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Rehabilitation care outcome of lower limb fractures in a Nigerian teaching hospital-a retrospective study.

SUMMARY

Fracture is a common cause of injuries to lower extremities. It is clinically assumed that younger and male patients have better outcome following acute care rehabilitation of lower limb fractures. This study was therefore carried out to investigate pattern and outcome of acute care rehabilitation of lower limb fractures.

All cases of unilateral lower limb fractures referred for physiotherapy at LAUTECH Teaching Hospital, Osogbo, Nigeria between November, 2001 and October 2006 were reviewed. Information on personal and clinical characteristics relating to acute care rehabilitation was retrieved from their case files. Data obtained were analyzed using descriptive and inferential statistics.

A total of 197 patients of male to female ratio 2.3:1 with mean age 38.7 [+ or -] 17.77 years were reviewed. Majority (48.2%) were aged 20-39 years. Majority of the patients (74.6%) under review were involved in road traffic accident with a half of them (51.3%) sustaining fracture of femur. A large proportion of patients (47.7%) under review were managed non operatively. More than half of these patients (67. 8%) completed their ambulation training with axillary crutches within three physiotherapy sessions with 148(75.1%) patients discharged satisfactorily with either axillary crutches or walking frame. Outcome of ambulation training was found to be associated with age (p=0.03) but was neither associated with gender (p=0.12) nor methods of reduction of fractures (p=0.31).

Age is a significant determinant of outcome of rehabilitation of fractures of lower extremities. In other words, the younger a patient with lower limb fracture is, the better the outcome of acute care rehabilitation.

Key words, lower limb fractures, rehabilitation outcome

INTRODUCTION

An injury which commonly occurs in the lower limbs is fracture involving bones of the lower extremities (1). In the United Kingdom, lower limb fractures account for approximately one third of all fractures with overall incidences of 3.4 per 1000 person years in women and 2.9 per 1000 person years in men between 1990 and 2001 (2). Hospital based studies in Nigeria and overseas have identified lower limb as the most common location of fractures with tibia reported as the most commonly fractured bone in the lower extremities (3-5).

Majority of lower limb fractures occur as a result of road traffic accident involving vehicle, motorcycle, or pedestrians and fall (6, 7) Risk factors for lower limb fractures (medical or non medical) include road traffic accident, dementia, osteoporosis, smoking and medications among others (2, 6-7). Medical risk factors lower limb fractures vary across different age group. Kaye and Jick (2) reported that dementia was a major risk factor for sustaining fracture of femur among people aged 80 years above. The authors also submitted that smoking and osteoporosis were important predictors of fractures of pelvis and femur among the elderly (50-79 years).

Lower limb fractures are often managed by close reduction and splinting. However, surgical interventions are required in cases of femur and open tibia fractures (4, 6). Rehabilitation is an important component of holistic care of patients with lower limb fractures pre and post reduction (8). The seven milestones of functional recovery following hip fractures as described by Giuccione et al (9) include supine to sit transfer, sit to supine transfer, sit to stand transfer, independent ambulation on leveled surface with walker, independent ambulation on leveled surface with crutches, independent ascent and descent of stairs with a railing and crutches and independent ascent and descent of stars with crutches only. Attaining independence in the first five keys was also identified as the goals of acute care rehabilitation following hip fractures. A number of personal characteristics and clinical factors have been studied for their association with functional outcomes in hip fractures. These include age (10-12), gender (10,12,13,), cognitive status (14), history of previous fractures (12,15), site and side of fractures (10-12,15) surgical fixation (12,15), physical therapy treatment (12,13,15,16) and length of hospital admission (13,16).

The prevalence, socio-economic burden, surgical and rehabilitative care for hip fracture are well documented in literature (8-16). However, few studies explored pattern of lower limb fractures and there is a dearth of information on rehabilitation outcome of lower limb fractures particularly in developing countries. This study was designed to investigate the outcome of acute care rehabilitation of lower limb fracture. Factors predicting outcome of acute care rehabilitation following fractures of lower extremities were also identified.

METHODOLOGY

Procedure for data collection: The authors reviewed all cases of unilateral lower limb fractures referred to physiotherapy department of Ladoke Akintola University of Technology Teaching Hospital, Osogbo between November 2001 and October, 2006. Cases of bilateral, multiple lower limb fractures and lower limb fractures complicated with head injury were excluded from the study. The following information was retrieved from the case files of patients who met the inclusion criteria: age, sex, pre-morbid ambulation status, sites, causes and method of reduction of fractures. Other data obtained were number of physiotherapy sessions, means of ambulation, complication on ambulation training and outcome of acute care rehabilitation.

Premorbid ambulation status was classified as ambulant with aids, non ambulant or independent ambulation. Acute care rehabilitation was defined as having attained the first five milestones of functional recovery as earlier described by Guiciones et al (9). Outcome of acute care rehabilitation was classified as: discharged from rehabilitation programme against physiotherapist's advice, discharged satisfactorily, discharged on supervision by close relatives and inconclusive training in the use of axillary crutchca or walking frame for non-weight bearing ambulation training. Moreover, a patient was said to have been discharged satisfactorily having learnt the usage of axillary crutches or walking frame without supervision whereas discharged unsatisfactorily if otherwise as stated earlier.

DATA ANALYSIS

Descriptive statistics of mean and frequency percentages were used to summarize and present data on patients' demographic characteristics, causes, site and method of reduction of lower limb fractures and acute care rehabilitation outcome. Chi square test was used to test the significance of associations among outcome of acute care rehabilitation of lower limb fractures and patients' demographic characteristics and clinical characteristics such as causes, sites and methods of reduction of lower limb fractures and means of ambulation training among others. P-value was set at 0.05.

RESULTS

A total of 197 patients with radiological evidence of lower limb fractures were referred for acute care rehabilitation during the study period. They consisted of 138 males and 59 females aged between 7 and 92 years with mean age 38.7 [+ or -] 17.77 years. About a half of these patients (48.2%) were aged between 20 and 39 years as shown in Table 1. Majority of these patients (86.8%) were ambulant before sustaining fractures of the lower extremities, 16 (8.1%) were ambulant with aids while the pre fracture ambulation status of 10 patients could not be ascertained.

Majority of the patients (74.6%) under review were involved in road traffic accidents at the time they had lower limb fracture while 3 (1.5%) of them had pathological fracture. Other causes of fractures were as shown in Table 2. The most common site of lower limb fracture during the study period was the femur (51.3%). This was closely followed by fracture involving tibia and fibula (28.9%). Lower limb fracture rarely occurred at the pelvis (1.5%) (Table 2). Lower limb factures were often reduced by Plaster of Paris (POP) (43.0%) and internal fixation (32.5%). Other methods of fracture reduction were as shown in Table 3.

Majority of the patients (87.3%) under review underwent non-weight bearing ambulation training with axillary crutches while the rest were trained with walking frame. More than half of the patients under review (67.8%) completed ambulation training with either crutches or walking frame between one and three physiotherapy sessions, however, thirty patients completed their training in four or more treatment sessions. Complications recorded during ambulation training included poor exercise tolerance (7.5%), fainting attack (5.6%) and pain (0.5%)

Three quarters of patients (75.1%) under review were discharged satisfactorily with either axillary crutches or walking frame while 13 (6.6%) were discharged on close supervision by their carers or relatives. Other patients (18.3%) were either discharged against physiotherapist's advice or had inconclusive training with crutches or walking frame. Outcome of acute care rehabilitation of the patients under review was found to be associated with age (p=0.03) (Table 4) and means of ambulation training (p=0.03) (Table 5), but not gender (p=0.12) (Table 6), sites (p=0.32) and methods of reduction of fractures (p=0.31)

DISCUSSION

The outcome of this study revealed that more males (70 .1%) than females sustained lower limb fractures. This is in agreement with the findings of previous studies (3, 5, 7) in Nigeria and overseas. One may speculate that males' greater participation in outdoor activities could be a reason for male gender's predisposition to fractures of lower extremities. About a half of patients under review were young adults (20 39 years) in agreement with the submission of Oluwadiya et al (3) that lower limb fractures are often sustained by active segment of Nigerian population. This therefore brings about concern about the need for development of preventive measures against lower limb fracture among these age groups as they constitute the workforce of Nigerian population. Moreover, considering the burden of care, lower limb fractures in young adults may not only have negative impact on societal participation but also on national economic growth.

About three quarters of incidences of lower limb fractures as revealed by the outcome of this study were due to road traffic accident. Previous studies (2-5) have also identified auto crash as the most frequent cause of fractures of lower extremities. This implies that incidence of lower limbs fracture in our society may be reduced road if preventive measures are strictly adhered to. Campaign on road collision free society as embarked upon by the Federal Road Safety Commission can now be regarded as an important preventive measure of curtailing incidence of lower limb fractures.

Majority of patients under review had fractures affecting femur (50.3%) and shaft of tibia and fibula (24.5%). These findings were at variance outcomes of previous studies (3-5) in Nigeria and overseas that reported the shaft tibia and fibular as most common sites of lower limb fractures. The low incidence of fractures of tibia and fibula as revealed in this study could be attributed to the fact that large proportions of these patients were not hospitalized. About a half of patients under review were managed by close reduction and splinting (Plaster of Paris and traction). This confirmed earlier findings by Oluwadiya et al (3) and Odelowo (7) in which majority of patient were managed non-operatively. However, the proportion of patients managed by internal fixation in this study was higher than those of previous studies (3,6). This could be due to the fact that the considerable proportion of patients in our study sustained fractures of femur than those reported in previous studies (3,5).

Majority of patients (87. 3%) under review were trained to ambulate with axillary crutches. This may be because majority of the patients were young adults who could easily comprehend and handle crutch ambulation. More than half of the patients under review (67.8%) completed ambulation training within three physiotherapy treatment sessions while others completed their training after four or more treatment sessions. The duration of completion of ambulation training may be attributed to age distribution of the patients under review and method of reduction of fracture that predominated in the study. In other words, young adults with internal fixation or Plaster of Paris had shorter duration of training than the elderly or patients managed on traction. However, the outcome of ambulation training of patients under review was not associated with the methods of fracture reduction as expected. These findings may be as a result of limitation imposed by our research design being a retrospective study. We therefore recommend the need for carrying out prospective studies to investigate the association between outcome of acute care rehabilitation of fractures and method of reduction of fractures.

The association between means of ambulation training and outcome of ambulation training, invariably, the outcome of acute care rehabilitation as revealed in this study could also be due to age distribution pattern and fracture management procedures earlier explained. It is often clinically assumed that young and male patients may have better outcome of ambulation training. On the contrary, our findings revealed association between outcome of training and age but net gender. Similarly, it is clinically assumed that patients with internal fixation (ORIF) and closed reduction by Plaster of Paris should be able to learn ambulation with crutches or frame faster than those on traction. However we found out that outcome of ambulation training was not associated with fracture management procedures.

CONCLUSION

This study revealed that more males than females sustained lower limb fractures across all age groups. Fractures of lower extremities affect active segment of the patients under review. Moreover road traffic accident is a major cause of lower limb fractures with high proportion of fracture of femur. Preventive measures aimed at reducing road collision could play a significant role in curtailing incidence of lower limb fractures in our society. Age is an important determinant of outcome of ambulation training following fractures of lower extremities.

REFERENCES

(1.) Road Accident Fund Commission Report 2002, volume 3 page 282.

(2.) Kaje, J.A and Tick, H. Epidemiology of lower limb fractures in general practice in the United Kingdom. Inj. Preven. 2004; 10:368374 accessed in2006 www.bmjjournal.co

(3.) Oluwadiya K.S Oginni, L.M Olasinde. A.A and Fadiora, S.D Motorcycle limb injuries in a developing country We s t Afri. J. Med. 2004;23(1): 42 47

(4.) Hou, S. Zhang Y and Wu, W. Study on Characteristic features from road traffic accident in 306 cases. Chin J. Traumatol. 2002; 5(1): 52 54

(5.) Lateef F. Riding motorcycle: is it a lower limb hazard? Singapore Med J. 2002; 43(11) 566 569

(6.) Ebong. W.W. Pattern of bone injury in Ibadan. Injury 1978; 9(3): 221 224

(7.) Odelowo E.O. Pattern of pedestrian injuries from road traffic accident in Nigeria. Afri. J. Med 1992; 11 (2) 130 134

(8.) Mangione K.K and Palombaro K.M Exercise prescription for a patient 3 months after Hip Fracture Phys. Ther. 2005; 85:676 687

(9.) GuccioneAAFagersonTL and Anderson J.J Regaining fractional independence in acute care setting following Hip following Hip fracture Phys. Ther. 1996; 76: 818-826.

(10.) Kiel DP, Eichorm, A Inaotor, O et al. Outcome of patients newly admitted to nursing homes after hip fracture. Am. J. Public Health 1994; 84: 1281-1286

(11.) Marottoli R.A Berkman L.F and Cooney L,M. Decline in physical function following hip fracture. J. Am. Geriatric. Soc. 1992; 40 861-866

(12.) Barnes. B. Ambulation outcomes after hip fracture. Phys Ther. 1984; 64:317-323

(13.) Bohanmon R.W, Kloter. KS and Cooper J.A. Outcome of patients with hip fracture by physical therapy in an acute care hospital. Topics in Geriatric Rehabilitation 1990; 6(2): 51-58

(14.) Meseey, J.M Murtan E, Knott K and Craik R.L Determinants of recovery 12 month after hip fracture: the importance of psychosocial factors. Am J. Public Health 1989; 76: 1675-1679.

(15.) Barnes. B and Dunovan K. Physical therapy discharge outcomes after hip fracture. Topics in Geriatric Rehabilitation 1987; 2(40):45-51.

(16.) Barnes B and Dunovan.K. Functional outcomes after hip fractures Phys Ther. 1987; 67: 1675-1679

O AKANDE. Principal Physiotherapist, Department Of Physiotherapy, Lautech Teaching Hospital, Osogbo, Nigeria.

OA OLAKULEHIN. Lecturer And Consultant Orthopaedic Surgeon, Department Of Surgery College Of Health Sciences, Ladoke Akintola University Of Technology, Osogbo. Nigeria.

Correspondence: Akande, Olutunmise Department Of Physiotherapy, Lautech Teaching Hospital, PMB 5000, Osogbo. Osun State Nigeria. E mail: olubuntunmiseakande@yahoo.com
TABLE 1
Age by sex Distribution of patients with lower limb fractures referred
for physiotherapy.

 Sex

Age group (Years) Male (%) Female (%) Total (%)

<9 2 (1.0) 3 (1.5) 5 (2.5)
10-19 8 (4.1) 5 (2.5) 13 (6.6)
20-29 45 (22.8) 13 (6.6) 58 (29.4)
30-39 22 (11.2) 15 (7.6) 37 (18.8)
40-49 21 (10.7) 5 (2.5) 26 (13.2)
50-59 20 (10.2) 8 (4.1) 28 (14.2)
60 and above 20 (10.2) 10 (5.0) 30 (15.2)
Total 138 (70.1) 59 (29.9) 197 (100.0)

Table 2
Causes and sites of lower limb fractures referred for physiotherapy

Clinical Characteristics Frequency (%)

Causes of Fracture
Road Traffic Incident 147 (74.6)
Fall 33 (16.8)
Gunshot 8 (4.1)
Industrial Accident 6 (3.0)
Pathology 3 (1.5)

Fracture Sites

Tibia/Fibula 57 (28.9)
Tibia 33 (16.8)
Femur 101 (51.3)
Femur and Tibia 5 (2.5)
Pelvis 3 (1.5)

Table 3
Fracture management procedures of lower limb fractures referred for
physiotherapy

Fracture management
Procedures Frequency (%)

Traction (Skin/ Skeletal) 27 (13.7)
Plaster of Paris (POP) 67 (34.0)
Open reduction and
Open reduction with internal fixation (ORIF) 64 (32.5)
Athroplasty 1 (0.5)
Hemi arthroplasty 2 (1.0)
Not identifiable (not recorded) 36 (18.3)

Table 4
Association between age and outcome of acute care rehabilitation of
cases of lower limb fracture seen at physiotherapy

 Outcome

 Satis- Unsatis- Total [chi square]
Age (Years) factory (%) factory (%) P Comment

9 2 (1.0) 3 (1.5) 5 (2.5) 15.49 0.03S
10-19 6 (3.0) 7 (3.6) 13 (6.6)
20-29 49 (24.9) 9 (4.6) 58 (29.4)
30-39 28 (14.2) 9 (4.6) 37 (18.8)
40-49 19 (9.6) 7 (3.6) 26 (13.2)
50-59 23 (11.7) 5 (2.5) 28 (14.2)
60 and above 22 (10.7) 8 (4.5) 30 (15.2)
Total 148 (75.1) 49 (24.9) 197 (100.0)

Key S = Significant at alpha level <0.05

Table 5
Association between means of ambulation training and outcome of
rehabilitation of lower of lower limb fractures referred for
physiotherapy

 Outcome

Means of Satisfac- Unsatis-
Ambulation tory (%) factory (%) Total (%) X P Comment

Crutches 137 (69.5) 38 (19.3) 175 (88.8) 11.31 0.03 S
Walking 11 (5.6) 11 (5.6) 22 (11.2)
frame
Total 148 (75.1) 49 (24.9) 197 (100.0)

Key: S = Significant at alpha level <0.05

Table 6
Association between sex and outcome of rehabilitation of lower of
lower limb fractures referred for physiotherapy

 Outcome

 Satisfac- Unsatis-
Gender tory (%) factory (%) Total (%) X P Comment

Male 108 (54.8) 30 (15.3) 134 (70.1) 2.42 0.12 N.S
Female 40 (20.3) 9 (9.6) 59 (29.9)
Total 148 (75.1) 49 (24.9) 197 (100.0)

Key: N.S = Not Significant at alpha level <0.05
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Title Annotation:Research Papers
Author:Akande, O.; Olakulehin, O.A.
Publication:Journal of the Nigeria Society of Physiotherapy
Article Type:Clinical report
Geographic Code:6NIGR
Date:May 1, 2008
Words:3153
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