Musculoskeletal System

Preferred Practice Patterns

The most relevant practice patterns for the diagnoses discussed in this chapter, based on the American Physical Therapy Association’s Guide to Physical Therapist Practice, second edition, are as follows:

• Fractures: 4G, 4H

• Dislocations: 4D

• Arthroplasty, Joint Resurfacing: 4H

• Limb Salvage Surgery: 4I

• Hip Disarticulation: 4I

• Hemipelvectomy: 4J

• Osteotomy: 4I

• Surgeries of the Spine: 4F

Please refer to Appendix A for a complete list of the preferred practice patterns, as individual patient conditions are highly variable and other practice patterns may be applicable.

An understanding of musculoskeletal health conditions, medical-surgical interventions, and use of orthotic and assistive devices in conjunction with weight-bearing restrictions is often the basis of physical therapy evaluation and treatment planning for patients with acute musculoskeletal impairments. Because a primary goal of the physical therapist working with a patient in the acute care setting is to initiate rehabilitative techniques that foster early restoration of maximum functional mobility and reduce the risk of secondary complications, the physical therapist is an integral member of the multidisciplinary health care team.

Structure and Function of the Musculoskeletal System

The musculoskeletal system is made up of the bony skeleton and contractile and noncontractile soft tissues, including muscles, tendons, ligaments, joint capsules, articular cartilage, and nonarticular cartilage. This matrix of soft tissue and bone provides the dynamic ability of movement, giving individuals the capacity to move through space, absorb shock, convert reactive forces, generate kinetic energy, and perform fine-motor tasks. The musculoskeletal system also provides housing and protection for vital organs and the central nervous system. As a result of its location and function, the musculoskeletal system commonly sustains traumatic injuries and degenerative changes. The impairments that develop from injury or disease can significantly affect an individual’s ability to remain functional without further pathologic compromise.

Examination

Common orthopedic diagnoses seen by physical therapists in the acute care setting include degenerative joint disease, spinal disorders, and fractures associated with trauma. Because many patients with these conditions have undergone surgical interventions, physical therapists must be familiar with physician-dictated precautions such as weight-bearing limitations and range-of-motion (ROM) restrictions.

Patients with orthopedic impairments often experience pain, frustration, and anxiety while maneuvering in an environment that frequently includes peripheral lines, catheters, casts, and drains. A challenge for physical therapists in the acute care setting is to accurately interpret the reasons for the patient’s presentation and then effectively achieve optimal outcomes in a very short time frame. To do this, the therapist must incorporate the judicious use of examination findings into the decision-making process. Various factors influence clinical reasoning. These factors include the therapist’s knowledge, expertise, goals, values, beliefs, and use of evidence; the patient’s age, diagnosis, and medical history, as well as his or her own goals, values, and beliefs; available resources; clinical practice environment; level of financial and social support; and the intended use of the collected information.1,2

Patient History

Information about the patient’s history can be obtained from the medical record, the patient, and/or the patient’s caregivers. According to the Guide to Physical Therapist Practice, the different types of data that can be generated from the patient history include general demographics, social history, employment/work, growth and development, general health status, social/health habits, family history, medical/surgical history, current condition(s)/chief complaint(s), functional status and activity level, medications, and other clinical tests.³

Medical Record Review

In addition to a standard medical review (see Chapter 2), information pertaining to the patient’s musculoskeletal history should include the following:

• Medical diagnosis

• Cause and mechanism of injury

• Medical treatment and/or surgical procedures

• Physician-dictated orders

• Weight-bearing status, limitations on ROM, positioning of extremities

• Equipment such as braces, orthotics, assistive device use

• Activity status

• Comorbidities and medical history

• Diagnostic test and laboratory results

• Medications (see Chapter 19)

Because many patients with musculoskeletal impairments have undergone some type of surgical procedure in which blood loss could have occurred, the physical therapist should review and monitor the patient’s hematocrit and hemoglobin levels. If they are low, the patient is experiencing a reduction in the oxygen-carrying capacity of the blood. Thus the patient may have decreased exercise tolerance and complain of fatigue, weakness, and dyspnea on exertion.

Diagnostic test results should be reviewed by the physical therapist because they may indicate that certain activity limitations are warranted. The most commonly used diagnostic tests for the musculoskeletal system are listed in the following section. These tests may be repeated during or after a hospital stay to assess bone and soft-tissue healing and disease progression or whether there is a sudden change in vascular or neurologic status postoperatively.

Diagnostic Tests Review

Clinical Tip

The coagulation profile of patients on a LMWH is not typically monitored via laboratory testing, whereas unfractionated heparin is monitored via the activated partial thromboplastin time (aPTT) test and warfarin via the prothrombin time (PT) test.

Coordination with Other Providers

After reviewing the medical record and before interacting with the patient, the physical therapist must have a conversation with the patient’s nurse. The physical therapist needs to determine if there is any reason why further examination of the patient at that time is not warranted. The therapist should inquire about the following information:

• Most recent lab values

• Type and last dose of pain medication

• Whether or not the patient has been out of bed since admission to the hospital

Patient Interview

The physical therapist should also collect information from the patient about his or her:

• Functional level before admission

• Previous use of assistive device(s)

• Recreation or exercise level and frequency

• Need for adaptive equipment or footwear on a regular basis (e.g., a shoe lift)

• Any additional medical problems that limit use of assistive devices, participation in physical therapy

• History of falls

• History of chronic pain

• Support system

• Anticipated discharge location to determine the presence of stairs, railings, and so forth

• Goals

Tests and Measures

Based on the data from the patient history, the physical therapist determines the specific tests and measures necessary to confirm his or her working hypothesis as to the main reasons for the patient’s presentation. These tests can also be used as outcome measurement tools to show patient improvement. The following tests and measures should be considered when examining patients with musculoskeletal impairments.

Mental Status

The screening of the patient’s mental status begins once the physical therapist asks questions of the patient during the patient interview/history. Based on the patient’s ability to effectively communicate, the physical therapist is able to determine if further specific testing is required. If a cognitive impairment is present, the therapist must determine whether onset occurred before or after the patient was hospitalized. The therapist should also screen the patient’s hearing status to ensure that the apparent impairment in mental status is not because the patient cannot hear the questions that are being asked.

Clinical Tip

Because the adverse effects of certain pain medications include an altered mental status, the physical therapist needs to know the medication schedule of the patient.

Observation

A wealth of information can be gathered by simple observation of the patient. The physical therapist should note the presence of any equipment and if it is being used correctly by the patient. The therapist should also observe the patient’s:

• General appearance

• Level of anxiety or stress

• Position of extremities

• Willingness to move or muscle guarding

The resting limb position of the involved extremity is important to observe. The therapist should note if the limb is resting in its natural anatomic position or if it is supported with a pillow, roll, or wedge. If the limb is being supported, the therapist needs to determine if the pillows are being used correctly. Some extremities must be elevated for edema management. In other situations, the patient might use pillows for comfort, but their use predisposes the limb to contracture development (i.e., pillows under the knee in a patient who has undergone total knee arthroplasty) and is contraindicated.

Clinical Tip

Joints should be placed in a neutral resting position to preserve motion and maintain soft-tissue length. A limb in a dependent position is at risk for edema formation, even if it is dependent for only a short period.

Cardiovascular and Pulmonary.

The cardiovascular and pulmonary systems should be assessed for any signs or symptoms that indicate that the patient might not tolerate aerobic activities. As the energy expenditure (i.e., cardiopulmonary demand) required for use of an assistive device is greater than the demand imposed during ambulation without a device, it is important for the physical therapist to examine the aerobic capacity of the individual.6,7 Heart rate and rhythm, blood pressure, respiratory rate, and oxygen saturation (if applicable) must be assessed at rest, before the initiation of further tests and measures, as well as during and at the completion of aerobic activities (e.g., walking).

Clinical Tip

Because orthostatic hypotension is a side effect of opioid use, the physical therapist needs to ensure that the patient’s cardiovascular system has accommodated to positional changes before progressing with upright activities.

The physical therapist should also examine the circulatory status of the patient. With decreased mobility, the risk for the development of deep venous thrombosis (DVT) increases. The lower extremities should be observed for signs of a DVT. Deficits in skin temperature, capillary refill, and peripheral pulses at the level of or distal to the injury or surgical site should also be noted. Refer to Chapter 7 for a further discussion on vascular examination.

Integumentary.

The patient’s skin should be screened for the presence and location of edema, bruising, lacerations, or surgical incisions. Skin integrity and color should be examined, especially around and distal to injuries and incisions. Pressure sores from prolonged or increased bed rest after trauma or orthopedic surgery can develop in anyone, regardless of age or previous functional abilities. The therapist should be aware of signs and symptoms of infection, circulatory compromise, or pressure ulcer development that would warrant further testing. Refer to Chapter 12 for a further discussion of skin integrity.

Sensation.

The neuromuscular system should be assessed for impairments in sensation, especially in the involved extremity. Physical therapists should be aware of signs and symptoms of sensory deficits in patients with diabetes, compartment syndrome, and peripheral nerve injury (e.g., after THA, acute foot drop may be present because of injury to the sciatic nerve). Patients should be asked if they are experiencing any changes in sensation. Light touch awareness should be performed by lightly brushing different areas (distal and proximal, medial and lateral) on the extremity. The patient with eyes closed must recognize that a stimulus has been applied for the system to be intact. If deficits are noted, more formal testing is required. Refer to Chapter 6 for more detailed information on the nervous system.

Pain.

Musculoskeletal pain quality and location should be determined subjectively and objectively. Pain scales appropriate for the patient’s age, mental status, and vision should be used. The physical therapist should understand the dosing schedule of the patient’s pain medication if the patient is not using a patient-controlled analgesia (PCA) pump in order to ensure that the patient can optimally participate in rehabilitation.

The physical therapist should observe the patient throughout the examination process (as well as during interventions) to determine if the patient is expressing or experiencing pain. The patient might present nonverbal indicators of pain such as behavior changes, facial expressions, and body language. The physical therapist should determine if pain is constant or variable and if movement or positioning increases or decreases the pain. Refer to Chapter 21 for more detailed information on pain assessment and management.

Clinical Tip

The patient’s experience of pain might be masked by medications, and thus the patient can be “overworked” if the intensity of the intervention is too high.

Range of Motion and Strength.

The musculoskeletal system, including the uninvolved extremities, should be assessed for impairments in ROM and muscle strength that might preclude the patient from successfully performing mobility activities. For example, a patient with a fracture of the femur who will require the use of an assistive device when ambulating should have both upper extremities examined to ensure that the patient can safely maintain the limited weight-bearing status.

It is optimal to determine if any deficits exist in the patient’s ability to move his or her extremities before the performance of higher-level functional activities. A gross screen of upper extremity ROM can be performed by having the patient lift his or her arms over head through the full ROM (i.e., shoulder flexion/abduction, external rotation, and elbow extension). The patient can then be asked to touch his or her shoulders (i.e., elbow flexion), flex and extend the wrists, and make a fist. A gross screen of the lower extremities can include having the patient bring one knee at a time up to the chest and then return it to the surface of the bed (i.e., hip flexion and extension, knee flexion and extension). The patient can then bring the leg to the edge of the bed and back to midline (hip abduction and adduction). Finally, the patient can do dorsiflexion and plantarflexion of the ankle.

The ability to move through the full ROM gives the therapist a gross estimate of minimal strength capabilities as well.

If the patient is unable to move through the full available ROM, the therapist will then need to move the limb passively through the remaining range to determine if it is a strength deficit or loss of ROM. Further assessment of the magnitude of the ROM impairment can be examined both passively and actively via the use of a goniometer (e.g., after total knee arthroplasty). Table 5-1 outlines normal ROM values.

TABLE 5-1

Normal Range-of-Motion Values *

^*Values are from the American Academy of Orthopedic Surgeons (AAOS) as reported in Appendix B of Reese NB, Bandy WD: Joint range of motion and muscle length testing, ed 2, St Louis, 2010, Saunders.

^†As the AAOS does not report a value for external rotation of the shoulder, the value is from the American Medical Association (AMA) as reported in Appendix B of Reese NB, Bandy WD: Joint range of motion and muscle length testing, ed 2, St Louis, 2010, Saunders.

If the patient is able to move through the full available ROM, the therapist should provide some manual resistance to the major muscle groups to determine if there are any strength deficits that would affect the patient’s ability to successfully perform functional mobility activities and ADLs. If there are no contraindications, the therapist can do formal manual muscle testing (MMT).

If manual muscle testing is not possible secondary to conditions such as altered mental status and pain or if putting force across a fracture or surgical site is required when providing resistance, then strength should be described in functional terms such as how much movement occurred within the available ROM (e.g., active hip flexion is one-third range in supine) or during the performance of a functional activity (e.g., heel slide, ability to lift leg off and/or onto the bed).

Posture.

The patient’s resting posture should be observed in supine, sitting, and standing positions. An inspection of the head, trunk, and extremities for alignment, symmetry, and deformity is warranted.

Clinical Tip

A leg length discrepancy that could affect standing posture and gait may be present after some surgical procedures (e.g., total hip arthroplasty [THA]).

Functional Mobility and Balance.

Functional mobility, including bed mobility, transfers, and ambulation on level surfaces and stairs, should be evaluated according to activity level, medical-surgical stability, and prior functional level. Safety is a key component of function. The patient’s willingness to follow precautions with consistency, as well as his or her ability to maintain weight bearing and comply with proper equipment use, must be evaluated. The patient’s self-awareness of risk for falls, speed of movement, onset of fatigue, and body mechanics should be monitored.

Clinical Tip

Safety awareness, or lack thereof, can be difficult to document. The physical therapist should try to describe a patient’s level of safety awareness as objectively as possible (e.g., patient leaned on rolling tray table, unaware that it could move).

The therapist should be prepared for the patient to experience symptoms associated with decreased mobility and pain medications: the patient may complain of dizziness, nausea, and lightheadedness. Patients should be taught to slowly transition from sitting to standing activities, and standing to ambulatory activities. Orthostatic hypotension and syncope may be avoided by waiting several minutes after each transition and encouraging the patient to perform ankle pumps and two or three deep breaths.

Nearly all patients will fear or be anxious about moving out of bed for the first time, especially if a fall or traumatic event led to the hospital admission. Before mobilization, the physical therapist should use strategies such as clearly explaining what will be occurring and the sensations the patient may feel (e.g., “Your foot will throb a little when you lower it to the floor”) to decrease the patient’s apprehension.

The therapist should also consider the patient’s aerobic capacity. The physical therapist needs to determine if the patient is only ambulating a certain distance because of pain, weakness, or fatigue. The patient’s cardiopulmonary response to the functional task must be assessed through the taking of vital signs at rest, during, and immediately at the completion of the activity.

Because orthopedic injuries can often be the final result of other medical problems (e.g., balance disorders or visual or sensory impairments), it is important that the physical therapist take a thorough history, perform a physical examination, and critically observe the patient’s functional mobility. Medical problems may be subtle in presentation but may dramatically influence the patient’s capabilities, especially with new variables, such as pain or the presence of a cast. Collectively, these factors lead to a decreased functional level.

Clinical Tip

It may be the physical therapist who first appreciates an additional fracture, neurologic deficit, or pertinent piece of medical or social history. Any and all abnormal findings should be reported to the nurse or physician.

Evaluation and Prognosis

On completion of the examination, the physical therapist must evaluate the data and use his or her clinical judgment to identify possible problems that require the skilled interventions provided by physical therapists and/or referral to other health care professionals. The therapist then determines the patient’s impairments and activity limitations, which will be the focus of the patient-related instruction and direct interventions.

Most patients with musculoskeletal impairments in the acute care setting do well and return to living at home. Medical complications or an inability to manage pain or achieve independent living in an environment of no social support may increase the length of hospital admission or lead to a transfer to another facility for continued nursing care or rehabilitation.

Interventions

Physical therapy interventions are provided either once or twice a day in the acute care setting and should be individualized to each patient according to the patient’s goals and clinical presentation. General physical therapy goals for the patient with musculoskeletal impairments include:

• Decrease pain and/or muscle guarding

• Prevent circulatory and pulmonary complications

• Prevent ROM and strength deficits

• Improve functional mobility while protecting the involved structures

When providing interventions to the patient, the physical therapist must take into consideration the medical and/or surgical management of the musculoskeletal impairment, physician orders, and need for equipment use during mobilization activities. The patient’s medical status, social support system, and ability to abide by all safety precautions will help guide the therapist in his or her decision making about prioritizing interventions.

Decrease Pain and/or Muscle Guarding

The physical therapist may choose to use relaxation and active assisted ROM exercises within the patient’s tolerance to decrease the patient’s experience of pain and muscle guarding. Cold, heat, and transcutaneous electrical nerve stimulation (TENS) are also options available in the acute care setting.

Prevent Circulatory and Pulmonary Complications

If edema is present, the limb can be elevated on pillows while the patient is resting. Active muscle-pumping exercises such as ankle pumps should be provided to all patients who have decreased mobility in order to minimize the potential for the development of a deep venous thromboembolism. The therapist should encourage the patient to take two or three deep breaths several times a day, especially on upright sitting, to minimize the development of pulmonary complications and discourage shallow breathing that can occur when a patient becomes anxious. Ultimately, having the patient perform functional activities, especially ambulatory tasks, will combat circulatory stasis and pulmonary impairments.

Prevent Range of Motion and Strength Deficits

The physical therapist should consider the use of isometrics to minimize muscle atrophy around an immobilized joint. Active ROM exercises can be used to maintain range of mobile joints. If strength deficits are present or loss of strength is expected and there are no contraindications to increasing the tension/force production of the muscle, initiating a strengthening program through progressive resistance exercises or the performance of functional activities is warranted.

Improve Functional Mobility While Protecting the Involved Structures

While ensuring that the patient has donned all prescribed equipment (e.g., braces, orthotics), the physical therapist must train the patient to perform all functional activities in a manner that maximizes the patient’s capabilities and ensures that the patient abides by all precautions (e.g., weight-bearing status). If the injury is to the pelvis or lower extremity, use of an assistive device will be required to maintain any limited weight-bearing status. Gait training must be provided to minimize any inefficient gait deviations. Balance training during static and dynamic activities must occur to ensure that in different positions the patient is still able to abide by all precautions. The patient must be educated on proper and safe positioning and limb movements during the performance of functional activities.

Health Conditions

Traumatic Fracture

Traumatic Fracture Classification

The analysis and classification of fractures reveal the amount of energy imparted to bone, the extent of soft-tissue injury, and optimal fracture management. Traumatic fractures can be classified according to well-recognized classification systems such as the one established by the Orthopedic Trauma Association (OTA).⁸ They can also be described according to the following^9,10:

1. The maintenance of skin integrity:

a. A closed fracture is a fracture without disruption of the skin.

b. An open fracture is a fracture with an open laceration of the skin or protrusion of the bone through the skin.

2. The site of the fracture:

a. An articular fracture involves a joint.

b. An epiphyseal fracture involves the growth plate.

c. A diaphyseal fracture involves the shaft of a long bone.

3. The classification of the fracture:

a. A linear fracture lies parallel to the long axis of the bone.

b. An oblique fracture lies on a diagonal to the long axis of the bone.

c. A spiral fracture encircles the bone.

d. A transverse fracture lies horizontal to the long axis of the bone.

e. A comminuted fracture has two or more fragments; a butterfly (wedge-shaped) fragment may or may not be present.

f. A segmental fracture has two or more fracture lines at different levels of the bone.

g. A compression fracture occurs when the bone is crushed; it is common in the vertebrae.

4. The extent of the fracture:

a. An incomplete fracture has only one portion of the cortex interrupted, and the bone is still in one piece.

b. A complete fracture has all cortices of bone interrupted, and the bone is no longer in one piece.

5. The relative position of the fragments:

a. A nondisplaced fracture is characterized by anatomic alignment of fracture fragments.

b. A displaced fracture is characterized by abnormal anatomic alignment of fracture fragments.

Clinical Goal of Fracture Management

The goal of fracture management is bony union of the fracture without further bone or soft-tissue damage that enables early restoration of maximal function.¹¹ Early restoration of function minimizes cardiopulmonary compromise, muscle atrophy, and the loss of functional ROM. It also minimizes impairments associated with limited skeletal weight bearing (e.g., osteoporosis).

Fractures are managed either nonoperatively or operatively on an elective, urgent, or emergent basis depending on the location and type of fracture, presence of secondary injuries, and hemodynamic stability. Elective or nonurgent management (days to weeks) applies to stable fractures with an intact neurovascular system or fracture previously managed with conservative measures that have failed. Urgent management (24 to 72 hours) applies to closed, unstable fractures, dislocations, or long bone stabilization with an intact neurovascular system. Emergent management applies to open fractures, fractures/dislocations with an impaired neurovascular system or compartment syndrome, and spinal injuries with increasing neurologic deficits.¹¹

Fracture reduction is the process of aligning and approximating fracture fragments. Reduction may be achieved by either closed or open methods. Closed reduction is noninvasive and is achieved by manual manipulation or traction. Open reduction with internal fixation (ORIF) techniques require surgery and fixation devices commonly referred to as hardware. ORIF is the treatment of choice when closed methods cannot maintain adequate fixation throughout the healing phase. In order to decrease the extent of soft-tissue disruption that occurs when direct reduction is required, minimally invasive surgical techniques for fracture fixation have been developed. In minimal access surgery or minimally invasive surgery (MIS), the surgeon uses the least invasive access portal and mainly indirect reduction techniques to fixate the fracture.¹²

Immobilization of the fracture is required to maintain reduction and viability of the fracture site. Immobilization is accomplished through noninvasive (casts or splints) or invasive (screws, plates, rods, pins, and external fixators) techniques (Figure 5-1). Regardless of the method of immobilization, the goal is to promote bone healing.

FIGURE 5-1 Fracture fixation methods. A, Compression plate and screws; B, external fixator devices; C, screws, pins, or wires. D, Rods/nails; E, short or long cast of plaster or fiberglass; brace. ORIF, Open reduction with internal fixation. (From Cameron MH, Monroe LG: Physical rehabilitation, St Louis, 2007, Saunders.)

Fracture healing is complex and proceeds through two different processes. Primary cortical or direct healing occurs when bone fragments are anatomically aligned via rigid internal fixation, encounter minimal strain, and are stable.¹³ More commonly, fracture healing occurs through endochondral or secondary bone healing (Figure 5-2).¹⁴ The first stage (inflammatory stage) of this process involves the formation of a hematoma with a subsequent inflammatory response. The reparative phase follows and includes the influx of fibroblasts, chondroblasts, and osteoblasts that results in formation of a soft calcified cartilage callus. The remodeling phase begins with the transition of the soft callus to a permanent hard callus consisting of lamellar bone. In children, the healing of bone can take less than 2 months, whereas in adults it typically takes 2 or more months.¹⁵ Box 5-1 lists the multitude of factors that contribute to fracture healing.

Box 5-1

Factors Contributing to Bone Healing

Data from Wood GW II: General principles of fracture treatment. In Canale ST, Beaty JH, editors: Campbell’s operative orthopaedics, vol 3, ed 11, Philadelphia, 2008, Mosby, pp 3040-3041; Buckwalter JA et al: Bone and joint healing. In Bucholz RW et al, editors: Rockwood and Green’s fractures in adults, vol 1, ed 7, Philadelphia, 2010, Lippincott Williams & Wilkins, pp 90-97.

FIGURE 5-2 Fracture healing occurs in four stages. A, Hematoma; B, granulation tissue; C, bony callus; D, remodeling. (From Damjanov I: Pathology for the health professions, ed 4, St Louis, 2011, Saunders.)

Complications of Fracture

Complications of fracture may be immediate (within days), delayed (weeks to months), or late (months to years). The immediate or early medical-surgical complications of special interest in the acute care setting include ¹⁶:

• Loss of fixation or reduction

• Deep vein thrombosis, pulmonary or fat emboli

• Nerve damage, such as paresthesia or paralysis

• Arterial damage, such as blood vessel laceration

• Compartment syndrome

• Infection

• Orthostatic hypotension

Delayed and late complications are as follows ¹⁶:

• Loss of fixation or reduction

• Delayed union (fracture fails to unite in a normal time frame in the presence of unfavorable healing factors)

• Nonunion (failure of fracture to unite)

• Malunion (fracture healed with an angular or rotary deformity)

• Pseudarthrosis (formation of a false joint at the fracture site)

• Posttraumatic arthritis

• Osteomyelitis

• Avascular necrosis

• Complex regional pain syndrome

Fracture Management According to Body Region

Pelvis and Lower Extremity

Pelvic Fractures.

The pelvis is formed by the paired innominate bones, sacrum, sacroiliac joints, and the symphysis pubis. Stability of the pelvis is provided by the posterior sacroiliac ligamentous complex.¹⁷ Pelvic fractures are classified, according to the Orthopedic Trauma Association (OTA) classification system, based on the mechanism of injury and the resultant stability of the pelvic ring (Figure 5-3).

FIGURE 5-3 Classification of pelvic fractures. Type A, Lesions sparing (or with no displacement of) the posterior pelvic arch. Type B, Incomplete disruption of the posterior arch (partially stable). Type C, Complete disruption of the posterior arch (unstable). (Courtesy of the Orthopedic Trauma Association.)

Stable pelvic fractures (Type A injuries), due to low-impact direct blows or falls, do not disrupt the integrity of the pelvic ring.⁸ Stable pelvic fractures include avulsion and localized nondisplaced iliac wing, pubic rami, or sacral fractures. When a pelvic fracture is described as stable, it is typically treated nonsurgically. Mobilization of the patient can occur in 1 to 2 days after a brief period of bed rest.^18,19 Ambulation with an assistive device that allows for limited weight bearing on the affected side is often prescribed.

Disruption of the pelvic ring is commonly the result of high-energy injuries that result in concurrent damage to the urinary, reproductive, and bowel systems as well as soft tissues, blood vessels, and nerves.¹⁹ When two or more components of the pelvic ring are injured, leading to rotational instability, but the pelvis remains stable vertically because the posterior osteoligamentous complex has been only partially disrupted, the pelvic fracture is considered to be partially stable (Type B).^8,17

If the posterior osteoligamentous complex is completely disrupted, the pelvis becomes unstable both vertically and rotationally (Type C).8,17 Type B and C injuries are treated with external fixation or internal fixation using plates and screws.¹⁸ Based on the stability of the fracture and type of fixation, the physician will determine the patient’s weight-bearing status, which could range from non–weight bearing (NWB) to weight bearing as tolerated (WBAT) on either one or both extremities. Functional mobility training, with the use of an assistive device, and active and active assisted ROM exercises for both lower extremities are encouraged as soon as the patient is physiologically stable.¹⁸

Acetabulum Fractures.

Acetabulum fractures occur when a high-impact blunt force is transmitted through the femoral head into the acetabulum. Depending on the direction of the force, different components of the acetabulum may be injured (Figure 5-4). If the hip is flexed and a force is transmitted through the femur posteriorly, as commonly occurs in a motor vehicle accident, the posterior wall will fracture.²⁰ An acetabulum fracture is a complex injury and is associated with retroperitoneal hematomas, injury to the lungs, shock, dislocation or fracture of the femoral head, and sciatic nerve palsy.^20,21 Acetabulum fractures are by nature intra-articular; hence, medical management focuses on the restoration of a functional and pain-free weight-bearing joint.²² Closed reduction via skeletal traction with bed rest for the initial 6 to 8 weeks may be used if the patient is unable to undergo surgery.²² Surgical management includes percutaneous pinning, open reduction with internal fixation, and hip arthroplasty.

FIGURE 5-4 The innominate bone and the acetabulum are divided into anterior and posterior columns to reference the location of the trauma. Classification of acetabular fractures: A, anterior column; B, posterior column; C, transverse, involving both columns; D, complex or T-shaped, involving both columns. (From McKinnis LM: Fundamentals of musculoskeletal imaging, Philadelphia, 2010, FA Davis, p 348.)

On stabilization of the fracture, functional mobility activities should be initiated. Gait training with the appropriate assistive is required because the patient will have limited weight bearing, typically touchdown weight bearing (TDWB) or partial weight bearing (PWB), through the involved lower extremity. Active assisted exercises to the involved hip should be prescribed bearing in mind any hip precautions dictated by the physician (e.g., following THA).

Proximal Femur Fractures.

Fractures of the proximal femur include proximal trochanteric, neck, and head fractures.⁸ Collectively they are often referred to as hip fractures. They can be classified as intracapsular or extracapsular. In the older adult, a femoral neck fracture can occur with surprisingly little force owing to osteoporosis of the proximal femur. Femoral neck fractures in younger adults are almost always the result of high-impact forces, such as motor vehicle accidents.

Femoral head fractures are associated with a posterior hip dislocation and acetabular fracture, although the fracture can occur in the absence of either of these conditions.²³ Hip dislocations require urgent reduction because the vascular supply to the femoral head may be compromised.²³ Management of hip dislocation without fracture includes closed reduction under conscious sedation and muscle relaxation followed by traction or open reduction if closed reduction fails. Rehabilitation includes functional mobility activities with weight-bearing limitations, exercise, and positioning per physician order based on hip joint stability and associated neurovascular injury. Hip dislocation with fracture warrants surgical repair.

Clinical Tip

After posterior hip dislocation, precautions typically include limiting hip flexion to 90 degrees, internal rotation to 0 degrees, and adduction to 0 degrees. For a confused or noncompliant patient who sustained a posterior hip dislocation, indirect restriction of hip movement during rest or functional activity can be achieved with the use of a knee immobilizer or hip abduction brace.

Intracapsular fractures are located within the hip joint capsule and include the femoral head, subcapital, and femoral neck regions. The four-stage Garden scale (Figure 5-5) is used to classify femoral neck fractures and is based on the amount of displacement and the degree of angulation.

FIGURE 5-5 The Garden classification of femoral neck fractures. Grade I is an incomplete, impacted fracture in valgus malalignment (generally stable). Grade II is a nondisplaced fracture. Grade III is an incompletely displaced fracture in varus malalignment. Grade IV is a completely displaced fracture with no engagement of the two fragments. The compression trabeculae in the femoral head line up with the trabeculae on the acetabular side. Displacement is generally more evident on the lateral view in grade IV. For prognostic purposes, these groupings can be lumped into nondisplaced/impacted (grades I and II) and displaced (grades III and IV) because the risk of nonunion and aseptic necrosis is similar within these grouped stages. (From Browner BD, Jupiter JB, Levine AM et al: Skeletal trauma: basic science, management, and reconstruction, ed 4, Philadelphia, 2009, Saunders.)

• Garden stage I fractures are impacted and incomplete.

• Garden stage II fractures are complete and nondisplaced.

• Garden stage III fractures are complete and partially displaced.

• Garden stage IV fractures are completely displaced.

Femoral neck fractures require reduction and internal fixation, often through the use of cannulated screws.23,24 In the older adult who has a displaced femoral neck fracture, some surgeons may elect to use a prosthetic replacement of the femoral head (hemiarthroplasty) in order to minimize the development of osteonecrosis or nonunion.^23,24

Extracapsular fractures occur outside of the hip joint capsule. They can be further classified as intertrochanteric or subtrochanteric. Intertrochanteric fractures occur between the greater and lesser trochanters. Subtrochanteric fractures occur below the lesser trochanter and end at a point 5 cm distally.²⁵ Intertrochanteric and subtrochanteric fractures are shown in Figure 5-6. Extracapsular fractures are typically stabilized via open reduction and internal fixation through the use of a sliding hip screw or intramedullary nail.²⁶ Mobility and gait training focuses on ensuring protected weight bearing. Active or assisted hip ROM and strengthening exercises should be initiated to foster an early restoration of function.

FIGURE 5-6 Fractures of the proximal femur: Neck (a); intertrochanteric (b); subtrochanteric (c). (From Pfenninger JL, Fowler GC, editors: Procedures for primary care, ed 3, Philadelphia, 2011, Mosby.)

Femoral Shaft Fractures.

Fractures of the femoral shaft typically result from high-energy trauma and are associated with concurrent injuries to the pelvis and ipsilateral lower extremity.²⁷ Femoral shaft fractures can be accompanied by life-threatening systemic complications, such as hypovolemia, shock, or fat emboli. There also can be significant bleeding into the thigh with hematoma formation. Femoral shaft fractures can be classified based on their location (e.g., proximal, middle, and distal third) and through descriptive terms (Figure 5-7). In the presence of contamination or hemodynamic instability, external fixation or skeletal traction may be applied temporarily.²⁸ For most surgeons, the treatment of choice is the use of an intramedullary nail.²⁷ After intramedullary nailing, the patient should avoid rotation of and pivoting on the lower extremity, because microrotation of the intramedullary rod can occur and place stress on the fixation device. Initially, weight bearing is limited to touchdown weight bearing. Active and assisted ROM of the hip, quadriceps setting, straight-leg raises, and hip abduction exercises should be initiated.

FIGURE 5-7 Femur fracture patterns. A, Transverse. B, Oblique. C, Spiral. D, Butterfly fragment (arrow). E, Comminuted. F, Segmental. (From Townsend CM, Beauchamp D, Evers M, Mattox KL: Sabiston textbook of surgery, ed 19, Philadelphia, 2012, Saunders.)

Clinical Tip

The uninvolved leg or a single crutch can be used to assist the involved lower leg in and out of bed.

Distal Femur Fractures.

Fractures of the distal femur are classified by the OTA classification system as extra-articular (type A), partial articular (type B), or complete articular (type C).⁸ Involvement of the articular surface of the knee joint complicates the fracture. Typically, this type of fracture is caused by high-energy impact to the femur, especially in younger patients, or a direct force that drives the tibia cranially into the intercondylar fossa. Distal femur fractures may be accompanied by injury to localized skin, muscle, and joint ligaments and cartilage with the potential for decreased knee joint mechanics.²⁹

Postoperative rehabilitation will depend on the severity of the fracture and surgical techniques used for reduction and fixation. Early mobility and gentle active assisted knee ROM exercises are encouraged for the majority of these patients. Depending on the type of surgery, the physician will dictate weight-bearing limitations—typically NWB, TDWB, or PWB—and the need for any bracing (e.g., knee immobilizer or locked hinged brace).

Patella Fractures.

A patella fracture results from direct trauma to the patella from a fall, blow, or motor vehicle accident (e.g., dashboard injury) or indirect mechanisms from a forceful contraction of the quadriceps with the knee flexed.³⁰ Injury to the patella may lead to alterations in the articular surface of the patellofemoral joint and abnormal extensor mechanism mechanics. Late complications include patellofemoral or hardware pain, osteoarthritis, decreased terminal extension, quadriceps weakness, or adhesions.³⁰ Nonsurgical management through immobilizing the knee in extension via a cast or brace may be chosen for nondisplaced fractures or patients with significant medical cormorbidities.³¹ Surgical treatment includes reduction and internal fixation, with a partial or total patellectomy reserved for highly comminuted fractures. Postoperatively, the knee is immobilized, and quadriceps setting exercises are initiated. Strong, forceful quadriceps contractions and straight-leg raises should be avoided. Protected weight bearing should ensue, abiding by the weight-bearing limitations prescribed by the physician.

Tibial Plateau Fractures.

Tibial plateau fractures typically result from direct force on the proximal tibia (e.g., when a pedestrian is hit by an automobile) and are considered extra-articular, partial articular, or complete articular.⁸ The Schatzker classification system is commonly used with displaced fractures (Figure 5-8). This high-force injury often presents with open wounds and soft-tissue injuries, including capsular, ligamentous, and meniscal disruption. Immediate or early complications of tibial plateau fractures include popliteal or peroneal nerve compression, compartment syndrome, infection, and DVT.²⁷ Late complications include abnormal patellofemoral mechanics, lack of ROM or stability, and posttraumatic arthritis of the articular surface. Surgical management via internal or external fixation is used for fractures that are unstable or associated with ligamentous and articular disruption.²⁷ The complexity of the tibial plateau fracture will dictate the precautions for movement and mobility after surgery. In most situations, no weight bearing will be allowed during the initial healing phases, and gentle active or active assisted knee ROM exercises may be delayed for several days postoperatively.