General Principles of Fracture Treatment and Rehabilitation

Roman Hayda, MD, COL (ret)

Dr. Hayda or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of AONA and Synthes; serves as an unpaid consultant to BioIntraface; has received research or institutional support from Stryker; and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, Clinical Orthopaedics and Related Research, the Journal of Bone and Joint Surgery–American, the Journal of Orthopaedic Trauma, METRC, and the Orthopaedic Trauma Association.

Introduction

Fracture treatment aims to restore function to the maximal extent possible. Fundamentally, fractures require immobilization not only for comfort and pain control, but also for healing. However, immobilization leads to joint stiffness, muscle atrophy, and even generalized patient deconditioning. Current fracture care has evolved to balance the immobilization and support required to achieve fracture healing with motion to limit joint contracture and muscle atrophy. Fixation of fractures with intramedullary devices, plates and screws, or external fixation provides fracture stabilization with appropriate alignment while allowing joint and, more important, patient mobilization. The goal is to restore normal function as early as possible. Optimizing the physical and psychological factors that affect fracture healing and functional recovery is critical in the recovery process. Exercise, performed with or without a therapist, is vital in this process. However, understanding all of the factors that affect therapy—including, but not limited to, weight-bearing status and joint motion parameters and their progression—is critical in the return of the patient to preinjury state of function.

In the past, lacking the surgical implants and techniques to effectively fix fractures, most fractures were treated with casts, braces, or traction. These methods led to “cast disease”: bone and muscle atrophy, joint contracture, and pressure sores. When bed rest was required with traction, systemic sequelae such as pneumonia, ileus, thromboembolic disease, and urinary tract infection were common complications. Nonetheless, today, using a cast is still an effective form of treatment, especially in pediatric patients, most of whom are treated with casts or braces for fractures. Rapid healing and high remodeling capacity in the pediatric patient result in typically excellent outcomes. In adults, cast treatment is effective in minimally displaced and stable injuries, particularly in the upper extremity, where some deformity is well tolerated. Otherwise, surgical management may be the preferred treatment.

Considerations for Surgical Fracture Management

Subsequent chapters will discuss considerations for surgical treatment of fractures in particular anatomic areas, with the techniques employed and their implications for therapy. In general, fracture surgery is performed when adequate alignment cannot otherwise be achieved and maintained during the healing process. Fracture displacement, healing capacity, tolerance of deformity, patient functional needs, and ability or willingness to undergo surgery all factor in the decision for surgery. Aside from a single fracture in a limb, which is described in subsequent chapters, it is useful to consider three scenarios: multiple fractures in a single limb, fractures in multiple limbs, and fracture treatment in a patient with multiple system injury.

Multiple Fractures in a Single Limb

An important consideration in choosing surgical treatment of fractures is whether the fracture is isolated or whether the limb or patient has multiple fractures. A limb with multiple fractures is difficult to adequately stabilize nonsurgically even if an individual fracture can be treated in this manner. In this circumstance, all fractures in the limb are surgically stabilized,
allowing for mobilization. For instance, a “floating elbow” consisting of a humerus fracture and forearm fracture will usually have both surgically fixed. Even though many isolated humerus fractures can be treated with bracing, in a combined fracture, surgery is done so that the shoulder, elbow, and wrist can be mobilized, reducing stiffness of those joints and disability. The same holds true in the floating-knee situation regardless of whether the tibia fracture is amenable to cast treatment.

Fractures in Multiple Limbs

The multiply fractured patient presents a different challenge to the team of surgeons and therapists. Multiple limbs with fractures can impair the patient’s ability to perform even the most basic ADLs. In such cases, surgery is performed to allow for patient participation in self-care. Even a fracture as simple as bilateral wrist fractures may benefit from surgical fixation to allow such basic activities as feeding, toileting, and grooming since casts are not required.

In patients with fractures of the upper and lower extremities, the upper extremity fracture may require fixation to assist with patient mobilization. A humeral shaft fracture may be treated with a rod or plate to allow the use of crutches or walker in a patient with a combined lower extremity injury when otherwise it may be adequately treated with a brace to provide mobility and support. The method and extent to which weight bearing is allowed in the upper extremity is dependent on the location and complexity of the fracture, which determines the degree of stability that can be achieved with fixation. An intra-articular fracture of the distal humerus will not allow weight bearing until the fracture is adequately healed. A complex fracture of the wrist or forearm might not allow immediate weight bearing through traditional crutches or walker, but may allow for weight bearing through a platform. In such cases, the method of weight bearing and timing of progression should be made through communication between the surgeon and therapist.

Fracture Treatment in a Patient with Multiple System Injury

The multiply injured patient with a number of organ systems affected presents yet another challenge to the surgical and rehabilitation teams. Head injury, chest or abdominal injury, and spine fracture or dislocation with or without neurologic injury, combined with fractures of the extremities all require evaluation and treatment. Often, there are competing priorities that require careful coordination of the teams to achieve the optimal result. Data have shown that fixation of femur fractures within 24 hours of injury in the multiply injured patient leads to shorter intensive care unit (ICU) stays and fewer systemic complications, such as pulmonary failure. Fixation lessens systemic stress and allows for more optimal patient positioning and mobilization, reducing morbidity and length of stay in the ICU. However, in the most severely injured patient, even this degree of surgery may be too much, leading to complications. Surgery may induce a second hit on overtaxed systems, leading to organ failure. In such a case, “damage control” surgery may be undertaken to allow for further stabilization and resuscitation of the patient. An external fixator may be applied and converted to a rod when the patient is deemed stable and not susceptible to secondary inflammatory insults of surgery, typically after 5 to 7 days. Current protocols emphasize early resuscitation with fixation of most fractures within 48 hours, reducing complications and length of stay. A patient with head injury may be delayed even if adequately resuscitated since hypotension associated with extensive surgery in the first 4 to 5 days of injury will adversely affect neurologic recovery.

Initiation of Therapy in the Injured Patient

In the hospitalized fracture patient, rehabilitation can be started as soon as the extent of injuries and treatment plan is established. Uninjured limbs are exercised to maintain their strength and flexibility. Instruction in using these limbs for mobilization and transfers reestablishes the patient’s sense of independence and control. Physiologic benefits of maintenance of strength and circulation also assist in the recovery of the patient. Active ankle pumping exercise may also reduce swelling and diminish the risk of thromboembolism.

As fractured limbs are repaired, they should also be incorporated into the therapeutic regimen. Doing so will reestablish the belief by the patient that even a severely injured limb may be restored to a functional status. Conversely, waiting until the fracture is healed or pain free will lead to atrophy of surrounding musculature and the development of scar, restricting motion. Therefore, mobilization is advanced as the nature of the injury and the quality of repair allows.

Even in the obtunded, intubated, or neurologically impaired patient, some form of therapy should be instituted early. The goals may obviously be different than in patients able to participate in their own therapy, but equally important. Therapy in these cases is directed toward avoiding complications related to disuse, namely, contracture and decubitus ulcers. Early institution of such measures is important, as the duration of intubation or impaired neurologic status may be hard to determine. Passive stretching of major joints—along with protective splinting of the hand, wrist, and ankle—are important. The hand is splinted in the “safe position” or intrinsic plus, with the wrist slightly extended and the metacarpophalangeal (MCP) joints in flexion with the interphalangeal (IP) joints extended. It is also important to keep the thumb abducted to avoid a contracture of the first web space. The ankle is splinted or braced in neutral position to keep the foot plantigrade. Equinus contracture is an all too common complication of the lower extremity that is not allowed to bear weight. The bed- or chair-bound patient is also subject to knee flexion contracture, which must be avoided. All providers must be reminded that contracture can occur in both injured and uninjured limbs. Obtunded, head-injured, paralyzed, or otherwise impaired patients are particularly prone to contracture. Frequent position changes and protective padding and mattresses reduce the
risk of decubitus ulcer formation. In many cases, the nursing team can be instructed in measures to limit contracture and pressure ulcer formation.

In all fracture cases, therapy should focus on regaining control of the limb as the extremity injury and the overall patient condition allows. This includes active contraction of major muscle groups, gross movement of the limb, passive and active motion of the joint, and ultimately coordinated functional use of a limb. In the acute setting, the patient may not even be able to fire major motor groups in the fractured limb even when neurologically intact due to pain inhibition. Activities geared to muscle reeducation are critical to recovery.

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