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 gun shot 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 closed
   • 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 Open Fractures or Wounds Inappropriately Managed by POP 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 Undiafgnosed 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 or Wound Infection Insufficient Stabilisation from Fixation Undiagnosed Nerve Injury Pins Inappropriateley Placed Through Tendon or Nerves
Traction	Widely used for the management of fractures and dislocations (including neck of femur, femoral shaft, displaced acetabulum and some pelvic fractures) Usually used when casting unsuitable, or as a temporary measure while awaiting definitive treatment. Skin traction can be a short-term measure for adults with a femoral fracture, or definitive treatment for paediatric patients. Skeletal traction is less effective for adults as a definitive treatment, but is effectively used for children with hip fractures.	Development of Pressure Areas Urinary Tract Infections Chest Infections Foot Drop Contractures Peroneal Nerve Palsy Pin Tract Infection Thrombembolic Events (DVT or PE)

Fracture Complication Considerations

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

References 

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