One of the best examples of this problem is a Colles fracture of the distal radius in the older patient (see Plate 9-11). Although this fracture almost always heals, adequate healing takes 8 to 10 weeks. If the limb is immobilized in a cast for this amount of time, severe stiffness of the elbow and wrist may occur, and even the shoulder and finger joints may become stiff. Therefore, again, although the fracture heals, the resulting joint stiffness and muscle atrophy render the arm useless. Rehabilitation of the joints and muscles is a long and difficult process that may not restore full limb function.
Methods have been developed to ensure adequate fixation of the fracture fragments yet maintain joint motion and muscular activity to prevent the stiffness and atrophy that result from cast immobilization. If joint stiffness appears likely, the fracture is treated with early open reduction and internal fixation. A few days after surgery, the patient resumes gentle active range-of-motion exercises of the adjacent joints. Surgical stabilization and early rehabilitation are most effective in fractures of the shafts of both forearm bones in adults. Open reduction and internal fixation can restore a stable anatomic configuration of the bone architecture, which allows early restoration of motion in the elbow, wrist, and hand.
With certain fractures, such as a fracture of the shaft of the humerus, use of a functional brace accomplishes the same objectives. Traditional cast immobilization for a fracture of the humeral shaft requires immobilization of the shoulder and elbow joints in a shoulder spica cast. Such immobilization of both joints for 8 to 10 weeks would lead to a significant loss of function. Conversely, a functional brace allows active range of motion in the shoulder and elbow joints yet provides adequate support of the healing fracture. A functional brace can be applied at the time of injury, but the brace will likely need to be adjusted 10 to 14 days after injury, once the initial swelling has subsided. The brace can be tightened to provide firm support about the arm and maintain acceptable alignment of the fracture.
When joint stiffness develops, restoring motion requires a long-term rehabilitation program, possibly lasting more than 1 year. After the patient regains joint motion with gentle passive range-of-motion exercises, active exercises are begun to strengthen the atrophied muscles. Manipulation under anesthesia, lysis of adhesions, and capsulotomy is commonly required for a stiff shoulder or elbow joint that has not improved with aggressive physical therapy. When fixed muscle contractures fail to respond to aggressive and prolonged rehabilitation, surgical release of soft tissue may be necessary as a last resort. One of the most effective soft tissue releases is a Z-plasty lengthening of the Achilles tendon for persistent equinus contracture after injury to the ankle. A posterior capsulotomy may also be needed to restore full mobility of the ankle joint.
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