Rehabilitation of Fractures in Disasters and Conflicts

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Introduction

A fracture is a discontinuity in a bone (or cartilage) resulting from mechanical forces that exceed the bone's ability to withstand them, and are one of the most common injuries seen in disaster and conflict settings, with at least one fracture seen in half of the patients presenting for treatment. The number and type of fractures vary depending on the type of disaster or conflict but in general during disasters and conflicts patients present with multiple injuries, with open and complex fractures common, which can complicate your rehabilitation plan.

Given the surge in demand for health services following disasters and conflicts, triage systems are employed whereby following initial evaluation the injured are placed into a specific category based on the probability of survivorship and severity of injury. In the case of fractures those with non-life threatening fractures may have definitive treatment delayed where there is no risk of significant subsequent morbidity or following treatment may be discharged very quickly following application of a cast or splint and even following orthopaedic surgery so rehabilitation professionals need to maintain close contact with the medical team in order to assess those with fractures prior to discharge.

Types of Fracture

Earthquakes in particular cause a significant burden of injuries, mainly of the limb, with fracture incidence shown to correlate with the Richter Magnitude Scale, where high-energy earthquakes cause more fractures. MacKenzie et al found that fractures accounted for 65% of the total injuries following earthquakes with lower extremities fractures accounting for 59% of those injuries. Bortolin et al found that 10% of fractures involved the pelvic ring, while spinal column fractures accounted for 17% of the total injuries, with more than 4% of these involving spinal cord injury.

Wounds obtained in armed conflict have their own specific epidemiology and demand principles of management that sometimes differ from civilian practices. In conflict settings the type of fractures will depend on the mechanism of injury and the type of weaponry used which can include gunshot wounds, knife, blast, shrapnel and landmine injuries, with poly-trauma including open fractures with bone and soft tissue injury common, which increases the risk of contamination of the fracture site and wound infection.

High-energy trauma, such as those seen in crush or blast injuries are often associated with fracture such as pelvic fractures that can also result in significant blood loss and poly-trauma that can be more complex to manage, and in many cases less likely to survive in disaster and conflicts settings. Where they do survive, they tend to have extensive associated injuries including severe soft tissue damage and organ damage, or spinal cord injury, which may further limit early rehabilitation and require significant discussion with the medical team to understand precautions and limitations prior to any assessment of treatment.

Given the range of fractures that can be seen within disaster and conflict settings it is important to have an understanding of common features of different types of fracture in order to understand the implications this may have for early rehabilitation.

1. Ensure you have information about the location of the fracture;
   • Is it through the bone shaft,
   • Into a joint or
   • Are there multiple fractures along the bone?
2. Assess for Deformity;
   • Is the bone in alignment?
   • Does it have continuity?
   • Did the bone emerge from the skin/soft tissues?
3. Are there any associated injuries?
   • Is the fracture open or close?
   • What is the condition of the surrounding soft tissues? Check the surgical notes and enquire with the medical team for damage to blood vessels or nerves, as they may impact rehabilitation
4. What was Medical or Surgical Management?
   • Are they any precautions or restrictions following management?

Bone Healing Considerations

Having an understanding of approximate timescales for bone healing is important. If we consider simple fractures we know that generally; paediatric fractures will heal most quickly (approximately 3-6 weeks) and adults upper limb fractures (approximately 6 weeks) will heal faster than adult lower limb fractures (approximately 8-12 weeks).

It is important to understand though that while it is helpful to understand approximate timescales of recovery for different fracture types, every patient will be different and in disaster and conflict situations patients may be more likely to heal slowly as a result of a range of factors including;

• Multiple Injuries
• Complex Injuries
• Vascular Injury (Impair Bone Healing)
• Infection (Impair Bone Healing)
• Late or Suboptimal Fracture Management
• Blast injuries / Gun Shot Wounds that leave shrapnel close to the bone have higher rate of delayed or non-union
• Blast or Crush Injuries which cause huge soft tissue damage are likely, (if the limb is salvaged) to heal slowly, due to impaired blood flow, and there is a high likelihood of long-term peripheral nerve injury.
• Patient’s Past Medical History (conditions such as diabetes, which affect vascular supply, will slow or limit healing)
• Smoking Status (Impairs Bone Healing)
• Nutritional Status

Weight bearing status should be discussed with the medical or surgical team, with safe limits determined for the initial phase of their recovery being mindful of the above considerations. Given that bone strengthens in response to the load it experiences, once safe limits are in place from the medical team early rehabilitation should include progressive weight bearing, prioritising the safe limits of weight bearing for the initial phase of their recovery and offer basic advice on when and how they can start to increase their weight bearing at home.

Medical and Surgical Intervention Considerations

Ideally the medical or surgical team will have recorded precautions and contraindications for rehabilitation before the patients is examined by the rehabilitation professional, but this may not always be the case when working in disasters and conflicts where post-operative or medical notes may be limited or not available at all. Prior to reviewing the patient you should try to get as much information from the medical team as you can, and if unsure of anything during assessment or treatment clarify first with the team and ensure to follow all precautions and contraindications.

The following table outlines some of the more common fracture management strategies and possible complications that can occur in disaster and conflict settings.

Intervention	Description	What to Watch for in Disaster and Conflict
Casting	Normally cheap and readily available - Plaster of Paris most commonly used Used to immobilise and protect a fractured bone while it heals. Fit should not be too tight to eliminate blood flow Only apply or assist with application if within your scope of practice	Compartment Syndrome Inappropriate management of Open Fractures and Wounds Undiagnosed Nerve Injury
Internal Fixation	Often contraindicated in conflicts and disasters, due to the risk of infection, suboptimal operating conditions and challenges with long-term follow-up. Should only take place in fixed facility, so less likely to encounter them in field hospital / tented facility.	Infection Failure of Fixation Undiagnosed Nerve Injury
External Fixation	More commonly used in disasters and conflicts Generally used on fractured bone which has fragmented into multiple pieces, or used to temporarily stabilise a patient with multiple injuries until they receive definitive orthopaedic surgery. External fixators may enable earlier weight bearing compared to a cast; however, always check with the surgical team.	Pin Site Infection Wound Infection Insufficient Stabilisation from Fixation Undiagnosed Nerve Injury Inappropriate Pin Placement Through Tendon or Nerves
Traction	Widely used for fractures and dislocations including neck of femur, femoral shaft, displaced acetabulum and some pelvic fractures Temporary measure while awaiting definitive treatment, or when casting unsuitable. Skin Traction Short-term treatment adult femoral fractures Definitive treatment paediatric patients Skeletal Traction Less effective for adults as definitive treatment Effective definitive treatment paediatric hip fracture	Pressure Areas Urinary Tract Infections Chest Infections Foot Drop Contractures Peroneal Nerve Palsy Pin Tract Infection Thrombembolic Events (DVT or PE)

Assessment Considerations

In disasters and conflicts your assessment of a patient with a fracture should follow the same format as a standard rehabilitation assessment, while understanding that those with poly-trauma, pain or post-operative medications may be unable to complete the assessment within one session. Where this is the case, complete the assessment elements that are possible but limit your treatment plan to what can be done safely until you are able to complete a full assessment. Specific considerations that might impact your fracture assessment within disaster and conflict settings may include:

• Limited Medical History including incomplete background information such as weight-bearing status or post-operative notes, which may be due to the emergency transfer of patient, disrupted services and that the patient has been separated from their family.
• Increased Risk of Infection as a result of the mechanism (blast, crush) or the context of the injury (prolonged exposure to dirty water), poor theatre conditions and a contaminated hospital environment, e.g. an emergency camp with limited sanitation services, can also increase the risk of infection. With disrupted care that makes continuity of treatment difficult, leading to extensive or hard to treat infections

NOTE: Only assess the components you feel competent to complete and which fall within your scope of practice

Subjective Assessment

Important fracture specific information to consider during subjective assessment in disaster and conflict settings;

History of Presenting Condition

• Timeline of Injury and Treatment to date
• Mechanism of Injury will indicate the extent of the associated soft-tissue injuries, any possible additional injuries and the risk of complications;
  • High- or low-energy?
  • Any twisting?
• Treatment Information
  • Is the treatment definitive or is further surgery required?
  • Note any post-operative instructions (such as weight-bearing status) from the operation notes or the orthopaedic team.

Social History

• Daily activities that the patient needs to complete for independence;
  • Will the patient need to manage with one hand?
  • Will the patient have to use stairs?
  • Will the patient be able to self-propel a wheelchair (considering environmental and personal factors)?
  • What will the patient sleep on?
  • Does the patient have access to adequate nutrition to support bone healing?

Pain

• Is the pain controlled to allow the patient to move and mobilise (as allowed by the weight-bearing status)?
• Is the pain proportionate to the injury and in the expected location?
• Is the pain coming from an undiagnosed injury or might it indicate a serious complication?

Sensation

Nerve and vascular injuries can occur as a result of high-energy injuries, surgical repair or procedures including internal or external fixators and pressure from splints may all cause nerve injuries so sensation and movement should always be monitored post-operatively as rehabilitation professionals may be the first to pick up these injuries. The following table highlights the fractures that can result in nerve injury.

Injury Type	Nerve Commonly Affected	Clinical Signs
Shoulder Fracture Dislocation	Axillary Nerve	Deltoid Weakness Decreased Shoulder Abduction Decreased Shoulder Flexion Loss of sensation over the lateral aspect of the upper arm (Sergeant’s Patch)
Humeral Fracture Proximal or Shaft	Radial	Wrist Drop Loss of Sensation in first web-space
Humeral Fracture Supracondylar	Median Anterior Interosseus Branch	Loss of Thumb IP Flexion Unable to Perform ‘OK’ sign
Radial Head Dislocation +/- Ulna-Radial Fracture 'Monteggia'	Radial Posterior Interosseus Branch	Loss of Wrist Extension Loss of MCP Joint Extension - All Digits
Fibular Head Fracture Knee Dislocation	Common Peroneal	Foot Drop
Hip Fracture Acetabulum, Fracture Pelvic Fracture	Sciatic Nerve - Posterior Femoral Nerve - Anterior	Foot Drop Decreased Hip Flexion Power Decreased Knee Extension Power

Objective Assessment

Given the increased risks of infections when working with disasters and conflict settings your first role as a rehabilitation professional is to monitor for any current or potential fracture complications either directly related to the fracture itself, related to other injuries sustained or as a result of the environment. Rehabilitation professionals should always perform a neurovascular assessment using the 5 P's following fractures to monitor for compromised blood flow or nerve damage, as neurovascular compromise can lead to permanent injury.

Range of Movement

Both active and passive range of movement should be assessed unless otherwise indicated, with active range always assessed first allowing you to assess both the range and quality of movement of the patient, although in some cases where a patient is unable to complete an active range of movement you might start with active assisted range of movement with the patient controlling the range and speed of movement.

For example, start with the active range of movement following a post tendon repair, so that the patient is in control and pain can be monitored. If the patient lacks full active range of movement that is not due to pain, then passive range of movement can be gently assessed, taking into consideration any soft-tissue structures that will be affected.

Strength

Strength testing following fractures should be completed using the Oxford Muscle Grading Scale/Manual Muscle Testing starting initially with isometric testing and progressing to movement gravity eliminated and then against gravity if permitted.

NOTE: Resisted Movements should be avoided in an Acute Fracture!

Function

Following a fracture it is important to consider how the patient will manage transfers (e.g. lie to sit, bed to chair, sit to stand), mobilise and perform activities of daily living while adhering to weight-bearing restrictions and whether they will require assistive technology (e.g. sliding boards, transfer belt, wheelchair, crutches, walking stick).

Other functional considerations may include the patient’s use of a latrine, bed pan and positioning to relieve skin pressure if they are on bedrest (see positioning guidelines in the ABI chapter and guidelines on avoiding respiratory complications).

Cast / Splint / Dressing

Always check that casts, splints and dressings are not too loss or too tight and that joints (toes and fingers) are not unnecessarily immobilised, particularly during the acute phase of a fracture. Monitor for complications and if infection suspected seek support from medical team.

External Fixators

Always complete pin site care by check pin sites for signs of infections, neurovascular compromise, or pin sites that impale tendons or muscle bellies that could cause pain and reduced range of movement. With clean hands systemically check that all wires and pins are solid and secure, that each nut and bolt is tight, which means you check it from top to bottom, left to right and do it and teach the patient to do it this same way every time.

Use of Scans

If available scans (x-ray, ultrasound) can be useful as part of an assessment if it is within your scope of practice as a rehabilitation professional to read them. If not, then where available read the scan reports and speak someone on the team. Do not attempt to interpret them yourself if outside your scope of practice.

Fracture Blisters

Always monitor for the development of fracture blisters, which are either clear (filled with serous fluid) or haemorrhagic (filled with blood) that usually occur in areas with little subcutaneous tissues, such as the ankle, tibia or elbow. In order to reduce swelling, elevate the limb and leave the blisters alone, as bursting these fracture blisters can increase the risk for infection in disaster and conflict settings. Educate the patient about fracture blister management and inform the medical team.

Outcome Measures

As in standard setting the most frequently used outcome measure in acute fracture management include range of movement, muscle strength and functional goals and given the complexity of care within disaster and conflict settings should be quick and simple to administer and easily repeatable.

Treatment Considerations

Given that most of the patients you see with in disaster and conflict settings are complex with multiple and unique injuries the priority for treatment in the early rehabilitation phase is to focus on the joints and muscles that are required for initial functional movements such as sitting up and getting out of bed.

As with standard care ensure adequate pain control prior to start any treatment and always beware of potential complications and red flags, which may not become clinically apparent until the patient begins to move.

Summary

Complex poly-trauma presentations frequently complicate the assessment and early rehabilitation of fractures in disaster and conflict settings, with a need for increased awareness and monitoring for red flags and complications that occur even alongside what would typically be considered a simple fracture as a result of the environment and conditions in which the fracture occurs.

It is important to complete a detail initial assessment, including social history top have an understanding of support structures so that you can appropriately prioritise the rehabilitation. Involvement of the patient in goal setting is really import and ensuring adequate education around the management of the fracture through the different stages of treatment, including advice on return to activity and use of the limb within any weight-bearing limits set by the medical / surgical team.

Resources

Rehabilitation Treatment Planning for Common Conflict and Emergency Related Injuries

References 

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