Dear Yeluflem and Minoshkapereira

Im finding the reasoning here interesting...I personally will not rehabilitate this patient until the orthopedic surgeons have reviewed in both cases. The first thing that comes to my mind is why? why are these fractures not uniting or why are these fractures mal-uniting...

I appreciate yeluflems view about stimulating callus formation by weight bearing and yes, physiotherapy has a role to play when cause and effect has been properly identified...however if you do not know the reason why this is happening you are definitely going to make things worse either with your exercises and/or weight bearing. a non uniting fracture is a fracture non the less...it should be treated as one...like Yeluflem has said...be well secured (immobilization), then weight bearing as pain will allow...if this is not happening, is there an infection? are the nails/screws loose? have the wrong sized nails/screws/ is the prosthesis the right size? is there another fracture somewhere else throwing the uniting ends out of alignment? is there a missed bone disease? is there soft tissue logded in between?

once you do not know why...movement can potentially through things seriously out of alignment....I personally will advocate static exercises at the best, even this can throw ends out of alignment if not properly stabilized....again only the orthopedic surgeon can guide you...if they cannot secure fracture ends properly/stabilize it for you to be able to guide it through a healing process, dont think you can make a difference to how this fracture will unite until you know why...remember that in non union cases...the fracture ends begin to close up as new bone cells are formed....if this has already happened, no union will ever take place...the surgeons need to be fully involved here....

with the mal uniting fracture...again...why? why has this happened? how strong is this callus...with this client, the prognosis looks better because there is at least some union...you can guide this through healing and your progressive weight bearing exercises...what you might end up having is some issues with function at vthe end of the day...

sometimes carrying out a revision may be needed but the prognosis always lowers each time this is done...

there are so many factors to consider in any of these cases, patient age, level of function prior to surgery, previous surgeries/revision in that area, strength of bones,

I have just seen a patient who was discharged home after an IM nail and advised to weight bear from the hospital...the ends of the bones didnt unite, a new fracture occured now the surgeons are not sure what they want to do...this is the problem with progressive weight bearing when surgical procedures are not optimal...

my advise get the surgeons involved fully...at least know why this is happening then you can make a reasonable/justifiable clinical decision....