Fracture Rehabilitation – When, How, and Why?

The greatest risk of falls occurs in older adults. In the elderly, fractures of the lower limb bones (e.g., femur) are common and often associated with complications. Therefore, older adults are advised to be cautious while walking. If a fracture occurs, after a clinical examination and radiological diagnostics, surgical treatment follows. Surgical fracture treatment can be:

• Conservative (e.g., immobilization with a splint or cast)

• Operative (various stabilization methods using osteosynthetic materials)

Rehabilitation is an essential part of any fracture treatment. The ultimate goal of the rehabilitation process is to restore the function of the injured area to its pre-injury level. Important factors to achieve this include:

• Achieving bone healing in anatomical or near-anatomical alignment

• Restoring full range of motion of the joints near the fracture

• Regaining normal muscle strength of the injured area and related muscle groups

• Preventing possible complications

Modern surgical stabilization methods allow early mobilization of neighboring joints, faster restoration of mobility, and, in some cases, earlier weight-bearing of the operated area. The approach to the patient in rehabilitation must be individual, tailored to the person and type of injury. The five basic principles of fracture rehabilitation are:

1. All joints that do not require immobilization should be mobilized immediately to prevent contractures. For example, in patients with a typical thumb fracture treated conservatively with an underarm cast, exercises for the shoulder, elbow, hand joints, and joints of uninjured limbs should start as early as possible.

2. For lower limb and spine injuries, walking training should begin as early as possible.

3. Mobilization of the injured area begins once adequate fracture stability is achieved and is carried out atraumatically to avoid further soft tissue damage.

4. Local physical therapy modalities are applied if necessary.

5. Muscle strengthening of the injured area is introduced when fracture stability permits.

Physical Therapy Modalities

Various physical therapy modalities are used at different stages of rehabilitation. In the acute phase, when swelling is present, cryotherapy is most commonly applied. Cryotherapy involves the use of cold to cause vasoconstriction, reducing swelling and bleeding. Cold also has an analgesic effect—directly on sensory nerve endings and nociceptors and indirectly by reducing associated muscle spasms. The optimal application period is the first 48–72 hours after injury. Cryotherapy is also useful postoperatively to reduce swelling after surgically treated fractures.

Application: ice obtained by freezing water in plastic cups, wrapped in a dry cloth to protect hands, applied for about 5 minutes. After initial blanching and numbness, hyperemia and a warm, analgesic sensation indicate treatment completion.

Thermotherapy is used in later stages. Heat causes physiological responses important for rehabilitation, increasing collagen extensibility, reducing joint stiffness and pain, and relieving muscle spasm. Deep heating modalities (ultrasound, short-wave therapy) affect deep tissues, while superficial modalities target surface structures. Heat therapy is contraindicated in areas with reduced sensitivity or in non-cooperative patients. Other modalities include electrotherapy and magnetotherapy.

Kinesiotherapy

Kinesiotherapy is the scientific use of movement for treatment and prevention. The goal in extremity injury rehabilitation is restoring function, performance, muscle strength, and endurance to pre-injury levels.

Maintaining and restoring range of motion:

• Restriction after injury may result from joint location or immobilization.

• Within the first 24 hours, early mobilization of all non-immobilized joints is recommended.

• Exercises are categorized as passive, actively assisted, active, and resistance exercises:

  • Passive: prevent contractures, maintain muscle-tendon length, reduce scar formation, aid cartilage nutrition.

  • Actively assisted: begin muscle re-education with therapist or patient assistance, used early after stable fractures or postoperatively.

  • Active exercises: performed by the patient alone; once partial range is restored, stretching exercises are introduced to regain full mobility.

Muscle strengthening:

• Muscle atrophy can occur 5% per day of immobilization.

• Strength is graded from 0 (no contraction) to 5 (normal strength).

• Strengthening begins when fracture stability allows. Exercises include:

  • Isometric: tension without movement, useful during immobilization.

  • Isotonic: muscle length changes with movement, progressive resistance training.

  • Isokinetic: with special devices (e.g., Cybex), controlling speed with varying resistance, useful in final rehabilitation stages.

• Early introduction of isometric exercises (e.g., quadriceps setting) during immobilization helps prevent atrophy.

Shoulder Fracture Rehabilitation

The shoulder girdle includes the clavicle, scapula, humerus, joints, muscles, and tendons. Rehabilitation aims to restore full range of motion, strength, and functional use for daily activities, work, and sports.

• Daily hand mobilization exercises during immobilization

• Pendulum exercises post-immobilization

• Rehabilitation duration depends on fracture type and treatment: typically 12 weeks to 1 year

Elbow Fracture Rehabilitation

Goals: restore elbow and shoulder motion, maintain carrying angle, regain strength.

• Duration: 12–24 weeks

• Early active movement is essential, starting with unloaded exercises and electromotor splints (Kinetek).

• Flexion/extension and forearm pronation/supination exercises.

• Contracture is the most common complication.

Wrist and Hand Rehabilitation

• Fingers remain free during thumb cast immobilization for early motion.

• Expected bone healing: 6–8 weeks; rehabilitation up to 12 weeks.

• Early edema prevention is crucial, including elevation, massage, lymphatic drainage, elastic bandaging.

• Active exercises in water can facilitate motion.

• Peripheral nerve injuries may require electrostimulation and EMG biofeedback.

Hip Fracture Rehabilitation

Hip movements: flexion, extension, internal/external rotation, abduction, adduction.

• Goals: restore hip and knee mobility, strength, and normalize gait.

• Minimum 90° hip flexion needed for proper sitting.

• Early postoperative rehab includes isometric glute and quadriceps exercises, isotonic ankle exercises, cautious active and assisted hip/knee/ankle movements.

• Gradual weight-bearing, full after 12–16 weeks.

Knee Fracture Rehabilitation

• Quadriceps atrophy occurs quickly; start static contractions during immobilization.

• Post-immobilization: exercises in unloaded positions, then resistance with weights or manual therapy.

• Stationary bike exercises introduced once strength permits.

• Duration: 14–20 weeks.

Ankle and Foot Fracture Rehabilitation

• Early toe exercises during immobilization activate calf muscles.

• Post-immobilization: active and assisted range-of-motion exercises, gait training with aids.

• Gradual weight-bearing, strengthening, and gait pattern correction.

• Physical therapy modalities help reduce swelling, muscle spasm, and pain.

• Challenges: advanced age, systemic diseases (diabetes, vascular or metabolic bone disorders), joint surface injuries, compartment syndrome, complex regional pain syndrome.