Thrombophlebitis (DVT)

• A significant source of morbidity and potential mortality following TBI, particularly in high age, severe injury, prolonged immobilization, and elevated thromboplastin time on admission (Lai, et al 1997; Cifu, et al 1996; Hammond & Meighen, 1998)

• Prophylaxis includes:
  • Full-length, lower extremity, sequential stockings
  • Subcutaneous heparin and routine monitoring with noninvasive Doppler ultrasound or duplex scanning
  • Placement of a prophylactic inferior vena cava (IVC)/Greenfield filter, if stockings or heparin are not possible

Contractures

• Loss of range of motion in a joint of the limbs and/or axial skeleton, to the extent that activities of daily living are impeded, is probably the most common musculoskeletal complication following TBI, particularly in patients with a long coma duration and immobility, poor positioning, severe brain injury, and altered muscle tone. Contractures can interfere with self-care, nursing care, mobility and vocalization

• Prophylaxis includes:
  • Ongoing program of range of motion exercises and maintenance of postural adaptation, with emphasis prolonged stretching of the lower extremity joints, with weights if possible, and with prior pain medication and ultrasound to increase the effectiveness of the stretch
  • Serial casting, with well-padded casts; nerve blocks prior to applying the cast may improve effectiveness of the cast

• Treatment includes:
  • Aggressive stretching program, together with physical modalities, serial casting, and dynamic bracing
    • Initial cast should remain in place 7-10 days, followed by drop-out casts at regular intervals until desired ROM is achieved
    • Dynamic splint, with a spring-tension, low-load, prolonged-stretch device, has a lesser risk for pressures sores than casts, but may be more uncomfortable
    • Phenol motor nerve blocks, in the early period of acquired spasticity when a temporary treatment is desirable (Botte, et al 1995), to differentiate spasticity from soft-tissue contractures
    • Surgical release of severely contracted tissue that does not respond to more conservative treatment, if necessary; may involve myotomy, tenotomy, tendon-lengthening, or neurectomy

Peripheral Nerve Injuries

• Common following TBI in patients:
  • Involved in high-speed collisions, particularly ulnar nerve entrapment in the cubital tunnel, followed by brachial plexus injury and peroneal compression neuropathies
  • With long-bone fractures
  • With upper extremity fractures (Kushwaha & Garland, 1998)
  • With extrinsic pressure from hematoma or heterotopic ossification, prolonged coma, severe spasticity, and fractures
  • With wrist and finger flexor spasticity, particularly median nerve compression
  • With poor body positioning and improper casts

• Diagnosis is critical to prevent progressive loss of function in the affected area, but can be problematic following TBI. If peripheral nerve injuries are suspected, electrodiagnostic studies are recommended

• Therapeutic measures include:
  • Strengthening and ROM exercises to avoid contractures
  • Splinting for function or positioning
  • Slings for support
  • Medications, nerve blocks, transcutaneous nerve stimulators, acupuncture, and massage for pain relief; surgical destruction of the dorsal root entry zone for intractable pain
  • Surgery if there is persistent paralysis

Heterotopic Ossification (HO)

• Click Posttraumatic Heterotopic Ossification, 2006 chapter in eMedicine by Auri A. Bruno
• More common in patients with severe TBI, prolonged immobility, increased duration of coma, and fractures of the large bones and joints, such as the hips, shoulders, arms and legs. For patients with fractures, this may be due to disturbances in the hormone prolactin (Wildburger, et al 1998). Neural mechanisms may be important in its pathogenesis (Goodman, et al 1997)

• May result in:
  • Disability due to limited range of motion, together with swelling, erythema, heat, and pain in the affected joint
  • Elevated fractionated alkaline phosphatase levels
  • Peripheral nerve compression
  • Vascular compression

• Diagnosis includes musculoskeletal examination, three-phased bone scan, and radiographs needed to determine location and extent of HO

• Prophylaxis includes diphosphonates and warfarin therapy

• Treatment includes aggressive ROM exercises and indomethacin, and, in advanced stages, surgery combined with radiation to arrest further bone development

     Click on Heterotopic Ossification for additional information on this major complication of spinal cord injury.

Oral and Skin Care

• Bruxism may occur following TBI and should be treated with bite-guards to reduce dental destruction

• Daily oral hygiene should be begun as soon as possible

• Pressure sores must be prevented by proper nutrition, skin care, and pressure reliefs and immediate treatment of any skin breakdown