Code: ortho407

Lecture number: 4th

Lecture name: Physical therapy for lower limb
Traumatic injuries
Lecturer: Dina Sayed Abd Allah
Dina Sayed Abd Allah
Lecturer of physical therapy, physical therapy for
Musculoskeletal Disorders and their surgery,
Faculty of Physical Therapy, Cairo University.
By the end of this lecture the student should be able
to:
• Describe different traumatic lower limb
injuries.
• Discuss general guidelines of management of
different traumatic lower limb injuries.

• Recognize physical therapy for the common

post-traumatic complications.
 It is an interruption or loss of bone continuity
that may arise from low energy forces or high
energy forces.
# classification
 Clinical picture of # 


Pain on WB, lifting or movement

tenderness on palpation at # site

Hotness & redness

Presence # line on X-ray

Full functional disability
Primary Secondary
Secondary bone healing
 Clinical picture of # Healing
Pain on WB, lifting or No pain on WB, lifting or
movement movement

tenderness on palpation No tenderness on

at # site palpation at # site

Hotness & redness No Hotness & redness

Presence # line on X-ray No # line on X-ray

Full functional disability Full or near full

functional ability.
1. Reduction restoring the anatomical alignment .
2. Hold & Immobilization or fixation .
3. Rehabilitation
1. Casting and external splints/braces
2. Traction
3. External skeletal fixator
4. Internal fixation (stress shielding & sharing)
Main goals of physical
therapy
Long term goal: to return patient to
their pre-injury level of function.
Short term goals:
1. Maintain circulation.
2. prevent pulmonary complications.
3. Decrease pain.
4. Maintain & increase muscular strength.
5. Maintain & increase range of motion.
6. Restore normal biomechanics, Correct posture &
gait deviations.
7. Improve proprioception & balance.
Type of WB Description Indication

NWB Affected limb is unstable # & post rigid load

completely off ground. shielding devices.

TDWB Toes in touch with Initiation of gradual WB after

ground but without WB healing ( load shielding
devices).
PWB Gradual WB (5-10-15%) Gradual WB after healing (load
shielding devices).

As WB as much as patient Stable # or # fixed by load

tolerated can. sharing devices.
FWB Patient walks fully
without assistive devices
 Intracapsular Extracapsular

Description Inside capsule including distal to capsule to a line 5 cm

head & neck of femur. distal to lesser trochanter.

Incidence Common with elderly Most common accidently

females, relatively minor affect any age, relatively
trauma. greater force .

Most common femaoral neck # intertrochanteric #

# site
1st common #in elderly 2nd common # in elderly

Complication • injury of blood supply • Doesn’t disturb blood

• delayed or non union supply
avascular necrosis • nonunion due to fixation
failure.
 Intracapsular Extracapsular

TTT Traction is alternative treatment for Traction is alternative

medically unstable patients , WB is treatment for medically
delayed by 10 : 12 w up to16 w, 30 − unstable patients , WB is
40% of patients die due to bed delayed by 10 : 12 w up
complications. to16 w.
 Intracapsular # Extracapsular #

Assessment +ve history of fall +ve history of fall

painful hip, leg is painful hip, leg is
shortened & externally shortened & externally
rotated position, can’t rotated position, can’t
bear weight on. bear weight on.
.
1. Relatively Stable# & intact blood
supply ORIF

2. Dynamic hip screw (DHS)

3. Displaced # Austin Moore

implant (hemi arthoplasty) often
used.
4. THA
1. Relatively Stable# ORIF

2. Dynamic hip screw ’ (DHS)

3. Proximal femoral nail

 Orthopedic complications :
1. Avascular necrosis & non union
2. dislocations/subluxations
3. leg-length discrepancies
4. prosthetic loosening
5. Heterotopic ossification
6. Nerve injuries (peroneal portion of sciatic n)
 Medical complications:
1. DVT
2. Death
3. Wound, urinary tract or chest infections(
pneumonia).
Cause: Dashboard accident
Depending on degree of hip flexion & intense of
trauma .
Clinical presentation: leg is flexed, add. &
shortened, femoral head may be palpable in
buttock. sciatic n. (lat. popliteal part) may be
damaged.
Treatment
Reduction under anesthesia. Once reduced, it is
usually stable & leg is then held on longitudinal
skin traction for 3 w to allow capsule to heal,
followed by a further 3 w of protected WB.
Stiffness is rarely .
seen in all age groups.
may occur at various levels in shaft, & is frequently
an open injury & associated with other injuries.
Bleeding is often. Injuries to femoral n. , sciatic n.
& ACL lig. are occasionally.
immediate Thomas splint.
Gallows traction is a simple method of applying
traction in a child aged up to 2 years.
The preferred treatment is intramedullary nail
fixation. it is inserted under X - ray control.
Full WB possible at 3rd :4th w.
Union occurs 12th:16th w. Knee stiffness is often,
but resolves with exercise.
Often displaced by action of
gastrocnemius ms.

Treatment : commonly surgical

via Intra -medullary nail fixation.
While in osteoporotic bone or comminuted # ,
locked plate fixation is used.
 Comminuted# Avulsion or
Cause: direct blow transverse#
TTT: Tension band wiring or k-wire
& pins or patellectomy. Cause: violent quadriceps
contraction

TTT: figure - of - eight wire

Simple stable# Very severe #
TTT: circular frames
TTT: may be Displaced #
conservative in a (external fixator)
TTT: Plates & screws
brace to +
movement.
 Lateral, Bicondylar & Medial
TTT:
1. External fixator

2. Or ORIF ( screws, locked or

unlocked platesbuttress
plates)

3. Or TKA
 Common in all age groups

Transverse stable #
closed reduction &full leg cast fix. with 20:30* knee flex.
TTT:of tibial shaft #

require 6:8 up to 12 ws, certin cases may last up to 5ms.

Oblique & spiral unstable #

ORIF via Plate &screw (delayed FWB after 8th up to 12th w) or intermud.
.nail (early immediate gradual WB )

Communited #& bone loss

External frame fixation (allow early immediate gradual WB)
TTT: cast fixation till painless
1. Compartment syndrome is common following
tibial shaft # ( if neglected may result in
flexion contractures of toes).
2. 2nd O.A following Intra articular # tibial
plateau.
 Single malleolus # with talar displacement may be
treated with closed reduction & cast fix. or may
ORIF.
 Bi - malleolar unstable # require ORIF .
 Tri - malleolar unstable # require ORIF.
Cause: forced ankle dorsiflexion

TTT: ORIF
# healing is evident on 8th w.
Complications: avascular necrosis
of body of talus
Cause: Fall on foot from a height.

TTT: external fixator Or ORIF

followed by cast, casts are removed
at 6th w.

Full recovery takes up to a year.

#of post. superior lip of
calcaneum (avulsion #) via action
of Achilles tendon.
TTT: reduced & immobilized with
ankle in equinus, or by ORIF.
Cause: fall from height
Displaced or comminuted
calcaneus #
ORIF by plate & screws
followed by splint till
edema control. At 2nd w
patients may be converted
to a # boot or cast 2nd :6th
w.
Stable calcaneus #
supportive well-padded
splint to allow resolution of
edema. then # boot or cast
within 2nd w with ankle in
neutral. Lasts for 6th:8th w.
NWB for at least 6th:8thw until radiographic
evidence of # consolidation.
Shoe wear is not recommended for about 10th: to
12th w to minimize stress across calcaneocuboid
joint.
Gentle Isometric strengthening may begin before
WB. When WB begins, exercises to regain full ROM,
strengthening exs, gait training & balance training.
 • Cause: avulsion via inversion strain by peroneus brevis ms.
Base of • TTT: walking cast or bandage for 3 – 6 w,
5th • if # extends into joint between 4th & 5th metatarsals (Jones ’ #),
metatarsa screw stabilization.
l

• Cause: crushing or falling from height.

• TTT: Elevation of foot, if swollen, followed by a walking below -
Metatarsal knee cast for 6 w.
shaft If displaced, plaster - cast or ORIF. •

• cause: walking or standing prolonged time.

Stress #of
neck of 2nd • TTT: rest for 6 w is usually sufficient.
metatarsal
Cause: accident (crushing or falling).
TTT: protective dressings, sometimes requires
reduction and K - wiring to correct deformity.
Injury type fixation methods Weightbearing recommendation
Comminuted femoral ORIF NWB for 6–12 w
shaft fracture External fixation Immediate WB as tolerated
Intramedullary fixation

Femoral shaft ORIF plate & screws NWB for 6–12 w

fracture External fixation Immediate WB as tolerated

Distal femoral ORIF plate & screws NWB for 6–12 w

fracture Intramedullary fixation Immediate WB as tolerated

Comminuted/high- ORIF plate & screws NWB for 6–12 w

grade tibial fracture External fixation Immediate WB as tolerated

Tibial shaft fracture External fixation Immediate WB as tolerated

Intramedullary fixation

Tibial plafond ORIF plate & screws NWB for 6–12 w

fracture External fixation Immediate WB as tolerated

Calcaneal fracture ORIF plate & screws NWB for 6–12 w

Common post-traumatic
complications
formation of bone in atypical locations of the
body.
Muscle, muscle-tendon unit, capsule, or
ligamentous structures.
1. Post traumatic as (around elbow joint trauma
as a comminuted # of the radial head, post.
elbow dislocation, a # dislocation,
supracondylar or radial head #, or a tear of the
brachialis tendon).
2. Neurological impairments e.g: TBI or SCI ( e.g:
aggressive stretching of the elbow flexors)
3. 2nd degree extremity burns ( e.g: aggressive
stretching of the elbow flexors)
Assessment: tender distal brachialis.
It takes 2 to 4 week period of time, to make the muscle
extremely firm to touch.
Painful Limitation of ROM may be permanent but in
most cases, to a large extent is reabsorbed over several
months, and ROM usually returns to near normal.
Contraindications: Massage, passive movement, passive
stretching, and resistive exercise are contraindicated if
the brachialis muscle is implicated after trauma.
Conservative ttt: The elbow should be kept at rest in a
splint, which should be removed only periodically during
the day for active, pain-free ROM. Rest should continue
until the bony mass matures and then resorbs.
Surgical ttt: Surgical excision of heterotopic bone from the
muscle or a total elbow arthroplasty, if the capsule is also
involved, is necessary only in rare instances.
It is a massive infarction, mainly on the muscles
and to a lesser degree on the other soft tissues.
Causes
1. Brachial artery injury post traumatic or faulty
injection.
2. Secondary to Compartment syndrome.
increased pressure within limited anatomic space
compromises circulation to surrounding tissues.
It is common after paediatric supracondylar
humerus # treated with long arm cast with elbow
placed in extreme flexion.
Pathology of volkman ischemic contracture
Decrease or absence of blood supply leads to
muscle damage, The severity of damage varies
from mild fibrosis to total necrosis.
The flexors are more affected than extensors. The
the flexor digitorum profundus and flexor polices
longus are more affected than the superficial
muscles.
The median n is liable to ischemia more than the
ulnar n.
1. Contracture: Short finger flexors & wrist
flexors.
2. Deformity: wrist Flex. IP Joints flex. & extension
of the MCP joints.
3. Atrophy: The forearm muscles become
atrophied.
4. Ischemic neuritis: Sensory loss along the
distribution of the median nerve.
5. Trophic changes in the fingers are often
present.
Prevention
1. Early reduction of the # around the elbow to
relieve any pressure of the brachial artery.
2. Position of fixation of supracondylar # should
be in full elbow extension with the forearm
supinated.
3. Avoid tight bandage or cast or faulty injection.
4. Early treatment at the onset of ischemia.
Treatment
A) Non operative TTT: Stretching of the contracture
on a splint.
B) Operative TTT followed by physical exercises to
regain the ROM and muscle power as much as
possible.
It describes painful disabilities of either upper or
lower extremity due to disturbances of the
sympathetic nerve supply. Associated with
vasomotor and trophic symptoms. That starts
within hours to days after the initial injury as after
coll's # or potts # .
Clinical picture:
1. Severe chronic pain with hypersensitivity to
normal stimuli.
2. Autonomic skin changes with cyanosis, altered
temperature, and inappropriate sweat response
3. Increased joint stiffness
4. Muscle wasting
5. Bone demineralization.
TTT: pain inhibition techniques and pain relieving
modalities as TENS, initiation of motion as early as
possible, weight bearing through the limb, mirror
therapy.

Treatment is difficult, especially in lower

extremities.

Prevention: several studies suggest that vitamin C

may help in prevention of CRPS, especially after
foot/ankle surgery.
It describes painful disabilities of the upper
extremity due to disturbances of the sympathetic
nerve supply. Associated with vasomotor and
trophic symptoms.
Or
It can be described as a painful shoulder with
limited movement following to hand pain.
Causes
1. Post-hemiplegia.
2. Cervical disc disease
3. Shoulder capsulitis
4. Wrist or hand pain as Post-trauma as in coll's
# or schaphoid #.
Clinical picture
1- Circulatory impairment (venous and lymphatic
in the arm and hand).
2- Limitation of shoulder ROM.
3- Edema and contracted collateral ligaments
leading to limitation of metacarpo-phalangeal
joints.
4- Restriction of wrist ROM and it is maintained in
a flexed position.
5- There may be associated with the sympathetic
nervous system.
TTT
a) Encourage early motion of the hand and
shoulder.
b) Sympathetic procaine blocks.
c) Procaine and cortisone injections into the
shoulder and trigger pain points.
• Elevate and warp the extremity & circulatory exs
• Paraffin baths to the hands.
• Joint mobilization technique.
• gentle & gradual Muscle stretching exs.
• Soft-tissue stretching.
• Gradual strengthening exercises
• Proprioception training
• Functional activities.
Thanks