いからシリーズ始まって以来，初めて複数の医師の方々にご執筆いただくこととした．具体的に医師の方々には，手術法の特徴，適応，手術アプローチ法についてわかりやすくご解説いただいた．さらに，手術特性からみて術後，理学療法士が治療する際に特に注意してほしいことや知っておいて欲しいことについても言及していただいた．理学療法士の方々には，手術後の理学療法の流れの概略をクリティカルパスなどに沿って時系列でまとめていただいた．また，術後から退院に至るまでの理学療法の評価と具体的治療，リスク管理などについてもご解説いただいた．特に豊富な臨床経験から蓄積された，術式別による手術特有の痛みの部位，関節可動域制限の方向，筋力低下の部位，ADL障害や跛行などをご紹介いただき，その理由についてもわかりやすくご解説いただいた．さらに，退院時のADL指導やホームプログラムなどについてもご紹介いただいた．<br>　MOOKの構成としては，PARTIでは，骨折・術後理学療法の基礎知識として，骨折時の大腿骨に作用する力学的特性や，細胞レベルでみたときの骨折の治癒過程，骨折部位の相異による病態特性，さらには，一般的な術後の回復過程（急性期，回復期，生活期）について整理することとした．PARTIIでは大腿骨頸部骨折〔ハンソンピン，CCHS，人工骨頭置換術（前外側・外側・後方アプローチ）〕，PARTIIIでは大腿骨転子部・転子下骨折（CHS, PFN），PARTIVでは大腿骨骨幹部骨折（順行性・逆行性髄内釘）について整理することとした．さらに，ミニレクチャーでは，大腿骨骨折に関連するキーワードを多数集め，これらキーワードとの関連性について紹介した．臨床現場において大腿骨骨折と日々，対峙している多くの理学療法士諸氏にとって，今以上に「大腿骨骨折」の理解を深め，明日の理学療法を極めていただきたい．<br><br>平成29年5月<br>常任編集者 斉藤秀之，加藤　浩</section><section class="indexes">PartI 骨折・術後理学療法の基礎知識<br>1 骨折時に大腿骨へ作用する力とは？<br>　大腿骨の構造を理解する！<br>　転倒のバイオメカニクスを理解する！<br>　大腿骨骨折の受傷原因を理解する！<br>2 骨折の治癒過程を知る<br>　骨癒合とは<br>　骨折の治癒過程を知ろう<br>　骨折の治癒過程に関与する分子メカニズムとは？<br>　骨折治癒に影響を及ぼす因子<br>ミニレクチャー 低出力パルス超音波（LIPUS）の有用性<br>ミニレクチャー ROM（range of motion）運動のコツ<br>3 大腿骨骨折の病態特性を理解する<br>　部位別に見る大腿骨骨折<br>　大腿骨骨折の疫学<br>　「大腿骨近位部骨折」は骨折線の位置が決め手！<br>　「大腿骨骨幹部骨折」は骨折線と筋の作用で転位方向が決まる！<br>　「大腿骨遠位部骨折」は膝関節の骨折<br>4 大腿骨骨折術後の理学療法の流れを確認する<br>　急性期（臥床期）の理学療法のポイント<br>　回復期（離床期）の理学療法のポイント<br>　生活期（在宅）の理学療法のポイント<br>ミニレクチャー 術前に必要な理学療法評価と全身管理について<br>PartII 術式別にみた大腿骨頸部骨折に対する理学療法<br>1 大腿骨頸部骨折─ハンソンピン（Hansson pin）の場合①─<br>　当該手術法の特徴<br>　手術適応<br>　手術アプローチ法<br>　手術手技のポイント<br>　当該手術療法の特性から理学療法士に注意してほしいこと<br>　おわりに<br>2 大腿骨頸部骨折─ハンソンピン（Hansson pin）の場合②─<br>　ハンソンピンはどんな骨折に適応なの？<br>　内側骨折って？<br>　内側骨折にハンソンピンはどんなメリットがあるのか？<br>　単純X線画像のチェックポイント<br>　アプローチの流れ<br>　術後アプローチ時の留意点<br>　アプローチ準備と治療戦略<br>　おわりに<br>3 大腿骨頸部骨折─ cannulated cancellous hip screw（CCHS）の場合①─<br>　頸部骨折に対するCCHS法は「三矢の訓」！<br>　骨接合術のときに注意することは？<br>　どのような症例に適応するか？<br>　手術アプローチ<br>　術後理学療法で特に注意してほしいこと<br>4 大腿骨頸部骨折─ cannulated cancellous hip screw（CCHS）の場合②─<br>　CCHSについて<br>　CCHS術後の理学療法について<br>　まとめ<br>5 大腿骨頸部骨折─人工骨頭置換術（前外側アプローチ）の場合①─<br>　特　徴<br>　適　応<br>　手術アプローチ法<br>　術後理学療法における注意点<br>6 大腿骨頸部骨折─人工骨頭置換術（前外側アプローチ）の場合②─<br>　術後理学療法の流れ<br>　術後理学療法の評価，リスク管理，治療<br>7 大腿骨頸部骨折─人工骨頭置換術（外側アプローチ）の場合①─<br>　特　徴<br>　適　応<br>　手術アプローチ<br>　術後の肢位<br>　合併症<br>　本術式の特性からみた術後理学療法で特に理解して欲しいこと<br>　インプラントの実際<br>　症　例<br>　まとめ<br>8 大腿骨頸部骨折─人工骨頭置換術（外側アプローチ）の場合②─<br>　患者を知る情報収集は患者と向き合う第一歩<br>　人工骨頭置換術前の理学療法がベースを作る<br>　人工骨頭置換術後の理学療法実施前確認項目は？<br>　人工骨頭置換術のクリニカルパスは把握しておく<br>　人工骨頭置換術後の理学療法<br>　日常生活における人工骨頭との付き合い方<br>　退院に向けて取り組むこと<br>9 大腿骨頸部骨折─人工骨頭置換術（後方アプローチ）の場合①─<br>　特　徴<br>　適　応<br>　手術アプローチ法<br>10 大腿骨頸部骨折─人工骨頭置換術（後方アプローチ）の場合②─<br>　臨床上よくみられる姿勢の特徴は？<br>　理学療法プログラムの進め方は？<br>　何をどのように評価するのか？<br>　実際のアプローチについて<br>ミニレクチャー 更衣（ズボン，靴下，靴）・トイレ・入浴動作のコツ<br>〜大腿骨頸部骨折を呈し人工骨頭置換術（後側方アプローチ）を施行した場合〜<br>PartIII 術式別にみた大腿骨転子部・転子下骨折に対する理学療法<br>1 大腿骨転子部･転子下骨折<br>─compression hip screw（CHS）の場合<br>─Evans分類（group1，2）, Type1　安定型①─<br>　特徴─大腿骨転子部骨折について<br>　CHSの適応<br>　手術アプローチ法<br>　該当手術特性からみた術後理学療法<br>2 大腿骨転子部･転子下骨折<br>─compression hip screw（CHS）の場合─Evans分類（group1，2）, Type1　安定型②─<br>　診療記録のどこに着目して情報を収集すればいい？<br>　本骨折後の疼痛の特徴は？ 頸部骨折例に比べて転子部骨折例の疼痛が強いのはなぜ？<br>　CHS術後に生じやすい疼痛の特徴は？<br>　本骨折後になぜ膝痛が出現するの？<br>　本骨折およびCHS術後に生じやすい可動域制限は？<br>　本骨折後に生じやすい筋力低下は？<br>　疼痛との関連からみた本骨折後の立ち上がり動作と特徴は？<br>　疼痛との関連からみた本骨折後の歩行の特徴は？<br>　関節可動域拡大に向けた理学療法の実際<br>　本骨折例に対する筋力トレーニングの考え方<br>　本骨折例に対する筋力トレーニングの実際<br>　歩行時の荷重痛に対する工夫<br>3 大腿骨転子部・転子下骨折<br>─ガンマネイル（γ-nail）の場合─Evans分類（group3，4），Type2不安定型①─<br>　分　類<br>　適　応<br>　手　術<br>　術後評価<br>　術後理学療法<br>4 大腿骨転子部・転子下骨折<br>─ガンマネイル（γ-nail）の場合─Evans分類（group3，4），Type2不安定型②─<br>　骨折の分類を確認しよう<br>　術前の問診，理学療法評価<br>　術前からのベッドサイド理学療法が重要！<br>　手術を見学しよう<br>　術後理学療法開始時の情報収集<br>　術後の理学療法プログラム<br>　不安定型の術後理学療法<br>　起居動作時の患肢の介助の重要性<br>　荷重することの重要性と注意点<br>　術後のX線画像を確認しよう<br>　退院（転院）時指導<br>ミニレクチャー 大腿骨転子部骨折における歩行のコツ<br>（short femoral nail：PFNA施行，術後10日）<br>PartIV 術式別にみた大腿骨骨幹部・顆部骨折に対する理学療法<br>1 大腿骨中央・近位部の骨折─順行性髄内釘（interlocking nail）の場合①─<br>　手術方法<br>　術後理学療法について<br>2 大腿骨中央・近位部の骨折─順行性髄内釘（interlocking nail）の場合②─<br>　大腿骨骨幹部骨折とは？<br>　術後の理学療法の流れ<br>　術後理学療法の具体的評価項目<br>　理学療法方針と目標設定<br>　術後理学療法の実際<br>3 大腿骨遠位部の骨折（顆上骨折）<br>─逆行性髄内釘（retrograde intramedullary nail）の場合①─<br>　特　徴<br>　適　応<br>　手術アプローチ法<br>　手術手技<br>　後療法<br>4 大腿骨遠位部の骨折（顆上骨折）<br>─逆行性髄内釘（retrograde intramedullary nail）の場合②─<br>　術後理学療法の流れ<br>　X線画像からの情報収集<br>　膝関節の可動域を獲得する<br>　歩行に対するアプローチ<br>　日常生活指導のポイント<br>5 大腿骨顆部骨折─ locking plate固定の場合①─<br>　最も大切なこと<br>　特　徴<br>　ここが大事！ 現場の注意点<br>　手術法について知っておこう<br>　おわりに<br>6 大腿骨顆部骨折─ locking plate固定の場合②─<br>　大腿骨顆部骨折に対するLCP固定のプロトコル<br>　大腿骨顆部骨折に対するLCP固定では何に注意すべきか<br>　大腿骨顆部骨折に対するLCP固定後の具体的アプローチ<br>ミニレクチャー 疼痛緩和のコツ<br>ミニレクチャー 筋力トレーニングのコツ<br>ミニレクチャー バランス練習のコツ<br>ミニレクチャー 起居動作練習のコツ<br>ミニレクチャー 階段昇降練習のコツ<br>ミニレクチャー 外来（通所）理学療法でチェック・指導する身体運動機能面のポイント<br>ミニレクチャー 退院から在宅への移行と環境整備や家族指導のポイント<br>ミニレクチャー 日常生活のための福祉用具選択のポイント<br>ミニレクチャー クリニカルパス導入の功罪<br>索引</section></article>
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