Postoperative fracture treatment: general considerations

Authors

Guidelines

Postoperative pain management

Dressings

Elevation and support of the injured limb

Swelling, mobilization, and thrombosis prophylaxis

Antibiotics

Activity and weight bearing

X-ray assessment

Communication

Bibliography

Links to other chapters

Author

Christian R Ryf, John Arraf

Guideline

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 typeand fixation

Postoperativepositioning

Additional limbsupport

Exercise, weight bearing

Comment

Humerus, proximal: “dynamic“, unstable splinting by K-

Orthopedic sling, Gilchrist’s bandage, etc

Immobilization for 3 weeks

Pendulum exercises starting at once, active-assisted mobilization after week 2 Partial functional use: week 3–6

Note: associated injuries (eg, rotator cuff)

Full functional use: week 6–10

Humerus, proximal: “stable“ fixation: PHILOS, PHN

Arm placed on a cushion, orthopedic sling

Orthopedic sling for 2 or 3 weeks

Arm placed on a cushion, orthopedic sling Active-assisted mobilization starting at once. Partial functional use: week 3–6Full functional use: week 6–10

More details in: shoulder rehabilitation protocol

Humerus, shaft: “stable“ fixation: intramedullary nail, plate

Arm placed on a cushion, elevated position

Sling Active-assisted mobilization starting at once. Partial functional use and limited rotation: week 4–6Full functional use: week 6–10

Mobilization of the shoulder and elbow

Humerus, distal: stable ORIF

Arm placed on a cushion, elevated position

Upper arm splint or sling

Active-assisted mobilization starting at once. Partial functional use: week 4–8Full functional use: week 6–10

Mobilization of the shoulder, no forced passive manipulation

Olecranon: tension band

Arm placed on a cushion, elevated position

None Active-assisted mobilization starting at once. Partial functional use: week 4–8Full functional use: week 6–12

Mobilization of the shoulder

Radial head: stable ORIF

Arm placed on a cushion, elevated position

Sling, exceptionally removable splint

Active-assisted mobilization starting at once. Partial functional use: week 4–6Full functional use: week 6–8

Note: associated ligament injuries, mobilization of the shoulder

Forearm, shaft: stable plate

Arm placed on a cushion, elevated position

None/light splint

Active-assisted mobilization starting at once. Partial functional use: week 4–6Full functional use: week 6–10

Note: mobilization of hand, wrist,elbow, and shoulder, splint for associated neurological injuries

Radius, distal: “stable” fixation: plate

Elevated position

Positioning splint

Active-assisted mobilization starting at once. Partial functional use: week 4–6Full functional use: week 6–10

Mobilization of adjacent joints (including shoulder)

Radius, distal: “unstable” fixation: K-wire

Elevated position

Dorsopalmar splint for 4–6 weeks

Mobilization of adjacent joints

—

Radius, distal: external fixation

Elevated position

Sling Active exercises for mobile fingers

Release of distraction after 3–4 weeks, mobilization of the elbow and shoulder

Femur, neck: screw fixation

Leg extended in slight abduction (cushion between legs)

None Partial weight bearing (toe-touch): 15 kg week 0–(6)–12, 30 kg week 12–14Full weight bearing: week 13–14

If stable: full weight bearing, consider compliance of the patient and bone quality

intertrochanteric

pertrochanteric: DHS/PFNA

Leg extended in slight abduction (cushion between legs)

None Young patients:Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 4–10Full weight bearing: when comfortable

Elderly patients:Full weight bearing

With intramedullary implant, full weight bearing can start immediatelyNote: cranial cutout of blade/screw in patients with osteoporosis

subtrochanteric: PFNA, AFN, DCS, angled blade plate

Leg extended

None Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 4–10Full weight bearing: when comfortable

(Dynamization of intramedullary nailing after week 6–8)

Femur, shaft: stable fixation with locked intramedullary

Leg extended

None Partial weight bearing (toe-touch): 15 kg week 3–4Full weight bearing: as tolerated

Dynamization is rarely indicated

Femur, shaft: stable plate

90°–90°-positioning or CPM Note:

None Partial weight bearing (toe-touch): 15 kg week 3–4Full weight bearing:

Consider compliance of the patient and fracture pattern/MIPO

protect common fi bular nerve

week 6–8

Femur, distal: LISS/DCS angled blade

90°-90°-positioning, (CPM) Note: protect the fibular nerve

Knee brace in case of associated ligamental lesions

Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 6–10Full weight bearing: week 10–12 on

“Stable” situation: full weight bearing from week 6–8

Tibia, proximal: LCP/L-plate LISS plate

Elevated position, (CPM)

(Dorsal splint or knee brace in extension)

Partial weight bearing (toe-touch): 15 kg week 4–8, 30 kg week 6–10Full weight bearing: week 10–14

Avoid resting knee flexion to prevent loss of knee extension

Patella: tension Elevated position, (CPM)

— Isometric quadriceps exercises at once Partial weight bearing on fully extended leg: 30 kg week 0–6Full weight bearing: week 6–8

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

Tibia, shaft: intramedullary

Elevated position

None Partial weight bearing (toe-touch): 15 kg week 0–2, 30 kg week 2–4Full weight bearing: when comfortable

Prevention of pes equinus

Tibia, shaft: plate fixation LC-DCP, LCP

Elevated position

None Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 6–10Full weight bearing: week 10–12

Prevention of pes equinus, watch for clinical signs of instability

Tibia, distal: pilon: different pilon plates

Elevated position, CPM

Postoperative U-splint to prevent pes equinus

Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 6–12Full weight bearing: week 12–14

Active-assisted mobilization at once

Malleoli Elevated position, CPM

Postoperative U-splint. Associated ligamental

Partial weight bearing (toe-touch): 15 kg week 0–4, 30 kg week 4–6.Full weight bearing:

In case of a position screw, dorsal extension and full weight bearing should be restricted until screw removal (week 8–12)

injuries: cast for 6 weeks

after week 6

Calcaneus Elevated position

Removable splint to prevent pes equinus

Partial weight bearing (toe-touch): 15 kg week 0–6, 30 kg week 6–10Full weight bearing: after week 10–16

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 1–4), moderate (VAS 4–7), or severe (VAS 7–10) and the World Health Organization’s Analgesic Ladder can be adapted to suit the needs of the orthopedic patient.

WHO’s 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

Acetaminophen = paracetamolCoanalgesics include antidepressants, anticonvulsantsRegional anesthesia techniques include epidural analgesia, plexus catheters or single injection nerve blocks

AnalgesicsAcetaminophen 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 10–15 mg/kg orally every 4–6 hours. For adults these may be doses of 500–1000 mg (depending on availability) every 4–6 hours. Rectal suppositories may be given in doses of 15–20 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]

Adult dose Pediatric dose

Ibuprofen Oral: 200–400 mg every 4–6 h, max 3.2 g/d Oral: 4–10 mg/kg every 6–8 h to max 40 mg/kg/d

Indomethacin Oral, rectal: 25–50 mg/dose, 2–3 times daily, max 200 mg/d

Oral: 1–2 mg/kg/d in 2–4 separate doses, max 4 mg/ kg/d

Acetylsalicylicacid (ASA)

Oral: 650–975 mg every 4–6 h, max 4 g/d Oral: 10–15 mg/kg every 4–6 h, max 60–80 mg/d

Naproxen Oral: 500 mg initial dose, then 250 mg every 6–8 h, max 1250 mg/d

Oral: 5–7 mg/kg every 8–12 h max 1000 mg/d

Diclofenac Oral: 50 mg, 3 times daily, max 200 mg/d Oral: 2–3 mg/kg/d in 2–4 separate doses

Ketorolac Intravenous: 10–30 mg every 6 h, max 120 mg/dOral: 10 mg every 6 h, max 40 mg/d

Intravenous: 0.5 mg/kg every 6 h

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 900–1800 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 μ-, κ-, and δ-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 7–10% 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]

Equianalgesic parenteral adult dose (mg)

Equianalgesic oral adult dose (mg)

Duration of action (hours)

120 200 3-4

Oxycodone 5-10 30 2-4

Hydrocodone - 5-10 2-4

Morphine 10 30-601 3-4

Meperidine 100 300 2-3

Hydromorphone 1.5 6 2-4

Fentanyl 0.1 - 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 15–30 minutes after intravenous injection. Morphine is conjugated in the liver, and the kidneys excrete its active metabolite morphine-6-glucuronide. 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 κ-receptor, which likely accounts for its ability to terminate shivering in low doses of 12.5–25 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 6–7 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 2–3 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 half-life. 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 blocksWithout 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.

Dressing

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 8–12 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 Ringer’s 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

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.

Antibiotic

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 bearing—up to 15–20 kg—should 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.

Communicatio

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

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 treatmentPostoperative management - Third phase: conclusion of the postoperative fracture treatmentPostoperative management - Implant removal