What is the appropriate management for a patient with a history of open reduction internal fixation (ORIF) to the right femur who presents with a popping note during therapy?

Management of Popping Sound During Physical Therapy After ORIF to Right Femur

For a patient experiencing a popping sound during physical therapy after ORIF to the right femur, evaluation for hardware complications is recommended, followed by appropriate imaging and orthopedic consultation if symptoms persist or worsen. 1

Initial Assessment

• Popping sounds during therapy after ORIF may indicate several potential issues including hardware loosening, impingement, or normal healing processes 1
• Evaluate for associated symptoms such as:
  • Pain (location, severity, timing related to the popping sound)
  • Swelling or erythema at the surgical site
  • Decreased range of motion or function
  • Instability or giving way sensations 1, 2

Immediate Management

• Temporarily modify therapy activities that provoke the popping sound 2
• Assess for signs of infection including fever, increased pain, warmth, redness, or drainage at the surgical site 3
• Document the specific movements or activities that elicit the popping sound 2
• If associated with significant pain, swelling, or decreased function, consider temporarily reducing weight-bearing status 4

Diagnostic Approach

• Plain radiographs should be obtained to evaluate hardware position and integrity, and to rule out hardware failure or displacement 4
• If radiographs are inconclusive but symptoms persist:
  • Consider advanced imaging such as CT scan to evaluate hardware position and bone healing 1
  • MRI may be helpful if soft tissue pathology is suspected (though artifact from hardware may limit usefulness) 4

Management Based on Findings

If No Hardware Issues Identified:

• Continue physical therapy with modified activities that avoid provoking the popping sound 2
• Consider physical medicine and rehabilitation (PMR) consultation for specialized rehabilitation protocols 2
• Implement pain management strategies including:
  • Regular acetaminophen
  • Carefully prescribed NSAIDs if not contraindicated
  • Regular pain evaluation during therapy sessions 1

If Hardware Issues Identified:

• Urgent orthopedic consultation is recommended for:
  • Evidence of hardware loosening or failure
  • Malunion or nonunion
  • Signs of infection 4, 1
• Surgical revision may be necessary if there is:
  • Hardware failure or loosening
  • Malunion affecting function
  • Deep infection requiring debridement 5, 3

Complications to Consider

• Hardware-related complications occur in approximately 31.5% of ORIF cases, with residual pain being the most common (17.2%) 5
• Nonunion or malunion occurs in approximately 2.4% of cases and may require surgical revision 5
• Deep infection occurs in approximately 1.5-3.4% of cases and requires prompt treatment 5, 3
• Factors increasing complication risk include smoking, alcohol use, diabetes, and obesity 6, 3

Follow-up Recommendations

• Close monitoring with serial radiographs to assess fracture healing 4
• Regular orthopedic follow-up until fracture union is confirmed 4
• If symptoms persist despite normal imaging, consider:
  • Diagnostic arthroscopy (if joint-related)
  • Hardware removal after complete fracture healing (typically not before 6-12 months post-ORIF) 5

Prevention of Further Complications

• Ensure appropriate weight-bearing status is maintained as prescribed by the orthopedic surgeon 4
• Continue thromboprophylaxis as indicated (typically 4 weeks postoperatively) 4
• Optimize bone health with adequate calcium and vitamin D supplementation 4
• Address modifiable risk factors such as smoking cessation and diabetes management 3