Hospital Practice

ISSN: 2154-8331 (Print) 2377-1003 (Online) Journal homepage: http://www.tandfonline.com/loi/ihop20

Rehabilitation of the Fracture Patient Jeffrey D. Reuben To cite this article: Jeffrey D. Reuben (1991) Rehabilitation of the Fracture Patient, Hospital Practice, 26:sup1, 46-48, DOI: 10.1080/21548331.1991.11704270 To link to this article: http://dx.doi.org/10.1080/21548331.1991.11704270

Published online: 17 May 2016.

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Date: 03 July 2016, At: 07:48

Rehabilitation of the Fracture Patient

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J EFFR EY D. R EU BEN

The University of Texas Health Science Center at Houston

With any type of fracture, it is important that rehabilitation begin when the fracture is stable, whether the stability occurred naturally or is achieved by internal fixation.

Dr. Reuben is Assistant Professor and Director, Biomechanics Laboratory, Division of Orthopaedic Surgery, Department of Surgery, the University of Texas Medical School at Houston.

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Rehabilitation is one of the most crucial aspects of orthopaedic care. A joint surgeon, for instance. can perfectly align a total-joint prosthesis, but if the patient does not receive appropriate rehabilitation. the result will be less than adequate. On the other hand. if the surgeon inserts the joint in less than ideal alignment and the patient receives sufficient rehabilitation. the results can be better than average. In the same way. rehabilitation is equally critical in fracture healing. Simply put. rehabilitation is crucial because movement is life and life is movement. Rehabilitation helps the patient maintain or recover movement. thereby improving function and the quality of life. Consequently. rehabilitation focuses not on the fracture itself but on the articular joints affected by the fracture. because the joints permit movement. Of the several kinds of joints, most important for rehabilitation is the synovial joint (see Figure). This structure is lined with hyaline cartilage and has a capsule of synovial membrane that produces a joint fluid that nourishes the cartilage and serves immunologic and other functions. Second are the syndesmotic joints, which are fibrous or fibrocartilaginous and are represented by the intervertebral disk. The synostotic joints. such as the cranial sutures. are essentially motionless bony connections.

On average. the joints in the lower extremity are subjected to approximately l million loading cycles per year. Normal walking results in joint forces of three to four times body weight. Endurance for a lifetime under these remarkable stresses is possible because joints have a coefficient of friction approximately l 0 times less than any known natural or manmade surface. in fact. very close to that of ice sliding across ice. Most of the fractures related to osteoporosis are centered around joints. That is true of fractures of the proximal femur. proximal humerus. distal radius. and vertebrae, which have a variety of associated problems that management must take into account. Angulation of the fracture. one potential complication. affects the patient's overall function because it changes the biomechanical relationships of the muscles that cross the fracture site. Range of motion of adjacent joints will then be reduced. A second complication is nonunion. which in the lower extremity obviously affects a patient's ability to bear weight. Delayed union can result in stiffness of the muscles surrounding the joints and limited range of motion. Complications such as compartment syndrome and soft tissue scarring can also affect the muscles controlling the adjacent joint. Fracture management is based on three categories of fracture stability. The first com-

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prises stable fractures. A fracture in a bone that is subjected to relatively small loads, such as the proximal humerus, can be managed with conservative treatment. The arm is placed in a sling, and the patient begins a rehabilitation program as soon as the pain has subsided sufficiently. The second category consists of unstable fractures that heal rapidly. For example, muscle forces in the distal radius are such that there is a high likelihood of displacement. External support in the form of casting is therefore required. Once the fracture becomes stable, usually within four weeks, the cast can be removed and rehabilitation can begin. The third is unstable fractures that require prolonged healing. Because of excessive muscle forces acting across the joint. they can result in malunion and difficulties with joint motion. A prime example is proximal femur fractures, for which open reduction and internal fixation are the recommended treatment. With any type of fracture, it is important that rehabilitation begin when the fracture is stable, whether the stability occurs naturally or is achieved by internal fixation.

Goals of Rehabilitation The goals of rehabilitation are to maintain joint range of motion, preserve function, improve gait (in lower extremity fractures), increase strength, and decrease pain and swelling. The three main techniques used for maintaining range of motion are passive, active, and active-assisted exercises. Each successive technique places greater stress on the joint or fracture site; therefore, the phy-

Of the various kinds of joints most important for rehabilitation are the synovial joints, such as the hip and knee. These structures are lined with hyaline cartilage and the fluid that is contained by the synovial membrane not only nourishes the cartilage but serves immunologic functions. The syndesmotic joints, characterized by intervertebral disks, are fibrocartilaginous. Synostotic joints, such as cranial sutures, are motionless bony connections with perforating fibers.

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sician who prescribes rehabilitation should know how stable the fracture is and to what loads the bone can be subjected. Continuous passive range of motion can now be achieved with a geared, electrically powered device that slowly and continuously flexes and extends a joint. The devices are perhaps most widely used for early rehabilitation after total knee replacement. but different types are available for virtually all joints. Preservation of function can be achieved with a number of aids. For example, "grabbers" are extension devices that help patients who cannot achieve sufficient hip flexion to touch their feet. grasp a shoe. and put it on. Such devices are extremely beneficial: They help the patient achieve and retain early independence. The wide variety of ambulatory aids includes walkers, canes, and crutches. Therapists can instruct patients on the best methods of functioning after discharge and can make limitations. such as stair climbing. clear to the patients. Exercise bicycles and other exercise machines permit patients to maintain aerobic capability while confined to the house. Finally. splints and orthoses provide support for patients to carry out otherwise restricted activities. Improving the gait in patients with lower extremity fractures is accomplished on the basis of weight-bearing status. There are four classes of weight-bearing status: non-weight bearing, touch-down, partial, and full weight bearing. It is essential that the physician who prescribes physical therapy understand the patient's tolerance so that the right degree of weight bearing is permitted.

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Non-weight bearing obviously produces the least stress on the fracture site or adjacent joints. Even with non-weight bearing. however. there may be excessive forces generated by a patient's musculoskeletal system. Recent studies show that the forces involved in trying to get on a bedpan can be four to five times body weight. In addition, the force of gravity and the forces generated by the muscles across the joint can produce a highstress situation. If a patient's fracture is marginally stable. touch-down weight bearing is prescribed. That allows the patient to put the foot down to maintain balance. It is important for the physician to inform the therapist of the degree of partial weight bearing: one quarter, one third, or one half. Finally. the patient can advance to full weight bearing when healing is judged complete. The key is that mobilization of patients must depend on an assessment of the stability of the fracture and the extent of healing. Increasing strength is achieved by isometric, isotonic, resistive, progressive resistive. and isokinetic exercises. Isometric and isotonic exercises involve constant length or constant force. In resistive exercise, the patient acts against a weight applied to the limb. With progressive resistive exercise, the weight is increased over time. Isokinetic exercise employs constant angular momentum using devices such as a Cybex machine, which became popular for its reputed ability to increase muscle strength in the most efficient fashion. Electrical stimulation is used to increase muscle mass and overcome the inhibitive effects of surgery involving muscle. Most notably. after total knee

replacement, the quadriceps muscle tends to be inhibited because of the incision through the musculotendinous junction. In the elderly patient who does not achieve early return of quadriceps function. electrical stimulation can be very helpful in the prevention of muscle atrophy. A decrease in pain and swelling is one of the most important benefits rehabilitation can offer. It can be accomplished with a variety of modalities, starting with cold and hot packs. Ultrasound, although principally used for pain relief in tendinitis and bursitis, can deliver deep heat without risk of thermal injury to the skin. Patients can use portable units at home. In ultrasonic phonophoresis, a steroid cream is applied to the extremity. The ultrasonic wave pulses the steroid into the area of interest. Whirlpool therapy is quite useful for soft tissue injury. Various sizes of whirlpools are available, allowing total body immersion. Bedridden patients can be transferred directly to a gurney, which is lowered into the whirlpool. As a last resort. transcutaneous electrical nerve stimulation can be employed. In patients who do not respond to the usual techniques, TENS units can be extremely helpful, by reducing or eliminating the need for narcotic analgesics. D

Selected Reading Kottke FJ, Lehmann JF (Eds): Krusen's Handbook of Physical Medicine and Rehabilitation. 4th ed. WB Saunders. Philadelphia 1990 Rockwood CA Jr. Green DP (Eds): Fractures. JB Lippincott. Philadelphia 1984

Rehabilitation of the fracture patient.

With any type of fracture it is important that rehabilitation begin when the fracture is stable, whether the stability occurred naturally or is achiev...
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