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Carpal Fractures

Carpal fractures and associated ligamentous injury or dislocation are

rypically due to compressive or hyperextension mechanisms of

injury.33 Management for the fracture of any carpal bone is similar.

Nondisplaced fractures are treated with short arm cast immobilization with the wrist positioned in neutral flexion-extension with slight ulnar deviarion.33 Displaced fracrures a re rreated with closed reduction and casring or ORIF wirh a postoperative splint or casr. Patients with isolated carpal fracrure are usually treared in rhe ambularory

care setting.

Clinical TIp

For patients who have concurrent lower- and upperextremity injuries and require the use of a walker or

crurches, a platform attachment placed on the assistive

device will allow weight bearing ro occur through the

upper extremity proximal to the wrist.

Metacarpal alld Phalallgeal Fractllres

Metacarpal fractures result from direct trauma, such as a crush injury,

or by long-axis loading, as with punching injuries. The fracture may be

accompanied by severe soft tissue injuries that can result in a treatment

delay of 3-5 days ro allow for a decrease in edema. Definirive trearment

depends on rhe locarion of the fracture-either the arricular surface

190 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

(ORIF), neck (closed reduction, percutaneous pinning, immobilization,

or a combination of these), shaft (ORlF, percutaneous pinning, immobilization, or a combination of these), or base (percutaneous pinning and immobilization) of the metacarpal.

Phalangeal fractures result from crush forces and consequently are

usually compounded by skin, tendon, and ligament damage. Management of nondisplaced phalangeal fracture is reduction and splinting.

Management of displaced or intra-articular fracture is OR1F with

splinting. Patients with isolated metacarpal and phalangeal fracture

are usually treated in the ambulatory care setting.

Joint Arthroplasty

Joint arthroplasty, the surgical reconstruction of articular surfaces

with prosthetic components, is indicated to restore function and

motion to a joint that is affected by degenerative arthritic changes."

Total joint arthroplasty is reserved for the individual with pain that is

no longer responsive to conservative measures, such as anti-inflammatory medication, restriction or modification of activity, exercise, weight loss, or the use of an assistive device. This surgery is elective in

nature and can be unilateral or bilateral. The incidence of bilateral

total joint arthroplasties, simultaneous or staged, being performed in

the acute care setting has increased in recent years. Bilateral joint

arthroplasty has been established to be a safe procedure that reduces

total rehabilitation time and hospital length of stay, thus decreasing

medical costs and length of debilitation of the patient.35

Joint arthroplasty provides patients and caregivers with a predictable postOperative course in the acute orthopedic care setting. For this reason, there are high expectations for these patients to achieve specific short- and long-term functional outcomes. The following sections provide basic surgical information and clinical techniques and suggestions for the acute care physical therapist.

Hip Arthroplasty

Hip arthroplasty involves the replacement of the femoral head, the

acetabulum, or both with prosthetic component . A hip arthroplasty

is most commonly performed on patients with severe hip arthritis

(degenerative or rheumatoid), AVN, hip infection, or congenital dis-

MUSCULOSKELETAL SYSTEM

191

Table 3-5. Hip Disorders That May Require Tara I Hip Arthroplasty

Degenerative arrhritis (hyperrrophic or osteoarrhritis)

Rheumaroid arthritis

Arraumatic avascular necrosis

Imrapelvic prorrusio acetabuli"

Congeniml subluxation or dislocation

Post-traumatic disorders (femoral neck, trochameric, or acetabular

fractures)

Failed reconstructive procedures (femoral osteotomy, arthrodesis, or

resurfacing)

Metabolic disorders (Paget'S disease, Gaucher's disease, or sickle cell

anemia)

Fused hip or ankylosing spondylitis

Infectious disorders (tuberculosis and pyogenic arthritis)

Bone tumors

Neurologic disorders (cerebral palsy and Parkinson's disease)

·Chronic progression of thc femoral head into rhe acetabulum and pelvis.

Source: Adapted from JW llarkcss. Arthroplasry of Hip. In ST Canale (cd), Campbell's

Opera rive Orthopaedics, Vol. 1 (9th cd). 51. Louis: Mosby, 1998.

orders. Refer to Table 3-5 for a complete list of hip disorders that may

require hip arthroplasty.

The 1110st common type of hip arthroplasty, a total hip arthroplasty

(THA), is the replacement of both the femoral head and the acetabulum with a combination of metal (titanium or cobalt alloys) and polyethylene components (Figure 3-13). Technology and research have introduced new materials for the weight-bearing components, such as

ultra-high-molecular-weight polyethylene and ceramic-on-ceramic and

metal-on-metal implants; however, long-term survival of such components is not yet known.36

The acetabular and femoral components may be tmcentenled or

cemented. Uncemenred components are commonly used in the

younger, active patient, as well as in a patient with a revision THA

involving a failed cememed prosthesis. The uncemented components

have areas of porous coated metal on the surface that may be treated

with a biochemical agent, hydroxyapatite, to promote bony ingrowth

for improved fixation.'7 Press-fit prostheses are also being used and

have heavily textured surfaces that achieve fixation through interference or interlocking of bone and metal surfaces." Use of uncemented