Rehabilitation of Fractures in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kalyani Yajnanarayan, Kim Jackson, Vidya Acharya, Jess Bell, Rishika Babburu, Tarina van der Stockt, Aminat Abolade, Anna Fuhrmann, Carin Hunter and Ewa Jaraczewska      

Introduction

A fracture is a discontinuity in a bone (or cartilage) from mechanical forces that exceed the bone's strength. In disaster and conflict settings, fractures are a common injury, 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, and open and complex fractures are common, which can complicate your rehabilitation plan.

Due to the high demand for healthcare services following disasters and conflicts, triage systems are often employed. Initial evaluations are conducted to assess the injuries and are categorised on the severity and probability of survivorship. Consequently, patients with non-life-threatening fractures may have definitive treatment delayed or are discharged promptly following application of a cast or splint. Hence, rehabilitation professionals are required to maintain close contact with the medical team in order to assess those with fractures prior to discharge.

Fracture Overview

Please read the linked articles for background knowledge on bone and an overview of fractures. Understanding the structure of bone and the impact on the type of fractures is important in managing fractures.

Types of Fracture

Type of Fracture	Description
Complete	Extends all the way across the bone (most common)
Incomplete	Does not cross the bone completely (usually encountered in children)
Non-Displaced / Stable	Fractured ends of the bone line up
Displaced / Unstable	Fractured portions of bone are separated or misaligned
Closed / Simple	Bone has not pierced the skin
Open / Compound	Skin has been pierced or punctured by the bone or by a blow that breaks the skin at the time of the fracture. The bone or may not be visible
Transverse	Fracture is in a straight line across or perpendicular to the axis of the bone
Oblique	Fracture is orientated obliquely across the bone
Spiral	Fracture spirals around the bone, or a helical fracture path usually in the diaphysis of long bones, common in twisting injuries
Comminuted	Fracture is in three or more pieces with fragments present at the site
Compression	Bone is crushed causing the fractured bone to be wider or flatter in appearance
Segmental	The same bone is fractured in two places so there is a ‘floating’ segment of bone
Stress	Small crack or severe bruising within a bone
Bowing	Incomplete fracture of the long bone in infants/children due to forces in the axial load
Buckle	Due to direct axial load, the cortex is buckled, often in the distal radius
Greenstick	Fracture in a young, soft bone in which the bone bends and the cortex is broken, but only on one side

Earthquakes, in particular, have been shown to cause a significant burden of injuries. In fact, the Richter Magnitude Scale has been shown to correlate with the fracture incident rate, where high-energy earthquakes equal a greater number of fractures. According to MacKenzie et al., fractures accounted for 65% of the total injuries following earthquakes, 59% of them consisting of lower extremity fractures. Bortolin et al. reported that 10% of fractures involved the pelvic ring, 17% involved spinal column fractures with more than 4% involving spinal cord injuries.

Wounds obtained in armed conflict have specific epidemiology and demand principles of management that occasionally differ from civilian practices. In conflict settings, the type of fractures will depend on the mechanism of injury and the type of weaponry used such as gunshot wounds, knife, blast, shrapnel and landmine injuries. In this population, poly-trauma injuries are common, and this can increase the risk of contamination resulting in wound infections.

High-energy traumas, such as those from crush or blast injuries, are often associated with poly-traumas and pelvic fractures that can also result in significant blood loss. Consequently, they can be more complex to manage, and in many cases, patients are likely to survive in disaster and conflicts settings. Where they do survive, they tend to have extensive associated injuries including: severe spinal cord injuries, soft tissue and organ damage, which may further limit early rehabilitation. Furthermore, due to the severity of their condition, these patients require extensive multidisciplinary discussions to understand precautions and contraindications prior to any assessment and 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 fractures 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?
   • 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 closed?
   • What is the condition of the surrounding soft tissues? Check the surgical notes and enquire with the medical team to find out about damage to blood vessels or nerves, as they may impact rehabilitation
4. What was the 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 also really important. If we consider simple fractures we know that generally:

• Paediatric fractures will heal most quickly (approximately 3-6 weeks)
• Adult upper limb fractures (approximately 6 weeks)
• Adult lower limb fractures (approximately 8-12 weeks)
  

While being aware of approximate timescales of recovery are instrumental, patient differences in disaster and conflict situations can alter recovery timeframes. These include:

• Multiple injuries
• Complex injuries
• Vascular injury (impairs bone healing)
• Infection (impairs bone healing)
• Late or suboptimal fracture management
• Blast injuries / gun shot wounds that leave shrapnel close to the bone have a 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 - there is also 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 impair bone healing)
• Medication use (some drugs can affect bone metabolism and impair bone healing including NSAIDs, glucocorticoids, blood thinners i.e. warfarin and heparin and some classes of antibiotics i.e. quinolones)
• Smoking status (impairs bone healing)
• Nutritional status (impairs bone healing)

With the above considerations in mind, weight bearing status should be discussed with the medical or surgical team, to determine safe limits in the initial phase of their recovery. Given that bone strengthens in response to the load it experiences, once the safe limits are determined, early rehabilitation should include progressive weight bearing exercises with basic advice on a progressive home exercise programme.

Medical and Surgical Intervention Considerations

Ideally, the precautions and contraindications for rehabilitation are recorded by the medical or surgical team prior to physiotherapy assessment. However, this is not always the case when working in disasters and conflict settings, where post-operative or medical notes may be limited or unavailable. Therefore, the medical team should be consulted prior to the session to gather thorough information about the patient and clarify any doubts to ensure patient safety.

The following table outlines some of the more common fracture management strategies and possible complications that can occur in disaster and conflict settings. You need to monitor closely for all early complications. Rhabdomyolisis, compartment syndome, and fat embolisms are commonly seen following crush injuries, while pulmonary embolism and deep vein thrombosis are common with immobilisation, and infection is a common complication with all types of injury. You can read more detail about early and delayed fracture complications here.

Intervention	Description	What to Watch for in Disaster and Conflict Settings
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 (too tight can eliminate blood flow) Only apply, or assist with the application of a cast if it is 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 a 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 for adult femoral fractures Definitive treatment for paediatric patients Skeletal Traction Less effective for adults as a definitive treatment Effective definitive treatment for paediatric hip fracture	Pressure areas Urinary tract infections Chest infections Foot drop contractures Peroneal nerve palsy Pin tract infection Thrombembolic events (DVT or PE) These complications stem from a lack of patient mobility especially with bed rest, muscle atrophy, weakness and stiffness that result from the fracture

Assessment Considerations

In disasters and conflicts, the assessment for a patient with a fracture should follow the same format as a standard rehabilitation assessment. As such, it is important to bear in mind that those with poly-trauma, pain or post-operative medications may be unable to complete the assessment within one session. In these cases, prioritisation of assessment techniques is key, along with, limiting treatment plans to aspects that can be done safely until a complete assessment is conducted. Specific considerations that might impact your fracture assessment within disaster and conflict settings include:

• Limited medical history, including incomplete background information such as weight-bearing status or post-operative notes. This may be a result of disrupted services, emergency transfers of the patient and/or the separation of the patient from their family.
• Increased risk of infection as a result of:
  • the mechanism (blast, crush) of injury,
  • the context of the injury (prolonged exposure to dirty water),
  • poor theatre conditions and/or contaminated hospital environment, e.g. an emergency camp with limited sanitation services.

With disrupted care, the continuity of treatment can be 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 (internal or external fixators) and pressure from splints. Therefore, it is imperative that sensation and movement are frequently monitored post-operatively. 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 in disaster and conflict settings, the primary role of the rehabilitation professional is to monitor for any current or potential fracture complications. These can be 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 to avoid a permanent injury. Please watch the video below for more information on the 5 P's.

Range of Movement

Both active and passive range of movement (ROM) should be assessed unless otherwise indicated. Active ROM (AROM) is assessed first to determine the range and quality of movement. However, active-assisted ROM can be used when the patient is unable to complete an AROM, 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 the 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. This assessment starts with isometric testing, followed by 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. Therefore, functional considerations include 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, bedpan and positioning to relieve skin pressure if they are on bedrest.

Cast / Splint / Dressing

Always check that casts, splints and dressings are not too loose 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 an infection is suspected seek support from the medical team.

External Fixators

Always complete pin site care by checking pin sites for signs of infections, neurovascular compromise, or pin sites that impale tendons or muscle bellies that could cause pain and reduced ROM. With clean hands, systemically check that all wires and pins are solid and secure, and that each nut and bolt is tight. This includes checking the wires and pins top to bottom and left to right and educating the patient to do the same.

Use of Scans

If available and within your scope of practice, scans (x-ray, ultrasound) can be a useful adjunct to patient assessment. If not, then where available scan reports should be read and discussed with the multidisciplinary team. It is crucial that scans are not interpreted if outside your scope of practice.

Fracture Blisters

Always monitor for the development of fracture blisters. These can be either clear (filled with serous fluid) or haemorrhagic (filled with blood). They 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 them can increase the risk for infection. Educate the patient about fracture blister management and inform the medical team.

Outcome Measures

As in a standard setting, the most frequently used outcome measures in acute fracture management include ROM, muscle strength and functional goals. These outcomes measures should be quick and simple to administer and easily repeatable due to the complexity of care within disaster and conflict settings.

Treatment Considerations

Given that most of the patients you see within 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 starting any treatment. It is also imperative to always beware of potential complications and red flags, which may not become clinically apparent until the patient begins to mobilise.

Early Rehabilitation

Rehabilitation should begin as soon as the patient is medically stable.

Early rehabilitation for fractures focuses on:

1. Oedema Management
2. Range of movement
3. Graded Progressive Exercises
4. Bed Mobility
5. Weight-bearing
6. Psychological Considerations
7. Patient and Caregiver Education

Oedema Management

Oedema is a normal response to injury and an important step in wound healing. However, excessive oedema can negatively affect wound and fracture healing, increase the risk for complications like compartment syndrome, and result in stiffness, decreased range of movement, increase pain and long term impairment or deformity. The 'Peace and Love Principle' includes the full range of soft tissue injury management from immediate care to subsequent management and highlights the importance of patient education and addressing the psychosocial factors involved that will aid recovery.

Range of Movement

Range of movement, including passive, active-assisted and active, for the uninjured limbs both above and below the immobilised joints is beneficial for healing and recovery from soft tissue and joint lesions. It helps to maintain existing joint and soft tissue mobility, minimises the effects of contracture formation, reduces the risk of pressure ulcers, assists neuromuscular reeducation, and enhances synovial movement.

Graded Progressive Exercise

Individualised progressive graded exercise should be utilised according to each patient's needs to improve strength, moving from isometric to anti-gravity to resisted-range exercises. Remember that in the acute phase for some fractures, isometric exercises may be the only exercise allowed. The goal is to increase the strength of both the involved and uninjured extremity, increase independence with a graded exercise programme and minimise deconditioning. Progressions can be achieved by: increasing sets and/or repetitions of sit to stand practice, sitting out of bed duration, and mobility practice with pacing (which is vital to minimise fatigue). Sitting out of bed for meals/dressing changes should also be encouraged to support this.

Bed Mobility

Bed mobility and transfers are extremely important functional activities that individuals with fractures need to master for independent mobility and quality of life, and more importantly to reduce the risk of pressure ulcers, postural hypotension and improve respiratory function, especially for those on traction and bed rest. This should be a major focus of early rehabilitation in order to build up to bedside sitting once cleared by the medical team. It should include education of the patient to assist in this activity as much as they are able, and where available, utilise family support. The goal of bed mobility is to build towards sitting and transfers.

Weight-Bearing

Weight bearing refers to how much weight a person puts through an injured body part. The medical or surgical team are responsible for prescribing an appropriate weight bearing status and adherence to these restrictions is vital for optimal recovery, as premature weight bearing can delay healing. You can follow the links to read more about weight bearing and safe transfers and mobility.

Education

Patient and caregiver education is of vital importance for successful fracture management and rehabilitation, particularly given the limitations in the health services in disaster and conflict settings. Education also promotes patient compliance with treatment, satisfaction with care, and self-care skills. It has also been shown to decrease unpleasant patient experiences in hospitals, resulting in reduced levels of pain and anxiety.

Psychological Considerations

Emotional instability, stress reactions, anxiety, trauma and other psychological symptoms are commonly observed following disaster and conflict experiences. These can have a massive impact on the individual and their caregivers. Consider onward referral to mental health services if you see a patient displaying or reporting emotional distress or psychological difficulties.

Summary

Complex poly-trauma presentations frequently complicate the assessment and early rehabilitation of fractures in disaster and conflict settings. Therefore, there is a need for increased awareness and monitoring for red flags and complications that can occur alongside what would typically be considered a simple fracture.

It is important to complete a detailed initial assessment, including social history, to have an understanding of support structures, so that appropriate prioritisation of rehabilitation can occur. Involvement of the patient in goal setting and adequate education on the management of the fracture is crucial. Education on management should include advice for the different stages of treatment, return to activity and use of the limb within any weight-bearing limits set by the medical/surgical team.

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion

Management of Lower Limb Injuries during Disasters and Conflicts, International Committee of the Red Cross

Plaster of Paris and other Fracture Immobilisations - ICRC Physiotherapy Reference Manual, International Committee of the Red Cross

Rehabilitation Treatment Planning for Common Conflict and Emergency Related Injuries