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Sunday, 11 September 2011


Principles of fracture < Rehabilitation >

Improved results in the treatment of fractures owe much to rehabilitation, perhaps the most important of the three great principles of fracture treatment. Reduction is often unnecessary; immobilisation is often unnecessary; rehabilitation is always essential. In Britain, much of the credit for early enlightenment on the
principles of rehabilitation must go to Watson-Jones.
Rehabilitation should begin as soon as the fracture comes under definitive
treatment. Its purpose is twofold: first, to preserve function so far as possible
while the fracture is uniting and second, to restore function to normal when the
fracture is united. This purpose is achieved not so much by any passive treatment as by encouraging patients to help themselves.
The two essential methods of rehabilitation are active use and active exercises. Except in cases of minor injury, the patient should, ideally, be under the
supervision of a physiotherapist throughout the whole duration of treatment.

Active use
This implies that the patient must continue to use the injured part as naturally
as possible within the limitations imposed by necessary treatment (Fig. 3.17).
The degree of function that can be retained depends upon the nature of the
fracture, the risk of redisplacement of the fragments, and the extent of any
necessary splintage. Although in some injuries rest may be necessary in the
early days or weeks, there should be a graduated return to activity as soon as
it can be allowed without risk.

Active exercises
These comprise exercises for the muscles and joints. They should be
encouraged from an early stage. While a limb is immobilised in a plaster or
splint, exercises must be directed mainly to the preservation of muscle function
by static contractions. The ability to contract a muscle without moving a joint
is soon acquired under proper supervision.
When restrictive splints are no longer required, exercises should be directed
to mobilising the joints and building up the power of the muscles. Finally,
when the fracture is soundly united, treatment may be intensified, movementsbeing carried out against gradually increased resistance until normal power is
Although every adult patient with a major fracture should attend for
supervised exercises as often as possible, it should be impressed upon the
patient that this organised treatment plays only a part in the rehabilitation, and
that much—indeed most—depends upon continuing normal activities so far as
possible when the patient is away from the department. Physiotherapy is often
enormously helpful, but it should supplement, not supplant, the patient’s own
independent efforts (Figs 3.18 & 3.19).So far as children are concerned, supervised exercises are relatively
unimportant, and in most cases children may safely be left to their own
endeavours, aided when necessary by encouragement from the parents, who
should always be fully informed of the programme of treatment and the likely
course of events.
Continuous passive motion
In the knowledge that movement between joint surfaces favours the preservation of healthy articular cartilage, surgeons and biomechanical engineers
have designed machines that provide continuous to-and-fro movement at a
joint without any effort on the part of the patient. The range of movement can
be varied as required, being increased gradually as the joint becomes more
mobile. This technique of exercising joints passively has many applications: it
is particularly valuable in situations where restriction of mobility tends to be
hard to overcome, for instance in the knee after fracture of the femoral shaft or
after the operation of quadricepsplasty.

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