Orthopaedic injuries incorporate a wide spectrum of injuries, from soft tissue injuries alone to complex fractures. These injuries may be multiple and have to be managed with knowledge of the patient’s pre-existing medical conditions, level of function as well as independence with an aim to restore pre-morbid status.

Clinical management issues to consider

Obtain knowledge regarding:

1. mechanism of injury
2. type of soft tissue injury / fracture
3. orthopaedic treatment received:
• review X-rays / CT scans / MRI scans
• review operation report if applicable
• discuss details of operative findings with orthopaedic surgeon (eg. quality of fixation achieved and bone quality) as this can affect rehabilitation progression and timing, check X-rays
4. normal course of healing for that injury/fracture, complications and expected outcomes

Acute stage management principles: PRICE

P protection/pain relief
R relative rest
I ice
C compression
E elevation

Rehabilitation MDT goals:

1. pain relief:
• pain relief ladder: paracetamol, NSAIDs, opiates
• consider analgesia prior to physiotherapy or OT session
2. correct deformity
3. protect injured tissue
4. prevent complications
5. restore range of movement (ROM)
6. muscle strengthening
7. personal care and ambulation retraining
8. consideration for investigation, prophylaxis or treatment of osteoporosis

Watch out for complications:

1. local:
• nerve damage: consider nerve conduction studies +/- liaison with specialist orthopaedic or neurosurgery team
• blood vessel damage: monitor circulation and liaise with vascular surgery team
• compartment syndrome: suspect this if patient complains of severe pain and paraesthesia of toes and fingers, inability to move toes and fingers and poor capillary refill. Liaise with orthopaedic team immediately as fasciotomies might be needed.
• stiffness of joints and muscle atrophy
• wound infection (especially in open fractures) – swab for culture and sensitivity (C&S) and start systemic antibiotics
• pin site infection if an external fixator is used – swab for C&S and discuss with orthopaedic team starting systemic antibiotics
• metal work loosening or damage
• delayed union which can progress to non-union
• malunion: monitor for fracture redisplacement, especially in
• fractures involving both the radius and ulna
• comminuted fractures
• oblique fractures
• fractures treated with a cast as this can become loose when swelling decreases
2. systemic:
• deep vein thrombosis (DVT) / pulmonary embolism (PE)
• anaemia
• fat embolism
• pneumonia
• urinary tract infections
• constipation
• pressure sores

Mobilisation:

1. Can be a progression from complete bed rest to assisted transfer activities, non-weight bearing ambulation, toe touch, partial weight-bearing, weightbearing as tolerated and finally full weight bearing.
2. Consider the need for a brace in, eg. spinal and knee injuries.
3. There is no specific time for weight-bearing after a pelvic or lower limb fracture. Decisions are in liaison with the orthopaedic team based on the type of fracture, type and quality of the fixation, bone condition, ability to control weight-bearing (eg. multiple injuries) and evidence of fracture healing.

Discharge planning

• Ensure communication and follow-up with orthopaedic surgery, vascular urgery, neurosurgery and rehabilitation medicine (including physiotherapy and occupational therapy) teams as applicable.
• Make referral to patient’s local area wheelchair services if applicable.