Orthopaedic Fracture Rehabilitation Table by Dr. Mark McAndrew
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| Table 1. Upper Extremity | ||||
Fracture
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X-rays Needed
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Immobilization
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Fixation
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MobilityPrecautions
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| Scapula scapular body acromion process coracoid process glenoid neck glenoid fossa | AP/axillary/scapular shoulder | sling | screws reconstruction plates tubular plates mini T-plates | Stable: WBAT Unstable: protected weight-bearing 2-3 months no deltoid isometrics until 6 weeks post-stabilization sling immobilization as needed |
| Clavicle displaced nondisplaced | AP/axillary Shoulder | Sling or Figure of 8 Strap | reconstruction plates dynamic compression plate (DCP) | Stable: WBAT Unstable: PWB-NWB 6-8 weeks postinjury sling, figure 8 immobilization as fracture/patient status dictates |
| Humerus | AP/axillary Shoulder AP/Lat Humerus | Coaptation Splint vs.Sling | plate | NWB 8-12 weeks sling, Neer protocol (circumduction, passive abduction & forward flexion, >4weeks then aarom) |
| 1. Proximal fractures | wires (tension-band, K-wire) | |||
| greater tuberosity | 2.5-mm Schanz pins | |||
| lesser tuberosity | screws | |||
| surgical neck | external fixation | |||
| anatomic neck | hemiarthroplasty (elderly patient) | |||
| 2. Humeral shaft | AP/Lat Humerus | Coaptation Splint | DCP locked IM nail | NWB-WBAT as fracture pattern dictates |
| 3. Distal humerus | AP/Lat Elbow AP/Lat Humerus | Posterior Elbow Splint | screws | NWB 8-12 weeks Aarom as soon as soft tissues allow |
| reconstruction plates tubular plates tension-band wire for olecranon osteotomy | ||||
| Radius & Ulna | ||||
| 1. Olecranon | AP/Lat ElbowAP/Lat Forearm | Posterior Elbow Splint | tension-band wiring screw, wire fixation | Aarom as soon as soft tissues allow NWB |
| 2. Radial head | AP/Lat ElbowAP/Lat Forearm | Posterior Elbow Splint | closed reduction mini-fragment screws mini T-plates | Aarom as soon as soft tissues allow NWB |
| 3. Forearm isolated radius, ulna - both bones | AP/Lat Forearm | Sugar Tong Splint | closed reductionplates screws (rare) IM nail (rare) | Aarom as soon as soft tissues allow NWB 8-12 weeks |
| Monteggia/Glaeazzi | AP/Lat Forearm | Sugar Tong Splint | ||
| 4. Distal radius | AP/Lat Forearm | Sugar Tong Splint | closed reduction external fixation ORIF | Aarom as soon as soft tissues allow NWB 8-12 weeks |
| Wrist & Hand | ||||
| carpal MC phalanx | AP/Lat Hand AP/Lat Hand & Fingers | Dorsal-Volar Splint Buddy Tape | closed reduction wires mini-plates | cast, splint immobilization NWB-PWB 8-12 weeks |
| Terminology: 1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity 2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation 3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance 4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs. 5. (PWB) Partial weight-bearing - weight limit specified by M.D. | ||||
| Table 1, Upper Extremity | ||||
Fracture
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Initial Physical Therapy Program
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Advanced Physical Therapy**
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| Scapula | Days 1-5: shoulder pendulum exercises elbow, forearm; wrist, hand AROM; grip strengthening Weeks 2-3: gentle PROM-AAROM shoulder;deltoid, rotator cuff isometrics If stable fracture pattern- shoulder PROM-AAROM initiated1 week postinjury, ROM, strengthening progressed to tolerance | Stable: PROM/strengthening as tolerated Unstable: strengthening at 3 months; progress to isometrics, surgical tubing, and free weights |
| scapular body | ||
| acromion process | ||
| coracoid process | ||
| glenoid neck | ||
| glenoid fossa | ||
| Clavicledisplacednondisplaced | Stable Day 1 post-stabilization: early shoulder AROM-AAROM to tolerance; shoulder isometrics; elbow, forearm, wrist, hand AROM; grip strengthening Unstable: limit ROM as fracture pattern dictates | Stable: PROM/strengthening as tolerated Unstable: strengthening at 6-8 weeks; return to activity in 10-12 weeks |
| Humerus | ||
| 1. Proximal fractures | Day 1 post-stabilization: elbow, forearm, wrist, hand AROM; grip strengthening Days 2-5: pendulum shoulder exercises Weeks 1-3: early gentle AAROM shoulder joint within mobility limitations; deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder | Week 12: begin strengthening; progress to isometrics, surgical tubing, free weights, isokinetics; scapular stabilization exercises are important |
| greater tuberosity | ||
| lesser tuberosity | ||
| surgical neck | ||
| anatomic neck | ||
| 2. Humeral shaft | Day 1 post-stabilization: elbow, forearm, wrist, hand AROM grip strengthening Days 2-5: Pendulum shoulder exercises Weeks 1-3: Early gentle AAROM shoulder joint within mobility limitations: deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder | Weeks 10-12: strengthening Week 12: progression the same as for the proximal humerus |
| 3. Distal humerus | Day 1 post-stabilization: shoulder AAROM-AROM; wrist, hand active range of motion-CPM (elbow) as M.D. indicates Days 2-5: gentle elbow, forearm AROM; deltoid isometrics; grip strengthening Weeks 8-10: gentle PROM-AAROM elbow, forearm | Weeks 10-12: strengthening Week 12: isokinetics |
| Radius & Ulna | Weeks 10-12: PROM; strengthening | |
| 1. Olecranon | Days 1-7 post -stabilization: early gentle AAROM-AROM forearm, elbow (initiated after 2-3 days); shoulder, wrist, hand AROM; grip strengthening | Weeks 10-12: PROM; strengthening |
| 2. Radial head | Days 1-7 post-stabilization: early elbow AROM shoulder, wrist, hand AROM; grip strengthening | |
| 3. Forearm isolated radius, ulna - both bones Monteggia/Glaeazzi | Days 1-5 post-stabilization: immediate shoulder, hand AROM; early, gentle AAROM forearm, elbow, wrist as fracture stability allows; grip strengthening | Weeks 10-12: PROM Week 12: Strenghtening |
| 4. Distal radius | Days 1-5 post-stabilization: immediate AROM shoulder, elbow, fingers; initiation of gentle wrist AROM as immobilization allows (after cast removal than splint); grip strengthening | Weeks 8-10: PROM; light activity Weeks 10-12: strengthening |
| Wrist & Hand carpal MC phalanx | Days 1-5 post stabilization: early AROM-AAROM fingers, wrist, forearm as fracture and stabilization allow; elbow, shoulder AROM; fine motor control, desensitization; techniques as indicated | Weeks 8-10: PROM; light activity Weeks 10-12: strengthening |
| Terminology: 1. (WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated 2. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercises 3. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion *Post-stabilization to healing **After fracture healing | ||
| Table 2. Lower Extremity: Acetabulum to Femur | ||||
Fracture
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X-Rays Needed
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Immobilization
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Fixation
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Mobility Precautions
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| Acetabulum Posterior wall; posterior columns; anterior wall; anterior column; transverse; T-shaped; posterior column/posterior wall; transverse/posterior wall; both column; anterior column with posterior hemitransverse (Letournel classification) | AP Pelvis Judet Views CT San (3mmCuts) | Distal Femoral Traction | Lag screws reconstruction plates | Kocher-Langenbeck approach: (posterior), avoid active hip extension rotation Ilionguinal approach: (anterior), avoid active hip flexion,vigorous trunk and abdominal flexion Extended iliofemoral approach: (posterolateral), no active hip abduction 6-8 weeks; weight-bearing; NWB 8-12 weeks; positioning ROM; posterior wall involvement - no hip flexion greater than 70 degrees for 6 weeks |
| Pelvis 1. Anterior ringpublic symphysis rami | AP, inlet & outlet Pelvis, CT scan | See pelvic fracture disruption protocol | plating external fixation lag screws | TDWB-WBAT 10-12 weeks postinjury (depends on associated, posterior ring involvement) |
| 2. Posterior Ring Sacrum SI fracture/dislocation iliac wing | screws plating | TDWB-WOLWB 10-12 weeks | ||
| Femur | AP Pelvis AP/Lat hip | Distal Femoral Traction | Screw fixation hemiarthroplasty THA(in elderly patient as fracture dictates) | Toe-touch weight-bearing 8-12 weeksno straight leg raises (SLR) TTWB, WBAT dependent on prosthesis fixation (see femoral neck fracture) |
| 1. Femoral head | ||||
| 2. Femoral neck | AP Pelvis AP/Lat both hips (uninjured side with templeates) | Buck's Traction | screws dynamic hip screw endoprosthesis (elderly) | WB as necessary for balance for ambulationWB as necessary for balance for ambulation WBAT ROM precautions: avoid simultaneous/combination movements of the operative hip. Allow flexion, extension, abduction, adduction or rotation in cardinal planes of motion with no restriction; no SLR 6 weeks Posterior surgical approach: no hip flexion greater than 60 degrees, avoid hip adduction, internal rotation past neutral; no SLR 6-8 weeks WB as necessary for balance for ambulation |
| 3. Interochanteric femur | AP Pelvis AP/Lat hip | Buck's Traction | DHS IM nail | TTWB; no SLR; no active hip abduction with blade-plate fixation |
| 4. Subtrochanteric femur | AP Pelvis AP/Lat Femur | Distal Femoral Traction | DHS Blade plate IM nail | Interlocked nail/plate TTWB 6-8 weeks |
| 5. Femoral shaft | AP/Lat Femur AP/Lat KneeAP PelvisIf severely comminuted get scanogram opposite femur | Distal Femoral or proximal tibilal Traction | IM nail DCP, LC, DCP | Note: Knee immobilizer, external support may be needed To allow early crutch training if quad control slowly achieved; DCP fixation same as IM nail protocol |
| 6. Supracondylar, intracondylar femur | AP/Lat Femur AP/Lat Knee AP Pelvis | Knee Immobilizer | condylar blade plate; condylar buttress plate; screws | TDWB 10-12 weeks |
| Terminology: 1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity 2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation 3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance 4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs 5. (PWB) Partial weight-bearing - weight limit specified by M.D. | ||||
Fracture
|
Initial Physical Therapy Program
|
Advanced Physical Therapy**
|
| Acetabulum | Days 1-discharge: bilateral UE strengthening; AAROM knee, ankle; quad, hamstring isometrics, TKE; early mobilization initiated (exercise instruction, bed mobility, transfer, ambulation training); hip AAROM, flex<60 if post wall fx; lying prone is encouraged to preven hip flexion contracture (2-3x/day, 20 min intervals); Weeks 6-8: AROM -AAROM hip, no limits; hip abductor isometrics; hip extensor strengthening | Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunkmuscles; initiate balance/proprioceptive awareness training; aerobic/fitness training; rehabilitation is tailored to the surgical approach (i.e., extended iliofemoral approach requires more extensive hip abductor strengthening) |
| Pelvis 1. Anterior ring public symphysis rami | Day 1-discharge: bilateral UE strengthening; AAROM hip joint as fracture stability/pattern allows; quad/hamstring sets, terminal knee extension; AROM knee, ankle | Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness training |
| 2. Posterior Ring Sacrum SI fracture/dislocation iliac wing | Day 1-discharge: bilateral UE strengthening; PROM hip joint as fracture stability/pattern allows; quad/hamstring sets, terminal knee extension; AROM knee, ankle | Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness training |
| Femur | ||
| 1. Femoral head | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training | Weeks 3-6: A/AAROM operative hip; hip abductor & extensor strengthening; balance/proprioception training Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training |
| 2. Femoral neck | Day 1-discharge: bilateral UE & contralateral LE strengthening; quad/hamstring, AAROM, isometrics, AP involved AAROM; bed mobilization/transfer and ambulation training | Weeks 3-6: A/AAROM operative hip; hip abductor & extensor strengthening; balance/proprioception training Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training |
| 3. Interochanteric femur | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training | Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training |
| 4. Subtrochanteric femur | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training | Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training |
| 5. Femoral shaft | ||
| 6. Supracondylar, intracondylar femur | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE, TKE/assisted SLR; bed mobilization/transfer and ambulation training | Weeks 3-6: A/AAROM operative LE; TKE, SLR; hip girdle, quad & hamstring strengthening; balance/proprioception training Week 6-12: WBAT, wean from crutches; hip abductor & extensor strengthening, balance/proprioceptive training; closed kinetic chain activities, functional training |
| Terminology: 1. WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated 2. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercises 3. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion *Post-stabilization to healing **After fracture healing | ||
| Table 3. Lower Extremity: Patella to Foot | ||
Fracture
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X-Rays Needed
|
Immobilization
|
Fixation
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Mobility Precautions
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| Patella Nondisplaced; | AP/Lat Knee | knee immobilizer | cylinder cast, lag screw (s) tension-band wiring | Stable: WBAT Unstable: TTWB 4-8 weeks |
| displaced | ||||
| Tibia | AP/Lat KneeCT Scan | knee immobilizer | buttress T-plate DCPscrews | TDWB 8-12 weeks NO TKE exercise (avoid excessive end-range anterior tibial glide) |
| 1. Tibial plateau | ||||
| 2. Tibial Shaft | AP/Lat tibia | Cadillac Splint | IM nail reamed and unreamed; plates and screws; external fixator | PWB 6-8 weeks TDWB 8-12 weeks PWB 6-8 weeks |
| Ankle 1. Pilon | AP/Lat AnkleMortise View AP/Lat Tibia | Cadillac Splint Calacneal Traction | screws and plates | NWB 12 weeks |
| 2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C) | AP/Lat Ankle Mortise View | Cadillac Splint | screws, plates, and tension-band wiring | PWB 8-12 weeks |
| Foot 1. Calcaneus extraarticular intraarticular | Lat Foot Oblique Foot Harris Heel ViewCT Scan (3mmCuts) | Cadillac Splint, Use a lot of Padding to protect from Inevitable swelling. | Reconstruction plateH-plate; lag screw K-wires | NWB 12 weeks |
| 2. Talus | Lat Foot /Oblique Foot | Cadillac Splint With toe plate | lag screws K-wires (rare) | NWB 12 weeks |
| 3. Metatarsals and phalanx | AP/Lat & oblique Foot | Cadillac Splint With toe plate | screws, wires, and pins | closed reduction immobilization |
| Terminology: 1. (NWB) Nonweight-bearing - patient may not use extremity for any weight-bearing activity 2. (TDWB) Touch-down weight-bearing - extremity may touch the ground just during rest, not during ambulation 3. (TTWB) Toe-touch weight bearing - toe may touch ground just for balance 4. (WOLWB) Weight-of-leg weight-bearing - approximately 20-30 lbs. 5. (PWB) Partial weight-bearing - weight limit specified by M.D. 6. (WBAT) Weight-bearing as tolerated - patient may bear weight through extremity as tolerated 7. (TKE) Terminal knee extension - short-arc quadriceps strengthening exercise | ||||
| Table 3. Lower Extremity: Patella to Foot (Continued) | ||
Fracture
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Initial Physical Therapy Program
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Advanced Physical Therapy**
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| Patella Nondisplaced; | Days 1: bilateral UE strengthening; ankle AROM; knee CPM post-op if indicated Days 2 to discharge: quad hamstring isometrics***; knee/AROMas fracture pattern allows***; SLR*** | Weeks 4-8: strengthening; progress knee A/AAROM; begin quad Isometrics and SLR if there was quad mechanism involvement Week 8: WBAT, wean from crutches; concentrate on short arc/end range; quadriceps strengthening; closed kinetic chain activities (i.e., cycling, partial squats, leg press); balance proprioceptive training |
| displaced | ||
| Tibia | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training | Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training |
| 1. Tibial plateau | ||
| 2. Tibial Shaft | Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training | Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training |
| Ankle | Immediate post-stabilization: bilateral UE strengthening; gluteal, quad, hamstring isometrics Day 2 to discharge: hip, knee toe AROM; SLR, TKE Week 2: ankle subtalar AROM; progressive hip and knee strengthening | Week 12: PROM initiated; strengthening; balance/proprioceptive awareness training; WBAT, wean from crutches; closed kinetic chain program |
| 1. Pilon | ||
| 2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C) | same as pilon fracture | Weeks 8-10: gait progression after fracture healing; AROM/PROM ankle and subtalar joints; balance/proprioceptive awareness training |
| Foot 1. Calcaneus extra articular intra articular | Preoperative: UE strengthening; uninvolved extremity strengthening Involved extremity hip, knee isometrics; crutch training for short distance (primary elevation of extremity) Day 1: UE strengthening; uninvolved extremity AROM strengthening involved extremity hip- knee isometrics; AROM, Toe AROM to tolerance Days 2-3: crutch training, NWB involved extremity (limited time in dependent position) Days 4-7: early ankle, subtalar AROM when surgical incision is sealed Week 1 to month 3: continue early AROM ankle, subtalar, toes; gentle PROM toe dorsiflexion and plantar flexion; progress involved extremity; hip-knee conditioning Same as calcaneus | Month 3: gradually increase weight-bearing starting at 20lbs to FWB over 1 mo; gradually wean from assistive devise as patient tolerates; pool therapy if available; gait training, re-education;desensitization techniques as needed; ankle subtalar AAROM isometrics; low impact endurance training Months 4-6: gait progression, advanced balance and proprioceptive activities; ankle, subtalar isometric, isotonic strengthening with tubing/theraband; no free weights; soft-tissue immobilization Month 6: ankle, subtalar PROM; joint mobilization; isokinetic assessment, strength-endurance training; advanced balance, gait training as indicated |
| 2. Talus | Day 1 post-stabilization: biliateral UE strengthening; hip, knee AROM, isometrics; ankle, subtalar, toe AROM as fracture Pattern allows | |
| 3. Metatarsals and phalanx | Same as calcaneus Weeks 8-12: WBAT; wean from crutches; proprioceptive/balance training;; closed kinetic chain activities | |
| Terminology: 1. (SLR) Straight leg raises - isometric strengthening exercises with hip flexion 2. (UE) Upper extremity 3. (LE) Lower extremity *Post-stabilization to healing **After fracture healing ***Note: No active quads if quadriceps mechanisms involved or disrupted ΟΙ ΠΛΗΡΟΦΟΡΙΕΣ ΔΙΝΟΝΤΑΙ ΓΙΑ ΕΝΗΜΕΡΩΣΗ ΚΑΙ ΔΕΝ ΑΝΤΙΚΑΘΙΣΤΟΥΝ ΕΝΑ ΕΠΑΓΓΕΛΜΑΤΙΚΟ ΚΑΙ ΕΞΑΤΟΜΙΚΕΥΜΕΝΟ ΠΡΟΓΡΑΜΜΑ ΑΠΟΚΑΤΑΣΤΑΣΗΣ ΟΥΔΕΜΙΑ ΕΥΘΥΝΗ ΑΝΑΛΑΜΒΑΝΕΤΑΙ ΑΠΟ ΚΑΚΗ ΕΚΤΕΛΕΣΗ ΤΩΝ ΑΣΚΗΣΕΩΝ ΚΑΙ ΛΑΝΘΑΣΜΕΝΗ ΕΠΙΛΟΓΗ ΠΡΟΓΡΑΜΜΑΤΟΣ ΑΣΚΗΣΕΩΝ  | ||
