Postoperative fracture treatment: general

considerations
Authors
Christian R Ryf, John Arraf

Guidelines
Guidelines for postoperative treatment of specific adult fractures according to AO
principles: The aim of operative fracture treatment is functional restitution and early
painfree active mobilization. Surgery followed by immobilization is a bad combination.
Fracture type
Postoperative Additional limb Exercise, weight Comment
and fixation
positioning
support
bearing
Humerus,
Orthopedic
Immobilization Pendulum
Note: associated
proximal:
sling,
for 3 weeks
exercises starting injuries (eg, rotator
dynamic,
Gilchrists
at once, active- cuff)
unstable splinting bandage, etc
assisted
by K-wire
mobilization
after week 2
Partial functional
use: week 36
Full functional
use: week 610
Humerus,
Arm placed on Orthopedic sling Arm placed on a More details in:
proximal: stable a cushion,
for 2 or 3 weeks cushion,
shoulder
fixation: PHILOS, orthopedic
orthopedic sling rehabilitation
PHN
sling
Active-assisted protocol
mobilization
starting at once.
Partial functional
use: week 36
Full functional
use: week 610
Humerus, shaft:
Arm placed on Sling
Active-assisted Mobilization of the
stable fixation: a cushion,
mobilization
shoulder and elbow
intramedullary
elevated
starting at once.

nail, plate

position

Humerus, distal:
stable ORIF

Arm placed on Upper arm splint

a cushion,
or sling
elevated
position

Olecranon: tension Arm placed on None

band
a cushion,
elevated
position

Radial head: stable Arm placed on Sling,

ORIF
a cushion,
exceptionally
elevated
removable splint
position

Forearm, shaft:
stable plate
fixation

Arm placed on None/light splint

a cushion,
elevated
position

Radius, distal:
stable fixation:
plate

Elevated
position

Positioning splint

Radius, distal:
unstable
fixation: K-wire
Radius, distal:
external fixation

Elevated
position

Dorsopalmar
splint for 46
weeks
Sling

Elevated
position

Partial functional
use and limited
rotation: week 4
6
Full functional
use: week 610
Active-assisted
mobilization
starting at once.
Partial functional
use: week 48
Full functional
use: week 610
Active-assisted
mobilization
starting at once.
Partial functional
use: week 48
Full functional
use: week 612
Active-assisted
mobilization
starting at once.
Partial functional
use: week 46
Full functional
use: week 68
Active-assisted
mobilization
starting at once.
Partial functional
use: week 46
Full functional
use: week 610
Active-assisted
mobilization
starting at once.
Partial functional
use: week 46
Full functional
use: week 610
Mobilization of
adjacent joints

Mobilization of the
shoulder, no forced
passive
manipulation

Mobilization of the
shoulder

Note: associated
ligament injuries,
mobilization of the
shoulder

Note: mobilization
of hand, wrist,
elbow, and
shoulder, splint for
associated
neurological
injuries
Mobilization of
adjacent joints
(including
shoulder)

Active exercises Release of

for mobile
distraction after 3
fingers
4 weeks,
mobilization of the

Femur, neck:
screw fixation or
DHS

Leg extended
in slight
abduction
(cushion
between legs)

Femur:
intertrochanteric/
pertrochanteric:
DHS/PFNA

Leg extended
in slight
abduction
(cushion
between legs)

Femur:
Leg extended
subtrochanteric:
PFNA, AFN, DCS,
angled blade plate

Femur, shaft:
Leg extended
stable fixation with
locked
intramedullary nail

Femur, shaft:
stable plate
fixation

9090positioning or
CPM Note:
protect
common fi
bular nerve

Femur, distal:
90-90LISS/DCS angled positioning,
blade plate
(CPM) Note:
protect the

elbow and shoulder

None
Partial weight
If stable: full
bearing (toeweight bearing,
touch): 15 kg
consider
week 0(6)12, compliance of the
30 kg week 12 patient and bone
14
quality
Full weight
bearing: week
1314
None
Young patients: With
Partial weight
intramedullary
bearing (toeimplant, full
touch): 15 kg
weight bearing can
week 06, 30 kg start immediately
week 410
Note: cranial
Full weight
cutout of
bearing: when
blade/screw in
comfortable
patients with
osteoporosis
Elderly patients:
Full weight
bearing
None
Partial weight
(Dynamization of
bearing (toeintramedullary
touch): 15 kg
nailing after week
week 06, 30 kg 68)
week 410
Full weight
bearing: when
comfortable
None
Partial weight
Dynamization is
bearing (toerarely indicated
touch): 15 kg
week 34
Full weight
bearing: as
tolerated
None
Partial weight
Consider
bearing (toecompliance of the
touch): 15 kg
patient and fracture
week 34
pattern/MIPO
Full weight
bearing: week 6
8
Knee brace in
Partial weight
Stable situation:
case of associated bearing (toefull weight bearing
ligamental
touch): 15 kg
from week 68
lesions
week 06, 30 kg

fibular nerve

Tibia, proximal:
Elevated
LCP/L-plate LISS position,
plate
(CPM)

(Dorsal splint or
knee brace in
extension)

Patella: tension
band

Elevated
position,
(CPM)

Tibia, shaft:
intramedullary
nailing

Elevated
position

None

Tibia, shaft: plate Elevated

fixation LC-DCP, position
LCP

None

Tibia, distal: pilon: Elevated

Postoperative Udifferent pilon
position, CPM splint to prevent
plates
pes equinus

Malleoli

Elevated
Postoperative Uposition, CPM splint. Associated
ligamental

week 610
Full weight
bearing: week
1012 on
Partial weight
bearing (toetouch): 15 kg
week 48, 30 kg
week 610
Full weight
bearing: week
1014
Isometric
quadriceps
exercises at once
Partial weight
bearing on fully
extended leg: 30
kg week 06
Full weight
bearing: week 6
8
Partial weight
bearing (toetouch): 15 kg
week 02, 30 kg
week 24
Full weight
bearing: when
comfortable
Partial weight
bearing (toetouch): 15 kg
week 06, 30 kg
week 610
Full weight
bearing: week
1012
Partial weight
bearing (toetouch): 15 kg
week 06, 30 kg
week 612
Full weight
bearing: week
1214
Partial weight
bearing (toetouch): 15 kg

Avoid resting knee

flexion to prevent
loss of knee
extension

Active-assisted
flexion of the knee
starting at once (to
a maximum of 90)

Prevention of pes
equinus

Prevention of pes
equinus, watch for
clinical signs of
instability

Active-assisted
mobilization at
once

In case of a
position screw,
dorsal extension

Calcaneus

Elevated
position

injuries: cast for week 04, 30 kg

6 weeks
week 46.
Full weight
bearing: after
week 6
Removable splint
to prevent pes
Partial weight
equinus
bearing (toetouch): 15 kg
week 06, 30 kg
week 610
Full weight
bearing: after
week 1016

and full weight

bearing should be
restricted until
screw removal
(week 812)
Active-assisted
mobilization at
once of the ankle,
subtalar joint, and
toe

Postoperative pain management

The International Association for the Study of Pain (IASP) defines pain as an unpleasant
sensory and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage [1]. In addition to being an unpleasant experience for the
patient, poorly controlled pain may have deleterious physiological consequences for the
patient leading to increased morbidity [2].

With adequate analgesia the orthopedic patient will be better able to mobilize
and perform physical therapy and recover more quickly.

Numerical Visual Analog Scale.

The simplest and most common methods used to quantify pain are one-dimensional scales
that measure the intensity of the pain. Among the most commonly used is the Visual Analog
Scale (VAS). The VAS consists of a straight line with the words no pain at all on one end
and worst pain imaginable on the other. Patients quantify the severity of their pain by
placing a mark along the scale [3]. Measurement can be improved by using a standard 10 cm
line and then quantifying the pain from 0 to 10 for later comparison. By quantifying pain on
the VAS, pain can be classified as mild (VAS 14), moderate (VAS 47), or severe (VAS 7
10) and the World Health Organizations Analgesic Ladder can be adapted to suit the needs of
the orthopedic patient.
WHOs Analgesic Ladder for pain in orthopedics

Mild pain
Acetaminophen1, acetylsalicylic acid, or other NSAIDs +/ coanalgesics2
Moderate pain Weak opioid analgesics such as oxycodone, codeine, or tramadol with
acetaminophen +/ NSAIDs +/ coanalgesics
Severe pain
Potent opioid analgesics such as morphine or hydromorphone +/
acetaminophen +/ NSAIDs +/ coanalgesics +/ regional anesthesia
techniques3
1

Acetaminophen = paracetamol
Coanalgesics include antidepressants, anticonvulsants
3
Regional anesthesia techniques include epidural analgesia, plexus catheters or single
injection nerve blocks
2

Analgesics
Acetaminophen exerts its analgesic effect by blocking the synthesis of prostaglandins in the
central nervous system with minimal effect on peripheral prostaglandin synthesis. Although it
has no antiinflammatory effect, it is an effective analgesic and antipyretic. Doses are 1015
mg/kg orally every 46 hours. For adults these may be doses of 5001000 mg (depending on
availability) every 46 hours. Rectal suppositories may be given in doses of 1520 mg/kg
every 4 hours. The total daily dose of acetaminophen for adults from all sources must not
exceed 4 g.
NSAIDs exert their analgesic effect by inhibiting the cyclooxygenase enzyme, thereby
decreasing prostaglandin production. NSAIDs given even as a single dose preoperatively can
significantly decrease morphine requirements by up to 29% over 24 hours [4]. This decrease
in morphine requirements translates into a lower incidence of opioid induced side effects such
as pruritis and postoperative nausea and vomiting. Unlike opioids, which exert their effect
predominantly on rest pain, NSAIDs have shown considerable efficacy in minimizing pain
associated with movement [5]. This may have a greater effect on minimizing postoperative
physiological impairment [6]. Reducing postoperative opioid requirements may also decrease
the likelihood of sedation and opioid-induced respiratory depression. In addition to single
preoperative doses, NSAIDs may also be given at regular scheduled intervals as appropriate.
NSAID dosing [7, 8]
Drug
Adult dose
Ibuprofen
Oral: 200400 mg every 46 h, max
3.2 g/d
Indomethacin
Oral, rectal: 2550 mg/dose, 23
times daily, max 200 mg/d
Acetylsalicylic
Oral: 650975 mg every 46 h, max
acid (ASA)
4 g/d
Naproxen
Oral: 500 mg initial dose, then 250
mg every 68 h, max 1250 mg/d
Diclofenac
Oral: 50 mg, 3 times daily, max 200
mg/d
Ketorolac
Intravenous: 1030 mg every 6 h,

Pediatric dose
Oral: 410 mg/kg every 68 h
to max 40 mg/kg/d
Oral: 12 mg/kg/d in 24
separate doses, max 4 mg/ kg/d
Oral: 1015 mg/kg every 46 h,
max 6080 mg/d
Oral: 57 mg/kg every 812 h
max 1000 mg/d
Oral: 23 mg/kg/d in 24
separate doses
Intravenous: 0.5 mg/kg every 6

max 120 mg/d

h
Oral: 10 mg every 6 h, max 40 mg/d

Some of the more common adverse effects of NSAIDs include gastric bleeding and
ulceration, bleeding from the operative site, nephrotoxicity, bronchospastic hypersensitivity
reactions and the suppression of heterotopic bone formation [9].
Of special interest is the effect of NSAIDs on bone healing. There is evidence from animal
studies that both traditional NSAIDs and cyclooxygenase-2 (COX-2) inhibitors inhibit bone
healing via their antiinflammatory effect [10]. More specifically, it may be the inhibition of
prostaglandin-E2 (which ordinarily shifts the balance of bone remodeling towards bone
formation) that has a deleterious effect on bone healing.

NSAIDs undoubtedly have a benefi cial impact on the quality of analgesia as well
as an opioid sparing effect but their effect on bone healing can make them an
unsuitable choice for certain orthopedic patients. Most surgeons now avoid their
use following nonunion surgery.

COX-2 inhibitors are well known for their analgesic efficacy. Their lower potential to
induce gastrointestinal bleeding and minimal effect on platelet function [11] make them seem
an attractive choice in the elderly orthopedic patient. However, COX-2 inhibitors will
selectively suppress prostaglandin-I2 without affecting thromboxane-A2. This may explain
their greater potential for serious cardiovascular side effects, especially in elderly patients.

Because of concerns about cardiovascular problems, many COX-2 inhibitors

have been withdrawn.

Anticonvulsant drugs have been useful in the treatment of neuropathic pain such as
trigeminal neuralgia. However, untoward side effects and the requirement to monitor serum
drug levels have made them less attractive in the treatment of acute pain. More recent studies
have explored the coanalgesic effect of gabapentin in the setting of postoperative pain. Turan
et al [12] found that in the setting of spinal surgery, a single oral dose of gabapentin 1200 mg
preoperatively decreased not only early postoperative pain scores but also resulted in a large
reduction in morphine requirements. Not surprisingly, this led to a significant reduction in
opioid related side effects in the postoperative period. Anticonvulsant drugs exert their
diverse pharmacological effects on both ascending and descending pain pathways through a
variety of mechanisms including sodium and calcium channel blocking [13]. The dose of
gabapentin for chronic pain ranges from 9001800 mg/d.
Opioid analgesics are a cornerstone of treatment for moderate to severe postsurgical pain.
Opioids exert their analgesic effects in the central nervous system at the -, -, and receptors. All pure opioid analgesics cause a dose-dependant sedation and respiratory
depression that is similar at equianalgesic doses. This phenomenon is exacerbated by the
concomitant use of benzodiazepines, sedating antiemetics, and antihistamines.

Codeine is a weak opioid analgesic frequently used in conjunction with acetaminophen for
the treatment of mild to moderate pain. Codeine undergoes hepatic O-demethylation to
morphine, which is primarily responsible for its analgesic effect. Approximately 710% of
Caucasians lack the enzyme cytochrome P450IID6 [14] that is necessary to convert codeine
to morphine and it is likely that this sizable segment of the population will not obtain pain
relief from this drug. For this reason codeine should not be used as the opioid analgesic of
choice in the treatment of mild to moderate pain unless the patient reports a prior favorable
outcome with the use of this drug.
Opioid analgesics [8, 15]
Drug
Equianalgesic
parenteral adult
dose (mg)
Codeine
120
Oxycodone
5-10
Hydrocodone
Morphine
10
Meperidine
100
Hydromorphone
1.5
Fentanyl
0.1

Equianalgesic oral
adult dose (mg)

Duration of action
(hours)

200
30
5-10
30-601
300
6
-

3-4
2-4
2-4
3-4
2-3
2-4
0.5

60 mg morphine for acute dosing, 30 mg for chronic dosing due to accumulation of

metabolites.

Oxycodone and hydrocodone are oral opioid analgesics used in the treatment of moderate
to severe pain. Unlike codeine, neither drug needs to undergo extensive metabolism prior to
exerting their analgesic effect. Both oxycodone and hydrocodone are commonly used in
conjunction with acetaminophen for the treatment of pain. Oxycodone, like morphine, is
commonly used as a sustained release preparation for around-the-clock dosing.
Morphine is the drug to which other opioids are compared. It is available as oral, parenteral,
rectal, and intrathecal formulations. Due to its low lipid solubility and its high degree of
ionization at a physiological pH, morphine penetrates the blood-brain barrier poorly, so that
peak analgesic effects do not occur for 1530 minutes after intravenous injection. Morphine
is conjugated in the liver, and the kidneys excrete its active metabolite morphine-6glucuronide. Because this metabolite can accumulate in renal failure and cause respiratory
depression, morphine should be avoided in patients with renal insufficiency.
Meperidine is a synthetic opioid with approximately 1/10 the potency of morphine. Its onset
of peak analgesia after intravenous injection is 5 minutes, making it signifi cantly faster than
morphine. Meperidine also exerts a potent effect on the -receptor, which likely accounts for
its ability to terminate shivering in low doses of 12.525 mg intravenous. Its major drawback
however is that it is metabolized in the liver to normeperidine, which can induce epileptic
seizure even in patients who are not susceptible to them. For this reason many institutions

discourage its use as a PCA (patient-controlled analgesia) drug and limit its dosage to 10
mg/kg/d. The kidneys excrete normeperidine, making meperidine an unsuitable choice for
patients with a history of either epileptic seizures or renal failure.
Hydromorphone is 67 times as potent as morphine and is indicated for moderate to severe
pain. It has a slightly faster onset than morphine and like morphine undergoes
glucuronidation in the liver. Unlike morphine and meperidine, however, it is relatively devoid
of toxic metabolites that depend on renal excretion making it a more appropriate drug in
patients with renal insufficiency.
Fentanyl is a synthetic opioid analgesic with approximately 100 times the potency of
morphine. It is also indicated in the treatment of moderate to severe pain and is extremely
lipid soluble; its onsets is in less than 30 seconds with a peak effect of 23 minutes when
given intravenously. This same lipid solubility allows it to redistribute in the body within 40
minutes, giving it a relatively short duration of action despite having a long elimination halflife. Like hydromophone, the lack of toxic metabolites depending on renal excretion makes it
a suitable drug for patients with renal failure. Its short duration of action in the normal dose
range, however, makes it more difficult to maintain a steady state of analgesia in patients
using fentanyl as a patient-controlled analgesia.

Fear of causing addiction has traditionally been one of the major reasons that physicians
underprescribe opioid analgesics.

In reality, the incidence of addiction when prescribing opioids appropriately for

the treatment of pain is remarkably low, likely far lower than the incidence of
untoward cardiopulmonary side effects when pain is not adequately treated.

Another common reason for underprescribing opioid analgesics is the fear of inducing
respiratory depression. This can be minimized or avoided by using PCA to deliver opioids
instead of larger intramuscular or intravenous injections. When PCA is compared with
intramuscular administration of opioids, PCA is found to provide better analgesia with fewer
pulmonary and cognitive complications [16]. Smaller, more frequent PCA doses will result in
more consistent blood levels with fewer and smaller peaks and troughs in drug levels. Other
ways to avoid oversedation in patients receiving opioids is to minimize the use of
unnecessary sedating medications. Benzodiazepines or sedatives should not be used unless
the patient is used to them; even then they should likely be given smaller doses. Opioid
consumption is greatest during the first 24 hours and patients require closer monitoring
during this time. In many institutions, patients will routinely be administered oxygen by nasal
prongs once therapy with PCA is started.
Nerve blocks
Without question the most profound analgesia will be obtained via neural blockade, whether
it is a neuraxial or peripheral technique. With long-acting local anesthetics the analgesic
effects of a nerve block can be expected to last for between 18 and 24 hours (following a
single injection), or for several days if a catheter technique is chosen.

There are many studies confirming the analgesic advantages of neural blockade over general
anesthesia. Brown et al [17] described less pain, nausea, and a faster discharge with neural
blockade when shoulder arthroscopy patients were randomized to either general anesthesia or
interscalene block. For patients with significant cardiac or pulmonary disease, the challenge
may not be the anesthetic but rather the relatively debilitating side effects of postoperative
opioid analgesics. These patients may derive the greatest benefit from regional anesthesia, be
it a single injection or a catheter technique. Regional anesthesia, however, is not without its
drawbacks, and compartment syndrome is a potential problem in the limbs (chapter 1.6:4.3)
[18]. One of the earliest signs may be pain that is disproportionate to the degree of injury
accompanied by pain on passive motion or neurological signs such as numbness and
paresthesia. Neural blockade may delay the diagnosis by masking these signs and symptoms.
Strecker et al [19] described a case of lower extremity compartment syndrome, in which the
delay in diagnosis was attributed to epidural analgesia achieved with 0.125% bupivacaine at
10 cc/h. If the use of regional anesthesia cannot be avoided in patients at risk of compartment
syndrome, then perhaps the local anesthetic concentration of the postoperative infusion can
be lowered and the patient monitored with extra vigilance for the development of this
syndrome. The use of compartment pressure monitoring may also be considered.

Dressings
To allow the surgical wounds to dry as quickly as possible, they are covered in the operating
room with sterile, absorbent gauze that allows for air circulation. If used, suction drainage
remains in place for about 24 hours, with routine amounts of exudation. For larger amounts,
as in pelvic or hip fractures, 48 hours may be required. Articular fractures are a special case
and should be drained for no more that 812 hours. Beyond these times, the risk of infection
is increased. If the wounds have bled a good deal, the first change of dressings takes place 24
hours after surgery; otherwise they can remain in place for 48 hours. Thereafter, the dressings
are changed daily in an effort to prevent the formation of a moist environment. Such changes
are carried out under strict hygienic conditions. Diluted iodine or chlorhexidine solutions are
recommended for skin disinfection. Open wounds should be regularly moistened with a
balanced electrolyte solution (eg, lactated Ringers solution), or a vacuum dressing can be
used (chapter 4.3). Contaminated wounds are flushed with antiseptic solutions such as
Lavasept (chapter 5.3). Such mechanical rinsing is particularly effective. As soon as bleeding
or secretion ceases, the wound is left uncovered. Even with sutures in place the patient can
bathe or undergo hydrotherapy, if the wound is temporarily protected by a water-tight
dressing (eg, OpSite film, Tegaderm).

Elevation and support of the injured limb

Many surgeons have their own preferred regimes, but the following guidelines are widely
applicable.
Following osteosynthesis of the upper extremity, the limb is either placed on a cushion or
elevated in a bag. When the latter is used, flexion of the elbow should not exceed 75. After
any procedure, pressure, malpositioning and deformity must be prevented. In particular, the

medial epicondyle of the elbow (ulnar nerve), and the head of the fibula (fibular nerve) must
be well padded. Removable plaster bandages or splints, if they are used, must not lead to
malpositioning nor inhibit early postoperative mobilization and physical therapy. Splints on
the forearm and hand are placed in the position of safety to prevent contracture of the muscles
and joints of the hand.

Positioning after operations.

a Upper extremity.
b Distal/midshaft femur.
c Lower leg.

A continuous passive motion (CPM)

splint may be used for joint fractures.
In fractures close to the hip, the affected extremity is placed in moderate abduction and held
in that position between cushions or in a padded splint. In distal and midshaft femur fractures,
the lower leg is supported with the hip and knee joints each in 90 of flexion . An operated
lower leg is similarly supported, but it is sufficient to fl ex the knee and hip to 45 . Articular

fractures in the knee are best managed by continuous passive motion (CPM). In all patients
with lower limb fractures it is essential to prevent pes equinus deformity of the ankle and foot
by using appropriate splints.

Such efforts to reduce swelling may be reinforced with cooling. In patients with a tendency
towards pes equinus position, a U-bar is adapted to fit the limb. Splints with hinges that allow
limited mobility are helpful either in gradual mobilization after an articular fracture, or if
there have been associated ligamentous lesions.

The combination of surgery and subsequent protracted immobilization is

inappropriate, due to the increased rate of associated complications.

External splintage should only be used, when unavoidable, to prevent malpositioning, to

ensure smooth wound healing, or in connection with an additional injury.

Swelling, mobilization, and thrombosis prophylaxis

Early mobilization from bed with

physiotherapy is essential after
fracture surgery.
Early mobilization, and in certain circumstances elastic supports, can be very effective in
preventing thrombosis. Medical prophylaxis against thrombosis may be employed in
addition, as described in "Thromboembolic prophylaxis". Patients who have had an operation
on the upper extremity should get up on the day of their surgery. If the lower extremity has
been operated, ambulation is minimized until soft-tissue swelling has disappeared and the
wound shows no signs of inflammation.
The weightbearing status of the limb will depend upon

the personality of the fracture;

function of implants employed;

coexisting injuries;

preoperative morbidity;

patient compliance [20].

After surgery, the leg should be

elevated and active mobilization of
joints encouraged.
Although guidelines are helpful, the responsibility for deciding this must remain with the
operating surgeon, who should be in the position of knowing how reliable the fixation is.
Care must be taken not to allow early mobilization to interfere with wound healing. If
swelling occurs, elevation and icing of the limb is helpful. AV foot pumps may also be very
effective.

Antibiotics
The use of antibiotic prophylaxis and in the treatment of contaminated wounds is dealt with
in chapter 4.5.

Activity and weight bearing

Active-assisted exercises reduce

joint stiffness and help start muscle
rehabilitation.
Postoperative physical therapy begins on the first postoperative day. In long-bone injuries, the
neighboring joints start active and active-assisted movement. Continuous passive motion may
also be used. At first, weight bearingup to 1520 kgshould take place with the assistance
of crutches and walkers and only under the guidance of trained personnel [21].

Elderly patients must be given

instructions on activities, such as
stair walking, before discharge
from hospital.
Training in walking up and down stairs with canes is particularly difficult for patients and
should be carefully overseen. Hydrotherapy is an important means of providing weightless
and pain-free mobilization for patients with fractures of the spine, shoulder, pelvis, and hip; it
also helps to build up confidence.

X-ray assessment
Intraoperatively or postoperatively, x-rays are taken in at least two planes. These serve to
document fracture reduction and fixation, record the orientation of implants, and provide a
basis for the evaluation of how fracture healing is progressing.

Communication

Patients can be instructed how to

partially bear weight by using
scales.
Throughout this first phase, the patient and relatives should be informed regularly and fully
about the clinical state, the rate of progress, and what is to be expected along the timetable to
recovery. The expectations of the patient and the family should be ascertained and the
involved persons should be appropriately educated towards an understanding of the actual
situation. All relevant support services should be involved at an early stage.
The following points should be established between patient
and staff:

The wound is healing without complication and pain is controlled.

Postoperative x-rays have been taken.

Instructions have been given for ambulation with crutches (including stairs), and for
further mobilization.

Information has been provided about symptoms and signs of possible complications.

Instructions have been given to care-providers about postoperative treatment and

follow-up.

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Links to other chapters

Postoperative management - General considerations

Postoperative management - The second phase of postoperative fracture treatment

Postoperative management - Third phase: conclusion of the postoperative fracture

treatment

Postoperative management - Implant removal