Surgical intervention, physiotherapy care and X-ray objectives throughout rehabilitation following tibia-fibula fracture
| Injury 20th January 2018 | 3-Week post-injury | 6-Week post-injury | 12-Week post-injury | 15-Week post-injury | 16-Week post- injury | 28-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.