Case Report: Standard rehabilitation protocol for complex tibial plateau fracture associated with fibular head fracture managed with plate osteosynthesis

Introduction

The primary long bone in the lower leg is termed the tibia. It is referred to as the “shin bone” and can easily be felt sliding down the anterior (front) of the shin between the knee and the ankle. Located laterally to the tibia, the fibula is a shorter long bone that aids in ankle rotation and stability. The tibia is the longest bone that is most likely to fracture out of all the bones in the lower extremity.¹ There are many different morphological presentations of tibial plateau fractures, and several categorization schemes have been suggested to reflect this variance.² Fractures of the tibia that occur close to the articular surface are referred to as tibial plateau fractures. The prevalence of these fractures comprises around 1.2 percent of all fractures and is often higher among young individuals who have had high-energy trauma.³ Most older people who have had low-energy trauma are also affected by them.³ According to the Schatzker classification, there are six different types of tibial plateau fractures: lateral plateau fractures without depression (type I), lateral plateau fractures with depression (type II), compression fractures of the lateral or central plateaus (type IIIA or IIIB), medial plateau fractures (type IV), bicondylar plateau fractures (type V), and plateau fractures with diaphyseal discontinuity (type VI).⁴ The fibula is one of the most often fractured long bones, mostly as a result of its anatomical location and function. Fibular fractures frequently occur with tibial fractures as a result of a high-energy pattern of damage.⁵ Post-operative physiotherapy rehabilitation shows beneficial improvement in pain score, mobility activity, range of motion, increased muscle strength, gait pattern, and activities of daily living, etc.⁶ This case report describes a complex Schatzker type 6 proximal tibial fracture with the head of a fibula fracture right side following a road traffic accident who underwent surgical intervention and subsequently underwent physiotherapy rehabilitation. This article is reported in line with CARE guidelines.¹⁰

Case report

Clinical examination

Proper informed consent was taken from the patient prior. Physical examination was done in the supine position. On inspection and palpation, scar marks (Figure 1A and 1B) were present on the anteromedial and anterolateral aspects of the proximal tibial and fibular regions. The scar was hyperpigmented, vascularity was intact. Shiny skin was present along the course of the tibial shin. An 8 cm long scar was present on the anterior-medial aspect of and a 6 cm long scar mark on the anterolateral aspect of the proximal leg. There was obliteration of the hollowing which was present at the medial and lateral edge of the patella. Diffused swelling was present in the knee joint, which was extending beyond the limit of the joint cavity. Wasting and loss of the bulk of quadriceps muscle as compared to non-affected limb which was confirmed on girth measurement. Grade 2 tenderness was present: over the inferior pole of the patella, tibial tuberosity, along the tibial shin proximal to distal. All sensation and reflexes were intact. There was no limb length discrepancy. Manual muscle testing is shown in Figure 2.

Figure 1. Shows the scar mark.

(A): Scar mark on the anterolateral aspect of proximal leg. (B): Scar mark on the posterolateral aspect of proximal leg.

Figure 2. Manual muscle testing of lower limb muscles.

Timeline

The timeline of the event is mentioned in Figure 3 which shows the sequence of events from when the patient was admitted to the hospital till the start of the rehabilitation.

Figure 3. Timeline of the events.

Diagnostic assessment

The radiological evaluation indicates a pre-operative computed tomography scan, as illustrated in Figure 4A and 4B, which revealed a right-sided Schatzker type 6 proximal tibial fracture with fibular head fracture. The patient underwent surgical intervention open reduction and internal fixation with plate osteosynthesis for proximal tibial fracture right side mentioned in Figure 5A and 5B.

Figure 4. Pre-operative computerized tomography scan which shows the Schatzker type six fracture.

(A): Shows tibial plateau and fibular fracture in anterior aspect of knee joint. (B): Shows tibial plateau and fibular fracture in posterior aspect of knee joint.

Figure 5. Post-operative x-ray of knee joint which shows fracture fixed with plate osteosynthesis mention.

(A): Antero-posterior view. (B): Lateral view.

Therapeutic intervention

Physical therapy intervention is essential in the restoration and functional activities of patients with Schatzker type 6 fractures, which usually requires a multidisciplinary approach. Tables 1 and 2 show some broad ideas and elements of rehabilitation for Schatzker type six with fibular head fracture. Smarts objectives include patient and his family education: Inform the patient about their illness, teach them how to take care of themselves, and provide them tips on how to avoid getting injured or relapsing in the future. Teach the patient about ergonomics, correct body mechanics, and ways to prevent the worsening of their existing ailment. Pain management: Lower pain levels using a variety of methods, including physical treatment, therapeutic exercises, and techniques like heat or cold therapy. Joint flexibility and range of motion (Figure 6A): increase the range of affected joints and mobility by using an angle frame (Figure 7B) to stretch specific structures. Strengthening of lower limb muscles with a bolster (Figure 6B), theraband (Figure 7A), and weight cuff (Figure 8A): substantially improves muscular strength and structural stability of joints. Enhance overall posture and balance to decrease the risk of falls and perform better in daily activities. Gait training (Figure 8B): Focus on correcting locomotor inefficiencies, improving steps, and encouraging balance, and load redistribution in order to return to a normal walking pattern. Help the patient recover independence by doing activities of daily living (ADLs) including dressing, using the bathroom, and taking care of themselves. Functional independence: Allow the patient to restore the greatest amount of functional independence and carry out their prior level of activities, including jobs, hobbies, and leisure activities. Enhance the patient’s entire quality of life by enhancing physical function, minimizing restrictions, and fostering psychological wellness. Long-term self-management: Provide the patient with the information and abilities to autonomously manage their disease, including self-care, exercise, and continuous maintenance techniques. No adverse effect to the intervention was noted.

Table 1. Rehabilitation protocol for first six week after the operation.

Post-operative rehabilitation (one-six weeks)
Physiotherapeutic goals	Physiotherapeutic interventions
Patient Education	Educate the patient regarding the condition and the physiotherapy protocol that is to be given. The patient must be reminded to avoid bearing weight on the affected extremity, as any further weight bearing may cause further displacement of the fracture. Explain the knee stiffness and common complication which should be avoided by obtaining an adequate range of motion.
To minimize pain and swelling	Application of crepe bandage from distal to proximal, cryotherapy for distal to proximal for fifteen to twenty minutes, and deep friction massage for five minutes (circular friction to decrease swelling).
To improve range of motion	1) Gentle passive range of motion exercises to maintain mobility and prevent joint stiffness. Progression: to improve the knee flexion from 30° to 60° and further progress to 90°. Active assisted knee flexion and extension of the knee are allowed while protecting the knee from valgus and varus stress 2) Muscle Energy Technique: for quadriceps and hamstring as tolerated (Reciprocal Inhibition). 3) Mobilization: Patellar mobilization to regain patellar mobility. Passive graded mobilization for the tibiofemoral joint to increase knee flexion.
To increase muscle strength	1) Gentle ankle isotonic exercises. 2) Isometric exercises for the quadriceps. 3) Isometric exercises for the hamstring. 4) Multi-angle isometric (to regain the muscle mass and strength of the quadriceps). 5) Vastus medialis oblique strengthening. 6) Set of gluteal exercises (helping the patient to raise from a sitting to a standing position and maintain the strength of hip extensors). 7) Clamshell exercise (to increase abduction and lateral rotation). 8) Progression of open chain exercises: Straight leg raising in lying position, knee extension in sitting position, hip abduction in side lying position, hip adduction in side lying position, hip extension in prone, hamstring curl in prone.
Gait training	Non-weight bearing gait training with frame and long knee brace support to the right lower limb.

Table 2. Rehabilitation protocol for further progression of intervention after six weeks.

Post-operative rehabilitation (seven-fourteen weeks)
Goals	Physiotherapeutic intervention
Patient Education	Educate the patient about the phase one exercise, all the previous exercises such as stretching and strengthening need to be performed. Between the second and third month, will aim to progress your weight bearing from non-weight bearing to partial weight bearing and further progression to full weight bearing
Gait Traning	Gait training progression for fracture varies depending on the severity of the injury and the specific treatment plan: 1) Non-weight bearing walking was continued till four weeks. 2) Touch-down weight bearing was continued till fifth and sixth weeks. 3) Partial weight bearing with increase the amount of weight on the affected limb was continued after sixth weeks. 4) Full weight bearing was initiated after 12 weeks of operation. 5) Gait Retraining: This phase focuses on refining your walking pattern, and improving gait mechanics, will encourage the patient to increase the distance and speed without getting fatigued. Guide the patient's overall gait quality. 6) Advance Training and Functional Activities: Progress these exercises after fourtheen weeks. In this phase more challenging activities such as walking on different surfaces, stair climbing and navigating obstacles
Proprioceptive Training	Incorporated into a rehabilitation program once the fracture has started to heal and the patient can tolerate weight-bearing activities. Training helps to improve joint stability, balance, and coordination: 1) Balance Exercises: Standing on a single leg with eyes open and progression to eyes closed, throwing. and catching a ball while standing on the affected leg, balance board standing, calf raises on unstable surfaces, perturbation training, and performing mini squats. 2) Proprioceptive neuromuscular facilitation (PNF): PNF patterns of the lower limb to improve strength, coordination, and proprioception. 3) Coordination drills: lateral stepping, forward and backward lunges, or ladder drills. 4) Joint position sense exercises: These exercises involve actively moving the affected joint through its full range of motion and then trying to replicate specific positions without looking. This can help improve proprioception by training the body to accurately sense the joint's position. (Examples: pelvic bridging, lateral step-ups, swiss ball sitting, drawing alphabets with a heel, etc.)

Figure 6. Shows range of motion and strengthening exercises.

(A): Shows active assisted straight leg raise. (B): Vastus medialis strengthening with bolster.

Figure 7. Shows the use of theraband and angle frame.

(A): Strengthening exercises with theraband. (B): Knee flexion using angle frame.

Figure 8. Shows strengthening and gait training.

(A): Strengthening exercises with weight cuff. (B): Partial weight-bearing using frame.

Discussion

The rehabilitation strategy for bi-condylar tibial plateau fractures is extremely challenging because they frequently occur from high energy trauma and are complicated by soft tissue injuries.³ Tibial plateau fractures are a significant source of morbidity. In situations of high velocity injuries, treatment should be dependent on the fracture pattern, soft tissue condition, and overall health of the patient.⁷ In order to restore full knee flexion, manage swelling, ensure appropriate gait training, and improve the strength of quadriceps muscle, muscle strength should be maintained throughout the healing process using isometric, isotonic, and isokinetic muscle contraction.⁶ The muscle energy technique is a the type of manual therapy that increases range of motion and strength of the muscles. Physiotherapy can assist in preserving and enhancing mobility and strength in stressful post-operative situations.⁸ The aim of the treatment sessions was to preserve muscular integrity while enhancing the lower extremity activities, non-weight-bearing walking with a walker and little help for everyday activities. To start and improve the knee range of motion, electrotherapy modalities including continuous passive motion were applied.⁹ A structural rehabilitation programme is always advised for the post-operative patient’s recovery based on their physical condition and functional requirements to provide favourable prognostic results. The patient in our case was given written protocol, urged to schedule follow-up appointments, and instructed to complete all exercises as part of home workouts. The objective of this case study was to highlight the need of quick surgical intervention and crucial physical therapy rehabilitation to achieve the functional goals regarding the patient and its prognosis.

Conclusion

In this study, rehabilitation of a patient with a Schatzker type VI tibial plateau fracture were emphasized. The patient had open reduction and internal fixation (ORIF), which was followed by a thorough rehabilitation regimen. Several phases made up the rehabilitation programmed, including initial immobilization, pain management, range-of-motion exercises, muscle strengthening, balancing training, and functional status. The patient progressed through these stages based on their level of comfort, functional capacity, and the results of the radiographs. The patient demonstrated remarkable improvements in pain levels, range of motion, muscular strength, and functional skills throughout the rehabilitation procedure. They were fully capable of performing daily tasks on their own including activities related to the lower limb. The positive results obtained in this instance serve as a guideline for future clinical work and additional study in the area of musculoskeletal rehabilitation.

Consent

Written informed consent for the publication of their clinical details and clinical images was obtained from the patient.