Tibia Fracture, Post-ORIF

Synonyms

Broken leg

Definition

A fracture is essentially a structural failure of bone. The nature of the fracture is determined by the inherent properties of bone, its structure, and type of forces applied to it.

Patient History

Patient History may include

Patient Data

Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly a result of a fall from a significant height.

Specific Considerations

Red Flag

Possible Consequence or Cause

Severe trauma

Ligament tear

Fever, severe pain

Infection

Loss of distal pulse, severe pain 12-24 hours after trauma

Compartment syndrome, arterial occlusion

Diabetes

Neuropathy

Multiple joint involvement

Rheumatologic diseases

Unilateral edema

Deep vein thrombosis

Cancer

Cause of symptoms (metastatic or primary)

Discoloration of leg or foot

Arterial occlusion

Immune-compromised state

Infection

Presentation

Patient may present in a splint or functional brace, with an antalgic gait, knee joint stiffness and muscle atrophy.

Subjective Findings

Objective Findings

Objective Findings may include

Scope of Examination

Examine the musculoskeletal system for possible causes, or contributing factors to the complaint.

Specific Examination Considerations

The following standardized test may be used to assess functional limitations:

Results if Tibia Fracture, Post-ORIF

Differential Diagnosis

Not applicable.

Physical/Occupational Therapy Management

Therapy must show measurable functional progress.

Requirements for Physical/Occupational Therapy Visits

Two or more of the following findings must be present to establish medical necessity. At least one of the findings must address functional limitation.  Degree of abnormality should be specified at initiation of therapy, and periodically, to establish an objective response to therapy:

  1. Significant Functional Limitations (i.e. social, recreational, vocational activities) - Practitioners are strongly encouraged to utilize peer reviewed, standardized tools to quantify Functional Limitations.

  2. Strength: <4/good (5 = normal; 4 = good; 3 = fair; 2 = poor; 1 = trace)

  3. ROM: limited >30% (norms:Knee Joint: flexion = 135; extension = 0; lateral rotation = 30; medial rotation = 20)

  4. Pain: limiting function and at least 3/10

  5. Neurological signs: altered reflexes and/or sensations

Treatment frequency and duration must be based on:

Treatment Methods

Therapy program goals are to:

The therapy program will consist of modalities to:

Discharge Criteria

Referral Guidelines

Refer patient to their primary care provider to explore alternative treatment options when you find:

Appropriate Procedures/Modalities

Use of modalities and/or passive treatments should be limited. The goal is to transition the patient as quickly as possible to active, self-management and functional independence.

The following table lists the procedures for Early Phase presentation:

Expected Outcome

Procedures/Modalities Such As

Control pain and edema

  • Modalities i.e. Cryotherapy, interferential current , soft tissue massage

Improve range of motion and flexibility

  • Passive stretching

  • Active assited exercises

  • Auto-assisted exercises using a stationary bicycle

  • Active exercises

  • Ankle and knee joint mobilization

Improve strength and endurance

  • Isometric exercises

  • Isotonic exercises

  • Add closed chain exercises and isokinetic exercises when weight-bearing is allowed

Improve proprioception of the lower extremity

  • Balance re-training

  • Coordination exercises

Improve gait and stair mobility

  • Gait training with/without assistive device

  • Community ambulation

  • Stair mobility with/without assistive device

Gradual intergration into community activities, sports, leisure and vocation

  • ADL training

  • Tolerance for different positions and activities

  • Sports/vocation specific training i.e. plyometrics or kneeling, squatting

Patient self-management and education

  • Teach application of pain relieving modalities

  • Teach stretching, strengthening and joint mobilization for home exercise program

Note

Modalities are approved with the intent of providing the treating practitioner wide discretion in the choice of treatments. Not all approved modalities are appropriate for each individual case; they require the skill and judgment of persons properly trained and licensed for safe use. Use of diathermies, including microwave, shortwave, and ultrasound, is controversial and may be contraindicated in the presence of metals, and prior to neurological, and/or orthopedic maturity. Landmark recommends following all manufacturer and educational guidelines in the use of electrotherapeutic modalities.

Home and Self-Care Techniques

The patient can be taught to use medical equipment and administer self care at his residence.

Home Medical Equipment

Self-Care Techniques

Alternatives/Adjuncts to Physical/Occupational Therapy Management

References

American Physical Therapy Practice, Interactive Guide to Physical Therapist Practice, Version 1.0

Basmajian, J.V., ed., Therapeutic Exercise Student Edition, The Williams and Wilkens Co.

Bischel, Margaret D., The Managed Physical/Occupational Therapy and Rehabilitation Care Manual, Apollo Managed Care Consultants, 2002.

Brotzmen, S.B., ed., Handbook of Orthopaedic Rehabilitation, Mosby

Magee, David J., Orthopedic Physical Assessment, Second Edition, W.B. Saunders Company, 1992

Richardson, Jan K., Iglarsh, Z. Annette, Clinical Orthopaedic Physical Therapy, W. B. Saunders Company, 1994

Roy, S., Irvin, R., Sports Medicine, Prevention, Education, Management, and Rehabilitation, Prentice-Hall, Inc.

Southmeyd, W., Hoffman, M., Sports Health, The Complete Book of Athletic Injuries, Quick Fox

The Merck Manual, Merck, Sharp, and Dohme Research Laboratories, Merck and Co.

Turek, S.L., Orthopaedics Principles and Their Applications, J.B. Lippincott Co.