physiotherapy in non union and malunion fracture cases

[minoshkapereira]

i am treating two cases in ortho one is a non union fracture case of intertrochanteric fracture femur and the other a malunion case of the same....the malunion case has incomplete callus formation on xray....what physiotherapy programme and precautions should i take in both cases

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[Dr Damien]

Dear Minoshkapereira

Shouldnt these patients be reviewed by the orthopedic surgeons? your physiotherapy input really can make things worse...these patients will be in pain probably...why have they been sent for physiotherapy without an orthopedic review...

I would generally just ensure that the patients transfers are safe, that they have the right walking aid if they are allowed to bear any weight...

I dont see what else you can or should be doing without risking making things worse....

[yelufem]

physio surely has a big role to play in fracture nonunion.A nonunion of trochanteric fracture usually throw some challenges.Physio manage fracture nonunion by delivering progressive and guided longitudinal pressure to the fracture plane.this procedure usually stimulates callus formation.But delayed trochanteric fracture of the femor may throw a big risk with this method without paying adequate attention to some things .I want to take it that the fracture was reduced with a knail ,a screw or ziklag wire depending on the surgeon discretion and the pattern of the fracture with some other things been equal.If physio must facilitate calus formation by partial weight bearing,the weight is transmitted longitudinal along gravitational axis parallel to the trochanteric fracture plane.one would be doing more damage and aggravating the problem.
Giving the info given by u which are not detailed enough,i guess u communicate well with the surgeon for a review.If the fracture site is well secured with wire, an open chain exercise of the affected limb could make a difference.If the surgeon consiider a full leg cast, a patial wt bearing on parallel bar in a progresive manner could stimulate a dramatic improvement.
Pls u can get me informed about your decision on this interesting case.yelufem

[Dr Damien]

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....

[yelufem]

Dr Damien,
I think my post on the subject matter was not affirmative.I also stressed the need for communication with the referring surgeon on the condition at hand.U could see that i also raised concern at the risk involved in managing a nonunion trochanteric fracture of the femur b/c of its anatomical position in relation to the line of body gravity.U got it that fracture may not unite due to many reasons (infection,nutrition,malalignment etc) secondarily there may not be a clear course for such delay.There may not be infection or nutitional deficiency and good alignment yet the fracture refuse to unite.This is very common and many surgeon find solace in physio.We got a case in our clinic few months ago referred as a case of delayed bilateral fracture of both tibial fibula in an undergraduate.We successfuly managed it with progressive weight bearing progm stabilising one of the limb with a KAFO.Progress in calus formation was monitored bimonthly and we had a resounding success.In this case there was no clear reason for the delay.
So,i guess we are on thesame slate of reasoning on this matter.U are welcome, love to read from u soon.yelufem.