Motor control is necessary before any active exercises can begin or progress. Sometimes electrical stimulation is needed to activate muscles that demonstrate atrophy, muscle inhibition or painful muscle guarding (Hopkins & Ingersoll, 2000). Coordination is crucial to motor control. It involves smooth and accurate movement of the joints in the kinetic chain. The timing and sequencing of movements of ipsilateral and contralateral joints requires neural control and musculoskeletal integrity. For example, a humeral fracture that disrupts the coordinated movement of the involved arm also reduces the contralateral arm swing during normal reciprocal gait. Proper breathing, decreased muscular guarding and reduced abnormal flexor and adductor tone in either the upper or lower extremities facilitates improved muscle activity and coordination.

When some degree of comfortable motion and muscle control are attained, strengthening can be started. Increased strength often results in increased motion. It has been shown that age is no barrier to regaining or even increasing strength. (See Chapter 61, Contractures and Stiffness.)

An effective method of strengthening is progressive resistive exercise (PRE). Initial efforts with strengthening may begin with isometric training. Isometric strength training may provide increased joint stability, promoting improved joint motion, as ROM increases. As the patient’s strength increases, the therapist may elect to progress strengthening through techniques that exercise each muscle group with enough resistance to allow 20–30 repetitions. It is recommended that the therapist break the patient’s sets/reps into more manageable bouts of exercise to prevent fatigue that often can lead to poor performance or injury. Once 30 repetitions can be achieved, the resistance is increased and the progression of repetitions from 20 to 30 is repeated. Another method involves the patient completing three sets of 10–15 repetitions, decreasing the resistance with each set, or three sets using the same resistance but decreasing the number of repetitions (from 20 to 15 to 10).

Fractures of the proximal humerus are the third most commonly encountered fractures in the geriatric population, with only hip and distal radius fractures seen occurring more often. The frequent occurrence of this fracture in the elderly population certainly suggests an association with osteoporosis and impaired balance. A fall onto an outstretched hand (FOOSH) is the most common mechanism of injury for these fractures. Fortunately approximately 85% of these fractures are either nondisplaced or minimally displaced (Flynn, 2011). These fractures can be treated by sling and swathe immobilization for 10–14 days followed by gentle ROM exercises. Elbow flexion and extension as well as forearm pronation and supination can be started during this period of immobilization. Prior to initiating the exercise program for the shoulder, clinical continuity (the fracture moves as a single unit) must be present.

If there is stability at the fracture site, passive and active assisted ROM is started early. This consists of pendulum exercises and supine external glenohumeral rotation with a stick. About 3–4 weeks after the fracture has occurred, active-assisted forward elevation, pulley exercise, extension and isometrics can be added (Withrow et al., 2010). After this first phase has been complete, active and early resistive exercises become important. Therabands are often used to strengthen the shoulder rotators and deltoid muscle. A program that emphasizes further stretching and strengthening is appropriate 3 months after fracture.

It is important in the early stages of fracture healing for the patient to avoid using the affected arm when getting into and out of bed or a chair. Such actions can displace the fracture even when there has been stable internal fixation. Displacement is more likely to occur in the patient with multiple injuries or limited cognitive capabilities. Throughout the entire rehabilitation program, the therapist should be working with and assessing functional mobility of the cervical spine, scapula, elbow, wrist and hand. Most patients with fractures of the proximal humerus do obtain satisfactory results; however, it must be understood that usually there is some resultant loss of motion and strength. Complications include malunion, delayed union, nonunion, loss of motion, stiffness and post-traumatic arthritis.

Open treatment may prove to be necessary when a displaced fracture cannot be reduced. Treatment options consist of either a closed reduction with percutaneous pinning, an open reduction with internal fixation using a precontoured locking plate or hemi-arthroplasty when the articular surface is non-reconstructable.

The results of open reduction with internal fixation for proximal humerus fractures demonstrate good surgical outcomes when correct surgical technique is employed. Brunner et al. (2009) reported that the most common postoperative complication was screw perforation into the glenohumeral joint. Primary hemiarthroplasty is usually successful in eliminating pain; however, in many instances only moderate function and poor strength levels were achieved. It is felt that the reduction in function is due to lack of rotator cuff integrity (Gronhagen et al., 2007).

Distal radial fractures account for approximately 20% of all fractures and therefore are the most common fractures seen in the upper extremity. Such fractures usually occur following a FOOSH and are seen quite often in the geriatric population, particularly women with osteoporosis (Flynn, 2011). A Colles’ fracture involves the distal radial metaphysis and demonstrates dorsal angulation and displacement. Often there may be comminution and intraarticular extension of the fracture. A Smith’s fracture demonstrates volar angulation of the distal radius with resultant instability.

Treatment options for these fractures include simple cast immobilization, closed reduction with cast application, closed reduction with external fixation and open reduction with internal fixation. The trend today is toward open reduction and internal fixation using a volar fixed-angled locking plate for displaced intraarticular fractures. The usual indications are radial shortening of more than 3 mm, dorsal tilt greater than 10° or intraarticular displacement of more than 2 mm (American Academy of Orthopedic Surgeons, 2011). The possible complications that may result from this particular type of fracture include delayed union, nonunion, malunion, median nerve compression, tendon damage, post-traumatic arthritis and loss of motion.

Restoration of motion and strength, which leads to improved function, is of vital importance in the rehabilitation of these fractures. Early rehabilitation includes management of pain and edema, digital ROM and care of the surgical site (Smith et al., 2004). After appropriate consultation with the attending physician, ROM and strengthening exercises for areas of the upper extremities that are not immobilized should be initiated immediately, if possible, to prevent residual stiffness in the shoulder, elbow and hand. Once immobilization is no longer necessary, active-assisted and active exercises are encouraged in all six directions – flexion, extension, radial and ulnar deviation, pronation and supination. Modalities such as hydrotherapy, electrical stimulation, heat, cold, or ultrasound may be helpful. Depending on the status of fracture healing and the amount of stiffness, the therapist may incorporate specific mobilization techniques to increase the ROM. The initiation of muscle control and coordination may be difficult when motion is painful. In addition to addressing the inflammatory process, which causes pain and swelling, the therapist should attend to head, neck and trunk posture, which may contribute to the patient’s discomfort and limitation of movement. As ROM in the wrist increases, strengthening exercises using motion against resistance should be included in the treatment plan. The final goal should be to restore ROM and strength of the injured wrist to preinjury levels. Unfortunately this is not always possible and some degree of impairment may remain as a result of the fact that normal architecture could be restored secondary to the severity of the injury (Smith et al., 2004).

When rehabilitating a patient who has undergone an open reduction with internal fixation using a volar plate, attention must be directed accordingly to prevent a contracture of the pronator quadratus, which could cause a limitation of forearm rotation.

Stable intertrochanteric fractures are still best treated with a sliding screw (Flynn, 2011). The treatment of the unstable intertrochanteric fracture remains somewhat controversial but often requires the use of a cephalomedullary nail. The surgery should be performed within the first 48 hours if at all possible. The success of the surgical procedure largely depends upon: (1) bone quality, (2) fracture pattern, (3) accuracy of the reduction and (4) the adequacy of internal fixation.

The major goal of rehabilitation after an intertrochanteric fracture is to enable the patient to walk, especially if they were ambulatory prior to the injury. Mobilization of the patient should be initiated almost immediately after completion of the surgical procedure. ROM exercises are encouraged as soon as the initial pain subsides and the patient can safely cooperate with the physical therapist. ROM in all directions is advised, to prevent flexion and adduction contractures that can make ambulation more difficult. Getting the patient to a level where they can control the involved limb is essential to permit adequate mobility in bed, preventing and/or lessening the occurrence of pressure ulcers, to allow for independent transfers into and out of bed and to promote the initiation of weight-bearing and restoration of gait (Kagaya & Shimada, 2007). Balance and coordination instructions are given concurrently with all phases of rehabilitation.

Usually the patient should get out of bed and transfer to a chair on the day following surgery. With intertrochanteric fractures, partial weight-bearing may often be necessary. The weight-bearing status is determined by the accuracy and stability of the reduction achieved at the time of surgery, bone quality, premorbid status and mental alertness. The patient who is not strong enough to manage partial weight-bearing or not coherent enough to understand the therapist’s instructions may be limited to a wheelchair and/or pre-gait activities, such as sit to stand and static stance with weight shift until they are stronger or until the fracture has healed sufficiently to permit full weight-bearing. Early assisted swing (slide) phase of gait of the involved leg may be helpful in facilitating proper weight-bearing and restoration of functional gait in the future. This is achieved with the patient standing in parallel bars or with a walker, and simply sliding the foot of the involved leg forward and backward or lifting the involved leg over a lower obstacle (cane, cup or cone) that is placed on the floor in front of the patient.

Strengthening the hip abductors gradually reduces the Trendelenburg gait pattern commonly seen following a hip fracture. PREs are used, starting with abduction while standing or the use of a sliding board while supine. As strength increases, the patient is instructed to perform the exercises while lying on the contralateral side, thus abducting against gravity. Coexisting musculoskeletal and cardiovascular conditions may necessitate modification of these positions. Once 20–30 repetitions can be performed, progressive resistance is added. Strengthening the hip flexors, extensors, rotators and adductors is also important to insure restoration of muscle strength, flexibility and endurance to allow progression of gait.

After the fracture heals and rehabilitation is complete, occasional decreased mobility may be the end result. Patient adaptation may involve having to accept the permanent use of a cane or walker to aid in balance, reduce Trendelenburg characteristics associated with weak abductors seen in gait, and to increase patient confidence, safety and mobility. The patient with an intertrochanteric fracture should be expected to transfer and ambulate independently before being discharged home. If this is not possible, placement in an assisted living facility or a nursing home may be necessary.

Femoral neck fractures occur most commonly in the eighth decade of life as a result of bone that is weakened by either osteoporosis or osteomalacia. The most common mechanisms of injury are either a fall that causes a direct blow to the greater trochanter or forced lateral rotation of the lower extremity (Bucholz et al., 2009). If the fracture is displaced, often the arterial supply to the proximal end of the femur is disrupted, thus creating an environment favorable to the development of either a nonunion or avascular necrosis.

Elderly patients with nondisplaced or valgus impacted fractures can be treated with percutaneous pin fixation using cannulated screws (Flynn, 2011). The displaced fracture is best treated with hemiarthroplasty using a cemented stem. Today a trend is developing that suggests perhaps total hip arthroplasty is favorable over simple hemiarthroplasty for the highly functional elderly patient (Flynn, 2011).

The same principles that govern motor control, coordination, strengthening and adaptation in fractures of the proximal femur apply to fractures of the distal femur. In addition, attention to distal lower extremity pain, weakness and decreased ROM will be required. The therapist should be aware of and proactive in the management of any patient having weight-bearing restrictions and decreased mobility issues as a result of lower extremity fracture and surgery with regard to an increased incidence of DVT or pulmonary emboli (PE). While Homan’s Sign is but one tool that the therapist has at their disposal to assess for DVT, they need to be aware that the test has a low sensitivity (<50%) and be familiar with other methods of patient assessment and monitoring (Riddle & Wells, 2004).

Fractures of the tibial plateau (Fig. 25.1) involve the proximal tibial articular surface. Fracture patterns vary greatly. Sometimes associated soft tissue damage may be quite significant. In the elderly, often a low energy mechanism of injury produces such a fracture. The goals of treatment should be the attainment of an accurate reduction and if at all possible the institution of early ROM exercises. Delayed weight-bearing often is necessary to prevent the fracture site from collapsing.