Swing design dynamic traction splinting for the treatment of intra-articular fractures of the digits

The concept of treating acute PIP fractures with traction splinting to allow early motion to mitigate against the known deleterious effects of prolonged immobilization of this problematic joint has been around for a long time and was made popular by Schenck. Our author in this PF piece has modified a splint design of Griet Van Veldhoven to further refine the dynamic traction approach.

Rehabilitation for distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians.

DATA COLLECTION AND ANALYSIS

The authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done.

MAIN RESULTS

Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. For interventions started during immobilisation, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilisation (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial).

AUTHORS' CONCLUSIONS

The available evidence from randomised controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Surgical Treatment for Distal Clavicle Fracture Associated With Coracoclavicular Ligament Rupture Using a Cannulated Screw Fixation Technique

BACKGROUND

A clavicle fracture is a common traumatic injury. However, the high percentage of distal clavicle fractures associated with a rupture of the coracoclavicular (CC) ligament can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces a method for treating distal clavicle fractures associated with a ruptured CC ligament using a cannulated screw.

METHODS

Seventeen patients suffering from a clavicle fracture caused by a rupture of the CC ligament were treated with a closed reduction and a cannulated screw fixation technique. Twelve patients were male and five were female and the average age was 30.5 years (range, 8-64 years). The patients were assessed using a clinical and radiologic evaluation as well as by the University of California at Los Angeles (UCLA) shoulder rating scale for 12 to 16 months after surgery.

RESULTS

After confirming the formation of a callus, the implants were routinely removed approximately 8 weeks after surgery in all patients except for one. In this patient, the implant was removed 16 weeks after surgery as a result of a loosened screw, which caused displacement at the fracture site. During the final follow-up, the fracture site displayed nonunion and a partially limited range of motion (ROM). The shoulder function of the other 16 patients was restored to the preinjury level after 4 approximately 6 months of treatment. In one patient, heterotopic ossification was observed along the CC ligament without any functional deficit. All but one patient showed good results according to the UCLA scale.

CONCLUSIONS

The cannulated screw fixation technique can maintain the rigid fixation of fracture fragments and allow an early return to work and sport activities. Therefore, the cannulated screw fixation technique is expected to be a useful method for treating distal clavicle fractures associated with a coracoclavicular ligament rupture.

Closed Reduction and Internal Fixation for Acute Midshaft Clavicular Fractures Using Cannulated Screws

BACKGROUND

Although most acute midshaft clavicular fractures can be successfully treated nonsurgically, surgery is more appropriate for cases with severe displaced fractures, skin tenting, initial shortening of fracture ends, and associated with multiple injuries. However, methods of surgical treatment for such fractures remain controversial. This study discusses a closed reduction and internal fixation technique for midshaft clavicular fracture.

METHODS

Between 2000 through 2003, 34 acute midshaft clavicular fractures were operatively treated with cannulated screws using closed reduction technique by one surgeon. The follow-up and clinical evaluation was performed by another surgeon.

RESULTS

Thirty-one patients were followed for an average of 27.4 months (range, 24-37 months). Thirty (96.8%) fractures healed within 12 weeks, and one fracture healed at 18 weeks. No major surgical complications occurred, although superficial wound infection occurred in one patient. No implants needed to be removed. The final union rate was 100%.

CONCLUSIONS

Closed reduction and internal fixation with cannulated screw is an alternative choice for treating acute midshaft clavicular fracture in selected cases where surgery is indicated and should be done cautiously.

A prospective multi-center cohort study of acute non-displaced fractures of the scaphoid: operative versus non-operative treatment [NCT00205985]

BACKGROUND

Acute scaphoid fractures are common in active adults and do lead to reasonable time lost to work. One important goal of treatment is early return to work or sport. On this background, the adequate treatment of non-displaced acute scaphoid fractures is still under discussion. The aim of this study is to compare time to return to previous activity level comparing surgical versus non-surgical treatment of non-displaced acute scaphoid fractures.

METHODS/DESIGN

The study is designed as a non-randomized multiple center cohort study including 12 sites in Germany and Austria. The inclusion period is planned to be 12 months with a follow up of 6 months. Allocation to operative or non-operative treatment is chosen by the patient together with his treating surgeon. The primary outcome is time to return to previous activity level adapted for loading of the wrist in daily life as measured by a newly developed questionnaire (PLDL-wrist). Factors identified a priori to be associated with the outcome, e.g., poverty status, age, education, smoking status, gender, and occupation, are measured to ensure adequate control for their potential confounding effects.

DISCUSSION

The rationale and the design of a multiple center cohort study are presented. As it is not considered feasible to randomize patients in this study, potential confounding effects need to be controlled adequately.

Balance in single-limb stance after surgically treated ankle fractures: a 14-month follow-up

Background

The maintenance of postural control is fundamental for different types of physical activity. This can be measured by having subjects stand on one leg on a force plate. Many studies assessing standing balance have previously been carried out in patients with ankle ligament injuries but not in patients with ankle fractures. The aim of this study was to evaluate whether patients operated on because of an ankle fracture had impaired postural control compared to an uninjured age- and gender-matched control group.

Methods

Fifty-four individuals (patients) operated on because of an ankle fracture were examined 14 months postoperatively. Muscle strength, ankle mobility, and single-limb stance on a force-platform were measured. Average speed of centre of pressure movements and number of movements exceeding 10 mm from the mean value of centre of pressure were registered in the frontal and sagittal planes on a force-platform. Fifty-four age- and gender-matched uninjured individuals (controls) were examined in the single-limb stance test only. The paired Student t-test was used for comparisons between patients' injured and uninjured legs and between side-matched legs within the controls. The independent Student t-test was used for comparisons between patients and controls. The Chi-square test, and when applicable, Fisher's exact test were used for comparisons between groups. Multiple logistic regression was performed to identify factors associated with belonging to the group unable to complete the single-limb stance test on the force-platform.

Results

Fourteen of the 54 patients (26%) did not manage to complete the single-limb stance test on the force-platform, whereas all controls managed this (p < 0.001). Age over 45 years was the only factor significantly associated with not managing the test. When not adjusted for age, decreased strength in the ankle plantar flexors and dorsiflexors was significantly associated with not managing the test. In the 40 patients who managed to complete the single-limb stance test no differences were found between the results of patients' injured leg and the side-matched leg of the controls regarding average speed and the number of centre of pressure movements.

Conclusion

One in four patients operated on because of an ankle fracture had impaired postural control compared to an age- and gender-matched control group. Age over 45 years and decreased strength in the ankle plantar flexors and dorsiflexors were found to be associated with decreased balance performance. Further, longitudinal studies are required to evaluate whether muscle and balance training in the rehabilitation phase may improve postural control.

[After care of fractures of the extremities]

Today, early mobilization is recommended, irrespective of whether a patient with a fracture of the extremities has been treated conservatively or surgically. In this way, morbidity and mortality risks can be considerably reduced, in particular in the elderly patient. As a result of the continuing trend towards an ever shorter hospital stay, the general physician is faced with the task of providing aftercare to such patients at an early stage in the healing process of the fracture. This includes wound care, prevention of thromboembolism, the timely initiation of physiotherapeutic measures, and the requesting of x-ray follow-up.

[Ambulation training with bilateral limited weight bearing after foot injuries]

AIM

Bilateral foot injuries are not uncommon. Operative treatment usually requires partial weight bearing over several weeks. This is a challenge for physiotherapy especially for ambulation training. We describe a new rehabilitation aid allowing for bilateral limited weight bearing during ambulation.

METHODS

Ambulation training was initiated in the early postoperative period using the Regensburg ambulation aid. A lift system allows for exact limitation of weight bearing on both sides controlled by balances integrated into the floor. Using a rail system a 15 m free walking distance is available. This study included 10 patients with bilateral foot fractures. The functional outcome was assessed using the AOFAS score and quality of life with the SF-36 score. Plain X-rays were used to evaluate loss of correction. The control group consisted of 20 patients where ambulation training was discontinued for at least 6 weeks postoperatively.

RESULTS

The system is very safe, during the entire period no complication was recorded. Acceptance among the patients was extremely high. Worries about unwanted weight bearing could be reduced. Patients mobilized with early ambulation training showed a better compensation of gait if compared to the control group. Secondary problems in the knee, hip or spine, as well as muscular deficiencies had a significantly lower incidence. No loss of correction could be seen in either of the two groups.

CONCLUSION

The presented ambulation aid is a significant contribution to the physiotherapy of bilateral foot injuries.

Brief osteoporosis education in an inpatient rehabilitation setting improves knowledge of osteoporosis in elderly patients with low-trauma fractures

The effect of an osteoporosis education program on knowledge of osteoporosis was assessed in elderly rehabilitation inpatients with low-trauma fractures. A modified version of the Osteoporosis Questionnaire (OPQ) was administered prior to and following a brief education program on the rehabilitation ward, and again at 4-6 months. A historical control group, admitted to the same ward prior to the educational program, was used as a comparison. The baseline mean OPQ test score (out of 20) for the intervention group was 7.26. The OPQ score significantly increased by a mean of 2.16 during the admission. The difference was increased in the available subjects at the 6-month questionnaire, with a significant mean increase of 2.67. There was a significant correlation between admission Functional Independence Measure (FIM) score and both baseline OPQ score (r=0.59) and follow-up OPQ score (r=0.60). There was a significant correlation between discharge FIM score and increase in OPQ score from baseline to follow-up (r=0.77), and with OPQ score at follow-up (r=0.76). There was a significant correlation between the Mini Mental State Examination at follow-up (r=0.78), and the change in OPQ score between initial survey and follow-up (r=0.70). Osteoporosis education in elderly rehabilitation inpatients with fractures is effective, but requires adequate patient cognitive skills.

[Dynamic distraction and early reeducation in proximal interphalangeal joint fractures: preliminary results of a 15 patients' prospective series]

INTRODUCTION

The authors present early results of the treatment of interphalangeal fractures with external dynamic distractor and early reeducation.

PATIENTS AND METHODS

Fifteen proximal interphalangeal fractures were treated with a "do-it-yourself" external distracter. Distraction was performed with rubber band or steel stitches. Patients sustained immediate self-mobilization and physiotherapy. Total duration of the treatment was 45 days.

RESULTS

Thirteen patients had good results with normal mobility after three months and recovered 80% of their controlateral force. Algodystrophia occurred in one case with poor functional results. One late management led to severe interphalangeal rigidity.

CONCLUSION

External distraction is a safe and economical treatment providing good early results with few complications. Long-term follow-up is necessary to make this procedure a standard-of-care in the management of proximal interphalangeal fractures.

Functional treatment and early weightbearing after an ankle fracture: a prospective study

OBJECTIVE

Postoperative care for ankle fractures is generally 1 of 2 regimens: 1) functional treatment combined with early weightbearing (EWB), or 2) immobilization in a cast/orthosis for 6 weeks without weightbearing (6WC). The objective of this study was 2-fold: 1) to follow a prospective group treated with EWB as to long-term subjective and objective outcomes, and 2) to compare a subset of this group with a matched group of historic controls treated with 6WC.

DESIGN

Prospective, clinical, cohort observation, and retrospective matched pair analysis.

SETTING

University hospital, level 1 trauma center.

PATIENTS

Forty-three patients (20 males; mean age, 49 +/- 14 years) with operated Weber B/C fractures underwent EWB. For comparison, 23 patients of this group were matched to a same number of historic controls with respect to age, gender, body mass index, and fracture type.

INTERVENTION

Open reduction and internal fixation (ORIF) using a 1/3-tubular-fibula-plate for the fibula, and malleolar screws for the medial malleolus fracture (in cases with a bimalleolar ankle fracture) followed by EWB or 6WC.

MAIN OUTCOME MEASUREMENTS

Olerud and Tegner scores at follow-up (at least 12 months after surgery), time to full weightbearing, return to work, pain intensity (numerical rating scale (NRS)), and hospital stay. Statistical comparisons were performed by using the Mann-Whitney U test or Fisher exact test (P < 0.05).

RESULTS

Patients with EWB were full weightbearing at 7 +/- 3 weeks and returned to work at 8 +/- 5 weeks after surgery. At follow-up (mean, 20 +/- 11 months after surgery), all EWB patients showed good results in the Olerud score (90 +/- 13 points). Matched-pair analysis in 23 patients in each group revealed differences between EWB and 6WC groups for hospital stay (mean, 10.8 +/- 4.7 vs. 13.6 +/- 6 days; P = 0.12), time to full weightbearing (mean, 7.7 +/- 3.1 vs. 13.5 +/- 9.4 weeks; P = 0.01), and time until return to work (mean 9.2 +/- 5.5 vs. 10.8 +/- 7 weeks; P = 0.63). No differences concerning pain intensities were observed (EWB vs. 6WC: NRS = 1.9 vs. 1.7; P = 0.12). At follow-up, Olerud scores were generally considered good for both groups; however, mean values in EWB patients were slightly higher (87 +/- 14 vs. 79 +/- 19 points; P = 0.25). In both groups, the majority of patients reached their preinjury level of activity as demonstrated by Tegner scores.

CONCLUSIONS

EWB patients tolerated earlier full weightbearing compared with 6WC patients, and there were no disadvantages with EWB compared with 6WC concerning hospital stay, pain intensities, time until return to work, and Olerud/Tegner Scores. Potential candidates for EWB are patients with a stable osteosynthesis of their fractured ankles as judged by the responsible surgeon, compliance, and high motivation.

[Demographic features and difficulties in rehabilitation in patients referred to hand rehabilitation unit for phalangeal fractures]

OBJECTIVES

We evaluated demographic and occupational features of patients with phalangeal fractures of the hand, etiologies and types of injuries, and the results of rehabilitation.

METHODS

The study included 91 fingers of 62 patients (54 males, 8 females; mean age 28+/-13 years; range 4 to 59 years) who were referred to our hand rehabilitation unit for phalangeal fractures. Demographic features, the cause and localization of injury, the type of surgery, time from surgery to rehabilitation, and the follow-up period were determined. At the end of rehabilitation, range of motion (ROM) of the phalangeal joint and total ROM of the injured fingers were assessed using the Strickland-Glogovac rating system.

RESULTS

A great majority of injuries were caused by work accidents, followed by sport injuries and falls occurring in students. Sixty patients (96.8%) were right-handed. The fractures occurred in the dominant hand in 29 patients (46.8%). The majority of patients (n=45) were primary school graduates. The most common mechanism of injury was accidents related to heavy work machinery (n=18). The most commonly injured finger and the phalanx were the third finger (n=25, 27.5%) and the proximal phalanx (n=59, 56.7%), respectively. Only 27 patients (43.6%) had a sufficient follow-up with a mean of 79.7+/-46.6 days (range 30 to 254 days). Following rehabilitation, the mean ROM and the total ROM were 45.0+/-22.9 degrees and 63.3+/-16.1 degrees for the injured joint and the thumb, and 31.3+/-22.5 degrees and 122+/-60.3 degrees for the injured joint and the other fingers, respectively.

CONCLUSION

Our data provide important insight into appropriate treatment and rehabilitation of phalangeal fractures, in particular, shortcomings in the treatment and follow-up.

Partial weight bearing after surgery for fractures of the lower extremity--is it achievable?

Partial weight bearing is a generally accepted principle of rehabilitation following trauma or reconstructive surgery of the lower extremity. Individual dynamic loads during partial weight bearing to a given load level of 200 N were compared in 23 patients who had sustained a fracture of the lower extremity and 11 healthy volunteers using dynamic sole pressure measurements. Excessive dynamic loading compared with the statically pre-tested 200 N level was observed in all groups. Maximum force levels were up to 690 N in young patients and up to 580 N elderly patients beyond the prescribed static load. None of the healthy volunteers was able to keep within the given load of 200 N. The set load level was exceeded by at least 38 N (119%) in the elderly patient group. In comparison, elderly patients showed statistically significantly higher maximum forces than young patients during the first two test days (p=0.007 and 0.013). On the 3rd test day the maximum ground contact forces were on average 71 N higher than in the young patients group. Analysis of the force time integrals (impulses transferred to the ground) displayed higher values in the older again than in young patients. The differences were statistically significant during the first two test days (p=0.006 and 0.037). This study implies that the conventional concept of postoperative partial weight bearing starting from 200 N and a stepwise increase of the load level until full weight bearing is not valid during clinical practice.

Cannulated variable pitch compression screw fixation of scaphoid fractures using a limited dorsal approach

Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union.

The functional capacity index, second revision: morbidity in the first year post injury

As the field of injury outcomes measurement has moved beyond counting deaths and injuries, the need for instruments to measure long-term outcomes has increased. Early validation efforts indicated that the Functional Capacity Index (pFCI12) was a promising tool for predicting functional loss 12 months post trauma, but that the predictive validity for lower extremity fractures was low. The pFCI12 was recently revised in conjunction with the 2005 revision of the Abbreviated Injury Scale (AIS). This preliminary study was undertaken to assess the performance of the revised pFCI12 in predicting outcomes for patients with lower extremity trauma. This case review study used the Crash Injury Research and Engineering Research (CIREN) database which includes AIS codes, extensive clinical data and 3- and 12-month outcomes. Generally predicted functional loss at 12 months was greater with the pFCI12 (AIS 2005) than with the original FCI based on AIS 1990. All patients whose pFCI12 scores predicted functional loss experienced some morbidity at 1 year. The pFCI12 appears to provide improved predictions of functional outcome 12-months post-trauma for persons experiencing lower extremity trauma.

Intramedullary nailing of metacarpal shaft fractures

Uncorrected bony deformity or stiffness resulting from a metacarpal shaft fracture can produce a significant functional or cosmetic deficit. Intramedullary fixation of metacarpal shaft fractures using small flexible rods can provide stable internal fixation while minimizing the extent of soft tissue trauma that is associated with more extensive surgical techniques such as plate or screw fixation. The flexible rod is usually introduced in a proximal to distal direction to avoid injury to the metacarpophalangeal joint and extensor mechanism. Closed reduction of the fracture and percutaneous insertion of the rod improve operative efficiency and allow what is truly a minimally invasive procedure. The use of a proximal locking pin greatly enhances fixation and has resulted in an expansion of the surgical indications to include spiral and comminuted fractures. Usually a single locked nail is used, although it is possible to insert multiple nails if necessary. A radiopaque plastic cap can be applied over the cut end of the nail to minimize irritation of the adjacent soft tissues during rehabilitation. Post-operatively, splint or cast immobilization is often unnecessary. The nails are routinely removed after the fracture has completely healed.

Resuming driving after a fracture of the lower extremity: a survey among Dutch (orthopaedic) surgeons

BACKGROUND

Patients with a fracture of the lower extremity often ask their physician during their rehabilitation when they can resume driving. Since no guidelines exist and only scarce literature is available with varying advices the physician has to rely on his own clinical experience and judgment. The Dutch legislation also fails to provide rules when driving can be resumed after a temporary invalidity, it relies on the physician to judge when driving can be assumed to be safe. With this study, we investigated the need for specific guidelines concerning driving after fractures of the lower extremity among Dutch (orthopaedic) surgeons.

METHODS

A survey was conducted among Dutch (orthopaedic) surgeons consisting of four parts; the first part contains questions about how the physician handles with patients who suffered from a lower extremity fracture. The second part of the survey is about which criteria are used to judge whether driving can be resumed. The third part contains true/false/do not know questions about the legal context on participation in motorized traffic with a (temporary) disability. The fourth and last part is a series of examples of fractures with a description of how the fracture was treated in which we asked how long it should normally take before a patient can resume driving again safely per case. A final question is about the need for specific guidelines on this topic.

RESULTS

One third of the surgeons do not advise their patients regarding driving. A wide range of criteria is used to consider whether driving is safe, however the possibility of full weight bearing is considered the most important. The legal knowledge of the surgeons on this subject is poor; up to 10% believe that driving with a plaster on the right leg is allowed. Seventy-nine percent of the questioned surgeons believe that guidelines concerning driving after a fracture should be developed.

CONCLUSIONS

Our study shows that there is a great demand for guidelines concerning car driving after a fracture of the lower extremity.

Progressive resistance exercise in physical therapy: a summary of systematic reviews

Progressive resistance exercise (PRE) is a method of increasing the ability of muscles to generate force. However, the effectiveness and safety of PRE for clients of physical therapists are not well known. The purpose of this article is to review the evidence on positive and negative effects of PRE as a physical therapy intervention. Electronic databases were searched for systematic reviews on PRE and any relevant randomized trials published after the last available review. The search yielded 18 systematic reviews under major areas of physical therapy: cardiopulmonary, musculoskeletal, neuromuscular, and gerontology. Across conditions, PRE was shown to improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities. Further research is needed to determine the potential negative effects of PRE, how to maximize carryover into everyday activities, and what effect, if any, PRE has on societal participation.

Closed Reduction of Hand Fractures

Stiffness is the most frequent consequence of open hand fracture treatment. Although initial injury severity and occurrence adjacent to the flexor tendon sheath are the most highly correlated determinants of hand fracture outcome, operative intervention accentuates the ultimate risk of stiffness. Closed treatment may minimize this risk. Articular fractures are at greater risk for stiffness than extra-articular fractures. Functional tolerance for small amounts of variation from perfect anatomic restoration gives us increased latitude for closed hand fracture management. Operative treatment may be justified for simple closed fractures when they are unstable, irreducible, or open, or when the surgeon believes that the risk-to-benefit ratio is favorable.

Conservative treatment of scapular neck fracture: the effect of stability and glenopolar angle on clinical outcome

The aim of this study was to determine the effect of stability and glenopolar angle on the clinical outcome of conservatively treated scapular neck fractures. Eighteen patients with scapular neck fractures were treated with conservative treatment. Twelve of the 18 patients had surgical neck fractures, whilst six of them had anatomical neck fractures. Anteroposterior radiographs and computerised tomography were performed for each patient. Glenopolar angle was measured through anteroposterior radiographs in the scapular plane. After 3-5 weeks of immobilisation, a rehabilitation programme was started, throughout which all the patients were treated in a 3-phase rehabilitation programme. The mean follow-up was 25 months, and the Constant score was 78.83+/-8.12 point (range: 68-94 points). Patient gender and the type of scapular neck fractures had no effect on functionality or clinical outcome (p>0.05), whilst associated injuries significantly affected the clinical outcome (p<0.05). There was a positive correlation between the Constant score and glenopolar angle (r=0.891, p<0.05) and between the age and glenopolar angle (r=0.472, p<0.05).

A Pilot Study: Post-Acute Geriatric Rehabilitation Versus Usual Care in Skilled Nursing Facilities

OBJECTIVES

To compare discharge outcomes, postdischarge health care use, and death rates among patients treated in a postacute geriatric rehabilitation unit (GRU) housed within a skilled nursing facility (SNF) with those treated in a traditional SNF.

DESIGN

Retrospective observational pilot study.

SETTING

Two similar SNFs were compared.

PARTICIPANTS

All patients were admitted from the acute hospital to either the GRU (n = 95) or to the usual care (UC) SNF (n = 55).

INTERVENTION

The GRU intervention consisted of comprehensive geriatric assessment and weekly interdisciplinary team rounds with a geriatrician and a geriatric nurse practitioner (GNP). The geriatrician visited the GRU twice a week and the GNP was present 4 to 5 times per week. On discharge, GRU patients were followed up with telephonic case management for 1 year.

MEASUREMENTS

Demographic data collected included age, gender, and race. Information collected from each facility's patient records included admitting diagnosis, length of stay, discharge disposition, and functional outcomes. Emergency department (ED) visits and hospital readmissions for 1 year after discharge from the nursing facility were obtained from our institutional database. The Rehabilitation Outcome Measure (ROM) was used by each facility to measure functional status on admission and at the time of discharge.

RESULTS

Baseline patient characteristics were comparable between the 2 facilities. At discharge from the nursing facility, GRU patients showed greater improvement in ADLs and mobility, had a significantly shorter length of stay, and were discharged to home more often. At 1 year, GRU patients had significantly fewer hospital readmissions. GRU patients also had fewer ED visits and days in the hospital at 1 year, however these results were not significant.

CONCLUSION

These pilot results suggest that GRU may be an effective means to improve patient outcomes and reduce undesirable health care use after an acute illness. Further studies using a randomized design are needed.