Fractures: pathophysiology, treatment and nursing care

Many nurses working in the primary and secondary sectors will care for patients who have sustained fractures. The ability to assess these patients systemically in addition to the injury is important in detecting complications and enhancing bone healing at the various stages of injury or treatment. This article describes different types of fracture and principles for their management. The nursing care of patients who has sustained a fracture is discussed from admission to discharge.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Joint loading modality: its application to bone formation and fracture healing

Sports-related injuries such as impact and stress fractures often require a rehabilitation programme to stimulate bone formation and accelerate fracture healing. This review introduces a recently developed joint loading modality and evaluates its potential applications to bone formation and fracture healing in post-injury rehabilitation. Bone is a dynamic tissue whose structure is constantly altered in response to its mechanical environments. Indeed, many loading modalities can influence the bone remodelling process. The joint loading modality is, however, able to enhance anabolic responses and accelerate wound healing without inducing significant in situ strain at the site of bone formation or fracture healing. This review highlights the unique features of this loading modality and discusses its potential underlying mechanisms as well as possible clinical applications.

Rehabilitation after falls and fractures

Falls are one of the most common geriatric problems threatening the independence of older persons. Elderly patients tend to fall more often and have a greater tendency to fracture their bones. Fractures occur particularly in osteoporotic people due to increased bone fragility, resulting in considerable reduction of quality of life, morbidity, and mortality. This article provides information for the rehabilitation of osteoporotic fractures pertaining to the rehabilitation of the fractured patient, based on personal experience and literature. It also outlines a suggested effective and efficient clinical strategy approach for preventing falls in individual patients.

Development of virtual reality exercise of hand motion assist robot for rehabilitation therapy by patient self-motion control

This paper presents a virtual reality-enhanced hand rehabilitation support system with a symmetric master-slave motion assistant for independent rehabilitation therapies. Our aim is to provide fine motion exercise for a hand and fingers, which allows the impaired hand of a patient to be driven by his or her healthy hand on the opposite side. Since most disabilities caused by cerebral vascular accidents or bone fractures are hemiplegic, we adopted a symmetric master-slave motion assistant system in which the impaired hand is driven by the healthy hand on the opposite side. A VR environment displaying an effective exercise was created in consideration of system's characteristic. To verify the effectiveness of this system, a clinical test was executed by applying to six patients.

Biomechanical analysis of fracture healing in guinea-pigs

To validate the hypothesis that healing of fractures can be accelerated by oral administered L-arginine a guinea-pig model was chosen. A diaphyseal defect fracture was established in the right femur of each of the 32 small animals and stabilized. According to randomization groups the oral administration was realized (2 or 4 weeks medication / solvent). The following biomechanical variables were measured after 4 weeeks in 32 right femora and the corresponding uninjured left femora. The measurement for the healed femur was individually compared with that of the uninjured femur in each animal; bending, force (necessary for refracture) and energy (necessary for refracture). To apply the bending moment in a measurable and reproducible way each end of the femur was secured using a special device. For each femur a strain/momentum graph of the measurements and the essential parameters were drawn (stiffness, end of the linear range, and failure-point). The bending moment was always applied with the same loading rate. The following three variables were used for the biomechanical evaluation; bending stiffness, force until failure and energy necessary for refracture. The bending stiffness reached 73% by the control group and 88% by the 4-week treatment group. The force necessary for refracture was 52% in the control compared with 65% in the 4-week treatment group. The energy necessary for refracture was 36% in the control compared with 73% in the group treated for 4 weeks. The 2 week treatment group showed no statistical significant differences to the control, but the femora from the 4 week treatment group required statistically significant higher energy for refracture than the femora from the control.

Workplace accident-related finger-fracture at the Mexican Institute of Social Security. Resolution time, economic impact and sequelae

OBJECTIVE

To identify resolution time and economic impact of occupational finger fracture with permanent disability.

METHODS

A cross-sectional study was conducted in 2004; the main variables were age; sex; disability days and sequelae. The International Classification of Diseases (ICD 10) was used for the study. The analysis included frequency, exceeded disability days and estimation of cost of disabilities, pensions and direct costs. Chi square test was used to identify the differences.

RESULTS

13,410 Fractures occurred nationwide: multiple finger fractures (803); thumb fractures (1982) and other finger fractures (10,625). Days of resolution time were: 70.5 days for multiple finger fractures and 51.1 days for another finger fractures. Permanent disability partial rate of thumb fracture was 5.3/100, 15.8/100 multiple finger fractures and 5.9 fractures of other finger. The estimated cost by temporary disability in the Instituto Mexicano del Seguro Social was on $10,669,000 U.S., while permanent disability costs in cases of settlements and annual pension payments were $758,536 U.S.

CONCLUSIONS

Finger-fracture is a prevalent pathology whichever needs that medical procedures are review, also identify factors that decrease resolution time and establish improve actions that create boundaries on the workers damage health. It must be considered that this condition affects enterprise' productivity and decrease the quality of life from workers.

[Rehabilitation of elderly patients after fracture]

Hip fracture in the elderly is associated with increased mortality and disability. The rate of recovery of the pre-fracture functional or ambulatory level is less than 70%. Different intervention programs accelerate the recovery and decrease the mortality; these programs include early ambulation, recovery of the activities of daily living, muscle training and correction of malnutrition (protein supplements, vitamin D). Successful interventions concern patients able to walk with or without help before the fracture. Pre-fracture motor and not cognitive level is the most important predictive factor for motor recovery. The degree of involvement of the geriatric team and organization of the intervention play a major role in its efficacy.

Immediate unprotected weight-bearing of operatively treated ankle fractures

The objective of this study was to determine whether immediate mobilisation and unprotected weight-bearing of rigidly internally fixed fractured ankles had a significant effect on ankle function or whether it predisposed the ankle to loss of reduction or hardware failure. Twenty five patients with operated Weber A/B/C fractures were allowed immediate full weight-bearing without a plaster and were compared with matched historical controls treated in a non-weight-bearing plaster cast. Matched-pair analysis revealed no differences for hospital stay and functional outcome on Olerud and Molander scoring system but significant difference in time until return to work (mean: 91.3 +/- 20.2 vs. 54.6 +/- 15.5 days). In the cast group four patients had postoperative complications; one patient had loss of internal fixation and one had non-union while four patients in the non cast group had mainly wound-healing related problems. Patients in the non cast group tolerated earlier full weight-bearing compared with patients in the cast group, and there were no disadvantages concerning hospital stay, pain intensities, and functional scores. Treating patients without plaster may result in faster rehabilitation.

Crescent fracture-dislocation of the sacroiliac joint

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma.

Long-term outcome in patients with combined spinal and pelvic fractures

The outcome of 30 patients with combined spinal and pelvic fractures (C group) was retrospectively investigated and compared with matched group of similar number of isolated spinal fractures (S group) and isolated pelvic fractures (P Group), admitted to our institution between Jan 1998 and May 2002, following a high-energy trauma. After a mean follow-up of 57 months their outcomes were studied using EuroQol questionnaire and return to work status. The EQ-5D scores for patients in the S group were 0.71 (SD 0.29) compared to 0.60 (SD 0.14) for patients in the P group and 0.63 (SD 0.23) for patients in the C group. The EQ-VAS scores were similarly favourable towards patients in the S group. Seventy percent of patients in the S group returned to their previous level of employment after a mean duration of 5.3 months compared to 55% in the P group and 57% in the C group after a mean duration of 9.4 months and 12.8 months, respectively. Patients with isolated spinal fractures had an overall satisfactory outcome compared with patients in the other 2 groups. However, no difference was noted while analysing the outcomes in the later 2 groups (p<0.05), suggesting that the pelvic fracture contributes to the poor outcome, and the presence of a spinal fracture does not influence the long-term outcome. However, problems related to associated injuries and motor neurological deficits have profound confounding effect on the outcome in all 3 groups.

Aftertreatment of malleolar fractures following ORIF -- functional compared to protected functional in a vacuum-stabilized orthesis: a randomized controlled trial

In a monocenter randomized controlled trial, 45 patients with isolated malleolar fracture type OTA/AO 44 A1-B2 undergoing ORIF were allocated randomly to a postoperative treatment either with a vacuum-stabilized orthesis with prescribed full weight bearing after the second week (23 patients) (orthesis group -- OG) or with functional aftertreatment with partial weight bearing of 15 kg for 6 weeks (22 patients) (control group -- CG). Outcomes were compared at 6- and 10-week follow-up examinations. The Olerud and Molander ankle (OMA) score, ankle swelling, usage of crutches, range of motion, Short Form 12, patient-reported visual analogue scales (VAS) (pain, comfort, walking confidence) and time to return to work were evaluated. All patients of OG showed reduced swelling at discharge. The median OMA scores after 6 weeks were 42 and 42.5 (p = 0.46) and after 10 weeks 69 and 72 (p = 0.55) in the OG and CG, respectively. The time to achieve secure walking capacity was reduced by 1 day (p = 0.03) in the OG. After ORIF of simple malleolar fractures, patients with a vacuum-stabilized orthesis can bear full weight 2 weeks postoperatively. This group experienced no adverse events. Postoperative swelling was significantly reduced and of the ability to walk on stairs confidently was shorter as compared to a functional aftertreatment without any external stabilization of the ankle.

Effects of wearing foot orthosis with medial arch support on the fifth metatarsal loading and ankle inversion angle in selected basketball tasks

STUDY DESIGN

Preintervention and post-intervention, repeated-measures experimental design.

OBJECTIVES

The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run.

BACKGROUND

Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture,

METHODS AND MEASURES

Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks.

RESULTS

The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P< or =026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions.

CONCLUSION

Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

Passive dorsiflexion flexibility after cast immobilization for ankle fracture

Ankle fracture is frequently managed with cast immobilization, but immobilization may produce ankle contracture (loss of flexibility). We aimed to quantify recovery of ankle dorsiflexion flexibility in people treated with cast immobilization after ankle fracture, and to determine if initial orthopaedic management was associated with recovery. Ankle flexibility was measured in 150 people with plantarflexion contracture who had been referred for outpatient physical therapy following cast immobilization for ankle fracture. We obtained measurements using an instrumented footplate within 5 days of cast removal and then 4 weeks and 3 months later. Data were compared with published normative data. Both stiffness and the torque corresponding to the peak dorsiflexion angle at baseline decreased during the 3 month recovery period, but recovery was still incomplete 3 months after cast removal. Surgical fixation was associated with higher stiffness, preload and torque values. Passive ankle flexibility does not return to normal values within 3 months of cast removal after ankle fracture. Recovery of normal ankle dorsiflexion flexibility typically takes longer than the initial period of immobilization.

Fifth metacarpal neck fractures: is follow-up required?

This study examines the premise that follow-up after fifth metacarpal neck fractures is unnecessary after initial assessment in a hand clinic. Forty consecutive patients with this fracture were managed in plaster and followed up. The next 38 patients were treated with neighbour strapping, given information sheets and no follow-up visits were arranged. In the first group, most return visits were for removal of plaster. Almost half of the appointments, thereafter, were not attended. In the second group, only two patients returned to the clinic, one with minor complaints and one with a repeat injury. Patients reported better satisfaction when managed with neighbour strapping (P=0.04) and without regular follow-up visits (P<0.01). The time to return to work was a mean of 5 weeks and 2.7 weeks in the first and second groups, respectively (P<0.01). There was no significant difference in the functional outcome at 12 weeks, as assessed by the DASH score.

Synthesis of Nitric Oxide in Human Osteoblasts in Response to Physiologic Stimulation of Electrotherapy

Electrotherapy for bone healing, remodeling and wound healing may be mediated by modulation of nitric oxide (NO). Using NO-specific fluorophore (DAF-2), we report here that application of non-invasive, physiologic electrical stimulation induces NO synthesis in human osteoblasts, and that such NO generation is comparable to that induced by estrogen treatment. For example, application of a sinusoidal 1 Hz, 2 V/cm (peak to peak) electrical stimulation (ES) increases NO-bound DAF-2 fluorescence intensity by a 2-fold within 60 min exposure by activating nitric oxide synthase (NOS). Increase in the NO level is found to depend critically on the frequency and strength of ES. While the frequency of 1 Hz ES seems optimal, the ES strength >0.5 V/cm is required to induce significant NO increase, however. Nitric oxide synthesis in response to ES is completely prevented by blocking estrogen receptors using a competitive inhibitor, suggesting that NO generation is likely initiated by activation of estrogen receptors at the cell surface. Based on these findings, physiologic stimulation of electrotherapy appears to represent a potential non-invasive, non-genomic, and novel physical technique that could be used to regulate NO-mediated bone density and facilitate bone remodeling without adverse effects associated with hormone therapy.

Early predictors of long-term work disability after major limb trauma

BACKGROUND

A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries.

METHODS

Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire.

RESULTS

Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW.

CONCLUSIONS

Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

Use of pulsed shortwave diathermy and joint mobilization to increase ankle range of motion in the presence of surgical implanted metal: A case series

STUDY DESIGN

Case series.

BACKGROUND

Traditionally, all forms of diathermy have been contraindicated over metal implants. There is a lack of research-based evidence for harm regarding the use of pulsed shortwave diathermy (PSWD) over orthopedic metal implants. Because PSWD is an effective modality for deep heating, we investigated whether ankle range of motion (ROM) could improve with the cautious use of PSWD and joint mobilizations, despite orthopedic metal implants being in the treatment field.

CASE DESCRIPTIONS

Four subjects presented with decreased ankle ROM due to extensive fractures from traumatic injuries. All subjects were postsurgical, with several internal fixation devices. Subjects previously received rehabilitation therapy involving joint mobilizations, therapeutic exercises, moist heat, and ice, but continued to lack 15 degrees to 23 degrees of ankle dorsiflexion. The Human Subjects Review Board of Brigham Young University approved the methods of this case series. Subjects gave written informed consent. Initial dorsiflexion active ROM for each patient was -3 degrees, 0 degrees, 8 degrees, and 5 degrees, respectively. Treatment regime consisted of PSWD to the ankle for 20 minutes at 27.12 MHz, 800 pps, 400 microseconds (48 W). Immediately after PSWD, mobilizations were administered to the joints of the ankle and foot. Ice was applied posttreatment.

OUTCOMES

Dorsiflexion improved 15 degrees, 15 degrees, 10 degrees, and 14 degrees, respectively, after 8 or 13 visits. All patients returned to normal activities with functional ROM in all planes. Follow-up 4 to 6 weeks later indicated that the subjects maintained 78% to 100% of their dorsiflexion. No discomfort, pain, or burning was reported during or after treatment. No negative effects were reported during the short-term follow-up.

DISCUSSION

When applied with appropriate caution, we propose PSWD (48 W) may be an appropriate adjunct to joint mobilizations to increase ROM in peripheral joints, despite implanted metal. We continue to advise caution when applying diathermy with machines other than the Megapulse II. Further research is needed to determine the safety parameters of other diathermy machines. As a final caution, we advise that diathermy not be used in the presence of a cardiac pacemaker or neurostimulator.

Relative contributions of muscle activation and muscle size to plantarflexor torque during rehabilitation after immobilization

Muscle atrophy is clearly related to a loss of muscle torque, but the reduction in muscle size cannot entirely account for the decrease in muscle torque. Reduced neural input to muscle has been proposed to account for much of the remaining torque deficits after disuse or immobilization. The purpose of this investigation was to assess the relative contributions of voluntary muscle activation failure and muscle atrophy to loss of plantarflexor muscle torque after immobilization. Nine subjects (ages 19-23) years with unilateral ankle malleolar fractures were treated by open reduction-internal fixation and 7 weeks of cast immobilization. Subjects participated in 10 weeks of rehabilitation that focused on both strength and endurance of the plantarflexors. Magnetic resonance imaging, isometric plantarflexor muscle torque and activation (interpolated twitch technique) measurements were performed at 0, 5, and 10 weeks of rehabilitation. Following immobilization, voluntary muscle activation (56.8 +/- 16.3%), maximal cross-sectional area (CSA) (35.3 +/- 7.6 cm(2)), and peak torque (26.2 +/- 12.7 N-m) were all significantly decreased ( p < 0.0056) compared to the uninvolved limb (98.0 +/- 2.3%, 48.0 +/- 6.8 cm(2), and 105.2 +/- 27.0 N-m, respectively). During 10 weeks of rehabilitation, muscle activation alone accounted for 56.1% of the variance in torque ( p < 0.01) and muscle CSA alone accounted for 35.5% of the variance in torque ( p < 0.01). Together, CSA and muscle activation accounted for 61.5% of the variance in torque ( p < 0.01). The greatest gains in muscle activation were made during the first 5 weeks of rehabilitation. Both increases in voluntary muscle activation and muscle hypertrophy contributed to the recovery in muscle strength following immobilization, with large gains in activation during the first 5 weeks of rehabilitation. In contrast, muscle CSA showed fairly comparable gains throughout both the early and later phase of rehabilitation.

Osteoporotic fractures in older adults

Osteoporotic fractures are emerging as a major public health problem in the aging population. Fractures result in increased morbidity, mortality and health expenditures. This article reviews current evidence for the management of common issues following osteoporotic fractures in older adults including: (1) thromboembolism prevention; (2) delirium prevention; (3) pain management; (4) rehabilitation; (5) assessing the cause of fracture; and (6) prevention of subsequent fractures. Areas for practice improvement and further research are highlighted.