Unstable thoracolumbar injuries

Physical rehabilitation of the critically ill trauma patient in the ICU

OBJECTIVES

To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients.

DATA SOURCES

A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011.

STUDY SELECTION

Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980.

DATA EXTRACTION

Reviewers extracted data and summarized results according to anatomical areas.

DATA SYNTHESIS

Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting.

CONCLUSIONS

There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.

Health-related quality of life after short segment instrumentation of lumbar burst fractures

Management of lumbar burst fractures remains controversial. Surgical reduction/stabilization is becoming more popular; however, the functional impact of operative intervention is not clear. The purpose of this study was to assess health-related quality of life and functional outcome after posterior fixation of lumbar burst fractures with either posterolateral or intrabody bone grafting. Twenty-four subjects were included. Radiographs and computed tomography scans were evaluated for deformity (kyphosis, vertebral compression, lateral angulation, lateral body height, and canal compromise) postoperatively, at 1 year, and at final follow-up (mean 3.2 years). Patients completed the SF 36 Health Survey and the Oswestry Low Back Pain Disability Questionnaire at final follow-up. Significant improvement was noted in midsagittal diameter compromise, vertebral compression, and kyphosis. The difference observed between the respondents mean scores on the SF 36 was not significantly different from those presented as the U.S. national average (p = 0.053). Data from the Oswestry questionnaire indicated a similarly high level of function. Overall, we found posterior spinal instrumentation to correlate with positive functional outcome based on both general health (SF 36) and joint-specific outcome scales (Oswestry). Posterior instrumentation provides sound canal decompression, kyphotic reduction, and maintains vertebral height with minimal transgression and long-term sequelae. In cases of severe initial deformity and neurologic compromise, intrabody bone grafting is most certainly indicated; the additional support provided by a posterolateral graft may also prove beneficial as an adjunct.

Emergency care in patients wearing body casts

OBJECTIVE

To describe a body cast modification that allows rapid chest exposure for cardiopulmonary resuscitation and alert the medical community to the 3% to 5% incidence of cardiopulmonary arrest in the hospital while wearing such a cast. DESIGN. Single trial timed cast cutting, multiple trial cast shell loading, and clinical observations of perforated casts for cracking or breakage.

SETTING

University hospital castroom, mechanical engineering laboratory.

INTERVENTION

Body casts mounted on a life-sized torso mold were perforated at 2-inch (50 mm), 1-inch (25 mm), or 1/2 inch (12 mm) intervals around the chest with a 12-mm-diameter vibrating drill. Using a cast saw, the chest piece of each body cast was removed and the time recorded. Engineering studies were performed on two cast shells with and without 12-mm-wide holes up to 1/2" (12 mm) apart, loading the fiberglass to the point of failure and recording the data. Body casts with 1" (25 mm)-interval holes worn by 40 patients were examined after 12 weeks for evidence of failure.

MAIN OUTCOME MEASURES

Chest piece removal times of body cast shells with and without holes were compared. Loading data of cast shells were compared to determine if holes as close as 1/2" (12 mm) significantly weakened the cast. Forty casts, perforated at 1-inch (25 mm) intervals, were observed for failure after 12 weeks of wear.

RESULTS

Chest exposure time of a mold encased in a fiberglass cast was reduced from 1 minute to 15 seconds; plaster cast removal was reduced from 3 minutes to 1 minute. Engineering studies of perforated casts showed no significant decrease in strength. Casts with and without holes could support chest forces of up to 330 pounds. No failure was observed in casts with perforations 1 inch (25 mm) apart worn for 12 weeks.

CONCLUSION

Perforated body casts reduced removal time to 15 seconds without weakening of the cast and provide lifesaving time to perform effective CPR.