Post op rehab

Post operative rehab after orthosurgery from campbel

1. Orthopaedic Postoperative care Dr. Md. Mahbub Hasan Resident, D- ortho , SZMC

2. 1. FIXATION OF THE MEDIAL MALLEOLUS 2. FIXATION OF THE LATERAL MALLEOLUS 3. FIXATION OF POSTERIOR MALLEOLAR FRACTURE 4. FIXATION OF ANTERIOR TIBIAL MARGIN FRACTURES Posterior plaster splint in neutral position and elevated. 1 st POD - replaced with a removable splint or fracture boot. - Range of motion exercises are begun. Weight bearing is restricted for 6 weeks, - after which partial weight bearing if healing progress. Otherwise - the fracture must be protected longer. - apply short leg cast. - not allowed to bear weight on the ankle until fracture healing is progressing well (8 to 12 weeks). - A short leg walking boot is worn, and weight bearing is progressed.

3. STABILIZATION OF UNSTABLE ANKLE FRACTURE-DISLOCATION The cast is removed at 4 to 6 weeks , and a short cast is applied. The pin is removed at 4 to 8 weeks (depends*) Weight bearing is not allowed until the pin has been removed, and then only as healing progresses.

4. MINIMALLY INVASIVE PLATING OF TIBIAL PILON FRACTURE Splint. drains removed on 1 st -2 nd POD. (depends*) Passive and active ROM exercises initiate. Sutures are removed between 2 to 3 weeks Full weight bearing is not permitted until full bony healing is confirmed radiographically , usually by 12 weeks .

5. POSTEROLATERAL APPROACH TO PILON FRACTURES The leg is splinted and elevated for 48 hours. Early ankle motion is encouraged with physical therapy once the wound permits and sutures have been removed. Weight bearing begins at 12 weeks when radiographs permit .

6. SPANNING EXTERNAL FIXATION OF TIBIAL PILON FRACTURE (BONAR AND MARSH) The limb is kept elevated kept non–weight bearing not allowed to bear more than 20 kg of weight during the first 6 weeks. The external fixator is dynamized (the locking nut is released to allow sliding of the telescoping body) at 4 to 12 weeks , weight bearing is increased. The fixator is removed with evidence and pain Ankle joint motion is begun when soft-tissue conditions permit, usually at 1 to 2 weeks . An Orthoplast (Johnson & Johnson, New Brunswick, NJ) splint is worn to maintain the ankle in neutral except during range-of-motion exercises.

7. RING EXTERNAL FIXATION OF TIBIAL PILON FRACTURES WATSON maintaining distraction across the ankle for 6 weeks. When tentative healing has occurred at the joint line, the foot frame or calcaneal pin is removed in an outpatient procedure . Physical therapy is begun Total non–weight bearing is maintained ( AO type C3) fractures. In fractures with shaft extension, tentative weight bearing is begun usually at 8 to 10 weeks . Progressive weight bearing is begun, and by 12 to 14 weeks the patient usually is ambulatory with the aid of one crutch or a cane

8. INTRAMEDULLARY NAILING OF TIBIAL SHAFT FRACTURES placed in a removable splint, and early range-of-motion exercises are begun. patellar tendon bearing brace or orthosis – if Noncompliant/ unstable Unrestricted weight bearing is permitted in axial stable patterns (i.e., transverse diaphyseal ). Weight bearing is restricted until early callus occurs (4 to 6 weeks) without axial stability and those at the proximal or distal metadiaphyseal junction. Nail removal usually is delayed until at least 12 to 18 months after injury,

9. EXTERNAL FIXATION FOR TIBIAL SHAFT FRACTURES Pin site care is started daily using a diluted hydrogen peroxide solution or antibacterial soap and water. Pin sites are inspected to ensure that they are tight. A removable splint is used to prevent equinus, with definitive fixation performed later

10. OPEN REDUCTION AND FIXATION OF A LATERAL TIBIAL PLATEAU FRACTURE Removable knee immobilizer. 1 st – 2 nd POD - Physical therapy is initiated with quadriceps exercises and gentle active-assisted exercises are begun, or a passive motion machine can be used. Crutch walking is begun , but no weight bearing is permitted for 10 to 12 weeks

11. OPEN REDUCTION AND INTERNAL FIXATION OF BICONDYLAR INJURIES Following drain removal, active and active assisted exercises, including controlled passive motion, are instituted . Weight bearing is not permitted for 10 to 12 weeks postoperatively.

12. CIRCUMFERENTIAL WIRE LOOP FIXATION - PATELLA A posterior splint from groin to ankle. quadriceps-setting exercises and within a few days should be lifting the leg off the bed. At 10 to 14 days , the sutures are removed and a cylinder cast or knee immobilizer is applied with the knee in extension. The patient is allowed to be ambulatory, using crutches when active muscular control of the leg has been obtained. In transverse fractures, the immobilization can be removed at 3 weeks and gentle active and active-assisted exercises are begun. As muscle power returns, the crutches are discarded , usually at 6 to 8 weeks. After fracture union, the wire should be removed in most instances; if not, it eventually may break, become painful, and be difficult to remove .

13. TENSION BAND WIRING FIXATION The limb is placed in extension in a posterior plaster splint or removable knee brace. 1 st POD - ambulate while bearing weight as tolerated 1 st POD - Isometric and stiff-leg exercises at 2 to 3 weeks - Active range-of-motion exercises at 6 to 8 weeks - Progressive resistance exercises + brace discontinued at 18 to 24 weeks - Unrestricted activity

14. less stable fixation or extensive retinacular tears, active motion should be delayed until fracture healing has occurred. Initiating range-of-motion exercises by the sixth postoperative week is desirable but not always possible. A controlled motion knee brace can be used, allowing full extension and flexion to the degree permitted by the fixation as determined intraoperatively . If fixation is lost and the fragments separate 3 to 4 mm, or 2 to 3 mm of articular incongruity is present, revision surgery may be required. If the reduction improves with the knee in full extension, the patient can be treated by 6 weeks of splinting or casting with the knee in full extension . If the reduction does not improve, revision fixation or partial patellectomy should be considered . Hardware can be removed after healing of the fracture if it causes symptoms

15. FRACTURE FIXATION OF THE MEDIAL CONDYLE FEMUR Removable long-leg splint or a bulky soft dressing with light compression wrap and knee immobilizer. Continuous passive motion can be initiated immediately after surgery if desired. Gentle active and active-assisted exercises are begun when swelling subsides. 2 nd – 3 rd POD - Ambulation with a walker or crutches allowing only touch-down Range of motion exercises and quadriceps and hamstring exercises - gradually . 8 to 10 weeks - partial weight bearing can be allowed at If * By 12 to 14 weeks - gradually progressed to full weight bearing.

16. SUBMUSCULAR MINIMALLY INVASIVE LOCKING CONDYLAR PLATE Early passive motion with some active motion is begun as tolerated. Focus also is placed on passive extension exercises to minimize contracture formation. Weight bearing is avoided for 10 to 12 weeks. Active and passive range of motion should be encouraged during this time

17. PLATE AND SCREW FIXATION OF FEMORAL SHAFT FRACTURES Patients are allowed to sit on the day of surgery. Drains are left in place for 24 to 48 hours . Patients are allowed touch-down weight bearing encouraged to perform passive and active range-of-motion exercises of the knee. Strengthening exercises are delayed until acute postoperative symptoms improve union is progressing radiographically , partial weight bearing for 1 month is allowed and aggressive strengthening exercises are begun. Unrestricted weight bearing is then permitted

18. ANTEGRADE FEMORAL NAILING Touch down or partial weight bearing is allowed in comminuted injuries. Hip and knee range of motion are encouraged. Quadriceps setting and straight-leg raising exercises are begun before hospital discharge. Hip abduction exercises are begun after wound healing. Weight bearing is progressed as callus formation occurs. Ambulatory aids such as crutches or a walker are used for the first 6 weeks. Hip and knee range-of-motion and strengthening exercises are recommended during this time. Unassisted ambulation is permitted as strength recovery and radiographic healing progress

19. RETROGRADE FEMORAL NAILING knee immobilizer. stable fixation – continuous passive motion program in the first 24 to 48 hours after surgery . Fractures with less secure fixation may require hinged bracing. Initial weight bearing depends on fracture stability after fixation. Patients with intercondylar fractures or supracondylar fractures require protected weight bearing until radiographic progression permits advancement of weight bearing (usually between 10 and 12 weeks).

20. FIXATION OF FEMORAL NECK FRACTURE WITH CANNULATED SCREWS OPEN REDUCTION AND INTERNAL FIXATION Touch-down (weight of leg) weight bearing for 10 to 12 weeks. Older patients are allowed protected weight bearing with a walker if their balance and other medical comorbidities allow . Patients who cannot safely ambulate are encouraged to mobilize to a chair to minimize pulmonary complications .

21. COMPRESSION HIP SCREW FIXATION OF INTERTROCHANTERIC FEMORAL FRACTURES allowed to bear weight as tolerated INTRAMEDULLARY NAILING OF INTERTROCHANTERIC FEMORAL FRACTURES allowed to bear weight as tolerated INTRAMEDULLARY NAILING OF SUBTROCHANTERIC FEMORAL FRACTURES allowed touch-down weight bearing for the first 6 weeks and advanced based on healing

22. FIXATION OF SUBTROCHANTERIC FEMORAL FRACTURE WITH A PROXIMAL FEMORAL LOCKING PLATE Touch-down weight bearing is allowed for the first 6 weeks and is advanced based on evidence of healing

23. OPEN REDUCTION OF POSTERIOR HIP DISLOCATION THROUGH A POSTERIOR APPROACH weight bearing is allowed as tolerated on crutches , instructed in posterior hip precautions and follow these for at least 6 weeks. Patients are followed closely for the first 2 years because of osteonecrosis

24. FIXATION OF COMMINUTED POSTERIOR WALL FRACTURE WITH OR WITHOUT A TRANSVERSE COMPONENT Weight-bearing is limited for 8 to 12 weeks. TOTAL HIP REPLACEMENT WITH ANT. WALL FRACTRURE FIXATION Physical therapy is begun on the first postoperative day and patients stand with assistance. Patients are instructed to limit their weight-bearing to 30 pounds for 8 weeks while standing. No dislocation precautions are imposed

25. OPEN REDUCTION AND INTERNAL FIXATION OF CLAVICULAR FRACTURES sling for comfort. Pendulum and Codman exercises avoid heavy lifting, pushing, or pulling . Full return of activities is allowed when fracture healing is present, usually at 2 to 3 months

26. NTRAMEDULLARY FIXATION WITH A HEADED, DISTALLY THREADED PIN (ROCKWOOD CLAVICLE PIN) sling for comfort, and gentle pendulum exercises At 10 to 14 days, sutures are removed - sling is discontinued; unrestricted range-of-motion exercises, but no strengthening, resisted exercises, or sports activities, are allowed. If radiographs at 6 weeks show union, resisted and strengthening activities are begun. Contact sports (e.g ., football , hockey) should be avoided for 12 weeks after surgery . If the fracture is healed at 12 weeks, the pin can be removed

27. INTRAMEDULLARY NAILING OF A PROXIMAL HUMERAL FRACTURE Early rehabilitation is begun with active-assisted range- ofmotion exercises PLATING for HUMERUS Postoperatively, range of motion of the shoulder and elbow is begun within the first week and weight bearing usually is allowed if fixation is stable.

28. DISTAL HUMERUS THROUGH OLECRANON OSTEOTOMY The elbow is splinted in extension . The drain is removed 2 days after surgery, range of motion is begun 3 days after surgery. No bracing is used.

29. OPEN REDUCTION AND INTERNAL FIXATION OF RADIAL HEAD FRACTURE The arm is placed in a molded posterior plaster splint at 90 degrees. At 3 to 7 days, the splint is removed and the arm is supported in a sling. At about that time, active and active-assisted exercises are begun . The patient should discontinue the sling at 3 weeks , gradually increasing the exercises as tolerated . Forceful manipulation of the elbow is never permitted

30. STABILIZATION OF “TERRIBLE TRIAD” ELBOW FRACTURE-DISLOCATION The splint is left in place for 1 to 10 days, depends* Range of motion exercises are started on 1 st POD Active and active-assisted exercises are allowed Full forearm rotation is allowed with the elbow flexed 90 degrees. Unrestricted shoulder and wrist exercises are encouraged. Typically , patients should avoid the terminal 30 degrees of extension (the most unstable position ) for 4 weeks

31. OPEN REDUCTION AND INTERNAL FIXATION OF OLECRANON FRACTURE The splint is worn for 2 to 5 days ; if the elbow is stable, protected range-of-motion exercises are begun and advanced as tolerated

32. OPEN REDUCTION AND INTERNAL FIXATION OF BOTH-BONE FOREARM FRACTURES Typically, only a soft dressing is necessary . Splinting is used if the elbow or wrist joint is involved or if fixation is questionable. Range-of-motion exercises are begun 3 to 7 days after surgery ; heavy lifting is avoided until fracture healing is evident.

33. CLOSED REDUCTION AND PERCUTANEOUS PINNING OF DISTAL RADIAL FRACTURE The splint is worn for 2 weeks then a soft arm cast is applied. The cast and pins are removed at between 5 and 6 weeks Supervised hand therapy is begun, including wound care and 1 to 2 weeks of splinting. As edema and pain decrease, active and active-assisted range-of-motion exercises are begun. Functional use and activities are strongly encouraged by 8 to 10 weeks after surgery

34. EXTERNAL FIXATION OF FRACTURE OF THE DISTAL RADIUS a sugar-tong splint for 10 days Ex-fix removed at 6 weeks; any supplemental pins are kept in place for 8 weeks. Active and passive finger motion is begun as soon as the anesthesia wears off Supination and pronation of the forearm are begun at the first postoperative visit. Supervised hand therapy is recommended for patients who are unwilling or unable to mobilize their fingers and forearm independently

35. VOLAR PLATE FIXATION OF FRACTURE OF THE DISTAL RADIUS At 1 week, the sutures are removed and active wrist motion is begun A removable Orthoplast splint is worn for 6 weeks . Home therapy