The New Challenges of Physical Therapy for External Fixation Treatment of Fractures*

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1 /81/0204-Ol71$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O 1981 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association The New Challenges of Physical Therapy for External Fixation Treatment of Fractures* PETER LALLY, PT, DAVID SELIGSON, MD, T. SCOTT STANWYCK, MS External fixation, the restoration of skeletal integrity using pins connected by an external support, had its birth in the mid- 1800's. Recent improvements have caused a resurgence of interest in this art when dealing with complicated fractures. The health team is involved in enhancing the benefits gained from this method of fracture management. The physical therapist works in conjunction with the orthopaedic surgeon to achieve maximal rehabilitation of the injured limb. Rehabilitation includes functional training and education concerning limitations and daily care of the patient apparatus. In 1850, Professor Rigaud of Strasbourg treated a fracture of the olecranon by placing a screw in the piece held by the triceps and another screw in the ulna. "I brought together and held the two screws and the fragments with a simple string. I let the arm hang alongside the body without an appliance. At the end of two months I took the screws out and the cure was perfe~t."~ This early example emphasized two basic principles of external fixation-the reestablishment of skeletal continuity and the functional rehabilitation of the patient. External fixation is a method for fixing fractures by placing pins in bone and then clamping these pins in a frame. Recent improvements in materials, design, pin care, and antibiotics have revived interest in this method of fracture management, particularly for fractures complicated by significant soft tissue damage, bone loss, or infe~tion.~ Currently, there are several types of external fixateurs in use, such as the Wagner, Kronner, Roger Anderson, and Hoffman devices. The Wagner unit is a uniaxial design utilizing halfpins while the Kronner is biaxial in design and uses transfixation pins. The Roger Anderson and the Hoffman can be used in either uniaxial or biaxial modes. The use of a uniaxial versus a biaxial fixation system is based upon the amount * From the Departments of Physical Therapy and Orthopaedic Surgery. University of Vermont College of Medicine. Burlington, VT of rigidity the surgeon wants to achieve across the fracture site. The double-framed fixateur provides a rigidity equal to or superior to bone and is used with comminuted fractures and pseudoarthroses.' Variation in the design of these devices provides different degrees of adjustability. Depending on the fixateur used, the frame may be angled, shortened, rotated, or lengthened after application to the fractured bone to insure proper alignment. Proper alignment and adequate restriction of motion at the fracture site have been appreciated as early as The various fixateurs have different inherent stiffness; however, the general stiffness of the montage is proportional to the number of pins used, although the bone can be weakened if too many pins are used.' The benefits of external fixation are wound accessibility, early mobility, decreased muscular atrophy, and decreased chance of infection, all contributing to decreased morbidity. The role of the therapist in managing a patient treated with an external fixateur is to maximize these benefits gained from this choice of treatment and to return the patient to his highest functional level. A therapist's interaction with the patient includes the following: educating the patient about the mechanics, limitations, and proper care of the device; reassuring the patient and answering in times of doubt; and applying mo dalities and treatment techniques to allow contin-

2 172 LALLY ET AL JOSPT Vol. 2, No. 4 ued joint mobility and to maintain muscle tone and circulation. CASE STUDIES Greg S., a 24-year-old male, suffered a comminuted fracture of the right femur (Fig. 1 ). After debridement and open reduction, a Vidal-Adrey double-framed fixateur was applied. Groups of pins were inserted through the skin, muscle, soft tissue, and bone, both proximal and distal to the fracture site (Fig. 2). In addition, the patient had a thoracic contusion which made breathing and movement painful. Initial physical therapy sessions were done at bedside, due to his chest condition. They included active-resistive range of motion exercise in all of his noninvolved extremities. His right lower extremity was suspended above his bed by connecting ropes with weights directly to the external frame. Active motion of the knee and hip joints was limited by the protective positioning which prevented the leg from becoming dependent. Range of motion in the other joints of Fig. 1. X-Ray showing comminuted fracture of the right femur

3 JOSPT Spring CHALLENGES FOR EXTERNAL FIXATION 173 Fig. 2. X-Ray showing groups of pins inserted both proximal and distal to the fracture site the right lower extremity was within normal limits. Isometric exercises of the right thigh musculature caused a burning sensation around the pins as a result of the muscles pulling on the underlying soft tissue. As the soft tissues adapted, the pain subsided. During chest therapy, the therapist elevated the head of the bed to a level comfortable to the patient and went over breathing techniques (diaphragmatic, intercostal) to help prevent pulmonary problems such as pooling of secretions in the lower lobes of the lung. As Greg's general condition improved, education concerning the importance of daily pin hygiene was added in these sessions. Pin care, done by the therapist initially and later by the patient, prevents abscesses from forming around the pins and thus decreased the chance of pin tract infection by allowing drainage to the outside. Pin care included removing the eschar and any pus, applying hydrogen peroxide with a cotton swab, and drying the pins with a clean gauze sponge. Five days after Greg's accident, his chest condition was determined to be medically stable. At

4 174 LALLY ET AL JOSPT Vol. 2, No. 4 this time, his physician ordered non-weight-bearing gait training with crutches; current fixateurs are not designed for weight bearing. Initially, there were problems with coordination because the inside frame made it awkward to swing his left leg forward. With practice, his gait became smooth-flowing, and stair and transfer training were initiated. Getting in and out of the bathroom and shower, getting into and out of bed, getting clothes on and off, as well as performing other activities of daily living, were mastered by Greg before his hospital discharge. Prior to discharge, Greg was instructed in a home exercise program consisting of: isometric exercises with the right thigh and gluteal muscles in the supine position and range of motion exercises of the knee in the sitting position. In Greg's case, the fixateur was removed at 16 weeks, and the limb was protected in a cast brace. At 1 year, the fracture was solidly healed (Fig. 3). The second case illustrates how this treatment technique assists the therapist in managing a patient with multitrauma in a concentrated area. Fig. 3. X-Ray showing fracture solidly healed

5 JOSPT Spring CHALLENGES FOR XTERNAL FIXATION 175 Keith B., a 41-year-old sawmill worker, lost a chunk of skin and soft tissue from the back side of his left leg and fractured his left tibia when he fell onto a circular saw blade. Following debridement and open reduction, a Hoffman doubleframed fixateur was applied. Groups of pins were inserted through the skin, muscle, soft tissue, and bones of the foot and tibia. The pin location was both proximal and distal to the site of bone damage. The stabilization of the fracture with the external fixateur allowed the area to be submerged in a whirlpool during physical therapy session (Fig. 4). The whirlpool bath contained diluted Dakin's solution, an antibacterial agent. The water softened the eschar and made the removal of the gauze dressing and the debridement of necrotic tissue less painful. Active ROM exercises of the toes were also done in the whirlpool. Fig. 4. Fracture area stabilized with the external fixateur submerged in a whirlpool. Following hydrotherapy, the left lower leg was dried with a sterile towel. Sterile gauze pads soaked with saline solution were then applied directly over the wound area. Early wound accessibility permitted immediate medical intervention to control infection. Hydrotherapy prevented pin tract infection by maintaining an opening around the pins so that drainage to the outside could occur. Active range of motion exercises with the left lower extremity and hydrotherapy increased the circulation to the wounded area. This results in the removal of infected secretions from the area and maintains a balance in favor of healthy granular tissue formation, setting the stage for skin coverage with free grafts. When the fracture finally heals, the fixateur is removed, and final rehabilitative therapy will be administered. DISCUSSION The physical therapist is involved in all stages of the healing process of a fracture treated with external fixation. In the acute phase, the goals are to avoid secondary complications such as decreased pulmonary function and decreased vasomotor control. In the subacute phase, the therapist educates the patient about daily pin care and the mechanics of the fixateur. The therapist works with the patient to maintain strength and range of motion in the uninvolved limbs. Active range of motion exercises of the unaffected joints of the involved extremity prevent joint degeneration and stiffening. Also, isometric exercise of the muscles surrounding the fracture prevent their atrophy. Functional rehabilitation is instituted so that the patient is better able to carry out daily activities after hospital discharge. Functional rehabilitation means returning a limb to activity within the mechanical limitations of the device being used. This includes gait, stair, and transfer training. The patient is initially taught correct three-point gait. Then, preparatory to hospital discharge, functional daily activities are stressed. After discharge, the physician monitors fracture union by routinely taking X- rays on an outpatient basis. Once partial bony union is observed, the patient is referred to a physical therapy clinic, where he learns partial weight-bearing four-point gait. At this time, active resistive exercises with the involved limb are also initiated to increase muscular strength.

6 176 LALLY ET AL JOSPT Vol. 2, No. 4 There are several possible routes that can be taken to regain full function of the limb. All of these routes allow increased load bearing by the bone as it heals by reducing load sharing by the fixateur. This can be accomplished by adjusting the fixateur gradually so that it provides less and less support or by completely removing the fixateur and replacing it with an alternative splinting device, such as a cast or cast brace. At this point, the physical therapist educates the patient in the use of his changing treatment regimen, which normally includes weight bearing to tolerance. CONCLUSION The increasing use of external fixateurs to salvage limbs which might have been amputated a short while ago will provide challenging prob- lems in physical therapy. It is necessary for therapists to know the limitations of the fixateur, as well as the treatment protocols, in order to prevent complications and to provide reliable rehabilitative care. REFERENCES 1. Burney F: Elastic external fixation of tibia1 fractures: study of 1421 cases. In: Brooker AF, Edwards C (eds), External Fixation: The Current State of the Art, pp Baltimore: The Williams i3 Wilkins Co Burney F. Bourgois R: Etude Biomechanique du Fixateur Externe d'hoffman. Acta Orthop Belg 38: Cucuel U, Rigaud U: Des Vis Metalliques Enfoncees dans le Tissue des 0s. pour le Traitment de Certaines Fractures. Revue Med Chir Paris 8: , Mears DC: History of external fixation. In: Brooker AF. Edwards C (eds). External Fixation: The Current State of the Art, pp 3-8. Baltimore: The Williams i3 Wilkins Co Smith HH: Treatment of ununited fractures. Am J Med Sci 29: , 1855