Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628]

Comprehensive Physiotherapy Protocol in Post-operative Case of Trimalleolar Fracture: A Case Report

A common ankle fracture that can have major consequences and expensive medical bills is the trimalleolar fracture. The trimalleolar fracture is the least frequent type of ankle fracture. The number of afflicted malleoli, the kind of fracture of the lateral and medial malleolus and the congruence of the ankle joint were all examined in detail for the trimalleolar ankle fracture. This type of fracture is brought on by high-energy trauma. In this case report, we describe a 56-year-old female patient who was involved in a road traffic accident. After being taken to the hospital for further examination, her ankle fracture was determined to be a trimalleolar one. She had an internal fixation with canulated cancellous screws and nails for open reduction. For such patients, we designed a physiotherapy course based on early rehabilitation and sensorimotor retraining to help with proprioception training, gait training and lower-limb muscular strength training. The lower limb's strength and range of motion were improved with the treatment. The outcomes used were the numerical pain rating scale (NPRS), functional independence measure (FIM), lower-extremity functional scale (LEFS), range of motion (ROM), gait parameters and manual muscle testing (MMT).

Physiotherapy Rehabilitation Strategies for Post-operative Trimalleolar Ankle Fracture: A Case Report

The trimalleolar fracture of the ankle is the least common type of fracture among ankle fractures. This type of fracture occurs due to high-energy trauma and is seen mostly in females than males. In this case report, we present a 52-year-old female patient who met with a road accident 15 months before presentation. She was brought to the hospital for investigation and was diagnosed with a trimalleolar ankle fracture. She was managed with open reduction and internal fixation using rush nailing and canulated cancellous screws. There was pus discharge from the suture site post-operatively. Due to this, there was a delay in the weight-bearing phase. Medications were given for relief. Ten months post the operation she saw pus discharge from the scar site, she was re-operated for implant removal and physiotherapy was advised. Due to fear of pain, she was not bearing weight on that limb. This prolonged non-weight-bearing phase caused muscle wasting of the right leg, and reduced ankle dorsiflexion range and strength. The patient attended physiotherapy treatment. A Mulligan’s movement with mobilization was prescribed to increase the range of ankle dorsiflexion, and ultrasound was used to improve scar mobility. Strength training of lower limb muscles, proprioception training, and gait training was given to the patient. The treatment showed improvement in the range and strength of the lower limb. 

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008.

OBJECTIVES

To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults.

SEARCH METHODS

We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy.

AUTHORS' CONCLUSIONS

There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Early mobilization of operatively fixed ankle fractures: a systematic review

BACKGROUND

It is commonly believed that early motion after joint fixation is advantageous, especially in the upper limb. In the ankle joint this is much less clear. No previous systematic review of the evidence for this could be found in the literature.

MATERIALS AND METHODS

Nine randomized control trials were identified which met the inclusion criteria and compared early motion of the ankle joint to immobilization in a cast for 6 weeks. These varied in quality and numbers. All treated patients equally in all other respects including weight bearing. Where outcome measures were similar, some data pooling was possible.

RESULTS

There is good evidence that early motion is associated with a quicker return to work on average (p = 0.008) and also with an improved range of motion at 12 weeks (dorsiflexion p = 0.001; plantarflexion p < 0.00001) compared to cast immobilization. However it is also associated with an increased risk of wound infection (p = 0.002). There is a suggestion that early motion results in a lower rate of deep vein thrombosis (p = 0.12). There is no evidence that it results in improved joint specific outcome scores or range of motion at 1 year.

CONCLUSION

It is difficult to conclude whether early motion is overall better or worse than cast immobilization. The evidence suggests however that a young fit patient who needs to return to work may benefit from early motion of the ankle joint whereas a patient with poor skin or at risk of infection may be better treated in a cast after surgery.

Rehabilitation for ankle fractures in adults

BACKGROUND

Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies.

OBJECTIVES

To compare the effectiveness of rehabilitation interventions following ankle fracture in adults.

SEARCH STRATEGY

We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate.

MAIN RESULTS

Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching.

AUTHORS' CONCLUSIONS

There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.