Post-Fracture Rehabilitation

Rehab Goals & Principles - Roadmap Rules

• Primary Goals:
  • Restore full, pain-free function (ROM, strength, endurance).
  • Achieve maximal independence in Activities of Daily Living (ADLs).
  • Prevent complications: joint stiffness, muscle atrophy, DVT, CRPS.
  • Facilitate timely return to work/sport.
  • Comprehensive patient education on self-management.
• Guiding Principles (📌 P.R.E.C.I.S.E.):
  • Patient-specific, goal-oriented plan.
  • Restoration of normal biomechanics & function.
  • Early, yet protected and controlled, mobilization.
  • Coordinated multidisciplinary team approach.
  • Incremental, criteria-based progression (phased).
  • Stability of fracture dictates activity levels.
  • Education for adherence and empowerment.

⭐ Early controlled mobilization is key to prevent stiffness and promote optimal healing, guided by fracture stability.

Phases of Healing - Stepping Stones

• 1. Inflammatory (Reactive) Phase (Days 1-7)

  • Hematoma formation & acute inflammation.
  • Platelets release growth factors (PDGF, TGF-β).
  • Cellular influx: neutrophils, macrophages.

• 2. Reparative Phase (Weeks 2-12+)

  • • Soft Callus Formation (~2-3 weeks):
    • Granulation tissue, angiogenesis.
    • Fibrocartilaginous callus forms, ↓ pain & ↑ stability.
  • • Hard Callus Formation (~4-12 weeks):
    • Woven bone replaces soft callus via endochondral ossification.
    • Clinical union: non-tender, no movement at fracture site.
    • Radiological union: bridging callus on X-ray.

• 3. Remodeling Phase (Months to Years)

  • Woven bone gradually replaced by lamellar bone.
  • Medullary canal re-established.
  • Bone reshapes according to mechanical stress.

⭐ Wolff's Law: Bone adapts to the loads placed upon it, underpinning the importance of progressive weight-bearing and exercise in remodeling.

Rehab Modalities - Movement Arsenal

• Range of Motion (ROM) Exercises:
  • Passive ROM (PROM): Therapist/device moves joint.
  • Active-Assisted ROM (AAROM): Patient assists movement.
  • Active ROM (AROM): Patient moves joint independently.
• Strengthening Exercises:
  • Isometric: Muscle contraction, no joint movement.
  • Isotonic: Constant tension (concentric/eccentric).
  • Isokinetic: Constant speed via machine.
• Proprioception & Balance Training:
  • E.g., Wobble boards, balance pads, single-leg stance.
• Physical Agents (Modalities):
  • Cryotherapy: ↓pain, ↓swelling (e.g., ice packs 15-20 min).
  • Thermotherapy: ↑blood flow, ↓stiffness (e.g., hot packs 15-20 min).
  • Electrotherapy: TENS (pain), NMES (muscle function).
  • Therapeutic Ultrasound: Deep heating, promotes healing.
  • Hydrotherapy: Buoyancy aids movement, reduces stress on joints.
• Functional Training:
  • Task-specific activities, Activities of Daily Living (ADL) retraining.

⭐ Neuromuscular Electrical Stimulation (NMES) can be vital in mitigating disuse atrophy during periods of immobilization or restricted movement.

Complications & Fixes - Rehab Hurdles

• Common Hurdles & Management:
  • Pain:
    • Chronic: Multimodal (NSAIDs, opioids, adjuvants).
    • CRPS: Severe pain, edema, skin changes. 📌 Budapest criteria.

      ⭐ Complex Regional Pain Syndrome (CRPS) Type I (formerly RSD) can occur after trauma, characterized by severe pain, autonomic dysfunction, and trophic changes, often disproportionate to the initial injury.

    • Tx: Mobilization, PT, Gabapentin.
  • Stiffness/Contractures:
    • Prevent: Early ROM.
    • Tx: Stretching, splints, MUA.
  • Muscle Weakness/Atrophy:
    • Resistive exercises, NMES.
  • Swelling (Persistent Edema):
    • Elevation, compression, MLD.
  • Delayed Union/Non-union:
    • Causes: Poor vascularity, infection, instability.
    • Tx: Bone stimulators, surgery (grafting, revision).
  • Malunion:
    • Corrective osteotomy if limiting.
  • DVT/PE:
    • Prophylaxis, early mobilization.
  • Infection (Surgical Site/Hardware):
    • Antibiotics, debridement, hardware removal.

High‑Yield Points - ⚡ Biggest Takeaways

• Early mobilization prevents joint stiffness, muscle atrophy, and DVT.
• Rehab phases: Inflammatory, Reparative, Remodelling; guide interventions.
• Weight-bearing advances with healing: NWB → PWB → FWB.
• Effective pain management is crucial for active rehabilitation.
• Restore ROM (Passive → Active) and strength (Isometric → Isotonic) progressively.
• Proprioception training is key for functional recovery, especially lower limb.
• Monitor for CRPS, non-union, and joint contractures.