Rehabilitation of the Child with Multiple Injuries

Therapeutic Exercise

Fractures are typically immobilized during the protection phase of rehabilitation to allow adequate healing. However, it is important to consider fracture and fixation stability to avoid excessive immobilization that delays rehabilitation. Therapy then progresses to controlled range of motion (ROM). Although isolated fractures in children often return to full ROM on their own, ROM and physical therapy are critical for patients with head injuries, spine injuries, or multiple fractures to avoid joint contractures. Communication between the orthopedist and therapist facilitates rehabilitation at the proper pace.

Active ROM exercises (movement generated by the patient) are performed if possible. These are facilitated by active-assistive ROM exercises that consist of having the child actively move through as much of the range as possible and then passively completing as much movement as possible through the normal range. The use of body weight often increases the effectiveness of ROM exercises. For example, the best stretch of the gastrocnemius muscles is obtained when the patient is standing. Children are encouraged to participate in their ROM exercise program, and young children may be able to perform simple stretches if properly supervised. Passive ROM is performed if the child is too young, weak, or unable to cooperate. Standards for full and functional ROM have been established ( Table 22.1 ).

After additional fracture healing is well established, therapy then transitions to strengthening exercises. These exercises usually involve extremely simple equipment such as a ball, putty, or exercise band. Strengthening programs may also include isometric exercises, which maintain muscle length with increasing tension during contraction, or isotonic exercises with muscle shortening and steady tension. Isotonic exercises include open kinetic chain exercises, such as with free weights, and closed kinetic chain exercises, such as with pulley systems. Closed kinetic chain exercises are often favored in the early postinjury period because they provide a more predictable path of movement. During this phase, progress is also made with balance and proprioception exercises. Sports-specific and functional training are also helpful before return to activities. Return to play is not allowed until pain relief, full strength, and full ROM have been restored.

Orthoses and Adaptive Equipment

Casts and braces for fracture healing are discontinued as soon as possible to facilitate recovery. Lower extremity orthoses are often prescribed for abnormal gait dynamics in patients with associated spinal cord or TBI. These orthoses are named according to the region of the body that they help control, such as ankle-foot orthoses and knee-ankle-foot orthoses. Generally, the more joints controlled by the orthosis, the bulkier it becomes and the greater the potential to interfere with balance, gait, and function.

Adaptive devices can be helpful in extending reach, providing grasp, reducing force, and improving safety. Examples include reachers, sock aids, a long-handled sponge or shoe horn, grooming aids, built-up feeding utensils, a rocker knife, a raised toilet seat, tub chair, and built-up door handles ( Fig. 22.1 ). Velcro or elastic shoe closures also may be helpful. Such devices can provide increased independence in activities of daily living including feeding, dressing, bathing, grooming, and toileting. Evaluation by an occupational therapist is valuable for problem-solving to increase independence and quality of life during recovery.

Gait aids are prescribed taking into account the child’s function and any cognitive or balance limitations. These aids may be useful for a child with weight-bearing restrictions on the lower extremity. Initial crutch training is needed to prevent axillary irritation and injury from falls. A child who requires additional support because of instability or reduced lower extremity strength may require a walker. For patients with concurrent wrist or hand injuries, the walker or crutches can be modified with an upper extremity platform support to distribute the weight through the forearm and elbow. Wheelchairs are used if both lower extremities are involved or the patient cannot comply with weight-bearing restrictions. A sliding board may be helpful in increasing a child’s independence in transfers for children who can weight bear on more than two limbs. Otherwise, a lift is prescribed, and caregivers are taught how to perform transfers.

Pain Control

Adequate pain control in children after sustaining multiple fractures is required for successful rehabilitation. Providing a description of their pain is difficult for preschool-age children who do not possess the language ability or the understanding to correctly identify the location and characteristics of the pain. Pain management is facilitated by using age-specific objective measurement scales based on expressive capability to quantify pain levels. The Children’s Hospital of Eastern Ontario Pain Scale and the Objective Pain Scale are used in infants and very young children. For children 3 to 6 years of age, visual progression of happy to sad faces such as the McGrath Facial Affective Scale and Beyer Oucher Scale are frequently used. Older children have improved abstract and numeric reasoning and may be able to use more adult measures, such as the visual analog scale. Inadequate pain control should be included in the differential diagnosis of unexplained agitation or vital sign changes such as tachycardia or hypertension in patients who are uncommunicative because of age or neurologic insult.

Pain relief should not be achieved with the indiscriminate use of narcotics. It has been shown that nonopioid analgesics such as acetaminophen and ibuprofen are as effective as opioids for acute fracture pain management. In addition, ibuprofen is also as effective as morphine for postoperative management following minor orthopedic procedures. However, for a multiply injured child, pain may be an ongoing problem such that narcotics are required. In this setting, efforts are made to slowly wean the child from the opioids while managing their side effects. Weaning is often started by switching to longer-acting medications.