What is the appropriate physiotherapy management for a fracture from the acute phase through rehabilitation?

Physiotherapy Management of Fractures

Physiotherapy should begin with early range-of-motion exercises within the first postoperative days, followed by progressive weight-bearing and structured exercise programs, with the critical caveat that overly aggressive therapy must be avoided to prevent fixation failure. 1

Acute Phase Management (First Days to Weeks)

Immediate Post-Injury/Post-Surgical Period

Early mobilization is essential and should commence as soon as orthopedically appropriate to reduce thromboembolism risk and optimize rehabilitation outcomes. 2

Site-Specific Early Mobilization:

• Distal radius fractures: Early finger motion must begin immediately after casting or surgery to prevent edema and stiffness; when immobilization is discontinued, aggressive finger and hand motion is necessary for optimal outcomes. 1

• Shoulder fractures: Range-of-motion exercises including shoulder, elbow, wrist, and hand motion should begin within the first postoperative days; slings are worn for comfort only and may be discarded as pain allows, but above-chest-level activities must be restricted until fracture healing is evident. 1

• Tibial plateau fractures: Early range-of-motion exercises should be encouraged as soon as possible after the procedure, with immobilization after plate fixation providing no demonstrated benefit. 3

Critical Pitfall to Avoid:

Overly aggressive physical therapy increases the risk of fixation failure in the postoperative period, requiring careful balance between early mobilization and protection of surgical fixation. 1

Subacute Phase (Weeks to Months)

Weight-Bearing Progression

Early weight-bearing should begin as soon as orthopedically appropriate, as delaying mobilization unnecessarily increases thromboembolism risk and prolongs hospital stay. 2

• For tibial plateau fractures specifically, early weight-bearing is gaining support in recent literature despite historical controversy. 3

Structured Exercise Programs

High-intensity and extended exercise interventions are supported by evidence for maximizing functional recovery after fragility fractures. 4

Core Components:

• Physical training and muscle strengthening: Must be introduced early in the post-fracture period as part of the rehabilitation program. 1, 5

• Quadriceps strengthening: Particularly important for lower extremity fractures to restore function and prevent complications. 3

• Proprioception exercises: Essential for restoring balance and coordination, especially in tibial plateau and other lower extremity fractures. 3

Long-Term Rehabilitation Phase (Months to Year)

Ongoing Rehabilitation Goals

The primary aim is to regain the level of mobility and independence enjoyed before the fracture occurred, requiring early identification of individual goals and needs before developing the rehabilitation plan. 1, 5

Essential Long-Term Components:

• Balance training: Must continue long-term as part of multidimensional fall prevention strategy. 1, 5

• Fall prevention programs: Represent a hallmark of ideal non-pharmacological treatment, with positive effects on bone mineral density and muscle strength in patients who exercise rigorously, plus reduction in fall frequency. 1

• Exercise programs: Rigorous exercise demonstrates positive effects on bone mineral density and muscle strength, though evidence for direct fracture prevention remains limited. 1

Patient Education and Multidisciplinary Coordination

Patient education about the burden of injury, potential complications, risk factors for fractures, and expected outcomes is essential throughout the rehabilitation process. 1, 5

• Education should include follow-up expectations and duration of therapy. 1

• Orthogeriatric comanagement is recommended for frail, elderly patients with multiple comorbidities and polypharmacy in the acute fracture care phase. 1

Special Considerations for Fragility Fractures

Comprehensive Rehabilitation Services Required:

• Physical therapy assessment and mobilization training: Constitutes the majority of inpatient stay after hip fracture and must be coordinated before discharge. 2

• Occupational therapy evaluation: Necessary for activities of daily living and home safety assessment to ensure safe discharge. 2

• Social work consultation: Required to coordinate discharge planning and community resources. 2

Secondary Prevention:

Failure to address secondary prevention, including falls prevention and osteoporosis management, can lead to subsequent fragility fractures with poor prognosis. 2

• Only 44% of patients admitted from home are discharged back to their own homes within 30 days of hip fracture surgery, emphasizing the need for comprehensive discharge planning. 2

Monitoring for Complications

Postoperative cognitive dysfunction/delirium occurs in 25% of hip fracture patients and interrupts routine management and rehabilitation, requiring multimodal optimization including adequate analgesia, hydration monitoring, and early urinary catheter removal. 2

• Inadequate pain control interrupts rehabilitation and increases delirium risk; regional anesthesia techniques can significantly reduce opioid consumption. 2

• Nutritional status is critical, with up to 60% of hip fracture patients being malnourished on admission; nutritional supplementation may reduce mortality and length of stay. 2