Abstract
Objective: To evaluate the effectiveness of early rehabilitation nursing in preventing deep vein thrombosis (DVT) and promoting functional recovery in patients with lower limb traumatic fractures, and to identify independent risk factors for DVT. Methods: A retrospective cohort study was conducted, including 162 patients treated for lower limb traumatic fractures at Hanzhong Hospital of TCM from January 2022 to December 2023. The control group (n=78) received conventional nursing care prior to January 2023, while the observation group (n=84) received early rehabilitation nursing after January 2023. The control group received routine care, including preoperative education, intraoperative temperature monitoring, and postoperative vital signs monitoring, along with basic guidance for lower limb movement. The observation group received additional personalized early rehabilitation interventions, including tailored preoperative education, psychological support, optimized anesthesia management, advanced postoperative pain control, and progressive lower limb functional exercises. Collected data included baseline characteristics, rehabilitation indicators (e.g., catheter retention time, time to first feeding, and time to first ambulation), postoperative complications, and assessments of pain (Visual Analogue Scale, VAS), quality of life (World Health Organization Quality of Life [WHOQOL]-BREF), and lower limb functional recovery (Fugl-Meyer lower limb function score). Multivariate logistic regression was performed to identify independent risk factors for DVT. Results: There were no significant differences in baseline characteristics between the control and observation groups (all P>0.05). The observation group exhibited significantly lower VAS scores at 7 days postoperatively (P<0.001), along with significantly higher WHOQOL-BREF scores across physical, psychological, social, and environmental domains, and significantly higher Fugl-Meyer lower limb function scores one month after the intervention (P<0.001). Rehabilitation indicators, such as catheter retention time, time to first feeding, time to first ambulation, initiation of exercises, and hospital stay duration, were all shorter in the observation group compared to the control group (all P<0.05). The incidence of DVT was significantly lower in the observation group (P=0.002). Multivariate logistic regression analysis identified nursing intervention (OR=3.086, P=0.024), age ≥60 years (OR=2.589, P=0.043), body mass index (BMI) of 21-25 kg/m2 (OR=2.444, P=0.037), and catheter retention time ≥19.5 hours (OR=2.401, P=0.061) as independent risk factors for DVT. Conclusion: Early rehabilitation nursing is highly effective in preventing DVT and enhancing lower limb functional recovery in patients with traumatic fracture. It significantly reduces rehabilitation time and improves quality of life. Independent risk factors for DVT include nursing protocol, advanced age, BMI, and prolonged catheter retention time, all of which should be prioritized in clinical care.
Keywords: Early rehabilitation nursing, traumatic fractures, postoperative DVT, limb function
Introduction
Traumatic fractures, particularly in the lower limbs, are common in orthopedics due to high-energy injuries, often require surgical intervention [1]. Postoperative recovery significantly influences the prognosis and quality of life for these patients. Among the most common complications, deep vein thrombosis (DVT) presents a major challenge, as it not only impedes recovery but also extends hospital stay, increases healthcare costs, and may, in severe cases, be life-threatening [2]. Patients with lower limb fractures are especially prone to DVT due to hemodynamic changes from surgical trauma and prolonged immobility [3]. The risk is further heightened in older or frail individuals, highlighting the need for effective DVT prevention strategies and approaches to accelerate functional recovery.
With advancements in clinical nursing, early rehabilitation nursing has gained considerable attention [4]. This approach encourages patients to engage in light physical activity soon after surgery, promoting blood circulation and reducing the risk of venous thrombosis [5]. The core principle involves enhancing muscle contractions and venous blood return through gentle exercises, thus alleviating venous stasis. Additionally, early rehabilitation alleviates pain, boosts patient motivation for recovery, and accelerates functional restoration [6,7]. Despite its potential, research on early rehabilitation nursing for DVT prevention in postoperative lower limb fractures remains limited and fragmented, particularly in China, where standardized care protocols and intervention strategies are still developing.
The functional recovery of patients with lower limb fractures is critical during postoperative rehabilitation [8]. Improved function not only enhances self-care ability but also contributes to a better quality of life [9]. The Fugl-Meyer Assessment for lower limb function is a widely recognized tool for objectively evaluating the effect of rehabilitation nursing on functional recovery [10]. Early rehabilitation nursing, incorporating both active and passive exercises, strengthens lower limb muscles, improves joint flexibility, and reduces the risk of postoperative complications such as muscle atrophy and joint stiffness [11]. In contrast, traditional nursing models often delay mobilization, inadvertently contributing to muscle deconditioning and prolonged recovery times [12]. Early rehabilitation thus represents a crucial intervention for improving postoperative quality of life.
Recent studies have examined the application of early rehabilitation nursing in traumatic fractures, particularly for lower limb injuries, emphasizing its potential to reduce hospital stays and postoperative complications. However, many of these studies rely on small sample sizes or isolated interventions, limiting their broader applicability. Therefore, a systematic analysis of early rehabilitation nursing’s effects on DVT prevention and functional recovery in lower limb traumatic fractures is of great clinical value. This study aims to fill these gaps by providing evidence to optimize nursing care, improve recovery outcomes, and help patients return to normal life.
This study evaluates the efficacy of early rehabilitation nursing in preventing DVT and promoting lower limb functional recovery through a retrospective analysis. Unlike previous studies with small cohorts or single interventions, this research integrates a comprehensive early rehabilitation nursing protocol and systematically evaluates its impact on DVT prevention and functional recovery. Targeting a Chinese patient population with standardized care, the study compares postoperative changes in Visual Analogue Scale (VAS) scores, World Health Organization Quality of Life (WHOQOL)-BREF scores, Fugl-Meyer lower limb function scores, and other recovery indicators between groups. Additionally, the study identifies independent risk factors for DVT, offering actionable insight to optimize nursing strategies and improve patient outcome.
Materials and methods
Sample size calculation
According to Zhang et al. [13], the average incidence rate of postoperative DVT is 22.79%. Based on this incidence rate, the sample size was calculated using the formula N = Z2 × [P × (1-P)]/E2, where Z is the confidence level at 95% (1.96) and E is the margin of error (5%). The required sample size was approximately 270 participants. The final sample size was adjusted according to clinical conditions and patient availability to ensure statistical validity while maintaining practical feasibility.
Study design
This retrospective cohort study used hospital databases to collect clinical data on patients with lower limb traumatic fractures. All data were anonymized to protect patient privacy. The study was approved by the ethics committee of the Hanzhong Hospital of TCM, and informed consent was waived.
Participants
The study included patients treated for lower limb traumatic fractures at Hanzhong Hospital of TCM between January 2022 and December 2023. Inclusion criteria were: (1) age ≥18 years; (2) postoperative follow-up of at least one month; (3) clear diagnosis and surgical treatment; and (4) complete clinical data. Exclusion criteria were: (1) history of lower limb DVT; (2) severe preoperative comorbidities (e.g., malignancy or severe cardiopulmonary dysfunction) affecting recovery; (3) pre-existing limb paralysis; (4) coagulation disorders; and (5) pregnancy or lactation. Initially, 284 cases met the inclusion criteria. After applying the exclusion criteria, 162 cases remained eligible, consisting of 78 patients receiving conventional nursing care (control group) and 84 patients receiving early rehabilitation nursing (observation group). The study was approved by the Ethics Committee of Hanzhong Hospital of TCM.
Data collection
Baseline and postoperative recovery data were extracted from the hospital’s electronic medical record system. Collected data included patient characteristics (gender, age, body mass index, ABO blood type, surgery duration, ASA score, fracture type) and rehabilitation-related indicators (catheter retention time, time to first feeding, time to first ambulation, start of exercises, recovery tolerance time, and hospital stay). Postoperative complications, such as nausea, vomiting, bloating, hematoma, urinary retention, and DVT, were recorded. The following assessment scores were used: (1) Visual Analogue Scale (VAS) [14]: Assessed preoperative and 7-day postoperative pain on a scale from 0 to 10, with higher scores indicating greater pain. (2) WHOQOL-BREF [15]: Evaluated quality of life across physical, psychological, social, and environmental domains before nursing care and one month post-intervention. Scores ranged from 4 to 20, with higher scores indicating better quality of life. (3) Fugl-Meyer Lower Limb Scores [16]: Assessed lower limb functional recovery before and one month after nursing care, with scores ranging from 0 to 34, where higher scores indicated better functional recovery.
Surgical protocol
Hip fracture: joint replacement (arthroplasty)
Patients with hip fractures underwent total or partial joint replacement, depending on age, bone quality, and fracture type. Cemented or uncemented prostheses were selected based on bone density and surgeon preference. The Smith & Nephew REF 71390257 cemented total hip prosthesis was used, with Heraeus PALACOS® R+G Bone Cement containing gentamicin for fixation in cemented implants. Surgeries were performed under general or regional anesthesia (e.g., spinal or epidural). Intraoperative medications included cefazolin 2 g (Sandoz), administered intravenously 60 minutes before incision and every 8 hours for 24 hours postoperatively. To reduce bleeding, tranexamic acid 1 g (Pfizer) was administered intravenously before wound closure. Fluid management included lactated Ringer’s solution or normal saline, adjusted based on intraoperative blood loss.
Femoral shaft fracture: intramedullary fixation
Femoral shaft fractures were treated with closed or open reduction followed by intramedullary nailing using Synthes REF 456.401 titanium alloy nails and locking screws from the same system for additional fixation. Fluoroscopic guidance ensured accurate alignment and stabilization throughout the procedure. Anesthesia was general or regional, as appropriate. Intraoperative medications included cefazolin 2 g (Sandoz) and tranexamic acid 1 g (Pfizer), administered as in joint replacement procedures. Fluid replacement was managed with lactated Ringer’s solution or normal saline based on blood loss.
Interventions
Control group
Patients in the control group received conventional nursing care from January 2022 to December 2022. Routine care included preoperative health education and preparation to ensure normal surgical indicators, intraoperative temperature monitoring to maintain a comfortable surgical environment, and postoperative monitoring of vital signs, pain management, gradual dietary recovery, and basic lower limb activity guidance. Discharge instructions emphasized moderate lower limb movement, avoidance of weight-bearing, and timely follow-up.
Observation group
Patients in the observation group received early rehabilitation nursing from January 2023 to December 2023. The early rehabilitation protocol included multi-phase interventions during preoperative, intraoperative, and postoperative care: (1) Preoperative Care: Health education and psychological counseling to reduce anxiety, strengthen patient and family confidence in treatment, and provide personalized dietary guidance. (2) Intraoperative Care: Preference for nerve block or laryngeal mask anesthesia, control of surgery duration, and maintenance of appropriate temperatures to minimize stress response and reduce the risk of hypothermia. (3) Postoperative Care: Vigilant monitoring of vital signs, pain management using VAS scores with combined pharmacologic and non-pharmacologic interventions, progressive lower limb exercises (e.g., quadriceps and ankle pump exercises) to promote joint function recovery, leg elevation, warm compresses, and infrared therapy to alleviate limb swelling. Environmental nursing included daily ward disinfection, ventilation, and clean bedding to prevent cross-infection. Dietary management focused on high nutrition and fiber intake, with instructions to stay hydrated to promote urination. Discharge education provided guidance on daily activities and key points for home rehabilitation to support gradual return to normal activities and consolidate treatment outcomes.
This early rehabilitation nursing protocol offered a systematic and personalized approach, addressing the comprehensive rehabilitation needs of patients with lower limb traumatic fractures to accelerate functional recovery, reduce complication risk, and enhance overall WHOQOL-BREF scores.
Note: All patients received one week of nursing care. See Supplementary Material for the detailed nursing protocol; the above content is a condensed version.
Outcome measurements
The primary outcome was the analysis of risk factors for DVT. Baseline data from the DVT and non-DVT groups were compared to identify independent risk factors, shedding light on key elements influencing DVT occurrence and providing a basis for postoperative care and prevention. Secondary outcomes included VAS scores, WHOQOL-BREF scores, Fugl-Meyer scores, rehabilitation indicators, and the incidencQinghua Zheng, Department of Intervention and Vascular Surgery, Hanzhong Central Hospital, No. 557, Middle Section of Laodong West Road, Hantai District, Hanzhong 723000, Shaanxi, Chinae of postoperative complications. VAS scores were used to assess pain preoperatively and at 7 days postoperatively; WHOQOL-BREF assessed quality of life before nursing care and one month post-intervention; and Fugl-Meyer scores evaluated lower limb functional recovery. Rehabilitation indicators included catheter retention time, first feeding time, first ambulation time, exercise initiation, recovery tolerance time, and hospital stay, all used to measure recovery speed. Postoperative complications focused on DVT incidence, which served to evaluate the preventive effectiveness of the nursing protocol.
Statistical analysis
Data analysis was conducted using SPSS 26.0. Categorical data were expressed as percentages and compared using the chi-square test. Continuous data were presented as mean ± standard deviation or median (interquartile range), and analyzed with an independent sample t-test or Mann-Whitney U test, depending on the results of the normality test. Multivariate logistic regression analysis was performed using R (version 4.3.3), and the forest plot in was generated using the forestplot and grid packages. The forestplot package was used to create a clear visual representation of odds ratios (ORs) and their 95% confidence intervals (CIs) for each independent risk factor of DVT, while the grid package allowed for customization of graphical elements to ensure clarity and precision. The regression results were visualized in a forest plot to display the odds ratios (ORs) and 95% confidence intervals (CIs) for each independent risk factor of DVT. All tests were two-sided, with P<0.05 considered significant.
Results
Comparison of baseline characteristics
Baseline characteristics between the groups showed no significant differences across multiple factors (all P>0.05). For instance, the proportion of patients aged ≥60 years was 52.56% in the control group and 55.95% in the observation group (P=0.665). Gender distribution was also similar, with males comprising 70.51% of the control group and 65.48% of the observation group (P=0.493). BMI categories showed comparable distributions, with 17.95% of the control group and 22.62% of the observation group classified as <21 kg/m2 (P=0.748). No significant differences were observed in ABO blood type (P=0.480), surgery duration (P=0.726), ASA score (P=0.610), fracture type (P=0.793), nursing protocol (P=0.823), history of hypertension (P=0.528), or history of diabetes (P=0.628) (Table 1).
Table 1.
Comparison of baseline characteristics
| Factor | Control Group (n=78) | Observation Group (n=84) | Statistic | P-value |
|---|---|---|---|---|
| Age | ||||
| ≥60 years | 41 (52.56%) | 47 (55.95%) | 0.187 | 0.665 |
| <60 years | 37 (47.44%) | 37 (44.05%) | ||
| Gender | ||||
| Male | 55 (70.51%) | 55 (65.48%) | 0.471 | 0.493 |
| Female | 23 (29.49%) | 29 (34.52%) | ||
| BMI | ||||
| <21 kg/m2 | 14 (17.95%) | 19 (22.62%) | 0.58 | 0.748 |
| 21-25 kg/m2 | 53 (67.95%) | 53 (63.1%) | ||
| >25 kg/m2 | 11 (14.1%) | 12 (14.29%) | ||
| ABO Blood Type | 0.499 | 0.48 | ||
| O type | 31 (39.74%) | 38 (45.24%) | ||
| Other types | 47 (60.26%) | 46 (54.76%) | ||
| Surgery Duration | ||||
| ≥120 min | 43 (55.13%) | 44 (52.38%) | 0.123 | 0.726 |
| <120 min | 35 (44.87%) | 40 (47.62%) | ||
| ASA Score | 0.99 | 0.61 | ||
| I | 15 (19.23%) | 18 (21.43%) | ||
| II | 38 (48.72%) | 45 (53.57%) | ||
| III | 25 (32.05%) | 21 (25%) | ||
| Fracture Type | 0.069 | 0.793 | ||
| Hip Fracture | 48 (61.54%) | 50 (59.52%) | ||
| Femoral Shaft | 30 (38.46%) | 34 (40.48%) | ||
| Surgical protocol | 0.05 | 0.823 | ||
| Joint Replacement | 45 (57.69%) | 47 (55.95%) | ||
| Intramedullary Fixation | 33 (42.31%) | 37 (44.05%) | ||
| Hypertension | 0.397 | 0.528 | ||
| Yes | 19 (24.36%) | 17 (20.24%) | ||
| No | 59 (75.64%) | 67 (79.76%) | ||
| Diabetes | 0.234 | 0.628 | ||
| Yes | 10 (12.82%) | 13 (15.48%) | ||
| No | 68 (87.18%) | 71 (84.52%) |
Note: BMI, Body Mass Index; American Society of Anesthesiologists (ASA) Score; ABO, ABO blood group system.
Comparison of preoperative and postoperative 7-day VAS scores
Preoperative VAS scores were similar between the groups (P=0.593). However, at 7 days postoperatively, the observation group reported significantly lower VAS scores compared to the control group (Table 2).
Table 2.
Comparison of preoperative and 7-day postoperative VAS scores
| Variable | Control Group (n=78) | Observation Group (n=84) | Statistic | P-value |
|---|---|---|---|---|
| Preoperative VAS | 8.00 [7.00, 9.00] | 8.00 [7.00, 9.00] | 0.521 | 0.593 |
| 7-day Postoperative VAS | 3.00 [3.00, 4.00]* | 2.00 [2.00, 3.00]* | 6.662 | <0.001 |
indicates P<0.05 compared to pre-nursing;
VAS, Visual Analogue Scale.
Comparison of WHOQOL-BREF scores before and one month after nursing
Before nursing implementation, no significant differences were observed in WHOQOL-BREF scores across physical, psychological, social relations, or environmental domains (all P>0.05). After one month of nursing, both groups showed significant improvements (all P<0.05). However, the observation group demonstrated significantly higher scores across all domains compared to the control group (all P<0.001) (Table 3).
Table 3.
Comparison of WHOQOL-BREF scores before and one month after nursing
| Variable | Control Group (n=78) | Observation Group (n=84) | Statistic | P-value |
|---|---|---|---|---|
| Pre-nursing Physical | 14.50 [11.00, 17.00] | 14.00 [11.00, 16.00] | 0.856 | 0.391 |
| Post-nursing Physical | 17.00 [15.00, 19.00]* | 18.00 [18.00, 19.25]* | -4.048 | <0.001 |
| Pre-nursing Psychological | 12.00 [10.00, 13.00] | 12.13 ± 2.51 | -1.185 | 0.233 |
| Post-nursing Psychological | 16.00 [15.00, 18.00]* | 18.00 [17.00, 20.00]* | -4.388 | <0.001 |
| Pre-nursing Social Relations | 5.00 [3.00, 6.00] | 4.00 [3.00, 5.00] | 1.612 | 0.101 |
| Post-nursing Social Relations | 7.00 [5.00, 8.00]* | 9.00 [8.00, 10.00]* | -6.211 | <0.001 |
| Pre-nursing Environment | 13.76 ± 2.40 | 13.24 ± 2.94 | 1.233 | 0.22 |
| Post-nursing Environment | 17.00 [15.00, 18.00]* | 18.00 [17.00, 19.00]* | -4.405 | <0.001 |
indicates P<0.05 compared to pre-nursing.
Comparison of Fugl-Meyer lower limb scores before and one month after nursing
Pre-nursing Fugl-Meyer lower limb scores were comparable between the two groups (P>0.05). After one month of nursing, both groups exhibited significant improvements (P<0.05), with the observation group showing significantly higher scores (P<0.001) (Table 4).
Table 4.
Comparison of pre-nursing and one-month post-nursing Fugl-Meyer lower limb scores
| Variable | Control Group (n=78) | Observation Group (n=84) | Statistic | P-value |
|---|---|---|---|---|
| Pre-nursing Fugl-Meyer | 11.00 [10.00, 13.75] | 11.00 [9.75, 14.00] | -0.504 | 0.612 |
| Post-nursing Fugl-Meyer | 25.23 ± 2.87* | 28.00 [26.00, 31.00]* | -6.123 | <0.001 |
indicates P<0.05 compared to pre-nursing.
Comparison of rehabilitation indicators
The observation group demonstrated faster progress across all rehabilitation indicators compared to the control group. Specifically, the observation group had significantly shorter catheter retention time (P<0.001), time to first feeding (P<0.001), first ambulation time (P=0.02), initiation of exercises (P<0.001), rehabilitation tolerance time (P<0.001), and hospital stay (P<0.001) (Table 5).
Table 5.
Comparison of rehabilitation indicators
| Variable | Control Group (n=78) | Observation Group (n=84) | Statistic | P-value |
|---|---|---|---|---|
| Catheter Retention Time (h) | 18.96 ± 5.01 | 15.24 ± 4.24 | 5.087 | <0.001 |
| First Feeding Time (h) | 10.51 ± 3.81 | 5.00 [3.00, 8.25] | 7.056 | <0.001 |
| First Ambulation Time (d) | 3.00 [2.00, 4.00] | 2.50 [1.00, 3.00] | 2.271 | 0.02 |
| Exercise Start Time (h) | 24.00 [23.00, 26.00] | 7.00 [6.00, 8.00] | 10.981 | <0.001 |
| Rehabilitation Tolerance Time (min) | 5.00 [4.00, 7.00] | 10.68 ± 4.91 | -7.257 | <0.001 |
| Hospital Stay (d) | 7.00 [6.00, 8.00] | 5.00 [3.00, 6.00] | 6.226 | <0.001 |
Comparison of postoperative complications
Postoperative complications, including nausea and vomiting (P=1.000), abdominal distension (P=0.948), hematoma (P=0.389), urinary retention (P=0.638), and secondary infection (P=0.948), showed no significant differences between the groups. However, the incidence of DVT was significantly higher in the control group compared to the observation group (P=0.002) (Figure 1).
Figure 1.
Comparison of postoperative complications.
DVT risk factor analysis
Risk factors for DVT occurring within 7 days post-surgery were analyzed, including preoperative VAS scores, pre-nursing Fugl-Meyer scores, catheter retention time, time to first feeding, first ambulation time, initiation of exercises, rehabilitation tolerance time, nursing protocol, age, gender, BMI, ABO blood type, surgery time, ASA score, fracture type, treatment protocol, hypertension history, and diabetes history. Postoperative digestive function and social support were excluded as indirect factors.
Significant differences were found in nursing protocol, age, BMI, ABO blood type, and catheter retention time between the DVT (n=31) and non-DVT (n=129) groups. The proportion of control group patients was significantly higher in the DVT group (74.19%) compared to the non-DVT group (41.98%, P=0.001). Patients aged ≥60 years were more common in the DVT group (70.97%) than in the non-DVT group (45.8%, P=0.012). Patients with a BMI <21 kg/m2 were less prevalent in the DVT group (P=0.029), while non-O blood types were more common in the DVT group (P=0.012). Catheter retention time was significantly longer in the DVT group (P=0.027). No significant differences were observed in gender, surgery time, ASA score, fracture type, hypertension history, diabetes history, preoperative VAS score, or pre-nursing Fugl-Meyer scores (all P>0.05) (see Table 6).
Table 6.
Comparison of baseline characteristics between DVT and Non-DVT groups
| Variable | DVT Group (n=31) | Non-DVT Group (n=129) | Statistic | P-value |
|---|---|---|---|---|
| Nursing plan | ||||
| Control group | 23 (74.19%) | 55 (41.98%) | 10.417 | 0.001 |
| Observation group | 8 (25.81%) | 76 (58.02%) | ||
| Age | ||||
| ≥60 years | 22 (70.97%) | 60 (45.8%) | 6.352 | 0.012 |
| <60 years | 9 (29.03%) | 71 (54.2%) | ||
| Gender | ||||
| Male | 23 (74.19%) | 87 (66.41%) | 0.696 | 0.404 |
| Female | 8 (25.81%) | 44 (33.59%) | ||
| BMI | ||||
| <21 kg/m2 | 1 (3.23%) | 32 (24.43%) | 7.092 | 0.029 |
| 21-25 kg/m2 | 24 (77.42%) | 82 (62.6%) | ||
| >25 kg/m2 | 6 (19.35%) | 17 (12.98%) | ||
| ABO Blood Type | ||||
| O type | 7 (22.58%) | 62 (47.33%) | 6.279 | 0.012 |
| Other types | 24 (77.42%) | 69 (52.67%) | ||
| Surgery Duration | ||||
| ≥120 min | 19 (61.29%) | 68 (51.91%) | 0.887 | 0.346 |
| <120 min | 12 (38.71%) | 63 (48.09%) | ||
| ASA Score | ||||
| I | 4 (12.9%) | 29 (22.14%) | 1.404 | 0.496 |
| II | 18 (58.06%) | 65 (49.62%) | ||
| III | 9 (29.03%) | 37 (28.24%) | ||
| Fracture Type | ||||
| Hip Fracture | 20 (64.52%) | 78 (59.54%) | 0.260 | 0.610 |
| Femoral Shaft | 11 (35.48%) | 53 (40.46%) | ||
| Surgical protocol | ||||
| Joint Replacement | 18 (58.06%) | 74 (56.49%) | 0.025 | 0.873 |
| Intramedullary Fixation | 13 (41.94%) | 57 (43.51%) | ||
| Hypertension | ||||
| Yes | 5 (16.13%) | 31 (23.66%) | 0.823 | 0.364 |
| No | 26 (83.87%) | 100 (76.34%) | ||
| Diabetes | ||||
| Yes | 3 (9.68%) | 20 (15.27%) | 0.643 | 0.423 |
| No | 28 (90.32%) | 111 (84.73%) | ||
| VAS before care | 8.00 [7.00, 9.00] | 8.00 [7.00, 9.00] | 0.344 | 0.731 |
| Fugl-Meyer before care | 12.00 [9.00, 14.00] | 11.00 [10.00, 13.50] | 0.172 | 0.864 |
| Catheter Retention Time (h) | 18.81 ± 5.15 | 16.61 ± 4.86 | -2.237 | 0.027 |
| First Feeding Time (h) | 10.00 [5.50, 13.00] | 7.00 [4.50, 10.50] | 1.915 | 0.056 |
| First Ambulation Time (d) | 3.00 [2.00, 3.50] | 3.00 [1.00, 3.00] | 0.648 | 0.517 |
| Rehabilitation Tolerance Time (min) | 6.00 [4.50, 7.50] | 7.00 [5.00, 11.00] | 1.607 | 0.108 |
Note: BMI, Body Mass Index; American Society of Anesthesiologists (ASA) Score; ABO, ABO blood group system; VAS, Visual Analogue Scale.
Multivariate logistic regression analysis for DVT
Multivariate logistic regression analysis included variables with significant baseline differences between the DVT and non-DVT groups (see Table 7). The analysis revealed significant associations between nursing protocol, age, BMI, and catheter retention time with DVT occurrence. Specifically: Patients in the observation group had a significantly lower risk of DVT compared to the control group (OR=3.086, P=0.024). Patients aged ≥60 years exhibited an increased risk of DVT (OR=2.589, P=0.043). A BMI of 21-25 kg/m2 was associated with a lower DVT risk (OR=2.444, P=0.037). A catheter retention time of ≥19.5 hours increased the risk of DVT, though not significantly (OR=2.401, P=0.061).
Table 7.
Variable assignment for multivariate analysis
| Variable | Type | Assignment Details |
|---|---|---|
| Nursing Protocol | X | Control Group = 1, Observation Group = 0 |
| Age | X | ≥60 years = 1, <60 years = 0 |
| BMI | X | <21 kg/m2 = 0, 21-25 kg/m2 = 1, >25 kg/m2 = 2 |
| ABO Blood Type | X | O type = 1, Others = 0 |
| Catheter Retention Time | X | <19.5 h = 0, ≥19.5 h = 1 |
| DVT | Y | Yes = 1, No = 0 |
Note: BMI, Body Mass Index; American Society of Anesthesiologists (ASA) Score; ABO, ABO blood group system; VAS, Visual Analogue Scale.
ABO blood type did not significantly affect DVT risk (P=0.104). Sankey diagrams visually illustrated these relationships (see Figure 2), and forest plots summarized the odds ratios and confidence intervals for DVT risk factors (see Figure 3).
Figure 2.
Sankey Diagram of DVT Risk Factors. A: Catheter Retention Time and DVT Association. B: Nursing Protocol and DVT Association. C: Age and DVT Association. D: BMI and DVT Association. E: ABO Blood Type and DVT Association. Note: Body Mass Index (BMI); American Society of Anesthesiologists (ASA) Score; ABO blood group system (ABO); Visual Analogue Scale (VAS).
Figure 3.
Results of multivariate logistic regression analysis for DVT Occurrence. Note: Body Mass Index (BMI); American Society of Anesthesiologists (ASA) Score; ABO blood group system (ABO); Visual Analogue Scale (VAS).
Discussion
This study examined the effectiveness of early rehabilitation nursing in preventing postoperative DVT and promoting lower limb functional recovery in patients with traumatic lower limb fractures, focusing on identifying DVT risk factors. The results demonstrate that early rehabilitation nursing significantly alleviates pain, promotes functional recovery, improves quality of life, shortens rehabilitation time, and effectively reduces DVT incidence. Additionally, multivariate analysis identified nursing protocol, age, BMI, and catheter retention time as independent risk factors for DVT, offering novel intervention strategies for clinical care.
DVT is a common postoperative complication in patients with traumatic lower limb fractures. Our study showed that early rehabilitation nursing significantly reduces DVT incidence by shortening bed rest, progressively increasing lower limb activity, and promoting early ambulation post-surgery [17]. The observation group had a notably lower DVT incidence than the control group, reinforcing the role of early rehabilitation nursing in DVT prevention. Unlike traditional care models, early rehabilitation nursing emphasizes early, guided light activities such as ankle pumps and quadriceps contractions, which enhance venous blood flow, reduce venous stasis, and decrease thrombosis risk. Previous studies also highlight early mobilization as a critical strategy for DVT prevention. For instance, Meng et al. [18] reported that delayed mobilization increased DVT risk in patients with ankle fractures, while Aprisunadi et al. [19] found that early mobilization after hip and lower limb surgeries significantly reduced hospital stays, lowered complication rates, and improved both walking ability and overall quality of life. These findings align with ours, underscoring the effectiveness of early rehabilitation nursing in reducing DVT risk.
Restoring lower limb function is essential for postoperative recovery in patients with traumatic lower limb fractures. Our study found that the observation group achieved significantly higher Fugl-Meyer scores one month after surgery, emphasizing the positive effect of early rehabilitation nursing on functional recovery. Personalized exercise plans, including both active and passive lower limb exercises, ankle pumps, and quadriceps contractions, effectively enhance muscle strength and joint flexibility, preventing complications like muscle atrophy and joint stiffness due to prolonged bed rest [20]. These findings are supported by previous studies. For example, Yu et al. [21] reported that systematic early rehabilitation nursing significantly improved limb function and quality of life in elderly patients, while alleviating psychological stress related to functional loss. Similarly, Yang et al. [22] demonstrated that rehabilitation nursing based on Orem’s self-care theory resulted in substantial improvement in the Barthel Index and Fugl-Meyer scores. Wu et al. [23] also confirmed that early intervention in acute stroke patients not only improved treatment success and nursing satisfaction but also enhanced limb function and activities of daily living. These studies support our findings, reinforcing the conclusion that early rehabilitation nursing, guided by scientific principles, plays a crucial role in facilitating comprehensive lower limb functional recovery.
Another key outcome of early rehabilitation nursing is its significant positive impact on quality of life. In this study, the observation group showed notably higher WHOQOL-BREF scores across physical, psychological, social, and environmental domains one month after surgery. Early rehabilitation nursing not only supports physical recovery but also addresses patients’ anxiety and boosts their confidence through psychological counseling and health education. Previous literature supports the role of rehabilitation nursing in improving psychological well-being and overall quality of life [24]. For instance, Liu et al. [25] found that continuous care significantly enhanced quality of life and functional recovery in patients after hip fractures. Similarly, Ruan et al. [26] reported significant improvements in SF-36 quality of life scores and nursing satisfaction following rehabilitation care interventions. These findings are consistent with our study, reinforcing the conclusion that systematic and tailored nursing interventions can profoundly enhance quality of life and patient satisfaction.
Furthermore, our study confirms that early rehabilitation nursing significantly reduced DVT incidence compared to conventional nursing care. Identified risk factors, including age ≥60 years, abnormal BMI (both high and low), and prolonged catheter retention, provide actionable insights for clinical practice. Consistent with our findings, Chen et al. [27] identified age, elevated D-dimer levels, and fibrinogen as key risk factors for DVT in elderly patients with femoral neck fracture, highlighting the heightened risk among older patients and those with higher BMI due to reduced vascular elasticity, prolonged immobility, and coagulation changes. Prolonged catheter retention was also identified as an independent risk factor in our study. Zhang et al. [28] reported that extended bed rest and preoperative waiting times significantly increased DVT incidence in fracture patients, while Meng et al. [18] similarly linked prolonged waiting times with elevated DVT risk in ankle fracture patients. These studies align with our findings, demonstrating that prolonged immobility and catheter retention impede venous blood flow in the lower limbs, increasing the likelihood of DVT.
Our study also highlights the association between BMI and DVT risk. Patients with low BMI may lack adequate muscle support for effective venous circulation, while those with higher BMI may experience obstructed venous return due to weight-induced pressure on blood vessels. These findings are supported by Ruan et al. [25], who noted that rehabilitation nursing can improve hemorheological status, reducing DVT risk in patients with lower limb fractures. This evidence underscores the importance of integrating weight management strategies, including exercise and dietary guidance, into nursing interventions to enhance venous circulation and mitigate DVT risk.
Our findings underscore the significant role of early rehabilitation nursing in reducing the risk of DVT in postoperative care for patients with lower limb traumatic fractures. For high-risk patients - particularly those who are elderly, have abnormal BMI, or require prolonged bed rest - early rehabilitation intervention should be prioritized to mitigate DVT risk. Consistent with related literature [18,20], implementing systematic and individualized care strategies can optimize postoperative recovery, minimize complications, shorten hospital stays, and ultimately achieve a long-term recovery.
Despite the promising outcomes, this study has certain limitations. First, as a single-center retrospective study, the potential for selection bias and the relatively small sample size may limit the generalizability of the results. Second, the short follow-up period precluded a thorough evaluation of the long-term effects of early rehabilitation nursing on patient outcome. Additionally, variations in patient adherence to nursing interventions may have influenced the effectiveness of the protocols. To address these limitations, future research should focus on multicenter, prospective studies with larger sample sizes and extended follow-up periods to validate these findings for the long-term.
In conclusion, this study demonstrates that early rehabilitation nursing is significantly effective in preventing DVT and promoting lower limb functional recovery in patients with lower limb traumatic fractures, effectively reducing rehabilitation time and enhancing quality of life. Nursing protocol, age, BMI, and catheter retention time were independent risk factors for DVT, warranting attention in clinical care. Through systematic, individualized interventions, early rehabilitation nursing helps improve postoperative prognosis and should be further promoted and optimized to provide comprehensive support for the postoperative recovery of patients with lower limb traumatic fractures.
Disclosure of conflict of interest
None.
Supporting Information
References
- 1.Elam RE, Ray CE, Miskevics S, Weaver FM, Gonzalez B, Obremskey W, Carbone LD. Predictors of lower extremity fracture-related amputation in persons with traumatic spinal cord injury: a case-control study. Spinal Cord. 2023;61:260–268. doi: 10.1038/s41393-023-00879-1. [DOI] [PubMed] [Google Scholar]
- 2.Qian X, Ge Y, Luo J. Risk factors for deep vein thrombosis after traumatic lower extremity fracture: a systematic review and meta-analysis. Medicine (Baltimore) 2024;103:e38439. doi: 10.1097/MD.0000000000038439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Cheng J, Fu Z, Zhu J, Zhou L, Song W. The predictive value of plasminogen activator inhibitor-1, fibrinogen, and D-dimer for deep venous thrombosis following surgery for traumatic lower limb fracture. Ann Palliat Med. 2020;9:3385–3392. doi: 10.21037/apm-20-1604. [DOI] [PubMed] [Google Scholar]
- 4.Perera AC, Joseph S, Marshall JL, Olson DM. Exploring plan of care communication with a multidisciplinary rounding plan to nursing care plans. J Neurosci Nurs. 2023;55:49–53. doi: 10.1097/JNN.0000000000000690. [DOI] [PubMed] [Google Scholar]
- 5.Do DV, Pham THV, Nguyen TL, Vu VG, Dao XC. The impact of early rehabilitation in intensive care unit for COVID-19 patients. Disabil Rehabil. 2024;46:3077–3085. doi: 10.1080/09638288.2023.2243595. [DOI] [PubMed] [Google Scholar]
- 6.Jolivet A, Mata L, Mons A, Hoarau P. Early rehabilitation in medical intensive care. Rev Infirm. 2018;67:18–20. doi: 10.1016/j.revinf.2018.10.022. [DOI] [PubMed] [Google Scholar]
- 7.Huang J, Zuo J, Tang X, Zou J, Zeng Y, Chen S, He G. Early Rehabilitation and Nursing Intervention (ERNI) accelerates the recovery of patients with ischemic stroke. Neurologist. 2023;28:409–412. doi: 10.1097/NRL.0000000000000515. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Flowers DW, McCallister E, Christopherson R, Ware E. The safety and effectiveness of early, progressive weight bearing and implant choice after traumatic lower extremity fracture: a systematic review. Bioengineering (Basel) 2022;9:750. doi: 10.3390/bioengineering9120750. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Aprisunadi, Nursalam N, Mustikasari M, Ifadah E, Hapsari ED. Effect of early mobilization on hip and lower extremity postoperative: a literature review. SAGE Open Nurs. 2023;9:23779608231167825. doi: 10.1177/23779608231167825. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Cecchi F, Carrabba C, Bertolucci F, Castagnoli C, Falsini C, Gnetti B, Hochleitner I, Lucidi G, Martini M, Mosca IE, Pancani S, Paperini A, Verdesca S, Macchi C, Alt Murphy M. Transcultural translation and validation of Fugl-Meyer assessment to Italian. Disabil Rehabil. 2021;43:3717–3722. doi: 10.1080/09638288.2020.1746844. [DOI] [PubMed] [Google Scholar]
- 11.Zhang Y, Jiang R, Zhang L, Dai B, Zhang W. Clinical effects of combining psychological care with early rehabilitation guidance on inpatients with cerebral infarction. Panminerva Med. 2024 doi: 10.23736/S0031-0808.24.05173-5. [Epub ahead of print] [DOI] [PubMed] [Google Scholar]
- 12.Maddigan J, LeDrew K, Hogan K, Le Navenec CL. Challenges to recovery following early psychosis: nursing implications of recovery rate and timing. Arch Psychiatr Nurs. 2018;32:836–844. doi: 10.1016/j.apnu.2018.06.008. [DOI] [PubMed] [Google Scholar]
- 13.Zhang H, Dou Y. Precision nursing and intermittent pneumatic compression significantly reduce perioperative deep vein thrombosis in post-surgical ovarian cancer patients. Am J Transl Res. 2024;16:2533–2543. doi: 10.62347/IWUD6619. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Shafshak TS, Elnemr R. The visual analogue scale versus numerical rating scale in measuring pain severity and predicting disability in low back pain. J Clin Rheumatol. 2021;27:282–285. doi: 10.1097/RHU.0000000000001320. [DOI] [PubMed] [Google Scholar]
- 15.The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41:1403–1409. doi: 10.1016/0277-9536(95)00112-k. [DOI] [PubMed] [Google Scholar]
- 16.Riahi N, Vakorin VA, Menon C. Estimating Fugl-Meyer upper extremity motor score from functional-connectivity measures. IEEE Trans Neural Syst Rehabil Eng. 2020;28:860–868. doi: 10.1109/TNSRE.2020.2978381. [DOI] [PubMed] [Google Scholar]
- 17.Raya-Benítez J, Heredia-Ciuró A, Calvache-Mateo A, Martín-Núñez J, Valenza-Peña G, López-López L, Valenza MC. Effectiveness of non-instrumental early mobilization to reduce the incidence of deep vein thrombosis in hospitalized patients: a systematic review and meta-analysis. Int J Nurs Stud. 2024;161:104917. doi: 10.1016/j.ijnurstu.2024.104917. [DOI] [PubMed] [Google Scholar]
- 18.Meng H, Zhu Y, Zhang J, Li J, Zhao K, Zhang Y, Chen W. Incidence and risk factor for preoperative deep vein thrombosis (DVT) in isolated calcaneal fracture, a prospective cohort study. Foot Ankle Surg. 2021;27:510–514. doi: 10.1016/j.fas.2020.06.007. [DOI] [PubMed] [Google Scholar]
- 19.Aprisunadi, Nursalam N, Mustikasari M, Ifadah E, Hapsari ED. Effect of early mobilization on hip and lower extremity postoperative: a literature review. SAGE Open Nurs. 2023;9:23779608231167825. doi: 10.1177/23779608231167825. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Yin M, Yan Y, Fan Z, Fang N, Wan H, Mo W, Wu X. The efficacy of Enhanced Recovery after Surgery (ERAS) for elderly patients with intertrochanteric fractures who received surgery: study protocol for a randomized, blinded, controlled trial. J Orthop Surg Res. 2020;15:91. doi: 10.1186/s13018-020-01586-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Yu M, Wang L, Wang H, Wu H. The effect of early systematic rehabilitation nursing on the quality of life and limb function in elderly patients with stroke sequelae. Am J Transl Res. 2021;13:9639–9646. [PMC free article] [PubMed] [Google Scholar]
- 22.Yang Y, Niu L. Effect of early rehabilitation nursing on motor function and living ability of patients with traumatic brain injury based on Orem’s self-care theory. Comput Intell Neurosci. 2022;2022:7727085. doi: 10.1155/2022/7727085. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Wu Y, Yang Y, Guo X, Guo D, Lu Y, Li G, Gao F, Wang J. Effect of pre-hospital early intervention combined with an in-hospital emergency model in the emergency care of patients with acute stroke. Am J Transl Res. 2022;14:672–678. [PMC free article] [PubMed] [Google Scholar]
- 24.Ma Y, Wu H, Wang Y, Guo L. A feasibility study of modified self-efficacy for the improvement of adverse emotions and quality of life in traumatic fracture patients. Am J Transl Res. 2021;13:6507–6515. [PMC free article] [PubMed] [Google Scholar]
- 25.Liu J, Zhao Q, Wang J, Zhang J, Jiang J, Wang H. The effect of continuing care on postoperative life quality and long-term functional recovery in elderly patients with hip fracture. Am J Transl Res. 2021;13:5512–5518. [PMC free article] [PubMed] [Google Scholar]
- 26.Ruan Y, Wang F, Du X, Sun S. Rehabilitation nursing after lower limb fracture: preventing deep vein thrombosis and enhancing quality of life. Medicine (Baltimore) 2023;102:e36180. doi: 10.1097/MD.0000000000036180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Chen W, Su Z, Liu Q, Bai X, Huang J, Weng S, Chen M. Risk factors and new diagnostic index for deep venous thrombosis of lower extremities in elderly patients with traumatic femoral neck fracture. Front Surg. 2022;9:1050347. doi: 10.3389/fsurg.2022.1050347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Zhang W, Huai Y, Wang W, Xue K, Chen L, Chen C, Qian A. A retrospective cohort study on the risk factors of deep vein thrombosis (DVT) for patients with traumatic fracture at Honghui hospital. BMJ Open. 2019;9:e024247. doi: 10.1136/bmjopen-2018-024247. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.