PRM interventions for fractures and traumatic conditions. Functional assessment, rehabilitation goals, physical modalities, and kinesiotherapy. Prevention of complications

01How a fracture heals

A fracture is a break in the continuity of a bone. Bone is one of the few tissues that heals with the same tissue, not with scar, so the goal is complete restoration. The orthopaedic rule is: reduce (put the pieces back), hold (keep them still enough), and rehabilitate (keep the rest of the limb and the person working). Fracture rehabilitation is the third part, and it starts on the first day.

Most fractures heal by callus (secondary healing), which happens when the pieces can move a little, as in a cast or under a nail:

1. 1

   Haematoma and inflammation

   Days 1 to 7. A blood clot fills the gap; inflammatory cells clear debris and release signals that call in new cells. Pain and swelling are greatest.
2. 2

   Soft callus

   About weeks 2 to 3. Cartilage and fibrous tissue bridge the gap. The fracture becomes "sticky" and stops being painful to move, but is easily bent.
3. 3

   Hard callus

   About weeks 3 to 12. The soft callus turns into woven bone. When it bridges the gap the fracture is clinically united: not tender, not moving.
4. 4

   Remodelling

   Months to years. Woven bone is replaced by strong lamellar bone, shaped by the loads it carries (Wolff's law). Load is a signal to remodel.

With rigid internal fixation (a compression plate), the ends are held still and touching and heal directly without callus (primary healing), which is slower to show on X-ray but stable from the start.

Healing time depends on the bone and the type of break. Perkins' rule of thumb from Apley's textbook gives the logic: a spiral fracture of the upper limb unites in about 3 weeks; double it for consolidation (full strength); double it for the lower limb; double it again for a transverse fracture. So a transverse tibial fracture takes about 12 weeks to unite and 24 to consolidate. Children heal about twice as fast.

02Phases and the team

The surgeon sets the limits (range allowed, weight allowed, brace or not); the PRM physician and therapists plan within them; nurses, an occupational therapist, a psychologist and a dietitian join for complex cases. The slides divide recovery into four phases:

The phases follow healing, but are adjusted to the fracture, the fixation and the patient, and progression is better guided by what the patient can do (criteria) than by the calendar.

03Functional assessment

The assessment repeats at each phase and follows the ICF (see functional assessment).

• Pain at rest and on movement (0 to 10 scale).
• Swelling: girth measured at fixed points on both sides; skin colour, temperature, sweating (an early sign of complex regional pain syndrome).
• Wound, scar and its mobility.
• Range of motion of the joints above and below the fracture by goniometry.
• Muscle strength by manual muscle testing and dynamometry (grip strength after a wrist fracture); muscle wasting by girth.
• Neurovascular state: pulses, capillary refill, sensation and power in the nerves at risk (radial nerve in humeral shaft fractures, common peroneal nerve at the fibular neck).
• Balance, transfers, gait and the walking aid used; fear of falling.
• Activities and participation: Barthel index or FIM in older people, Timed Up and Go; work and sport demands in the young; region-specific questionnaires (DASH for the arm, the lower extremity functional scale).
• The bone: union on X-ray and in the clinic, read with the surgeon.

04Rehabilitation goals

The long-term goal is the function the patient had before, or the nearest to it the injury allows, and safe return to their roles. Typical short-term goals by phase:

• Acute: pain controlled enough to sleep and move; independent transfers and walking with crutches, keeping the weight-bearing limit; no complications.
• Early functional: full range in the free joints; a set range in the injured one (knee flexion to 90 degrees at 4 weeks); good isometric control.
• Recovery: strength within about 80 per cent of the other side; walking without aids, stairs; independent ADL.
• Long-term: return to work or sport; strength and hop tests near the other side; fall and osteoporosis risk addressed.

05Physical modalities

Modalities treat the symptoms that block exercise; none is proven to make a fresh fracture heal faster. Shock waves for a fracture that has failed to unite are the exception.

Shortwave and microwave diathermy are contraindicated over metal implants: the metal concentrates the field and burns the tissue around it. Heat and cold are avoided over skin without normal sensation, and any heating over an acute haematoma or fresh swelling worsens it.

06Kinesiotherapy

During immobilisation

The fracture is still, but the rest of the body is not:

• Active movement of every free joint, many times a day: fingers and shoulder with a forearm cast, toes, hip and the other leg with a leg cast.
• Isometric contractions of the muscles under the cast (quadriceps sets, gluteal squeezes): tension without movement, which slows atrophy and keeps the muscle's control. The professor's book names isometric contraction as the type useful during immobilisation.
• Training the uninjured limbs, which also gives a small strength gain on the immobilised side (cross-education, through the nervous system).
• Breathing exercises and ankle pumps against chest infection and thrombosis, especially in bed-bound patients.
• Positioning: elevation for swelling; joints in positions that will be useful (the ankle near 90 degrees, the hand in the safe position with the knuckles bent and fingers straight).
• Mobility within the weight-bearing limit: transfers and walking with crutches or a frame.

Weight-bearing

The surgeon prescribes the load from the fracture and its fixation:

Partial weight-bearing is hard to keep accurately, especially for older people, who often cannot manage it at all. That is why fixation for older people is chosen to allow full weight-bearing at once. The crutch gait follows the order (three-point gait for non- or partial weight-bearing), with crutches or a frame on level ground and stairs taught before discharge (see balance and coordination).

After immobilisation

When the cast comes off or the surgeon allows movement, the joint is stiff, the muscles weak and the patient often afraid. The order is range, then strength, then function:

1. 1

   Range of motion

   Active and active-assisted exercise, often in warm water or after heat; gentle passive movement and joint mobilization for capsular stiffness; never forced (forced movement provokes pain, swelling and, around the elbow, heterotopic ossification).
2. 2

   Strength

   Isometric, then isotonic exercise against gravity, then resistance bands and weights, with closed-chain exercises (squats, step-ups) as load is allowed; progression by the response of pain and swelling.
3. 3

   Balance and proprioception

   Single-leg stance, wobble boards after lower-limb fractures.
4. 4

   Gait

   From aids to independent walking, correcting limping; stairs, slopes, uneven ground.
5. 5

   Function

   Practice of the real tasks: work skills, driving, sport-specific drills; endurance.

Examples

07Prevention of complications

Complications come from the injury itself and from immobility. Each has a preventive step.

Two complications need to be recognised at once, because they are emergencies:

• Compartment syndrome: rising pressure in a closed muscle compartment, usually in the leg or forearm in the first 48 hours. Pain out of proportion to the injury and pain when the muscles are passively stretched come first; pallor, numbness and lost pulses come late. Split the cast down to skin, keep the limb at heart level, and call the surgeon for fasciotomy. Missed, it ends in muscle death and Volkmann's contracture.
• Fat embolism syndrome: 24 to 72 hours after a long-bone or pelvic fracture, breathlessness and low oxygen, confusion, and a petechial rash. Early fixation lowers the risk.