Causes of Fractures

Causes of fractures include falls, trauma from automobile accidents, osteoarthritis, and metastatic carcinoma.⁵ Other factors such as a current or previous smoking habit,⁶ alcohol abuse,⁷ diabetes,⁸ and decreased level of physical activity also correlate with the incidence of fractures.⁹

The majority of fractures in elders result from falls.¹⁰ Factors associated with falling include poor vision, orthostatic hypotension, poor balance, diminished mobility, side effects of medication, muscle weakness, neurological diseases, reduced alertness, urge incontinence, a cluttered home environment, and dementia.¹¹ (An in-depth examination of the causes of falls in elders is provided in Chapter 14.)

The number of elder drivers is increasing. For example, in 1995, about 9% of drivers in the United States were people age 70 years and older, and their number increased to 12% by 2010.¹² It is estimated that by 2020, 20% of all people who drive will be older than age 65 years.¹³ Elders have greater rates of fatal crashes than younger drivers, and they do not deal well with complex traffic situations.¹⁴ Trauma resulting from auto accidents accounts for a portion of the fractures seen in the elder population.

Elders are more likely to sustain fractures after a fall because of osteoporosis, osteomalacia, and the diminished ability to repair microfractures.¹⁵ Stress fractures also can occur in elders who, for example, suddenly increase their levels of activity by jogging, walking farther than usual, or walking on a different terrain.¹⁶

Fractures may also be caused by cancer that has metastasized to bone. Although any cancer may metastasize to bone, metastases from carcinomas, particularly those that arise in the breast, lung, prostate, kidney, and thyroid, are most common. Metastatic lesions weaken the strength of bones and may lead to fractures.¹⁷

Types of Fractures

A fracture is a break in a bone. Although radiographs are used to diagnose the fracture, it does not reveal damage to soft tissues or cartilage. Fracture sites can disrupt the intraarticular, epiphyseal, metaphyseal, or diaphyseal portions of the bone. If a fracture occurs and dislocates a joint, it is a fracture-dislocation.¹⁸

Various terms are used to categorize fractures. A fracture is considered to be compound or open if the bone protrudes through the soft tissue and skin. If the soft tissue and skin are undamaged, the fracture is considered to be closed or simple. Different physical forces can result in certain types of fractures. A transverse fracture occurs as a result of a direct force, whereas a spiral fracture results from a circular or twisting force. A fracture that results in more than two bone fragments is a comminuted fracture. Figure 22-1 shows these various types of fractures.

FIGURE 22-1 Types of fractures.

(Modified from Garland, J. J. (1979). Fundamentals of Orthopaedics. Philadelphia: WB Saunders.)

Medical Intervention for Fractures

The goals of medical management of a fracture are to reduce pain and align the fracture for proper healing.¹⁸ The fracture can be aligned with or without surgery. The process of manually realigning (sometimes using traction devices) and then casting a fracture is termed closed reduction. The open reduction is a surgical procedure that is used to internally fixate the fracture site. Internal fixation is performed with the use of orthopedic nails, screws, pins, rods, or plates. When external fixation is used to align or reduce a fracture, the fixator device is attached with pins or wire, which is inserted through the soft tissues and into the bone (Figure 22-2). This device usually involves the use of screws and rods that are removed after the fracture has healed. The skin around placement sites of the rods or screws must be kept clean to prevent infection (Table 22-1).

FIGURE 22-2 External fixator in place to maintain reduction.

(From Hunter, J., Mackin, E., & Callahan, A. (Eds.). (1995). Rehabilitation of the Hand: Surgery and Therapy, 4th ed. St. Louis, MO: Mosby.)

TABLE 22-1 General Recommended Pin Site Care

Adapted from Sims, M., & Whiting, J. (2000). Pin-site care. Nursing Times, 96(48), 46.

COTAs also should be familiar with terminology relating to the healing of fractures. Three terms used to describe fractures that do not heal well are delayed union, nonunion, and malunion.¹⁸ Delayed union describes a fracture that heals at an abnormally slow rate. Nonunion describes a fracture that has not healed within 4 to 6 months. Malunion describes a fracture in which the bone heals in a normal length of time but with an unsatisfactory alignment.

Complications After Fractures

Several complications can occur after a fracture.¹⁸ Edema can lead to joint stiffness, and joint contractures often are caused by adhesions or prolonged immobilization. After a fracture, posttraumatic arthritis can occur in joints associated with or near the fracture site. Reflex sympathetic dystrophy is a syndrome that often occurs after minor injuries. The condition is believed to be related to the sympathetic nervous system and presents with severe pain, edema, stiffness, muscle atrophy, muscle spasms, contractions, and loss of bone mineralization. Myositis ossificans is the formation of heterotopic ossification near a traumatized area. The most common joints where heterotopic ossification forms are the arms, thighs, and hips.

Factors Influencing Rehabilitation

Several factors affect the outcome of rehabilitation efforts in elders who sustain fractures. Age is a predominant factor in rehabilitation.¹⁹ Elders may need more time than younger persons to achieve their greatest levels of independence. For example, in elders, a comminuted fracture of the proximal humerus should be immobilized for the shortest period possible to reduce the chances of development of adhesive capsulitis or frozen shoulder. With a younger person, the threat of such a complication may not always be a concern.

The general condition of elders also affects the course of rehabilitation. For example, elders who are in shock or are unconscious require different intervention than those who are alert and oriented. In addition, past and current medical conditions may affect the rehabilitation of elders who have fractures. Elders with congestive heart failure or chronic obstructive lung disease may be limited in their abilities to participate in endurance and strengthening activities. Furthermore, a large percentage of elders with fractures also have associated medical problems such as arthritis, hypertension, hearing impairments, heart disease, cataracts, orthopedic impairments, sinusitis, and diabetes.²⁰

The presence of dementia often affects rehabilitation outcomes for elders with fractures. For example, teaching the integration of hip precautions or joint protection methods while engaging in self-care tasks to an elder with short-term memory deficits is difficult. (A detailed discussion of intervention considerations for elders who have dementia is presented in Chapter 20.)

Although hip fractures are the most common type of fracture sustained by elders, fractures of other bones also occur. COTAs should know the common fractures and general recommended intervention techniques (Table 22-2).

TABLE 22-2 General Recommended Intervention Techniques for Upper-Extremity Fractures

Total Hip Replacements

Total hip replacements (THRs), or total hip arthroplasties (THAs), are often elective surgeries indicated for reducing pain and restoring motion for elders who have severe osteoarthritis, rheumatoid arthritis, or ankylosing spondylosis. Emergency THAs frequently follow traumatic injuries to the hip, such as after a motor vehicle accident or fall. A hip replacement, or arthroplasty, may be full or partial. During a full hip arthroplasty, the hip’s ball and socket are replaced with metal or metal and plastic prosthetic implants.²⁶ During a partial joint replacement, which is commonly used for fractures of the femoral neck and head, the femoral neck and head are replaced with a prosthesis. Hip prostheses last approximately 10 to 15 years or longer in 90% of elders.²⁷ When radiographs show evidence of loosening of the cement and the client is experiencing pain, a hip revision arthroplasty may be performed.²⁸

The two basic surgical approaches for THRs are the anterolateral approach and the posterolateral approach.²⁹ When an anterolateral approach of surgery is used, elders must avoid adduction, external rotation, and extension of the operated hip. If a posterolateral surgical approach is used, elders should avoid flexion beyond 60 to 90 degrees, adduction, and internal rotation of the operated hip.³⁰ COTAs must be aware of which type of surgical approach was used to properly carry out OT intervention (Figure 22-3). COTAs also should note the position precautions for each surgical approach.

FIGURE 22-3 While the elder is supine, the elder’s legs should be abducted with a wedge to prevent hip rotation and adduction.

The movement precautions are usually observed for 6 to 12 weeks as indicated in a physician’s order (Table 22-4).³⁰ Cemented THRs usually have no weight-bearing restrictions. When cement is not used, bony ingrowth is used to secure the prosthesis to the elder’s bone. Often 6 to 12 weeks of weight-bearing restrictions are required when this type of prosthesis is used.²⁹

TABLE 22-4 Motion Precautions for Clients Who Have Had a Total Hip Replacement

After THA surgery, physicians often instruct clients to wear antiembolus hosiery. These thigh-high hose are worn 24 hours a day and removed during bathing only. Clients are instructed to wear this hosiery because it assists with blood circulation, prevents edema, and reduces the risk for deep vein thromboses. If an elder has not been instructed to wear these hose and complains of pain or swelling in the affected leg, the physician should be consulted immediately because it could be a sign of the presence of a thrombus. COTAs should be skilled in donning and doffing antiembolus hosiery because they may need to assist elders before bathing. If the hose are to be worn for a length of time, caregiver training should occur because it is often difficult for elders to perform this task independently.

Researchers show that there are several milestones during rehabilitation, including adherence to hip precautions; ambulating 100 feet with a mobility aid; independence with home exercise program; and requiring supervision only with toileting, transfers, and activities of daily living (ADL).²⁷

Three areas reported in research studies that are important concerns for clients with THA are sexual activity, driving, and work return.³¹ In a study of 86 clients with THA, 50% of preoperative clients reported experiencing difficulties with sexual activities because of hip problems, and 90% of these clients reported a desire for more information about sexual functioning after THA. The majority of clients (55%) resumed sexual activity within 2 months of the THA with physician approval and following positioning precautions. Most people report that the supine position during intercourse is the most comfortable.³¹ (A detailed discussion of addressing sexuality with elders is presented in Chapter 12.)

After surgery, driving reactions normalize between 3 and 8 weeks if elders resume good leg control. Return to work activities is dependent on the amount of stress and torque on joints. Typically, elders must take off from work for 3 to 6 weeks after surgery.

A number of studies exist on appropriate leisure activities after a THA.³¹ A survey of 28 orthopedic surgeons from Mayo Clinic recommended that activities such as cycling, golfing, and bowling are acceptable after a THA. Generally, many physicians counsel well elders to avoid participation in sports that impart high torque or stress on the hip joint, such as jogging. Often, active elders resume activities and athletics regardless of physician or therapist warnings.

Psychosocial issues after total hip replacement

A number of psychosocial issues may surface during an elder’s rehabilitation after a hip replacement. Dealing with a chronic condition such as arthritis can be stressful and frustrating; many elders are required to deal with pain, swelling, and mobility limitations on a daily basis. Providing information on support groups may be beneficial to the elder.

After a THR, some elders find it difficult to abide by the position precautions. They may view these precautions as impediments to resuming the lifestyles they had before the procedure, especially when they had no predisposing medical conditions that limited activities. COTAs should be empathetic to the elder’s concerns, but they must also help elders understand the rationale for adhering to hip precautions (Figure 22-4). The COTA also should address the consequences of not following these precautions. COTAs may need to reassure elders that healing takes time and that involvement in activities may continue but usually with some modifications.

FIGURE 22-4 The elder should extend operated leg and bear weight on arms when coming into a standing position.

Many elders feel guilty or become anxious when they require assistance from family or friends.³² Elders who are temporarily placed in an extended care facility while they heal may also find it difficult to accept assistance from nursing staff in the facility. Feelings of guilt are sometimes accompanied by financial worries about the cost of care. In addition, relocation to a new environment such as a hospital, extended care facility, or long-term care facility can be stressful.³³ COTAs should encourage elders to talk about their feelings. When possible, discussing the situation with elders before they are moved to a new facility is beneficial. In addition, the elder should be thoroughly oriented to the new facility.

Occupational therapy interventions

The specific intervention strategies and techniques used with an elder who has had a THA vary depending on whether the anterolateral or posterolateral surgical approach was used (Table 22-5). Adaptive equipment is typically supplied to patients regardless of approach. The most used piece of adaptive equipment tends to be the raised toilet seat, which often is used for at least 6 months after THA. Other pieces of equipment that participants reported to be helpful were the reacher, long-handled shoehorn, and sock aid; however, they did experience some difficulties in using them.

TABLE 22-5 Occupational Therapy Interventions for Posterolateral and Anterolateral Approaches to Total Hip Replacement

Bed mobilityWalking	Abduct legs with wedge or pillows to prevent hip rotation and adduction. Avoid pivoting on the leg that has been operated on. When approaching corners, take small steps in a circular fashion. If possible, take 10- to 15-minute walks four times per day 6 to 8 weeks after the operation. Walk at a slow, comfortable pace.
Chair transfers	Sit on chairs with firm seats, preferably with arm rests. Avoid low, soft chairs and rocking chairs. Extend leg that has been operated on, reach for arm rests, and bear some weight through arms when trying to sit down.
Commode chair transfersFor posterolateral approachFor anterolateral approach	Use a chair with a height that accommodates for hip flexion precaution. Wipe between legs while seated or wipe from behind while standing with caution to avoid internal rotation. Stand and face the toilet to flush. An over-the-toilet commode is usually used initially in the hospital and on discharge; elders usually have enough hip mobility to use a standard toilet seat. Avoid external rotation while wiping. Stand and face the toilet to flush.
Shower stall transfer	Use a nonskid mat to avoid slips and falls. Use a shower chair and grab bars.
Car transfer	Avoid bucket seats in small cars. Back up to passenger seat, hold onto a stable part of the car, extend the leg that has been operated on, and slowly sit in the car. Increase the seat height with pillows, if necessary. Avoid prolonged sitting in the car.
Lower extremity dressing	Sit on a chair or the bed’s edge when dressing. Use assistive devices, if necessary, to observe precautions. Use a reacher or dressing stick in donning and doffing pants and shoes. Dress the leg that has been operated on first using a reacher or dressing stick to bring pants over the foot and up to the knee. Avoid crossing the operated lower extremity over the nonoperated lower extremity. Use a sock aid to don socks or knee-high nylons and a reacher or dressing stick to doff these items. Use a reacher, elastic shoe laces, and a long-handled shoehorn, if necessary.
Hair shampooing	Use a long-handled sponge or back brush to reach the lower legs and feet safely, and use soap on a rope to prevent the soap from dropping (drill a hole into a bar of soap and thread a cord through the hole). Wrap a towel around a reacher to dry the legs. If a bath bench is used, place a damp towel on the seat to avoid sliding off of the bench. Consider a handheld shower extender. Shampoo hair while seated until able to shower.
Leisure interests	Adapt and use long-handled tools when appropriate. Use stools when appropriate to avoid bending, squatting, and stooping.
Home management	Avoid heavy housework (e.g., vacuuming, lifting, and bed making). Practice kitchen activities; keep commonly used items at countertop level. Carry items in large pockets, a walker basket, a fanny pack, or a utility cart. Use reachers to grasp items in low cupboards, or pick up items off of the floor. Move frequently used items located low in cabinets and shelves to counter level. Keep a cordless phone with a belt clip close by at all times. Carry a water bottle with a belt holster. When initially recovering, place the television remote control, radio, telephone, medication, tissues, wastebasket, and water glass in the most convenient location. Before surgery, stock up on food that can be easily prepared or reheated.

COTAs are involved in educating elders and their caregivers about proper and safe usage of adaptive equipment, observing hip precautions during functional activities, and making environmental adaptations. Laurel is a COTA who works in an acute care hospital and is involved in patient education. Before having a hip replacement, elders and their primary caregivers attend a class to prepare them to return home. Laurel reviews the precautions for both the posterolateral and anterolateral approaches. The elders bring clothing to practice using a dressing stick, reacher, sock aid, and long-handled shoehorn. Laurel has the elders practice transferring to and from a chair, couch, commode, and raised toilet seat. They also practice using reachers to retrieve items from the floor and cupboards. During one question-and-answer session, several elders expressed an interest in feeding their pets. Laurel asked a volunteer from her church to make pet feeders that could be easily lifted from the floor to the counter so that the elders could fill them with water and food without bending over (Figure 22-5). Laurel also reviews information in a notebook with elders and their caregivers that will be used as their home programs. After surgery, Laurel works with elders to review the dressing techniques and reinforces the information that they learned earlier in class. Laurel also makes recommendations for bathroom equipment that the elders may need to return home. Some elders have stated that it was helpful to be exposed to the information before surgery because it was harder for them to concentrate after surgery.

FIGURE 22-5 This easily constructed pet feeder allows elders to fill the water and food bowls without bending over.

(Courtesy Ron Connon).

Knee Replacements

The knee joint has a large amount of synovium fluid, and thus one joint is often affected by rheumatoid and osteoarthritis.²⁰ Chronic knee pain may cause difficulty in ascending and descending stairs, squatting, walking, and jogging, thus affecting one’s quality of life.

Nonsurgical intervention may include a variety of approaches, including medication, activity modification and exercise, braces, and weight reduction.²⁰ Nonsteroidal antiinflammatory drugs (NSAIDs) are often prescribed to reduce swelling and pain. Intraarticular injections are sometimes used when oral NSAIDs are ineffective.

Activity modification is targeted to minimize symptoms by avoiding high-impact activities. Maintaining a healthy body weight is difficult for people with knee pain because it often decreases their activities without changing their intake of calories. If possible, elders with knee pain should try to maintain a regular exercise program to maximize aerobic conditioning.

Physical therapists may provide braces to help active elders regain a sense of knee stability during activities. Such knee braces are helpful in the short term, but people tend not to use them on a day-to-day basis.²⁰ Surgical intervention includes a total knee joint arthroplasty or total knee replacement (TKR). Knee arthroplasties are best suited for sedentary persons older than age 65 years.³⁰ Approximately 90% of TKRs are successful up to 10 years after surgery.

Common Problems Associated with Arthritis

Osteoarthritis of the knee affects approximately 60% of people older than age 65 years.³⁷ Limitations caused by knee OA include difficulty using stairs, squatting, and high-impact activities (i.e., running or jumping).³⁰ These activities can be quite painful and can reduce the quality of life for an active elder.

Upper extremity deformities caused by OA can be problematic. Osteophytes form in the fingers and base of the thumb. Although osteophytes are not painful, they are seen at the distal interphalangeal (DIP) (Heberden’s nodes) and proximal interphalangeal (PIP) joints (Bouchard’s nodes). Such nodes result in difficulty and pain during pinching. In advanced stages, the thumb’s carpal metacarpal (CMC) joint can subluxate and result in joint instability.

The hands are the most severely affected joints in RA. Often, the PIP joints present with fusiform swelling or spindle-like shape. Boutonnière and swan-neck deformities are also finger deformities that may result from RA. Nalebuff deformities are common to the thumb when affected by RA. Ulnar drift is often present in the metacarpophalangeal (MCP) joints of the hand, and the wrist may sublux volarly.

Gout commonly affects the toes, ankles, elbows, wrists, and hands. Swelling can cause the skin to become taut around the joint and make the area appear red or purple and be tender. These presentations, in turn, reduce joint mobility (NIA, n.d.).

Occupational Therapy Intervention

The primary goal of OT intervention is to improve the quality of life of elders with arthritis. Specific goals may include maintaining joint mobility or joint stability, preventing joint deformity, maintaining strength, maintaining or improving functional ability, maintaining a healthy balance of rest and activity, modifying performance of activities, and improving psychosocial acceptance and coping mechanisms.

Case Study Review Questions