Table 1

Surgical intervention, physiotherapy care and X-ray objectives throughout rehabilitation following tibia-fibula fracture

20th January 2018
3-Week post-injury6-Week post-injury12-Week post-injury15-Week post-injury16-Week post- injury28-Week post-injury
Sustained injury to right leg during tackle
Initial Surgical Management of the Gustillo & Anderson Grade 3B open distal tibia and fibular fracture
Initial assessment, stabilisation and intravenous antibiotics in the emergency department
Surgical debridement, washout and ankle spanning external fixation of the fracture (general anaesthetic)<6 hours of injury, as per BOAST four guidelines (2017). A negative pressure vacuum dressing was applied. Intravenous antibiotics were continued until definitive closure and fixation. The limb was elevated and monitored for signs of compartment syndrome
The definitive procedure 48 hours later involving a consultant trauma and a consultant plastic surgeon. This involved a local fasciocutaneous rotation flap and insertion of a locked intramedullary nailing, using a blocking screw to obtain accurate reduction and ensuring compression across the fracture site
Fasciocutaneous flap was used to allow good quality soft tissues on the anterior shin in view of occupation
Aim for early weight-bearing as tolerated to encourage fracture union
2–3 weeks of rest and elevation to reduce swelling and encourage flap healing
Keep leg elevated
Early ROM exercises at knee and ankle
Early muscular contractions as pain allows
X-rays: Perfect reduction, and good apposition of the fracture
No change in metal work positioning
Progression of weight-bearing activity as pain allows
Aim to be free from walking aids by weeks 4–5
At present walks with a limp, if walks unaided >gait re-education work
~Full knee flexion/extension ROM
Large knee effusion
Ankle WBDF=16 cm from the wall. Very stiff ankle joint
Treated with ankle CPM (3 hours a day), joint mobilisations and soft tissue release around the ankle joint
Early weight-bearing exercises in the gym including double-leg hip thrusts, bridges, double-leg calf raises and supported double-leg squats
X-rays: Good, very good reduction and apposition of the fracture surfaces
No change in metal work or signs of worrying features
Some resorption of the anterior fracture line—appears fracture gap already starting to reduce
No obvious periosteal callus formation yet— due to open fracture
Surgeon highlights around a 9–12 month return to full training
Full weight bearing
Requires feedback to correct gait.
Walking drills>progress to running preparation drills
Full knee range of motion
Grade I effusion
Ankle WBDF=8 cm from the wall. Nb. slow improvement
Progressive loading in gym including transition from double-leg to single-leg exercises emphasis on movement control
Adding external resistance as indicated
X-rays: Good, very good reduction and good apposition of the fracture surfaces.
No change in metal work or signs of worrying features
Significant amount of early callus formation, especially medially and laterally to site of injury.
No callus anteriorly, but this was the tension side of the fracture
Gait near normal
Off-loaded cardiovascular conditioning that is, bike
Ankle WBDF=1 cm
(pre-injury WBDF-2cm)
Some complaint of discomfort around the lateral of the 2x proximal locking screw—arrange potential removal of screws in around 4 weeks.
X-Rays: Excellent, more callus formation than 3 weeks ago with anterior gap filling in, the fracture has virtually reunited
Tenderness over the medial locking screws—to be removed
Running on anti-gravity treadmill (60>90% BM; 2–4 min intervals; progression of speed
No pain experienced around the fracture site
Commenced daily exogen over the anterior fracture site to assist healing
Ankle WBDF=4 cm
Due to the continued pain being felt by the player removal of the proximal locking screws (dynamization)
Weight-bear as tolerates
Remove steri-strips in 5–7 days
Avoid pool until wounds have healed
Contact for next X-ray to confirm full union
Re-commence rehab once post-operation pain has settled
X-Rays: Excellent callus formation, fracture has fully radiologically united
No metal work problems
Players 6.5 months and proximal screws removed 3 months ago
No pain reported despite significant increments in rehabilitation
Very good range of motion at both knee and ankle
Progress with aim to resume full training within 3–4 weeks providing progress continues
Surgeon discharge
  • >, progression; BM, body mass; CPM, continuous passive motion; ROM, range of motion; WBDF, weight-bearing dorsiflexion.