From : SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE

Fracture Treatment Protocols
Table 1. Upper Extremity Fracture X-rays Needed Immobilization Fixation Mobility Precautions Stable: WBAT

Scapula scapular body acromion process coracoid process

AP/axillary/scapular sling shoulder

screws

reconstruction Unstable: plates protected weight-bearing tubular plates 2-3 months mini T-plates no deltoid isometrics until 6 weeks poststabilization sling immobilization as needed

glenoid neck glenoid fossa

Clavicle displaced nondisplaced

AP/axillary Shoulder Sling or Figure reconstruction Stable: WBAT of 8 Strap plates Unstable: dynamic PWB-NWB 6-8 compression weeks plate (DCP) postinjury sling, figure 8 immobilization as fracture/patient status dictates

Fracture

X-rays Needed

Immobilization

Fixation

Mobility Precautions

ulna ± AP/Lat Forearm both bones AP/Lat Forearm Monteggia/Glaeazzi AP/Lat Forearm 4. Distal radius mini-fragment screws NWB mini T-plates closed reduction plates screws (rare) IM nail (rare) closed reduction external fixation ORIF Aarom as soon as soft tissues allow NWB 8-12 weeks Aarom as soon as soft tissues allow NWB 8-12 weeks Wrist & Hand carpal MC AP/Lat Hand AP/Lat Hand & Fingers Dorsal-Volar Splint Buddy Tape closed reduction wires mini-plates cast. . splint immobilization NWB-PWB 812 weeks phalanx Terminology: y y (NWB) Nonweight-bearing ± patient may not use extremity for any weight±bearing activity (TDWB) Touch-down weight-bearing ± extremity may touch the ground just during rest. wire Splint fixation Sugar Tong Splint Sugar Tong Splint Sugar Tong Splint closed reduction Olecranon Radial head Aarom as soon as soft tissues allow NWB Aarom as soon as soft tissues allow 3. Forearm isolated radius.Radius and Ulna y y AP/Lat Elbow AP/Lat Forearm AP/Lat Elbow AP/Lar Forearm Posterior Elbow tension-band Splint wiring Posterior Elbow screw.

grip strengthening Unstable: limit ROM as fracture pattern dictates Humerus 1. forearm. grip strengthening Weeks 2-3: gentle PROMAAROM shoulder. rotator cuff isometrics Stable: PROM/strengthening as tolerated Unstable: strengthening at 3 months.y y y not during ambulation (TTWB) Toe-touch weight bearing ± toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing ± approximately 20-30 lbs. deltoid. scapular isometrics. hand AROM. progress to isometrics. Fracture Initial Physical Therapy Program Advanced Physical Therapy** Days 1-5: shoulder pendulum exercises elbow. wrist. progress to Stable Day 1 post-stabilization: early shoulder AROM-AAROM Stable: PROM/strengthening as tolerated Unstable: strengthening at 6-8 weeks. wrist. strengthening progressed to tolerance Clavicle displaced nondisplaced to tolerance. shoulder isometrics. return to activity in 10-12 weeks .D. hand AROM. wrist. surgical tubing. forearm. ROM. Week 12: begin strengthening. surgical tubing. Proximal fractures grip strengthening greater tuberosity Days 2-5: pendulum shoulder isokinetics. elbow. Day 1 post-stabilization: elbow. hand AROM. forearm. free weights. (PWB) Partial weight-bearing ± weight limit specified by M. and free weights Scapula scapular body acromion process coracoid process glenoid neck glenoid fossa If stable fracture patternshoulder PROM-AAROM initiated 1 week postinjury.

isometrics Weeks 3-6: AROM. biceps. wrist.lesser tuberosity surgical neck anatomic neck 2. indicates Days 2-5: gentle elbow. shoulder. hand active range of motion-CPM (elbow) as M. forearm Weeks 10-12: strengthening Week 12: isokinetics Radius & Ulna y Olecranon Days 1-7 post -stabilization: early Weeks 10-12: PROM. hand AROM. Distal humerus exercises Weeks 1-3: early gentle AAROM shoulder joint within mobility stabilization exercises are important Weeks 10-12: strengthening limitations. biceps. triceps.D. gentle PROM shoulder the proximal humerus Day 1 post-stabilization: elbow. isometrics Week 12: progression the same as for Weeks 3-6: AROM. forearm AROM. deltoid isometrics. gentle AAROM-AROM forearm. strengthening elbow (initiated after 2-3 days). gentle PROM shoulder Day 1 post-stabilization: shoulder AAROM-AROM. hand AROM grip strengthening Days 2-5: Pendulum shoulder exercises Weeks 1-3: Early gentle AAROM shoulder joint within mobility limitations: deltoid. triceps. forearm. wrist. deltoid. grip Weeks 10-12: . grip strengthening Weeks 8-10: gentle PROMAAROM elbow. Humeral shaft 3. wrist.

wrist. anterior wall. activity forearm as fracture and stabilization allow. gentle AAROM forearm. initiation of gentle wrist AROM as immobilization allows (after cast removal than splint). wrist as fracture stability allows.strengthening 3. (TKE) Terminal knee extension ± short-arc quadriceps strengthening exercises 8. X-Rays Needed AP Pelvis Immobilization Fixation Mobility Precautions Kocher-Langenbeck approach: (posterior). Forearm isolated radius. early. elbow. Distal radius Days 1-7 post-stabilization: early Weeks 10-12: PROM elbow AROM shoulder. (WBAT) Weight-bearing as tolerated ± patient may bear weight through extremity as tolerated 7.y Radial head strengthening PROM. ulna ± both bones Monteggia/Glaeazzi 4. grip strengthening Weeks 8-10: PROM. fine motor control. light AROM-AAROM fingers. posterior columns. hand Week 12: strengthening AROM. wrist. grip strengthening Days 1-5 post-stabilization: immediate AROM shoulder. light activity Days 1-5 post-stabilization: immediate shoulder. avoid active hip extension rotation Distal Femoral Lag screws reconstruction plates Judet Views Traction CT San . grip strengthening Wrist & Hand carpal MC phalanx Days 1-5 post stabilization: early Weeks 8-10: PROM. shoulder Weeks 10-12: strengthening AROM. elbow. fingers. techniques as indicated 6. desensitization. (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 Acetabulum Posterior wall. hand AROM. Weeks 10-12: strengthening elbow.

vigorous trunk and abdominal flexion Extended iliofemoral approach: (posterolateral). avoid active hip flexion. transverse/posterior wall. both column. Tshaped. no active hip abduction 6-8 weeks. anterior column with posterior hemitransverse (Letournel classification) Ilionguinal approach: (anterior). positioning ROM. posterior Cuts) column/posterior wall. WBAT dependent . weight-bearing. posterior wall involvement ± no hip flexion greater than 70 degrees for 6 weeks Pelvis y Anterior ring AP. posterior ring involvement) TDWB-WOLWB 10-12 weeks public symphysis screws rami plating y Posterior Ring Sacrum SI fracture/dislocation iliac wing Femur y AP Pelvis Femoral head Femoral AP/Lat hip AP Pelvis y Distal Femoral Screw fixation Traction hemiarthroplasty Buck¶s THA Traction (in elderly Toe-touch weight-bearing 8-12 weeks no straight leg raises (SLR) TTWB. NWB 8-12 weeks. (3mm transverse. inlet & outlet Pelvis. CT scan See pelvic fracture disruption protocol plating external fixation lag screws TDWB-WBAT 10-12 weeks postinjury (depends on associated.anterior column.

Femoral shaft 6. adduction or rotation in cardinal planes of motion with no restriction. no SLR. no SLR 6-8 weeks WB as necessary for balance for ambulation TTWB. Allow flexion. abduction. screws . avoid hip adduction. Subtrochanteric femur 5. Interochanteric femur 4. no SLR 6 weeks Posterior surgical approach: no hip flexion greater than 60 degrees. internal rotation past neutral. Supracondylar. no active hip abduction with bladeplate fixation Interlocked nail/plate TTWB 6-8 weeks Note: Knee immobilizer. extension. external support may be needed To allow early crutch training if quad control Distal Femoral screws Traction dynamic hip Distal Femoral screw or proximal tibilal Traction endoprosthesis (elderly) Knee DHS Immobilizer IM nail DHS Blade plate IM nail IM nail DCP.neck 3. LC. condylar buttress plate. intracondylar femur AP/Lat both hips (uninjured side with templeates) AP Pelvis AP/Lat hip AP Pelvis AP/Lat Femur AP/Lat Femur AP/Lat Knee AP Pelvis If severely comminuted get scanogram opposite femur AP/Lat Femur AP/Lat Knee AP Pelvis Buck¶s Traction patient as on prosthesis fixation (see fracture dictates) femoral neck fracture) WB as necessary for balance for ambulation WB as necessary for balance for ambulation WBAT ROM precautions: avoid simultaneous/combination movements of the operative hip. DCP condylar blade plate.

gait retraining. extended iliofemoral approach requires more extensive hip abductor strengthening) Acetabulum Pelvis y Anterior ring Day 1-discharge: bilateral UE strengthening. early mobilization initiated (exercise instruction. terminal knee extension. bed mobility.. gait retraining. Fracture Initial Physical Therapy Program Days 1-discharge : bilateral UE strengthening.slowly achieved. ankle Day 1-discharge: bilateral UE strengthening. hip AAROM. rehabilitation is tailored to the surgical approach (i. wean from crutches. strengthen quads. and lower trunk muscles. quad/hamstring sets. flex<60 if post wall fx. aerobic/fitness training Weeks 12-14: WBAT. extensors. hip extensor strengthening Advanced Physical Therapy** Weeks 12-14: WBAT. flexors. quad/hamstring sets. transfer. extensors. wean from crutches. Posterior . and lower trunk muscles. initiate balance/proprioceptive awareness training. AAROM knee. AROM knee. abductors. hamstring isometrics. strengthen quads. abductors. strengthen quads. PROM hip joint as fracture stability/pattern allows.D. AROM knee. DCP fixation same as IM nail protocol TDWB 10-12 weeks Terminology: y y y y y (NWB) Nonweight-bearing ± patient may not use extremity for any weight±bearing activity (TDWB) Touch-down weight-bearing ± extremity may touch the ground just during rest. lying prone is encouraged to preven hip flexion contracture (2-3x/day. hamstrings. AAROM hip joint as fracture stability/pattern allows. terminal knee extension. abductors. ankle. gait retraining. hip abductor isometrics. not during ambulation (TTWB) Toe-touch weight bearing ± toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing ± approximately 20-30 lbs ( PWB) Partial weight-bearing ± weight limit specified by M.e. Weeks 6-8: AROM ±AAROM hip. ambulation training). wean from crutches. aerobic/fitness training. flexors. hamstrings. no limits. TKE. 20 min intervals). ankle public symphysis rami y Weeks 12-14: WBAT. hamstrings. quad. initiate balance/proprioceptive awareness training.

hip abductor & extensor strengthening. TKE/assisted SLR. bed intracondylar femur mobilization/transfer and ambulation Week 6-12: WBAT. balance/proprioceptive training. AP involved LE. functional training . contralateral LE strengthening. AP involved AAROM. AP involved Week 6-12: WBAT. functional training Weeks 3-6: A/AAROM operative hip. hip abductor & extensor strengthening. AAROM. Supracondylar. AAROM. wean from LE. isometrics. AAROM. Day 1-discharge: bilateral UE & closed kinetic chain activities. and lower trunk muscles. aerobic/fitness training Femoral head Femoral neck Day 1-discharge: bilateral UE & contralateral LE strengthening. wean from training crutches. balance/proprioception training y 3. balance/proprioceptive training. Interochanteric femur 4. hip abductor & extensor strengthening. closed kinetic chain activities. functional training AAROM. bed mobilization/transfer and ambulation training Weeks 3-6: A/AAROM operative hip. SLR. bed crutches. Subtrochanteric femur 5. bed mobilization/transfer and ambulation Weeks 3-6: A/AAROM operative training LE. training balance/proprioceptive training. initiate balance/proprioceptive awareness training. LE. AAROM. TKE. Femoral shaft Day 1-discharge: bilateral UE & contralateral LE strengthening. AP involved 6. AP involved LE. quad/hamstring. extensors. isometrics. TKE/assisted SLR. hip abductor & extensor mobilization/transfer and ambulation strengthening.Ring Sacrum SI fracture/dislocation iliac wing Femur y flexors. quad & hamstring strengthening. hip girdle. wean from crutches. hip abductor & extensor strengthening. isometrics. balance/proprioception training Week 6-12: WBAT. isometrics. closed kinetic chain activities. isometrics. Day 1-discharge: bilateral UE & balance/proprioception training contralateral LE strengthening. TKE/assisted SLR. bed mobilization/transfer and ambulation training Day 1-discharge: bilateral UE & contralateral LE strengthening.

lag screw (s) tension-band wiring Mobility Precautions Stable: WBAT Unstable: TTWB 4-8 weeks AP/Lat Knee knee immobilizer . functional training Weeks 3-6: A/AAROM operative LE. wean from crutches. closed kinetic chain activities. SLR. quad & hamstring strengthening. displaced X-rays Needed Immobilization Fixation cylinder cast. (TKE) Terminal knee extension ± short-arc quadriceps strengthening exercises 8. functional training 6. closed kinetic chain activities. balance/proprioception training Week 6-12: WBAT. TKE. SLR. balance/proprioceptive training. hip girdle. balance/proprioceptive training.Weeks 3-6: A/AAROM operative LE. WBAT) Weight-bearing as tolerated ± patient may bear weight through extremity as tolerated 7. quad & hamstring strengthening. balance/proprioception training Week 6-12: WBAT. hip abductor & extensor strengthening. wean from crutches. TKE. hip girdle. Lower Extremity: Patella to Foot Fracture Patella Nondisplaced. (SLR) Straight leg raises ± isometric strengthening exercises with hip flexion *Post-stabilization to healing **After fracture healing Table 3. hip abductor & extensor strengthening.

external fixator TDWB 8-12 weeks NO TKE exercise (avoid excessive endrange anterior tibial glide) PWB 6-8 weeks TDWB 8-12 weeks PWB 6-8 weeks Ankle 1. Calcaneus extraarticular intraarticular 2. K-wires (rare) Cadillac Splint With toe plate screws. plates and screws. Tibial plateau 2. B. lag screw NWB 12 weeks closed reduction immobilization Oblique Foot Use a lot of Harris Heel View Padding to protect K-wires from lag screws Inevitable swelling. C) Mortise View Foot 1. and pins Oblique Foot Cadillac Splint AP/Lat & With toe plate . Tibial Shaft AP/Lat Knee knee immobilizer CT Scan AP/Lat tibia Cadillac Splint buttress T-plate DCP screws IM nail reamed and unreamed. AP/Lat Tibia Cadillac Splint posterior AP/Lat malleolus. Talus 3 . and PWB 8-12 weeks tension-band wiring 2. wires. lateral Ankle malleolus (Weber A. Pilon AP/Lat Ankle Mortise View Cadillac Splint Calacneal Traction screws and plates NWB 12 weeks screws. Metatarsals and phalanx CT Scan (3mm Cuts) Lat Foot Lat Foot Cadillac Splint Reconstruction plate NWB 12 weeks H-plate. Medial malleolus. plates.Tibia 1.

AAROM. (TKE) Terminal knee extension ± short-arc quadriceps strengthening exercise Fracture Patella Nondisplaced. closed kinetic chain activities (i. (PWB) Partial weight-bearing ± weight limit specified by M. initiate Initial Physical Therapy Program Days 1: bilateral UE strengthening. isometrics.oblique Foot Terminology: y y y y y (NWB) Nonweight-bearing ± patient may not use extremity for any weight±bearing activity (TDWB) Touch-down weight-bearing ± extremity may touch the ground just during rest. ankle AROM. progress knee A/AAROM. Tibial plateau 2. flexors. not during ambulation (TTWB) Toe-touch weight bearing ± toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing ± approximately 20-30 lbs. knee/AROM as fracture pattern allows***. extensors. Advanced Physical Therapy** Weeks 4-8 : strengthening. balance proprioceptive training Weeks 12-14: WBAT. initiate balance/proprioceptive awareness training. hip girdle. wean from crutches. isometrics. leg press). strengthen quads.D. abductors. wean from crutches. gait retraining. quad & hamstring strengthening. AP involved LE. begin quad Tibia 1. flexors.e. cycling. Tibial Shaft Day 1-discharge: bilateral UE & contralateral LE strengthening. aerobic/fitness & functional training Weeks 12-14: WBAT. hamstrings. . strengthen quads. knee CPM post-op if indicated displaced Days 2 to discharge: quad hamstring isometrics***. partial squats. (WBAT) Weight-bearing as tolerated ± patient may bear weight through extremity as tolerated 7. quadriceps strengthening. SLR*** Isometrics and SLR if there was quad mechanism involvement Week 8: WBAT. extensors. AP involved LE. bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated. wean from crutches. A/AAROM operative LE.. AAROM. gait retraining. balance/proprioception training Day 1-discharge: bilateral UE & contralateral LE strengthening. abductors. hamstrings. 6. concentrate on short arc/end range. and lower trunk muscles. and lower trunk muscles.

balance/proprioceptive awareness training Month 3: gradually increase weight-bearing starting at 20lbs to FWB malleolus (Weber strengthening A. hip girdle. posterior malleolus. AROM/PROM ankle and subtalar joints. lateral balance/proprioceptive awareness training. hamstring isometrics crutches. knee toe program AROM. ankle subtalar AAROM Days 2-3: crutch training. involved extremity hip. strengthening. Calcaneus extraarticular intraarticular 2. gluteal. TKE Week 2: ankle subtalar AROM. Medial malleolus. pool therapy if available. balance/proprioception training Ankle 1. wean from quad. uninvolved extremity AROM strengthening Preoperative: UE strengthening. progressive hip and knee Weeks 8-10: gait progression after fracture healing. crutch training for short distance over 1 mo. SLR. subtalar AROM when surgical incision is sealed Week 1 to month 3: continue early isometrics. gait training. A/AAROM operative LE. knee isometrics. ankle. re-education. balance/proprioceptive awareness training. UE strengthening. WBAT. Talus 3 . gradually wean from (primary elevation of extremity) assistive devise as patient tolerates. closed kinetic chain Day 2 to discharge: hip. Toe AROM to tolerance needed. Metatarsals and phalanx Day 1: UE strengthening. C) same as pilon fracture Foot 1. uninvolved extremity strengthening Involved extremity hip. B. subtalar isometric. low impact endurance training Months 4-6: gait progression. desensitization techniques as AROM. NWB involved extremity (limited time in dependent position) Days 4-7: early ankle. isotonic strengthening with .knee isometrics. advanced balance and proprioceptive activities. quad & hamstring strengthening.bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated. Pilon 2. aerobic/fitness & functional training Immediate post-stabilization: bilateral Week 12: PROM initiated.

gait training as indicated Day 1 post-stabilization: biliateral UE Same as calcaneus strengthening. progress involved extremity. toes. strength-endurance training.edu . IL 62794-9679 Street Address SIU School of Medicine Orthopaedics & Rehabilitation Division 800 North Rutledge Street. gentle PROM toe dorsiflexion and plantarflexion.O. closed kinetic chain activities 8. advanced balance. toe AROM as fracture pattern allows Weeks 8-12: WBAT. (SLR) Straight leg raises ± isometric strengthening exercises with hip flexion 9. (LE) Lower extremity *Post-stabilization to healing **After fracture healing ***Note: No active quads if quadriceps mechanisms involved or disrupted Mailing Address SIU School of Medicine Orthopaedics & Rehabilitation Division P. subtalar. isokinetic assessment. Box 19679 Springfield. no free weights. (UE) Upper extremity 10. Room D220 Springfield. subtalar PROM. subtalar.. wean from crutches. knee AROM. ankle. isometrics. joint mobilization. hip-knee conditioning Same as calcaneus tubing/theraband. soft-tissue immobilization Month 6: ankle. hip.AROM ankle. proprioceptive/balance training. IL 62702 Phone Number: 217-545-8865 Fax Number: 217-545-7901 E-mail Address orthopaedics@siumed.

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