lower limb fractures

IRENE TOHPRINCIPAL PHYSIOTHERAPIST

PHYSIOTHERAPY DEPARTMENTSINGAPORE GENERAL HOSPTIAL

Post op management of lower limb fractures

Learning objectives• Awareness of classification of various lower limb fractures• Understand the general medical/surgical management of fracture and

rehabilitation• To understand the management of the following conditions• Hip fractures• Patella fractures• Femur/Tibia fractures• Ankle fractures

Classification of fractures

https://www2.aofoundation.org/wps/portal/surgery

General Medical/Surgical Management• Reduce fragments • Prevent further injuries eg vascular injuries, avascular necrosis, soft tissue

damage• Prevent deformities• allow early mobilisation (esp in elderly)

• Immobilise fractures• Prevent displacement / angulation of fragments• Prevent movements that will affect union• Reduce pain

Methods of immobilisation1) Plaster of Paris (POP) or external splint / brace / backslab

2) Continuous traction

Methods of immobilisation3) External Fixation

4) Internal Fixation / ORIF

Test of union• Clinical and radiological tests are used to ensure that the fracture is

UNITED.• Clinical

• Absence of mobility.• Absence of tenderness.• Absence of pain (?)

• Radiological-X-ray criteria.1) visible callus bridging both fragment.2) contiunity of bone trabeculae across the fracture

Bone healingPhase Cells Time frame

Inflammatory phase Haemorrhage, necrotic cells, haematoma and fibrin clot formed to bridge gap

Immediately

Soft callus phase Fibrous and cartilaginous tissue formed between the fracture ends, increase in vascularity and ingrowth of capillaries into the fracture callus; increase in cellular proliferation, osteoclasts remove dead bone fragments

1-6 weeks

Hard callus phase Calcification of fibrocartilage into woven bone, osteoclasts and osteoblasts

4-6 weeks, up to 3 months

Remodeling phase Woven bone changes to lamellar bone, medullary canal reconstituted; fracture diameter deceases to orginal width

6 weeks to months or years

Rehabilitation Goals1) Early phase – control swelling and pain2) Preserve function while the fracture is uniting3) Restore function to normal when the fracture is united

Duration of rehab dependent on many factors – intrinsic and extrinsic. May take months to years.

Rehabilitation• Active use of other joints without compromising the healing of the

fracture – preserve joint mobility• eg Colles fracture, active shoulder/elbow AROM must be done to prevent

joint contractures

• Gradual active use of injured part without risk• Eg compression fracture – trunk extension and posture

• Active exercise of muscles and joints to prevent atrophy• Static muscle contractions• Once splint removed – start gentle joint mobilisation • Progressive resistive exercise when fracture united

Rehabilitation• Ambulate (most Internal fixated fractures are allowed

to begin TTWB or PWB) – dependent on surgeon’s order.• If only on external fixation – usually NWB• Maintain cardiovascular fitness

Proximal Hip Fractures• Garden’s classification of neck of femur fractures

Operative Management

Dynamic hip screw / Cancellous screwPhase 1 (Acute inpatient to 3 weeks)

Impairments ?

Phase 1 (Post op day 1 to Week 3)Goal?

1. Reduce pain2. Reduce swelling3. Promote bed mobility and transfers4. Improve hip range of motion as tolerated5. Gait training with walking aids as appropriate

Phase 1

What exercises would you prescribe to patient?

Phase 2 (Week 4 – 7)• Impairments?

Phase 2Goals?

1. Increase hip range of motion2. Increase lower limb strength3. Progress gait – may increase weight bearing status depending on

surgeon.

Phase 2

What exercises would you prescribe to patient?

Phase 3 (week 8-12)Impairments• Poor lower limb strength• Decrease balance• Reduce endurance

Goals?1. Increase lower limb strength2. Increase balance and stability3. Increase walking endurance

Phase 3

What exercises would you prescribe to patient?

Phase 4 (week 12-20 or longer)• Goals• Progression of phase 3

Proximal Tibial Fractures

http://orthoinfo.aaos.org/topic.cfm?topic=A00393

Fracture does not extend not the knee joint (extra-articular) – rod and screw.

Fracture extends into the joint (partial/complete articular) – plate and screws needed

https://www2.aofoundation.org/wps/portal/surgery

Proximal Tibial Fractures Rehab• What do you think will be affected?

• How would your plan your rehabilitation process?• Consider the phases of bone healing• Consider extend of fracture/soft tissue injuries• Consider fixation stability• Consider intrinsic and extrinsic factors• Any other things??

Tibial/Femur Shaft Fractures

Tibial/Femur shaft fractures rehab• What do you think will be affected?• Joints?• Muscles?• Circulation?

• How would your plan your rehabilitation process?

Ankle Fracture

Ankle fracture Rehab• What do you think will be affected?• Joints?• Muscles?• Ligaments?• Circulation?

• How would your plan your rehabilitation process?

Summary• Fixation of fracture allows for early ambulation• Rehabilitation important in fracture management – starts in the early

phase• Healing phases are not mutually exclusive• Look at the patient as a whole when planning rehab program• Consider exercising other joints without compromising the healing of the

fracture• Patient education (on fracture healing, effects of prolonged

immobilisation on muscles and joints, cardiovascular fitness etc) important.

References• AO foundation website (www.aofoundation.org)• Boris AZ, Kurt RW and Freddie HF: Pathogenesis of soft tissue and

bone repair. In Lisa M and Jim M, editors. Rehabilitation for the post surgical orthopaedic patient (2nd ed). Mosby Elsevier: St Louis.• SGH protocols• Pictures from google.