Tibial Plafond Fracture w/ C- Diff.

Case 12 Lavonia is a 49 yo RN in the hospital where you work. She slipped on a wet floor in a patient’s room and sustained a comminuted and displaced tibial plafond fracture. She was hospitalized for the repair, post-op she developed a fever, after 8 days of diarrhea clostridium difficile was cultured.

Fracture Management Fracture Detection –Cardinal Signs of Inflammation Erythema Swelling Pain Heat Loss of Function (unable to weight bear) –Pain on palpation –Positive Thump Test

Fracture Management Fracture Detection realistically: –Tibial Plafond are normally caused by high energy impacts such as MVAs or falls from heights –Most likely the pt. will be admitted to the ER before coming to PT

Fracture Management Fracture Characteristics: –Tibial plafond is the horizontal weightbearing surface of the distal tibia –Isolated fractures of the medial and lateral malleoli may or may not be present –Plafond is sometimes confused with the tibial pilon which is the supramalleolar portion of the distal tibia –Plafond fractures may or may not extend up into the pilon –Due to the usual mechanism of injury, these fractures are often comminuted and displaced

Fracture Management Images here

Fracture Management Orthopaedic Objectives: –Restoration of articular surface is vital to prevent arthritis and to allow pain-free function –Restore tibial and fibular length to promote normal anatomic alignment and prevent leg length discrepancy –Reconstruction of any connective tissue damage such as the distal tibiofibular syndesmosis

Fracture Management Stabilization Options: –ORIF –External Fixation –Casting –Arthrodesis

Fracture Management ORIF –Primary choice for plafond stabilization, Providing best realignment of articular surfaces greatly improving long-term prognosis (Hoppenfeld, 2000) –Primary healing without callus formation sometimes with the assist of a bone graft –Allows for early motion –A protective cast or splint is used postoperatively

Fracture Management External Fixation –Indicated when soft-tissue injury prevents ORIF –Allows for the care of muscle flaps or skin grafts if necessary –Articular restoration is not as complete as with ORIF –Secondary bone healing with callus formation

Fracture Management Casting –Indicated for non/minimally displaced fractures with little or no impaction –Does not allow for early motion Arthrodesis –Indicated when significant comminution prevents successful ORIF –Treatment of last resort

Fracture Complications Associatied ligamentous and tendonous damage due to typical mechanisms of injury –Often disruption of the ligamentous complex around the ankle joint rendering it unstable. –Unstable ankle joint can lead to abnormal stress and strain on the articular surface of the joint increasing likelyhood for developing arthritis –Predispose person to chronic ankle sprains

Complications Monitor for compartment syndrome especially with closed reduction and casting –Fasciotomies may be required to reduce pressure to prevent ischemia and protect the neuro-vascular structures –Symptoms of compartment syndrome: Monitor for signs of RSD –Signs of RSD

Fracture Rehabilitation Day one to one week –No stability of fracture –Monitor for compartment syndrome and infection of surgical site. With ORIF in particular monitor for sloughing or necrosis of tissue. –With ORIF Pt should be in a well-padded nonconstricting splint that keeps ankle in neutral position. Should be instructed to ice and elevate leg to help control swelling. –All types of stabilization should be non-weight bearing –ORIF may begin AROM of the ankle as tolerated, AROM of the MTP joints and knee joints

Fracture Rehab Days 1-7 Exam –monitor for compartment syndrome, cast fit, and infection of surgical site WB status: all pts should be non-weight bearing ROM –ORIF may begin AROM of the ankle as tolerated, also AROM of the MTPs and knee joint –Cast and external fixation may begin AROM of the MTPs and knee joint Strength –Quad sets as tolerated Functional Activities –Pts should be taught to perform stand-pivot transfers with assistive devices –Crutch training-using non-weight bearing two point gait

Fracture Rehab Days 7-14 Exam –Continue to monitor surgical site, cast fit, and signs of RSD WB –Non-weight bearing due to instability of fracture ROM –ORIF AROM of ankle, knee, and MTPs –Non-rigidly fixed AROM of knee and MTPs Strength –Isometric DF/PF and quad sets for rididly fixed fractures –No strengthening exercises for non-rigidly fixed fractures Functional Activities –Same as days 1-7

Fracture Rehab Wks 4-6 Exam –Monitor for signs of RSD –Pts in long leg-cast will typically have cast for radiographic exam to check status of fracture union. Expect stiffness, decreased ROM and strength WB status/Bone Healing –Fracture is now usually stable with callus formation. Callus is weak especially with torsional forces. –Non-weightbearing ROM –Rigid fixation: same as previous –Non-rigid fixation: add ankle ROM as immobilization devices allow Strength –Rigid fixation: same as previous –Non-rigid fixation: add gentle DF and PF isometrics in cast. No resistive exercises to long flexors or extensors of toes. Continue quad strengthening Functional Activity –Same as previous

Fracture Rehab Wks 6-8 Exam –All fractures should be examined radiographically for loss of reduction and healing status WBing/Bone Healing –Fracture usually stable with bridging callus but torsional strength remains limited –Non/minimally displaced showing good callus formation may begin partial wbing –Those with significant displacement or those with bone grafts should continue strict non- weightbearing ROM –Rigid fixation: AROM in all planes of ankle and subtalar jt –Non rigid fixation: ROM of ankle and knees as immobilization allows. Cont. AROM of MTPS Strength –Rigid fixation: Cont. isometrics to dorsiflexors and plantarflexors. Add knee and hip isometrics as indicated. No resistive exercise to long toe flexors/extensors. Cont. quad isotonic strengthening. –Non Rigid: Cont. isometric dorsiflexion and plantarflexion as allowed by cast. Cont quad strengthening. No resistive exercise to long toe extensors/flexors. Functional Activity –Rigid: Begin 3-point gait with crutches and partial wbing during transfers –Non-rigid: Remain non-wbing

Fracture Rehab Wks 8-12 Exam –Continue monitoring for RSD and surgical site incision Weightbearing/Healing Status –Cont. partial weightbearing as before –With comminuted fractures begin toe-touch weightbearing as tolerated –Bridging callus becoming laminar bone and ligamentous healing across ankle jt should be well established ROM/Strength –Rigid: Aggressive resistive exercise in all planes at the ankle and subtalar jt –Non-rigid: Begin A/PROM and pain-free resistive exercises at the ankle and subtalar jts Functional Activity –Rigid: Progress from partial to full weightbearing –Non-rigid: Partial weightbearing as tolerated

Fracture Healing Long Term Considerations: