Managing Post-Fracture Care in Elderly Patients with Polio and Diabetes

The patient has sustained a fracture due to a fall and also has a history of poliomyelitis and diabetes mellitus?

Hello, Doctor: The patient is 65 years old and suffered a right tibial fracture from a fall in mid-January, requiring surgery and hospitalization.
During the process, the attending physician initially mentioned that the patient could opt for self-paid hardware that would not require removal in the future.
However, after the surgery, we were informed that due to the patient's history of polio, there were no appropriately sized components available, and instead, they used hardware that would require removal in 2 to 3 years.
Considering the patient's polio, diabetes, and age, we inquired whether it was absolutely necessary to remove the hardware.
The attending physician simply stated that if we were okay with having the metal implants for life, he had no objections.

We found information online suggesting that considerations should be made regarding potential wear on nerves and muscles, so we would like to ask Dr.
Yeh if this is accurate.
Additionally, we came across many articles stating that rehabilitation should begin approximately 2 to 3 weeks post-surgery, but we are unsure why the attending physician scheduled a follow-up appointment for three months later.
We also heard discussions online indicating that rehabilitation requires finding a specialist independently, but the patient cannot bend the leg due to the fracture and had to take an ambulance to the hospital for suture removal, making hospital visits quite inconvenient.
In this situation, should we arrange to see a rehabilitation specialist before the follow-up appointment?

Da Mi, 20~29 year old female. Ask Date: 2018/03/03

Dr. Ye Qingnian reply Orthopedics

The fixed metal plate will not damage the nerves or muscles.
The timing for rehabilitation depends on the severity of the fracture and the stability of the plate fixation after surgery.
Therefore, the most appropriate time for rehabilitation should be determined by the attending surgeon.

Reply Date: 2018/03/03

More Info

Managing post-fracture care in elderly patients, especially those with underlying conditions such as polio and diabetes, requires a comprehensive and tailored approach. In your case, the patient is a 65-year-old individual who has undergone surgery for a right tibial fracture. Given the complexities associated with their medical history, including polio and diabetes, there are several key considerations to address.

1. Surgical Hardware Removal
The decision regarding whether to remove surgical hardware (such as plates and screws) after a fracture repair is often influenced by several factors, including the patient's overall health, the type of hardware used, and the potential for complications. In your situation, the surgeon indicated that the hardware might need to be removed in 2-3 years due to the patient's unique anatomy resulting from polio. This is a common practice, as hardware can sometimes cause discomfort or complications, particularly in patients with altered biomechanics.

However, if the hardware is not causing any pain or functional issues, it may not be necessary to remove it. The concern about potential nerve or muscle damage from the hardware is valid; however, this risk is typically assessed on a case-by-case basis. It’s essential to maintain open communication with the orthopedic surgeon about the risks and benefits of leaving the hardware in place versus removing it.

2. Rehabilitation Timeline
Regarding the rehabilitation process, it is crucial to understand that recovery from a fracture, especially in elderly patients, can be slow and requires careful monitoring. The typical recommendation for initiating rehabilitation is around 2-3 weeks post-surgery, but this can vary based on the patient's specific situation, including their mobility, pain levels, and overall health status.

The surgeon's decision to schedule a follow-up appointment in three months may be based on the need to ensure that the fracture is healing properly before beginning more intensive rehabilitation. However, if the patient is experiencing significant discomfort or has concerns about mobility, it would be prudent to seek earlier intervention from a physical therapist. Many rehabilitation centers offer home health services, which could be beneficial given the patient's current mobility limitations.

3. Managing Diabetes and Polio
In elderly patients with diabetes, wound healing can be significantly impaired. It is essential to monitor blood sugar levels closely, as uncontrolled diabetes can lead to complications such as delayed healing or infections. Regular follow-ups with an endocrinologist may be necessary to manage diabetes effectively during the recovery process.

Additionally, polio can lead to muscle weakness and atrophy, which may complicate rehabilitation efforts. A tailored physical therapy program that considers the patient's unique needs and limitations is crucial. This program should focus on gentle range-of-motion exercises initially, progressing to strength training as tolerated.

4. Pain Management and Mobility
Pain management is another critical aspect of post-fracture care. It is essential to address any pain the patient may experience, as this can hinder rehabilitation efforts. The use of analgesics, as prescribed by the physician, should be closely monitored to ensure effective pain control.

Encouraging mobility, even in small increments, is vital for recovery. If the patient is unable to attend physical therapy sessions in person, consider telehealth options or home visits from a physical therapist. This can help maintain continuity of care and ensure that the patient receives the necessary support during their recovery.

Conclusion
In summary, managing post-fracture care in elderly patients with polio and diabetes requires a multidisciplinary approach that includes careful monitoring of surgical hardware, timely rehabilitation, effective diabetes management, and pain control. Open communication with healthcare providers, including orthopedic surgeons and physical therapists, is essential to ensure the best possible outcomes for the patient. If there are any concerns or uncertainties, do not hesitate to seek further clarification from the healthcare team.

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