- (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, 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.D.
- (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, 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.D.
- (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, 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.D.
- 骨折康复运动原则
- 作者:陈华|发布时间:2012-10-15|浏览量:1724次
Fracture Treatment Protocols
Table 1. Upper Extremity | ||||
Fracture 北京301医院骨科陈华 |
X-rays Needed |
Immobilization |
Fixation |
Mobility Precautions |
Scapula |
|
|
|
|
scapular body acromion process coracoid process glenoid neck glenoid fossa |
AP/axillary/scapular shoulder | sling | screws reconstruction plates tubular plates mini T-plates |
Stable: WBAT Unstable: protected weight-bearing 2-3 months no deltoid isometrics until 6 weeks post stabilization |
Clavicle | ||||
displaced
|
AP/axillary Shoulder |
Sling or Figure of 8 Strap |
reconstruction plates
|
Stable: WBAT
Unstable: PWB-NWB 6-8 weeks postinjury sling, figure 8 immobilization as fracture/patient status dictates |
nondisplaced | dynamic compression plate (DCP) | |||
Humerus | ||||
1. Proximal fractures greater tuberosity lesser tuberosity surgical neck anatomic neck |
AP/axillary Shoulder AP/Lat Humerus |
Coaptation Splint vs.Sling | plate wires (tension-band, K-wire) 2.5-mm Schanz pins screws external fixation hemiarthroplasty (elderly patient) |
NWB 8-12 weeks sling, Neer protocol (circumduction, passive abduction & forward flexion, > 4weeks then aarom) |
2. Humeral shaft | AP/Lat Humerus | Coaptation Splint | DCP locked IM nail |
NWB-WBAT as fracture pattern dictates |
3. Distal humerus | AP/Lat Elbow AP/Lat Humerus |
Posterior Elbow Splint | reconstruction plates tubular plates screws tension-band wire for olecranon osteotomy |
NWB 8-12 weeks Aarom as soon as soft tissues allow |
Radius and Ulna | ||||
1. Olecranon | AP/Lat Elbow AP/Lat Forearm |
Posterior Elbow Splint | tension-band wiring screw, wire fixation | Aarom as soon as soft tissues allow NWB |
2. Radial head | AP/Lat Elbow AP/Lar Forearm |
Posterior Elbow Splint | closed reduction mini-fragment screws mini T-plates |
Aarom as soon as soft tissues allow NWB |
3. Forearm isolated radius, ulna ? both bones |
AP/Lat Forearm | Sugar Tong Splint | closed reduction plates screws (rare) IM nail (rare) |
Aarom as soon as soft tissues allow NWB 8-12 weeks |
Monteggia/Glaeazzi | AP/Lat Forearm | Sugar Tong Splint | ||
4. Distal radius |
AP/Lat Forearm |
Sugar Tong Splint |
closed reduction external fixation ORIF |
Aarom as soon as soft tissues allow NWB 8-12 weeks |
Wrist & Hand | ||||
carpal | AP/Lat Hand | Dorsal-Volar Splint | closed reduction wires mini-plates |
cast, splint immobilization NWB-PWB 8-12 weeks |
MC | AP/Lat Hand & Fingers | Buddy Tape | ||
phalanx |
|
|
|
|
Terminology:
|
Fracture |
Initial Physical Therapy Program |
Advanced Physical Therapy** |
Scapula | ||
scapular body |
Days 1-5: shoulder pendulum exercises elbow, forearm; wrist, hand AROM; grip strengthening Weeks 2-3: gentle PROM-AAROM shoulder; deltoid, rotator cuff isometrics If stable fracture pattern- shoulder PROM-AAROM initiated 1 week postinjury, ROM, strengthening progressed to tolerance |
Stable: PROM/strengthening as tolerated Unstable: strengthening at 3 months; progress to isometrics, surgical tubing, and free weights |
Clavicle | ||
displaced nondisplaced |
Stable Day 1 post-stabilization: early shoulder AROM-AAROM to tolerance; shoulder isometrics; elbow, forearm, wrist, hand AROM; grip strengthening Unstable: limit ROM as fracture pattern dictates |
Stable: PROM/strengthening as tolerated
Unstable: strengthening at 6-8 weeks; return to activity in 10-12 weeks |
Humerus | ||
1. Proximal fractures |
Day 1 post-stabilization: elbow, forearm, wrist, hand AROM; grip strengthening Days 2-5: pendulum shoulder exercises Weeks 1-3: early gentle AAROM shoulder joint within mobility limitations; deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder |
Week 12: begin strengthening; progress to isometrics, surgical tubing, free weights, isokinetics; scapular stabilization exercises are important |
2. Humeral shaft |
Day 1 post-stabilization: elbow, forearm, wrist, hand AROM grip strengthening Days 2-5: Pendulum shoulder exercises Weeks 1-3: Early gentle AAROM shoulder joint within mobility limitations: deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder |
Weeks 10-12: strengthening Week 12: progression the same as for the proximal humerus |
3. Distal humerus |
Day 1 post-stabilization: shoulder AAROM-AROM; wrist, hand active range of motion-CPM (elbow) as M.D. indicates Days 2-5: gentle elbow, forearm AROM; deltoid isometrics; grip strengthening Weeks 8-10: gentle PROM-AAROM elbow, forearm |
Weeks 10-12: strengthening Week 12: isokinetics |
Radius & Ulna | ||
3. Olecranon | Days 1-7 post -stabilization: early gentle AAROM-AROM forearm, elbow (initiated after 2-3 days); shoulder, wrist, hand AROM; grip strengthening | Weeks 10-12: PROM; strengthening |
4. Radial head | Days 1-7 post-stabilization: early elbow AROM shoulder, wrist, hand AROM; grip strengthening |
Weeks 10-12: PROM;strengthening |
3. Forearm isolated radius, ulna ? both bones Monteggia/Glaeazzi |
Days 1-5 post-stabilization: immediate shoulder, hand AROM; early, gentle AAROM forearm, elbow, wrist as fracture stability allows; grip strengthening |
Weeks 10-12: PROM Week 12: strengthening |
4. Distal radius |
Days 1-5 post-stabilization: immediate AROM shoulder, elbow, fingers; initiation of gentle wrist AROM as immobilization allows (after cast removal than splint); grip strengthening |
Weeks 8-10: PROM; light activity Weeks 10-12: strengthening |
Wrist & Hand | ||
carpal MC phalanx |
Days 1-5 post stabilization: early AROM-AAROM fingers, wrist, forearm as fracture and stabilization allow; elbow, shoulder AROM; fine motor control, desensitization; techniques as indicated |
Weeks 8-10: PROM; light activity Weeks 10-12: strengthening |
6. (WBAT) Weight-bearing as tolerated ? patient may bear weight through extremity as tolerated 7. (TKE) Terminal knee extension ? short-arc quadriceps strengthening exercises 8. (SLR) Straight leg raises ? isometric strengthening exercises with hip flexion *Post-stabilization to healing **After fracture healing |
Table Two: Lower Extremity: Acetabulum to Femur | ||||
Fracture |
X-Rays Needed |
Immobilization |
Fixation |
Mobility Precautions |
Acetabulum | ||||
Posterior wall; posterior columns; anterior wall; anterior column; transverse; T-shaped; posterior column/posterior wall; transverse/posterior wall; both column; anterior column with posterior hemitransverse (Letournel classification) |
AP Pelvis Judet Views CT San (3mm Cuts) |
Distal Femoral Traction |
Lag screws reconstruction plates |
Kocher-Langenbeck approach: (posterior), avoid active hip extension rotation Ilionguinal approach: (anterior), avoid active hip flexion, vigorous trunk and abdominal flexion Extended iliofemoral approach: (posterolateral), no active hip abduction 6-8 weeks; weight-bearing; NWB 8-12 weeks; positioning ROM; posterior wall involvement ? no hip flexion greater than 70 degrees for 6 weeks |
Pelvis | ||||
1. Anterior ring 2. Posterior Ring Sacrum |
AP, inlet & outlet Pelvis, CT scan |
See pelvic fracture disruption protocol |
plating screws |
TDWB-WBAT 10-12 weeks postinjury (depends on associated, posterior ring involvement) TDWB-WOLWB 10-12 weeks |
Femur | ||||
1. Femoral head | AP Pelvis AP/Lat hip | Distal Femoral Traction | Screw fixation hemiarthroplasty THA (in elderly patient as fracture dictates) | Toe-touch weight-bearing 8-12 weeks no straight leg raises (SLR) TTWB, WBAT dependent on prosthesis fixation (see femoral neck fracture) |
2. Femoral neck | AP Pelvis AP/Lat both hips (uninjured side with templeates) |
Buck’s Traction | screws dynamic hip screw endoprosthesis (elderly) |
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. Allow flexion, extension, abduction, adduction or rotation in cardinal planes of motion with no restriction; no SLR 6 weeks Posterior surgical approach: no hip flexion greater than 60 degrees, avoid hip adduction, internal rotation past neutral; no SLR 6-8 weeks |
3. Interochanteric femur |
AP Pelvis AP/Lat hip |
Buck’s Traction or Pillow Splints |
DHS or IM nail |
WB as neccessary for balance for ambulation on walker or crutches |
4. Subtrochanteric femur | AP Pelvis AP/Lat Femur |
Distal Femoral Traction | DHS Blade plate IM nail |
TTWB; no SLR; no active hip abduction with blade-plate fixation |
5. Femoral shaft | AP/Lat Femur AP/Lat Knee AP Pelvis If severely comminuted get scanogram opposite femur |
Distal Femoral or proximal tibilal Traction | IM nail | Interlocked nail/plate TTWB 6-8 weeks |
6. Supracondylar, intracondylar femur |
AP/Lat Femur AP/Lat Knee AP Pelvis |
Knee Immobilizer |
DCP, LC, DCP condylar blade plate; condylar buttress plate; screws |
Note: Knee immobilizer, external support may be needed To allow early crutch training if quad control slowly achieved; DCP fixation same as IM nail protocol TDWB 10-12 weeks |
Terminology:
|
Fracture | X-rays Needed | Immobilization | Fixation | Mobility Precautions |
Patella | ||||
Nondisplaced | AP/Lat Knee | knee immobilizer | cylinder cast, | Stable: WBAT |
displaced |
|
|
lag screw (s) |
Unstable: TTWB 4-8 weeks |
Tibia | ||||
1. Tibial plateau | AP/Lat Knee CT Scan |
knee immobilizer | buttress T-plate DCP screws |
TDWB 8-12 weeks NO TKE exercise (avoid excessive end range anterior tibial glide) |
2. Tibial Shaft |
AP/Lat tibia |
Cadillac Splint |
IM nail reamed and unreamed; plates and screws; external fixator |
PWB 6-8 weeks TDWB 8-12 weeks PWB 6-8 weeks |
Ankle | ||||
1. Pilon | AP/Lat Ankle Mortise View AP/Lat Tibia |
Cadillac Splint Calacneal Traction |
screws and plates | NWB 12 weeks |
2. Medial malleolus, posterior malleolus, lateral malleolus |
AP/Lat Ankle Mortise View |
Cadillac Splint |
screws, plates, and tension-band wiring |
PWB 8-12 weeks |
Foot | ||||
1. Calcaneus extraarticular intraarticular | Lat Foot Oblique Foot Harris Heel View CT Scan (3mm Cuts) |
Cadillac Splint |
Reconstruction plate H-plate; lag screw K-wires |
NWB 12 weeks |
2. Talus | Lat Foot |
Cadillac Splint with toe plate |
lag screws or K-wires (rare) |
NWB 12 weeks |
3 . Metatarsals and phalanx |
Oblique Foot AP/Lat & oblique Foot |
Cadillac Splint with toe plate |
screws, wires, and pins |
closed reduction immobilization |
Terminology: 6. (WBAT) Weight-bearing as tolerated ? patient may bear weight through extremity as tolerated 7. (TKE) Terminal knee extension ? short-arc quadriceps strengthening exercise |
Fracture |
Initial Physical Therapy Program |
Advanced Physical Therapy** |
Patella | ||
Nondisplaced;
displaced |
Days 1: bilateral UE strengthening; ankle AROM; knee CPM post-op if indicated Days 2 to discharge: quad hamstring isometrics***; knee/AROM as fracture pattern allows***; SLR*** |
Weeks 4-8 : strengthening; progress knee A/AAROM; begin quad Isometrics and SLR if there was quad mechanism involvement Week 8: WBAT, wean from crutches; concentrate on short arc/end range; quadriceps strengthening; closed kinetic chain activities (i.e., cycling, partial squats, leg press); balance proprioceptive training |
Tibia | ||
1. Tibial plateau 2. Tibial Shaft |
Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training |
Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training |
Ankle | ||
1. Pilon 2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C) |
Immediate post-stabilization: bilateral UE strengthening; gluteal, quad, hamstring isometrics Day 2 to discharge: hip, knee toe AROM; SLR, TKE Week 2: ankle subtalar AROM; progressive hip and knee strengthening same as pilon fracture |
Week 12: PROM initiated; strengthening; balance/proprioceptive awareness training; WBAT, wean from crutches; closed kinetic chain program Weeks 8-10: gait progression after fracture healing; AROM/PROM ankle and subtalar joints; balance/proprioceptive awareness training |
Foot | ||
1. Calcaneus extraarticular intraarticular 2. Talus 3 . Metatarsals and phalanx |
Preoperative: UE strengthening; uninvolved extremity strengthening Involved extremity hip, knee isometrics; crutch training for short distance (primary elevation of extremity) Day 1: UE strengthening; uninvolved extremity AROM strengthening involved extremity hip- knee isometrics; AROM, Toe AROM to tolerance Days 2-3: crutch training, NWB involved extremity (limited time in dependent position) Days 4-7: early ankle, subtalar AROM when surgical incision is sealed Week 1 to month 3: continue early AROM ankle, subtalar, toes; gentle PROM toe dorsiflexion and plantarflexion; progress involved extremity; hip-knee conditioning Same as calcaneus Day 1 post-stabilization: biliateral UE strengthening; hip, knee AROM, isometrics; ankle, subtalar, toe AROM as fracture pattern allows |
Month 3: gradually increase weight-bearing starting at 20lbs to FWB over 1 mo; gradually wean from assistive devise as patient tolerates; pool therapy if available; gait training, re-education; desensitization techniques as needed; ankle subtalar AAROM isometrics; low impact endurance training Months 4-6: gait progression, advanced balance and proprioceptive activities; ankle, subtalar isometric, isotonic strengthening with tubing/theraband; no free weights; soft-tissue immobilization Month 6: ankle, subtalar PROM; joint mobilization; isokinetic assessment, strength-endurance training; advanced balance, gait training as indicated Same as calcaneus Weeks 8-12: WBAT; wean from crutches; proprioceptive/balance training;; closed kinetic chain activities |
8. (SLR) Straight leg raises ? isometric strengthening exercises with hip flexion 9. (UE) Upper extremity 10. (LE) Lower extremity *Post-stabilization to healing **After fracture healing ***Note: No active quads if quadriceps mechanisms involved or disrupted |