Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in patient
with ankle fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
GR, 62 year old woman with recent history of
right ankle fracture and postmenopausal osteoporosis

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Moderate pain and stiffness in the right ankle, swelling and tenderness of the ankle, moderate disability in gait
Post surgical (complex fixation method of the right ankle fracture) rehabilitation status

ANAMNESIS (history)
Our 62 year old woman suffered, three months ago, a right ankle injury and has underwent surgical treatment.
She had previous history of postmenopausal osteoporosis and lumbar spondylosis.
She performed daily activities in standing posture, in her professional life.
Her history reveals an ankle fracture due to a fall from height in a housekeeping activity. When she fell, her right
ankle was in pronation and external rotation. After injury, GR was unable to stand and bear weight on her own
immediately following the accident. She presented to the emergency department on the same day and diagnosed with
right ankle fractures above the joint line, with syndesmotic injury and transverse medial malleolus fracture. The
surgical treatment was performed in the same day for fracture - open reduction and internal fixation with standard
lateral plate fixation and stainless steel cortical screw.
Sutures are removed after 14 days. Post operative period was uneventful. The patient was kept on short leg cast for 6
weeks and was allowed to bear weight with the help of crutches only after 3 months.
GR is coming in our department to perform and to teach her the rehabilitation measures for regaining her gait and
her independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. What is the most important mechanism of injury to the ankle in our patient?
a. Twisting or rotating
b. Rolling or a impact during a car accident
c. Tripping or falling
R = a, c

2. Is it important to regain the function of lower limb in our patient?

a. No
b. Yes
c. It is indifferent
R=b

3. How we can explain the type of the ankle fracture in our patient?
a. As the female ages, ankle fractures are becoming more common
b. History of prior trauma to the affected ankle may cause antecedent laxity, instability
c. Our patient has other joint diseases
R=a
 Personal data
Questions` answers

1. What is the most important mechanism of injury to the ankle in our patient?
Ankle fractures are commonly caused by the ankle twisting (rotating) inward or outward. Excessive inversion
stress is the most common cause of ankle injuries for anatomic reasons. As a result, the ankle is more stable and
resistant to eversion injury than inversion injury. However, when eversion injury occurs, there is often substantial
damage to bony and ligamentous supporting structures and loss of joint stability. Posterior malleolar fractures are
usually associated with other fractures and/or ligamentous disruption. They are commonly associated with fibular
fractures and are often unstable. Knowledge of the trauma, such as the direction of torque force applied to the
ankle and the foot's position, helps predict the nature and severity of an ankle injury.

2. Is it important to regain the function of lower limb in our patient?

Yes. Restoration of the functional integrity and strength of the joint ankle in our patient is essential for gait and
performing the daily activities.

3. How we can explain the type of the ankle fracture in our patient?
After vertebral fractures, ankle fractures are among the most common fractures in adults. Ankle fractures are
frequently observed in postmenopausal women although the pattern of incidence and risk factor profile suggest
that ankle fracture may not be a typical osteoporotic fracture. In the last years, all studies sustained that the
alterations of bone microstructure observed in postmenopausal women with prior ankle fractures provide a
rationale for considering ankle fractures, like forearm fractures, as fragility osteoporotic fractures and taken into
account in risk assessment for secondary fracture prevention.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

GR is 1.65 m height and a weight of 72 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with hip and knee joints in normal limits.
Left ankle
range of motion - passive dorsiflexion (10 to 15), passive plantar flexion is 50, passive inversion is 30 and
eversion is around 10, no pain during passive movement.
along the anterior aspect, we assessed (palpated) the body and tendon of the tibialis anterior, extensor hallucis
longus, and extensor digitorum longus; the peroneus longus and brevis tendon are palpated as it passes posterior to
the lateral malleolus; on the medial aspect, posterior to the medial malleolus, we palpated of the posterior tibialis,
flexor digitorum longs, and flexor hallucis longus. Manual muscular testing is normal.
Right (broken) ankle
range of motion - all motions were limited as a result of pain, swelling and scar tissues, especially inversion and
eversion
all muscles around had value 3 on the manual muscular testing.
Weakness of the ankle muscles was noted and the ability to stand and balance on right leg is significantly diminished.
Gait is possible with two crutches (partial weightbearing gait on the right lower extremity). The patient complained of
right ankle and foot pain when she got up from a chair and walked.
Neurovascular status of lower limbs are intact.
Vital Signs: temperature 36.7C, blood pressure 130/70 mmHg, rhythmic pulse 76 b/min, 18 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. How can we explain the loss in range of motion in our patient ankle?
a. Because the cartilage is destroyed
b. Because our patient is female in menopausal status
c. Because concomitant damage to the soft tissue around bones
R = a,c

2. Ankle range of motion is important for gait rehabilitation ?

a. Yes
b. No
c. It is a biomechanical parameter that can be ignored in gait rehabilitation program
R=a

3. Why is it important to perform AROM in our patient?

a. To establish the extension mechanism of foot and ankle
b. To complete the physical examination
c. To monitor the pain of lower limb
R=b

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the ankle pain
c. For choosing the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the loss in range of motion in our patient ankle?
The broken ankle will never return to the pre-injury level of function. Even with an ideal fracture reduction, the
concomitant damage to the soft tissue and cartilage causes some pain and loss of range of motion.

2. Ankle range of motion is important for gait rehabilitation ?

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint. Ankle fractures refer to
fractures of the distal tibia, distal fibula, talus, and calcaneus. The true ankle joint allows dorsiflexion and plantar
flexion or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward
the ceiling via the true ankle joint. The subtalar joint allows the foot to be inverted or everted, that is, the sole of
the foot can be made to face inward (inverted) or face outward (everted) through the subtalar joint. So, normal
gait is possible only if the two joints of the ankle are functional and without pain.

3. Why is it important to perform AROM in our patient?

A systematic ROM examination revealed a restricted motion in ankle joint and foot, altered gait and poor
balance, quite common after a period (almost 3 months) of immobilization. Optimal rehabilitation program must
include specific mobilization and manipulation of the ankle and foot and mobilization in kinetic chains (open
and close) to restore the complex movements that are necessary to walk and balance correctly, to regain all
functional movements.

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation programs for gait in patients with ankle fractures take into consideration the global kinetic
exercises, after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for
flexion are very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X-rays.
This type of scan is the most common and widely available diagnostic imaging technique.
X-rays can show if the bone is broken and whether there is displacement (the gap between broken bones).
It can also show how many pieces of broken bone there are. X-rays may be performed on the leg, ankle, and foot to
make sure nothing else is injured. To characterize the initial fracture pattern and subsequent maintenance of adequate
reduction, imaging should always include anterior-posterior, lateral, and mortise views.
After surgery, we can monitor the callus.

!! Stress test - the physician may put pressure on the ankle and take a special x-ray,
called a stress test; it is done to see if certain ankle fractures require surgery.

Computed tomography (CT) scan.

This type of scan can create a cross-section image of the ankle and is sometimes done to further evaluate the ankle
injury and may identify or better characterize injuries to the plafond and talus. It is especially useful when the fracture
extends into the ankle joint.

Magnetic resonance imaging (MRI) scan.

This type of scan, rarely indicated, provides high resolution images of both bones and soft tissues, like ligaments. For
some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the type of internal fixation performed in our patient?

a. Fixation of bimalleolar
b. Fixation of high fibular fracture
c. Fixation of Weber C/PER ankle fracture
R=c

2. The imagistic findings on ankle X-ray can suggest the mechanism of injury suffered by our patient?
a. Yes
b. No
c. It is a MRI image of ankle
R=a

3. Is arthroscopic examination essential for our patient when we started the rehabilitation program?
a. Yes
b. No
c. It is important to performed in the future
R = b, c
Imagistic data
Questions` answers

1. What is the type of internal fixation performed in our patient?

Postoperative anteroposterior and lateral x-rays of our patient who underwent open reduction demonstrate the
internal fixation of Weber C / PER (pronation-external rotation) fractures ankle fracture with standard medial and
lateral plate fixation and stainless steel cortical screw. Generally, options of treatment include plate and screws or
malleolar screws for the lateral malleolar fractures and tension band wiring or malleolar screws for the medial
malleolar fractures depending on fracture configuration or bone stock

2. The imagistic findings on ankle X-ray can suggest the mechanism of injury suffered by our patient?
The position of the ankle at the time of injury and subsequent direction of force generally dictates the fracture pattern
(Lauge Hansen classification). Pronation-abduction and pronation-external rotation fractures above the joint line,
generally are associated with syndesmotic injury and with transverse avulsion medial malleolus fracture or deltoid
ligament rupture.

3. Is arthroscopic examination essential for our patient when we started the rehabilitation program?
Posttraumatic arthritis has been described in 14% of patients with broken ankle. despite an anatomic reduction, most
likely as a result of chondral injury sustained at the time of initial injury. The arthroscopic examination can found that
more patients , especially with Weber C/ pronation-external rotation fractures, have some degree of chondral injuries,
in time.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness;
changes in body structures fibular fracture, syndesmotic injury, medial malleolus fracture;
activity limitation - limited walking ability and problems with ADLs;
participation restrictions - reduced participation in leisure activities and in household chores.
The primary ICF activities and participation codes associated with ankle stability and movement coordination impairments
are d450 walking, d4552 running, d4553 jumping, d4558 moving around, specified as direction changes while walking
or running.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 7 before, 3 after rehabilitation program;
6 Minute Walk, with crutches = 100 meters before; 220 meters after rehabilitation program;
Timed Up and Go, with crutches = 40 seconds before; 25 seconds after rehabilitation program;
scales for condition-specific health status measures
The Foot and Ankle Outcome Score (FAOS) is a self-reported questionnaire and was developed to assess function in
a variety of foot and ankle-related problems; it is a 42-item questionnaire assessing patient relevant outcomes in five
separate subscales (Pain, other Symptoms, Activities of daily living, Sport and recreation function, foot and ankle-
related Quality of life); Sum up the total score of each subscale and divide by the possible maximum score for the
scale;100 indicates no problems and 0 indicates extreme problems. FAOS = 21 before rehabilitation; 32 after.
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 34 before rehabilitation; 42 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to assess the functional status in our patient ?

a. No
b. Yes
c. Is no important to mention
R=b

2. The changes in body structures that appeared from surgery may explain?
a. A further disturbance in the neuromuscular status
b. Optimal balance and gait
c. Back pain and lumbar stifness
R=a

3. The final score of the two scales used for our patient The Foot and Ankle Outcome Score (FAOS) and SF-36
are in concordance with the disability status ?
a. Yes
b. No
c. It is no possibility to compare the two score scales
R=a

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for muscular joint status takes a few weeks after intervention
R=c
Functional data
Questions` answers

1. It is important to assess the functional status in our patient ?

Yes. Many investigators have evaluated both short- and long-term results after surgery, to establish the complete
clinical and functional status of patient. Today, it is used patient-reported scores to evaluate functional results, as has
been done in almost studies. In accordance with the International Classification of Functioning, Disability and Health
(ICF), the degree of impairments, disabilities, participation problems and health related quality of life should be
described from the patients perspective.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further
disturbance
in the neuromuscular status.

3. The final score of the two scales used for our patient The Foot and Ankle Outcome Score (FAOS) and SF-36
are in concordance for disability status ?
Yes. The both scales contain the items for quality if life and various daily activities in which the lower limb, ankle
especially, is responsible for balance and gait.

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients' recovering from ankle fracture reclaim 2 3 months for plateau in strength and functional gains. The
outcome measures chosen for our patient study are common clinical measures and their associated impairments are
theoretically addressable by targeted rehabilitation techniques, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Complex right ankle fracture (operated 3 months ago, open reduction and internal fixation surgery) type C
in accordance with Weber ankle fracture classification
2. Mechanical low back pain. Lumbosacral spondylosis.
3. Postmenopausal osteoporosis (medication controlled)
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the imagistic arguments for our patients complete diagnosis?
a. diaphyseal fracture of the fibula above the level of the ankle joint
b. distal extent at the level of the talar dome
c. medial malleolus fracture
R = a, c

2. The following diagnosis can be taken into consideration for possible complications in our patient?
a. Posttraumatic Arthritis
b. Reflex sympathetic dystrophy (RSD)
c. Malunion or nonunion of the fracture site
R = a, c

3. We must mention a complete diagnosis for all patient disorders? Why?

a. No, it is not an important aspect
b. Yes, because the disorders have an important conditioning for rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b
 Complete diagnosis
Questions` answers

1. What are the imagistic arguments for our patient complete diagnosis?
The Weber ankle fracture classification is a simple system for classification of lateral malleolar fractures, relating to
the level of the fracture of the distal fibula in relation to the ankle joint . It has a role in determining treatment.
The type C are defined through the following aspects: above the level of the ankle joint, tibiofibular syndesmosis
disruption with widening of the distal tibiofibular articulation, medial malleolus fracture, unstable: usually
requires surgical intervention (open reduction and internal fixation).

2. The following diagnosis can take into consideration for possible complications in our patient?
Posttraumatic arthritis complicates 20-40% of ankle fractures. When the fracture is more severe, the risk of this
complication is the greater . Older females have an increased risk of arthritic complications.
The reflex sympathetic dystrophy (RSD) generally precede ankle fractures. Our patient is female with
postmenopausal osteporosis, so her ankle fracture may consider a complication or manifestation of her basic bone
disorder.
Malunion or nonunion of the fracture site can occur more frequently in older female patient. Malunion has
potentially proceeds to degenerative changes of the joint. Chronic persistent symptoms such as pain, weakness, and
instability of the ankle may develop.

3. We must mentioned in complete diagnosis all patients disorders? Why?

Recovery program typically reclaims kinetic exercises. In older patient all kinetic programs must respect the
intensity, duration and frequency in accordance with cardiac and respiratory status. Also, the back pain (lumbosacral
spondylosis) is a real stone in rehabiliation program goals and sessions.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
controlling the residual inflammatory process;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the ankle in the economy of the limb biomechanics;
maintenance of normal daily activities and maximization of quality of life.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, biphosphonate drugs, vitamin D3 and calcium carbonate oral
non-pharmacological modalities:
- educational, dietary and hygienic,
- posture (activity modification),
- physical (thermotherapy ice-pack to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased joint
swelling and pain will reduce chances of developing complications during the rehabilitation process;
- massage classic and special massage (Cyriax) of ankle and foot,
- kinetic
- early rehabilitation includes gait training with assistive devices, crutches first, cane after; ankle pumps, ankle
range of motion, isometric contraction of all muscles of lower limbs;
- stretching and thera-band exercises for ankle (dorsiflexion, plantarflexion, inversion, eversion), heel and toes
rises, single leg balance and progressive ankle weights as indicated and tolerated by the individual;
- ankle strengthening exercises, calf, hip and knee exercises (to help improve waling ability), balance and
proprioception exercises, global exercise to improve functional mobility and walking ability.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why is it important to perform a rehabilitation program (RP) in our patient?

a. Because the RP improves only the ankle ROM
b. Because the RP improves the upper limb function
c. Because the RP improves the lower limb function
R=c

2. Why should we respect the kinetic algorithm program in our patient rehabilitation ?
a. Because ROM exercises must preceded the strength exercise
b. Because it is the patient option
c. Because it is performed open reduction and internal fixation (ORIF)
R=a

3. What are the goals of RP in our patient, when she came in our department ?
a. Initiate functional weightbearing exercises , open kinetic chain AROM and isotonic strengthening exercises
b. Initiate proprioception and gradual gait exercises
c. Restoration of strength, power, and endurance
R = a, b

4. The dysfunction in lower limb is optimally controlled in our patient?

a. Yes
b. No
c. It is no important
R=a
 Rehabilitation program
Questions` answers

1. Why is it important to perform a rehabilitation program (RP) in our patient?

The complex goal of rehabilitation is to restore range of motion, strength, proprioception, and function.
Anatomic reduction is necessary to restore the normal anatomy of this weight bearing joint. Earlier and well
controlled RP may prevent stiffness and lead to faster recovery and joint motion contributes to cartilage
health. Our patient should advance weight bearing as tolerated but limit activities such as heavy lifting and
running. An exercise conditioning program will help the patient return to daily activities.

2. Why should we respect the kinetic algorithm program in our patient rehabilitation?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and
progressed as indicated and tolerated by the individual.

3. What are the goals of RP in our patient, when she came in our department?
The patient is coming in our department after she removed the knee cast, after 12 weeks after intervention. The goals
of rehabilitation program are: continuing healing of fracture site, normalizing AROM and impaired proprioception,
initiate gradual return to functional activities and light work activities. All rehabilitation has to respect the
progression for optimal control of patients impairments and functional limitation, to prevent the falls.

4. The dysfunction in lower limb is optimally controlled in our patient?

Yes. Everyone heals differently, and everyone's ankle fracture injury is different. After RP performed, our patient had
optimal gait training. She was help to progress from using an assistive device to walking independently; applied
progression for walking included: using two crutches for walking, one crutch, a standard cane when our patient went
home. We informed our patient that it may take several months for the muscles around her ankle to get strong enough
for walking without a limp and to return to your regular activities.