Case Report: Effectiveness of physiotherapy rehabilitation in a patient with compound grade IIIC proximal third tibia fracture along with vascular injury

Introduction

Fractures of the proximal tibia are traditionally suspected to be those that extend into the bone’s proximal metaphyseal area. Despite the fact that fractures can result from relatively low energy mechanisms like sports injuries or falls from a standing position, high-energy trauma is more frequently linked to fractures. A widely used technique for evaluating fractures is the OTA/AO categorization of peri-articular fractures. A type A fracture is one that is entirely extra-articular. Type B injuries are intra-articular fractures that have a piece of the metaphysis that is still intact (partial articular injuries). Type C intra-articular fractures are those that have complete metaphyseal-diaphyseal separation. Every subgroup is further classified. The risk of concurrent vascular injury is highest in distal femur and proximal tibia displacement fractures, and dislocation of the knee is particularly associated with insufficient collateral circulation to sustain the distal limb. A high index of suspicion, aggressive angiography implementation, and tight collaboration between all trauma team members are necessary for the best care of such injuries.¹

High-energy bicondylar tibial plateau fractures and proximal tibial shaft fractures are still difficult to treat surgically. Bicondylar tibial plateau fractures frequently result in difficulties with the wound, infections, varus collapse, knee stiffness, and articular mal reductions.² Among the operative modalities are intramedullary nailing, external fixation with or without restricted internal fixation, open reduction and internal fixation, and external fixation alone. Since supra-cutaneous plating, also known as a locking compression plate, has proven to be adaptable, concealed, and well embraced by patients, it has been advocated as an essential tool in the treatment of difficult reconstructive situations.³

In patients with lower limb fractures, physical therapy rehabilitation is a highly important part of the healing process. In a study, Iliopoulas et al. demonstrated the value of early weight-bearing and range-of-motion exercises in tibial plateau fracture patients. In order to get better clinical results, continued rehabilitation should be taken into account.⁴ This review thus clarifies the significance of rehabilitation for people experiencing tibial plateau fractures. We are reporting the case of a 42-year-old man who had a compound grade IIIC proximal third tibia fracture on the right side that was addressed with closed reduction external fixation and vascular repair. Along with that the patient also had fibula fracture. This patient received a suitable physiotherapeutic regimen, and results of its efficacy were observed.

Case presentation

We are reporting a case of a 42-year-old male who is a farmer by occupation. Prior to his road traffic collision, the patient was in good health one month prior to hospital admission. The patient was returning from Yavatmal to Ghatanji. Around 6:30 p.m. (7/04/23) he crashed into a four-wheeler while returning to Tivsa and fell off the bike, suffering a right leg injury. He was unable to put weight on his right limb instantaneously following the injury. After that, he was transferred to Yavatmal government hospital where first wound care was provided. He was referred to Acharya Vinoba Bhave Rural Hospital (AVBRH) for follow-up care after the therapy. Numerous diagnostics were done in this case, including X-rays that showed a compound grade IIIC proximal third tibia fracture on the right side with a vascular deficit. Extracutaneous plating of the right proximal tibia was conducted on 8/04/23 for the same reason. On 10/04/23, subsequent angiogram revealed acute thrombotic blockage of the distal ATA and DPA. On the same day for the precise same reason, right limb intra-arterial thrombolysis was conducted. Since that time, the patient has reported of pain and a difficulty to move their right leg. On 13/04/23, a demand for physiotherapy was made, and since then, sessions have been held. The sequence of events is depicted in Figure 1.

Figure 1. Depicts the sequence of the events.

Clinical findings

After the patient provided his informed consent, the physical examination was conducted. The patient was alert, cooperative, and clearly aware of time, place, and people. A comprehensive musculoskeletal assessment was performed. The history of pain is shown in Figure 2. Patient has a history of diabetes and hypertension for six months. On Observation, there was edema present over the distal leg of the right side (Figure 3). The following findings were discovered during an examination of the right lower limb. On inspection, dressing present over medial aspect of the leg and plate with screws present over the lateral aspect of the leg. On palpation, wound present over the medial aspect of the leg of 7 cm (Figure 4), grade 1 edema present over the right distal leg, grade 1 tenderness present over the completer course of tibia over the medial aspect of right leg and over the complete lateral aspect of leg along the plating. The range of motion and manual muscle testing of the left side were completely normal. The range of motion and manual muscle testing of the right side are shown in Tables 2 and 3, respectively.

Figure 2. Illustrates the patient's pain history.

Figure 3. Exhibits the edema over the distal extremity.

Figure 4. Depicts the wound and the plate with the screws over the right lower leg.

Diagnostic assessment

Diagnostic examination was done using angiogram, colour doppler and X-ray. Right lower limb angiogram revealed acute thrombotic occlusion of the distal ATA and DPA. Colour Doppler revealed that distal DPA shows no flow. Post-operative X-ray of right knee joint (Figure 5) revealed compound Grade 3 C fracture of tibia and fibular fracture with mild displacement. The X-rays shows extracutaneous plating with three screws at the proximal and three screws at distal aspect of the tibia.

Figure 5. Depicting the post-operative X-ray of the right knee joint.

Therapeutic intervention

The therapeutic regimen’s main objective is to boost the patient’s quality of life. We recorded the outcome measures pre- treatment and post-treatment in order to evaluate the effectiveness of our treatment regimen. All exercises are given in 1 set of 10 repetitions each and further progressed.⁵ Table 1, Table 2 and Table 3 explains the therapeutic regimen for Week 1 to Week 12. Figure 6 depicts patient performing non-weight bearing walker-assisted ambulation.

Table 1. Explaining the treatment protocol for Week 1 to Week 4.

Goals with Rationale	Intervention	Regimen with progression
Patient Education to inform patients about their health conditions, the value of physical therapy rehabilitation, and the standards for ongoing rehabilitation that must be met.	• Counselling patients and their families on the value of physical therapy rehabilitation and the necessary maintenance of rehabilitation expectations	• Prior to the therapy session starting.
To protect against respiratory disorders and to maintain lung health.	• Deep breathing exercises • Incentive Spirometry	• Deep Breathing exercises while recieving the physiotherapist’s visual and auditory feedback. 5 cycles of 5 to 6 breaths each.9 • Using incentive spirometer, inspiratory muscle training is done once in every two hours.10
For reducing swelling from Grade 1 to Grade 0 around the right foot and pain in the right limb from 6/10 to 2/10.	• Cryotherapy • Ankle pumps with leg elevation	• It is applied for 10 minutes.7 • 1 set of 10 repetitions.
To improve range of motion (ROM) of the right limb.	• Assisted Active Range of motion exercises	• 1 set of 10 repetitions. Progression to Active ROM exercises further.
To prevent Reflex inhibition and strength of the knee and hip musculature of bilateral lower limbs.	• Muscle-setting exercises of the quadriceps, hamstrings and adductors. • Assisted progression to active SLRs in supine.	• Each exercise is performed for 10 repetitions in 1 set
To make patient functionally independent.	• The following transitions are taught: ➢ Supine to side lying transition ➢ Side lying to sitting transition ➢ Sit to stand transition	• The transitions are taught sequentially and progressed as per the patient.
To increase the patient's bilateral upper limb strength because this is necessary for gait training with a walker.	• Upper limb resistance exercises using 0.5 kg weight cuff.	• 1 set of 10 repetitions is given. Progression done by increasing weight.
To initiate Gait training.	• Non-weight bearing walker assisted ambulation is taught (Figure 6).	• As per the tolerance of the patient.
To improve Patellar mobility.	• Patellar mobilization.	• 1 set of 10 to 12 glides are administered.

Table 2. Explaining the treatment protocol for Week 4 to Week 8.

Week 1 to 4 regimen is continued along with that these interventions are added.
Goals Rationale	Intervention	Regimen with progression
To improve the strength of the Bilateral lower limbs.	• Lower limb resistance exercises using 0.5 kg weight cuff.	• 1 set of 10 repetitions is given. Progression done by increasing weight.
To continue the gait training.	• Partial weight bearing ambulation by putting 25% weight on the right lower limb.	• As per the tolerance of the patient.
To initiate dynamic exercises for the lower limbs.	• Dynamic Quadriceps • Dynamic Hamstrings	• 1 set of 10 repetitions were performed. Progression was done by increasing the repetitions and sets.
To improve the strength of the core and back muscles.	• Core strengthening exercises ➢ Abdominal crunches and Curl up’s ➢ Unilateral Pelvic Bridging ➢ Unilateral Pelvic Bridging using physio ball11	• 1 set of 10 repetitions were performed. Progression was done by increasing the repetitions and sets.
To initiate the proprioceptive training to improve balance of the lower limbs.	• Proprioceptive exercises: ➢ Sitting on Swiss Ball doing weight shifts ➢ Sitting on swiss ball lifting one foot. ➢ Standing and doing weight shifts.12	• 1 set of 10 repetitions were performed. Progression was done by increasing the repetitions and sets.

Table 3. Explaining the treatment protocol for Week 8 to Week 12.

Week 4 to 8 regimen is continued with further progressions along with that these interventions are added.
Goals Rationale	Intervention	Regimen with progression
To continue Gait training.	• Partial weight bearing ambulation by putting 50% weight on the right lower limb.	• As per the tolerance of the patient.
To further improve muscle strength and range of motion of the right lower limb.	• Muscle Energy Technique and • Maitland Mobilization for knee range of motion.	• 1 set of 10 repetitions were performed. • 1 set of 10 to 12 glides are administered.

Figure 6. Depicting patient performing non–weight bearing walker assisted ambulation.

Follow up and outcome of interventions

We utilized various outcome measures to analyse the results of our treatment regimen. Figure 7, Table 4 and Table 5 depicts the pre-rehabilitation scores and post-rehabilitation scores.

Figure 7. Depicting the pre-treatment and post-treatment scores of VAS, LEFS, KOOS and SF – 36.

Table 4. Depicting the pre-treatment and post-treatment range of motion of the right lower limb.

Movement	Pre-treatment measures		Post-treatment measures
	Active	Passive	Active	Passive
Hip Flexion (With Knee Flexed)	00-500	00-550	00-1000	00-1050
Hip Flexion (With Knee extended)	Not able to perform	00-500	00-700	00-750
Hip Abduction	00-200	00-250	00-400	00-450
Hip Adduction	00-100	00-100	00-200	00-250
Knee Flexion	00-850	00-900	00-1000	00-1050
Knee Extension	900-00	900-00	1000-00	1050-00
Ankle Plantarflexion	00-400	00-450	00-500	00-550
Ankle Dorsiflexion	00-50	00-50	00-150	00-150

Table 5. Depicting the pre-treatment and post-treatment manual muscle testing grades of the right lower limb.

Movements of right lower limb	Pre-treatment MMT grades	Post-treatment MMT grades
Hip Flexion	2- /5	3+/5
Hip Abduction	2-/5	3/5
Hip Adduction	2/5	3/5
Knee Flexion	2-/5	3+/5
Knee Extension	2/5	3+/5
Ankle Plantarflexion	3/5	4/5
Ankle Dorsiflexion	2+/5	3+/5

Discussion

For a full recovery from a variety of orthopaedic problems, physical therapy rehabilitation is absolutely essential. In addition to pre-operative conditions, post-operative rehabilitation is also a crucial element for patients’ full recovery and the enhancement of their quality of life. The primary goals of post-operative physical therapy are to enable patients to resume their ADLs without difficulty and to enhance their quality of life. Numerous studies have been conducted to demonstrate the value of physiotherapy treatment plans for a range of orthopaedic disorders. In one of their studies, Lalwani et al. demonstrated the significance of the post-fracture rehabilitation programme with significant improvements in the patient’s quality of life, well-being, and physical functioning.⁶ Similar studies have been done on lower limb fractures, including proximal tibial fractures, and they reveal that these patients benefit greatly from their physiotherapy routine. Nowadays a novel method called closed reduction external fixation using supracutaneous plating for the proximal tibial fractures is carried out. A specific type of low incidence tibial plateau fracture is the bi-condylar fracture. The traditional surgical strategy and rapid, systematic physical therapy rehabilitation improved the functional goals over time, which is a crucial factor in helping such post-operative patients recover.⁷ The patient was able to regain his functional independence at home and at work because the rehabilitation protocol showed significant reduction of discomfort and pain, greater range of motion, and increased muscle strength and endurance.⁸ Therefore, post-operative physiotherapy rehabilitation is crucial for these individuals. In our study, we rehabilitated a patient with compound grade IIIC proximal third tibia fracture right side managed with closed reduction external fixator application and vascular repair along with proximal fibula fracture. Our treatment plan produced positive outcomes and enhanced the patient’s quality of life. We developed a physiotherapy program through this study that will be very helpful for these individuals and could be applied to similar patients in the future.

Conclusion

High energy tibial plateau fractures are treated surgically utilising a variety of techniques, one of which is closed reduction and external fixation with supracutaneous plating. Recovery for such patients after surgery depends greatly on postoperative therapy. Through this study, we developed a physiotherapy routine that was very helpful for these patients, produced positive results, and served to enhance the patient’s quality of life.

Consent

Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/relative of the patient.