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dziowania śródszpikowego, stosowany w Klinice Ortopedii i Traumatologii Narządu Ruchu Collegium Medicum UJ. Gwoździowa- nie śródszpikowe jest jedną z ...
Medical Rehabilitation 2011, 15 (2), 13-19

Rehabilitation in lower extremity fractures treated with intramedullary nailing Postępowanie rehabilitacyjne w złamaniach kończyn dolnych leczonych metodą gwoździowania śródszpikowego Jarosław Brudnicki 1,2(A,E,F), Małgorzata Kubicz-Chachurska 1(A,E,F) 1 2

The Orthopaedics and Traumatology of the Motion System Clinic, Collegium Medicum UJ. Cracow, Poland Rehabilitation in Traumatology Unit of the Academy of Physical Education, Cracow, Poland

Key words

lower extremities, fractures, intramedullary nailing, coordination Abstract

This paper presents a model of rehabilitation of patients with lower extremities’ fractures treated with intramedullary nailing in the Orthopaedics and Traumatology of the Motion System Clinic of Collegium Medicum UJ. Intramedullary nailing is one of the main methods of fracture fixation. The evolution of this method has caused an increased number of indications for its application especially in the lower extremity. Regardless of the method of fracture fixation, every fracture has some important consequences for a patient as a result of the accompanying soft tissues injuries, gait due to weight bearing limitations etc. A general consideration of intramedullary nailing is presented in this paper as well as the methods of rehabilitation which are in use in patients after fixation of lower extremity fractures with intramedullary nails. The important points of rehabilitation after intramedullary nailing of proximal femur fractures, femoral shaft and tibial shaft fractures, which are a standard indications for a fixation with intramedullary nails, were discussed, especially the problem of the decision making concerning weight bearing. Special emphasis was placed on the importance of exercises improving motional coordination. Individual programs of rehabilitation designed on the base of the presented assumptions and clinical observations have led to final outcomes satisfying both patients and the team of surgeons and physiotherapists. Słowa kluczowe

kończyny dolne, złamania, gwoździowanie śródszpikowe, koordynacja Streszczenie

Artykuł przedstawia model postępowania rehabilitacyjnego u pacjentów ze złamaniami kończyn dolnych leczonych metodą gwoździowania śródszpikowego, stosowany w Klinice Ortopedii i Traumatologii Narządu Ruchu Collegium Medicum UJ. Gwoździowanie śródszpikowe jest jedną z podstawowych metod zespoleń kostnych. Jej ewolucja spowodowała znaczne rozszerzenie wskazań do jej stosowania, zwłaszcza w kończynie dolnej. Bez względu na metodę leczenia, kaŜde złamanie ma pewne konsekwencje dla pacjenta związane z towarzyszącym urazem tkanek miękkich czy zmianą chodu w wyniku ograniczeń obciąŜania kończyny. Obok ogólnych załoŜeń stosowania zespoleń śródszpikowych w obrębie kończyny dolnej, w niniejszej pracy przedstawiono metody rehabilitacji pacjentów po zespoleniach śródszpikowych złamań kończyn dolnych. Omówiono istotne załoŜenia rehabilitacji po zespoleniach śródszpikowych złamań bliŜszego końca kości udowej oraz złamań trzonu uda i piszczeli ze szczególnym uwzględnieniem podejmowania decyzji odnośnie obciąŜania kończyny. Szczególny nacisk połoŜono na znaczenie w postępowaniu usprawniającym ćwiczeń poprawiających koordynację ruchową. Programy rehabilitacji indywidualnie dobrane w oparciu o przedstawione załoŜenia i obserwacje kliniczne są niezbędnym uzupełnieniem procedur operacyjnych i prowadzą do wyników leczenia satysfakcjonujących tak pacjentów jak i zespół lekarzy i fizjoterapeutów.

Intramedullary nailing is a well known method of surgical stabilization of bone fragments. Since the early 1940s , when nailing was introduced

by Gerhard Küntscher, this method has evolved and after many changes and improvements has become a „golden standard” in the treatment of long

bone shaft fractures. Nowadays intramedullary locked nails reamed or undreamed are used as a basic form of bone fragments fixation both in

The individual division on this paper was as follows: A – research work project; B – data collection; C – statistical analysis; D – data interpretation; E – manuscript compilation; F – publication search; G – grant and funding acquisition Article received 19.05.2011; accepted: 05.08.2011 Medical Rehabilitation e ISSN 1896-3250 © ELIPSA-JAIM & WSA Bielsko-Biała

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Medical Rehabilitation 2011, 15 (2), 13-19

fractures and bone union disorders. The human musculoskeletal system consists of many levers enabling precise motions and transferring1. Muscles provide the driving force. Surgical procedure restores the biomechanical consideration of proper musculoskeletal system functioning. In order to restore a proper function the introduction of immediate rehabilitation is crucial. This article presents schema and basic guidelines of rehabilitation of patients with lower extremities injuries treated with intramedullary fixation in the Orthopaedics and Motion System Trauma Clinic of the Jagiellonian University’s Collegium Medicum. The aim of the fracture treatment, besides bone union of bone fragments, is restoration of function for the injured extremity. In the case of long bones (femur, tibia, humerus) the proper function is determined by correct length and the shaft axis . The length of the shaft determines the distance between muscles attachments which in turn determines their physiological strength. The shaft axis leads to the proper spatial relationships between the joints in the adjacent vicinity in order to achieve the optimal transferring of loadings. In the case of long bone shaft fractures anatomical reduction of the bone fragment is not necessary. The function of extremity will be achieved by a restoration of length and shaft axis and by the elimination of rotational displacements of bone fragments. The intramedullary nail restores the length and axis of the bone, locking bolts prevent shortening of the shaft and rotational displacements. As a method of bone fragment fixation intramedullary nails present some indisputable advantages. The introduction of an implant does not require the opening of the fracture side, and in consequence, evacuation of haematoma which is rich in factors stimulating bone union. They also preserve the periosteal blood supply, which is crucial for the vitality and healing of bone fragments. The surgical approach required for intramedullary nailing is not extended and localized out of the fracture zone. Subsequently it does not cause additional harm to soft tissues within the fracture zone, is 14

less burdening for the patient and decreases the risk of infectious complications. Fixation with intramedullary nails is also defined as internal splinting providing the relative stability of bone fragments leading to so called secondary bone healing with the formation of bone callus. Properly performed intramedullary nailing, together with appropriate rehabilitation is an effective way of long bone shaft fractures treatment leading to a shortening of hospitalization time to 3-4 days in the case of tibial shaft fractures and 4-5 days in the case of femoral shaft fractures. The largest group of indication for intramedullary nailing are femoral fractures. The introduction of so called cephalocondylar nails, with a possibility of proximal locking in the femoral neck, nails like Gamma, PFN, PFNA and nails applied by retrograde technique through the knee joint, practically cover the whole spectrum of femur fractures. In the case of unstable trochanteric fractures the application of a Gamma or PFN nail markedly eases the surgical procedure by a less extended surgical approach, shorter time of surgery and decreased blood lose. This kind of fixation has also better biomechanical properties comparing with extramedullary implants like DHS, Medoff’s plate or an angular blade plate (Fig. 1). The post-operative aftertreatment consists of a quick return to an upright position, maintaining or restoration of proper patterns of movements and learning to walk with appropriate weight bearing in the operated on extremity. Fractures of the proximal part of the femur appear mainly in the elderly. The aim of rehabilitation is to teach a patient such way of functioning which is as close to normal as possible and safe for the fixation of bone fragments. After such an injury patients walk on a stiff and straight extremity. They avoid flexion of the hip joint and plantar flexion of the ankle joint because they are afraid of pain. Introduction of coordination exercises prevents wrong patterns of locomotion. Wrong patterns of locomotion can be arosed due to the compensation mechanisms following soft tissues injuries. Coordination is a differentiating of movements based on analysis of infor-

mation from proprioreceptors2,3. The introduction of exercises improving coordination leads to more effective work of the muscles, allows one to decrease energy expenditure and simultaneously increases the general fitness of the organism4,5. The better the fitness level the higher the patients’ willingness for movements, which allows them to achieve higher organism efficiency. The proper choice of supporting equipment allows for a quick and safe placing of patients into an upright position. Providing support of the whole femur and foot is crucial during the passive bringing of a patient to an upright position. In such a situation the fracture site is in an isolated position which allows the patient to control the operated on extremity. This position also allows patient to assess the localization of the extremity (thanks to skin mechanoreceptors) which subsequently leads to a relaxation of the muscles3,6. Relaxation of muscles provides better blood supply in the extremity and decreases the feeling of pain in the fracture zone or the postoperative wound. The proper height of the seat and support of the feet is important. The height of the seat should be chosen in such a way so as to provide flexion in the hip joints of no more than 90º - this mean that the knee joints should be at the level of the hip joints or a bit lower. This position leads to the proper alignment of the spine when sitting. Different changes in the spine are observed in a patient, that is why the proper and comfortable support of the back is important. This allows one to avoid a kyphotic position of the spine, which decreases diaphragm movements leading to dyspnoea, which should be differentiated from cardiac angine. A comfortable position increases the feeling of security, makes sitting time longer and allows the introduction of exercises. If a patient tolerates sitting well the safe transition into an active upright position can be done. Using a high walker for the first active upright position decreases the patient’s effort. Supporting the patient on whole length of the forearms allows for no weight bearing thanks to the use of the upper extremity girdle muscles. This

Medical Rehabilitation 2011, 15 (2), 13-19

Figure 1 Comparison of biomechanical properties of extra- and intramedullary implants. In the case of extramedullary implants the lever of compressing forces (a) is longer.

allows one to avoid the bad habit of bending the upper extremities during the transmission of body weight. The taking of a safe upright position by a patient allows the introduction of exercises mobilizing the ankle, knee and hip joints, and leading to a reestablishing of the individual stereotypes of movements occurring during gait6,7. Providing proper conditions to maintain the body balance during

walking without weight bearing, if necessary, is equally important6,8. The organ of balance provides the information for the nervous system necessary for controlling the muscles3,9. Facilitation in maintaining balance with four additional supporting points provided by the walker, allows patients to walk longer and longer distances, while the pattern of locomotion without weight bearing of the injured extremity is the same in the case

of using a walker or crutches. If a patient efficiently uses a short walker it is possible to introduce crutches which allow for daily activity before bone union10. (Fig. 2) Exercises providing the proper length of muscles increase the range of joint motion in the vicinity and allow for a re-education of correct patterns of motion1,4. To achieve this aim postisometric relaxation and/or selfaid exercises are used. Well choosen self-aid exercises are most effective because they can be repeated by patients alone several times a day. One of the most important element of aftertreatment, after the intramedullary fixation of an unstable trochanteric fracture is making the decision on partial or full weight bearing, which is not easy, because the majority of these fractures occur in the elderly. Walking with partial or without weight bearing is particularly difficult in this group of patients. That is why the careful choice of supportive equipment (a walker or crutches), while taking into consideration individual capabilities, is so important. But in the case of weight bearing the performed type of fixation is crucial, because it should allow weight bearing immediately after surgery. To achieve such a situation the following requirements should be fulfilled: proper assessment of the fracture type, proper choice and proper application of implant and in the case of osteoporotic bone also augmentation with bone cement. Radiological signs of arising bone union, such as an erasing fracture gap or callus formation, entitles one to make a decision on gradually increasing the weight bearing. In the case of stable fractures partial weight bearing, mean-

Table 1

Time scheme for rehabilitation following the fracture of the proximal end of the thigh bone 1-2 day

2-4 day

from day 4 onwards

Breathing exercises

Continuation of exercises from the previous stage

Continuation of exercises from the previous stage

p-thrombotic exercises

Active tilting/straightening

Gait correction

Self-aiding exercises for bending Exercises increasing the scope for movement in the in the hip joint hip and knee joints

Learning to walk up stairs

Passive tilting/straightening

Coordinating exercises

Learning self service

Burdening of the extremity with up to 30-40% of body weight during the first attempts at straightening

Further increases in burden on the basis of

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Medical Rehabilitation 2011, 15 (2), 13-19

Figure 2 Bringing patient up to the vertical position with the aid of a high and low walker

ing 30-40% of body weight, can be introduced during the first attempts at bringing the patient to an upright position. In such cases walking with the aid of one crutch begins after 3 month from the date of surgery. Exercises with the use of a bath balance are very useful in teaching patients how to gradually increase the weight bearing of an injured extremity. Thanks to them patients are able to recognize the allowed load and become familiar with it.

In the case of femur fractures treated with an intramedullary nail, the aftertreatment and rehabilitation depend on the general status of the patient. It should be remembered that 36% of femur fractures occur in polytrauma patients, while in 25% these are open fractures. In these cases the standard aftertretment cannot be established because it should be carefully planned in detail individually for every patient.

Restoration of a proper gait pattern is the aim of rehabilitation. Compensatory mechanisms occurring during the time of bone union allow patients to move quickly. Anyway patients avoid flexion in the hip and knee joint. The lower extremity is positioned with the hip in external rotation and the lack of hyperextension in this joint is compensated for in the lumbar part of the spine. In isolated fractures of the femoral shaft, fixed with an intramedullary nail, rehabilitation should focus on restoration of the muscle functions responsible for flexion of the lower extremity joints during locomotion. The applied program of rehabilitation should allow for normal functioning once the surgical treatment is over11. Femur fractures are always accompanied by muscles destruction caused by bone fragments. The process of soft tissues healing is based on substitution of the injured structures, regardless of their kind, with fibrous scar connective tissue. It was proved that the amount of collagen in the wound between the 3rd and 4th week from the date of injury is constant and the arrangement of fibres depends on the mechanical forces acting on the wound. Muscle or tendon tension during exercises facilitates the creation of intercellular connections and leads to the longitudinal arrangement of fibres, which provides resistance to elongation. Nevertheless, excessive elongation of the wound leads to reinforcement of the intercellular connections and decreased mobility, because scar tissue fulfilling the wound has no ability to contracture as muscle12. The providing of proper elasticity is cru-

Table 2

Scheme for rehabilitation in a fractured hip shaft 1-4 weeks

From 4 weeks onwards

Mobilization of the patella

Massage or mobilization of transverse scars

Exercises increasing movement scope in the hip and knee joint

Exercises strengthening in closed kinematic chains the muscles of the lower extremity and the pelvic girdle

Active exercises in an open kinematic chain of the pelvic girdle muscles

Exercises re-educating proprioception

Exercises in closed kinematic chains of the muscles of the lower Introduction of quick alternating movements extremities

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Re-education of the correct gait stereotype

Control of muscle balance (length and strength)

In stable fractures burdening during the first attempts at tilting/ straightening within a painless scope of activities

Gait correction In unstable fractures partial burdening following the appearance of the first symptoms of bone adhesion

Medical Rehabilitation 2011, 15 (2), 13-19

Table 3

Time scheme for rehabilitation in fractures of the shin bone 1-2 days

From day 2 onwards

p-thrombotic exercises

Exercises strengthening and maintain the movement scope of the pelvic girdle

Tilting/straightening

Exercises strengthening lower leg muscles

Mobilization of patella

re-educating proprioception

Active exercises of plantar and back bending in the tarsal joint

Gait correction

Exercises increasing movement scope in the knee joint In stable fractures burdening during the first attempts at tilting/ In unstable fractures partial burdening following the appearance straightening within a painless scope of activities of the first symptoms of bone adhesion

cial both for the supporting and locomotive function of the operated on extremity. In this case rehabilitation is long and requires patience both from side of the patient and therapist. Regardless of the type of fracture, the application of intramedullary nails allows for the immediate introduction of movements in the operated on extremity, and mobilization of soft tissues is provided by motions in two joints in the vicinity. In the first period, 3 – 4 weeks after injury, exercises leading to a proper ROM of knee and hip joints are introduced4. Additionally, due to the long period of non-weight bearing, exercises increase the force of the muscles stabilizing the pelvic ring, and ones responsible for proper gait are applied. After a functional ROM of knee (0º110º) and hip joint (0º-100º) are achieved, exercises are introduced increasing muscle strength in closed kinematic chains. Exercises of this kind are easier for patients, for they allow careful and fully controlled motion and can be performed without weight bearing. In order to make the scar more elastic (especially in the case of open fractures) massage and crosswise mobilizations can be useful (but only 3–4 weeks after surgery)12. The effects achieved by the patient are used for the correction of gait. Patients walking without weight bearing should present the proper position of the foot on the soil with the preservation of the propulsion movement, this means the “rolling” of the foot on the base. Maintaining of this movement in the ankle joint prevents shin limphoedema and stimulates the musculovascular pump. It decreases also the decalcification of lower extremity

bones, which arises due to the lack of weight bearing. The program of rehabilitation is chosen individually as a result of the degree of soft tissues damage and the patient’s age. In the case of soft tissue damage the restoration of muscles strength can be expected between the 7th and 10th day, depending on the extension of the injury, and the presence of haematoma and oedema. The number of repetitions is adjusted according to the patient’s efficiency and fitness. A feeling of tiredness and the appearance of pain should be avoided. Short but frequent series of repetitions are used, especially in the after-surgery period. The decision on weight bearing in femoral shaft fractures depends on the morphology of the fracture. In stable fractures of type A and some type B according to AO CCF, proper fixation with a locked intramedullary nail allows for partial weight bearing directly after surgery, this means that during the first attempts at an upright position the after effects of analgesia have subsided. In these fractures after reduction and fixation the contact between the cortices of the main bone fragments is maintained, and the transmission of loadings occurs through the bone. In these fractures, an intramedullary introduced implant is the only loads sharing device. Subsequently there is no possibility of its mechanical failure and destabilization of the fixation. In comminuted, unstable fractures of type C and some type B after reduction and fixation there is no, or minimal contact between the cortices of the main bone fragments. In such a situation loadings are transmitted only through the nail and lock-

ing bolts in the main proximal and distal fragment. In these fractures early weight bearing can lead to locking bolts breakage, breaking of the nail, shortening of the extremity and fixation failure. Decision making considering weight bearing in such fractures is based mainly on radiological findings. A patient can walk without weight bearing until the first radiological signs of arising bone union, like callus formation or an erasing fracture line, appear. The degree of weight bearing is increased according to the results of consecutive follow up examinations. Usually after 2 months the bone callus bridging the fracture zone allows for weight bearing in the order of 30-40% of the body weight. The absence of signs of destabilization and further callus formation allows one to increase weight bearing to up to 50% of the body weight and walking with a single crutch. In the case of nails introduced from the side of the knee joint via a retrograde technique it is important to maintain the range of knee motion to where the entry point and surgical approach is localized. This situation requires the introduction of passive exercises (with the use of CPM devices), and then active exercises as soon as possible14. Tibia fractures have their own specificity due to the poorly developed soft tissue coverage. Practically 1/3 of the tibia is covered only by skin and a various amount of subcutaneous tissue. That is why intramedullary nailing, as a method which does not cause secondary soft tissues damage, is considered as the method of choice in tibial shaft fractures. Anterior knee pain syndrome – pain localized in the 17

Medical Rehabilitation 2011, 15 (2), 13-19

patellar region, is an issue concerning tibial fracture intramedullary nailing requiring a special remark. The appearance of anterior knee pain is related to the incorrect, non-complete introduction of a nail into the medullary cavity (Fig. 3) If the proximal part of the nail is left above the bone surface it may irritate the patellar tendon causing the above mentioned syndrome. Only in the case of a prominent sticking out of the nail, is its removal indicated. Usually after a proper physiotherapy (massage, taping, warmth or criotherapy) this syndrome subsides. This type of therapy uses the so called „control gate mechanism”15. Sensory nerves have a higher speed of impulse transmission than nerves responsible for the perception of pain. Intensive stimulation of sensory nerves causes the inflow of information to be analysed on the level of the spinal cord, locking at the same time the transmission of pain impulses to the central nervous system. If the nail is removed additionally electrotherapy can be applied in the form of interference currents (90-100 Hz/5 min, 0-100 Hz/10 min), asymmetric Tens (impulse 50µs, frequency 100Hz, time 10 min). The aim of rehabilitation in tibial shaft fractures is to restore neuromuscular coordination and proprioception. Patients avoid plantar flexion of the foot when walking and keep the foot in dorsal flexion to protect themselves from bumpy ground. This position causes increased tension of the quadriceps muscle, leading to a limitation of knee ROM and the walking on a stiff and straight extremity, without propulsion of the foot, and to an increased tension of the quadratus lumborum muscle on the operated side. That is why the choice of exercises should be mainly determined by restoration of proper proprioreceptor and exteroreceptor reaction allowing a maintaining of the correct pattern of gait1,6. Because the strength of muscle contracture depends on the amount of impulses and the frequency of their repetition, it is crucial during exercises to provide impulses for agonistic and antagonistic muscles1,6. Decision making concerning weight bearing in tibial shaft fractures is based on the same rules as in femoral 18

Figure 3 Wrong introduction of the nail into the medullary cavity

Figure 4 WrImplant failure due to early weight bearing in an unstable tibial shaft fracture

Medical Rehabilitation 2011, 15 (2), 13-19

shaft fractures. Stable fractures can undergo weight bearing of up to 30- 40% of body weight directly after surgery while unstable after the radiological signs of bone healing have appeared.(Fig.4) The treatment of femur and tibia fractures with intramedullary nailing together with properly chosen rehabilitation shortens the time of hospitalization and leads to optimal outcomes. References 1. Bober T., Zawadzki J.: Biomechanika układu ruchu człowieka. Wyd. BK Wrocław 2006 2. Lephart S.M., Pincivero D.M., Rozzi S. L.: Proprioception of the ankle and knee. Sports Med. 1998 Mar; 25(3): 149-55 3. DoleŜych B., Łaszczyca P.: Biomedyczne podstawy rozwoju z elementami higieny szkolnej. Wyd. A. Marszałek Toruń, 2005 4. Coutts F.: Gait analysis in the therapeutic environment. Man Ther. 1999 Feb; 4(1): 2-10 5. Gąsiorowski A.: Anatomia funkcjonalna narządu ruchu człowieka. Wyd. UMCS Lublin, 2006 6. Błaszczyk J.W.: Biomechanika kliniczna. PZWL Warszawa, 2004 7. Janiszewski M., Rechcińska-Roślak B., Błaszczyk-Suszyńska J.: Chód. Część I: Analiza biomechaniki chodu w rehabilitacji. Fizjoter. Pol. 2002; 2(4): 311-318 8. Mynarski W., śywicka A.: Empiryczny model koordynacyjnych uwarunkowań motoryczności człowieka. AWF Katowice, 2004 9. Raczek J., Mynarski W., Ljach W.: Kształtowanie i diagnozowanie koordynacyjnych zdolności motorycznych. AWF Katowice, 2003 10. Bryan L.R., Myers J.B., Lephart S.M.: Comparison of the ankle, knee, hip, and trunk corrective action shown during single-leg stance on firm, foam and multiaxial surfaces.; Arch Phys Med Rehabil. 2003; 84(1): 90-5 11. Paterno M.V., Archdeacon M.T.: Is there a standard rehabilitation protocol after femoral intramedullary nailing? J Orthop Trauma. 2009; 23(5 Suppl): S39-46 12. Lee D.: Badanie i leczenie okolicy lędźwiowo-miedniczno-biodrowej. DB Publishing, 2001 13. Winter D.A.: Human balance and posture control during standing and walking.: Gait & Posture, 1995; 3: 193-214 14. Salter R.B.: The biologic Concept of continous passive motion of synovial joints. Clin Orthop Relat Res. 1989; 242: 12-25 15. O’Driscoll W.S., Giori J.N.: Continuous passive motion (CPM). Theory and principles of clinical application.; J Rehabil Res Dev. 2000; 37(2): 179-88

Address for correspondence Jarosław Brudnicki MD PhD ul. Jaracza 24/20, 31-215 Kraków, Poland phone: +48-606-994-909 e-mail: [email protected]

Translated from the Polish by Jarosław Brudnicki

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