Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with tibial condyle fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
SA, 61 year old woman with recent history of
lateral tibial condyle fracture

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 both knees, swelling and tenderness of the knee, moderate disability in gait
Post surgical (complex fixation method of the type 3 lateral left tibial condyle fracture) rehabilitation status.

ANAMNESIS (history)
Our 61 year old woman suffered, three months ago, a left knee injury and has underwent surgical treatment.
She had previous history of knee osteoarthritis, cervical and lumbar spondylosis and postmenopausal osteoporosis
without fractures.
She performed daily activities in sitting postures in her professional life.
Her history reveals a knee fracture due to a fall from height in a housekeeping activity. When she fell, her left knee
was forced in valgus, and the lateral condyle is crushed by the opposing femoral condyle, which remained intact.
After injury, SA 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 left lateral tibial plateau fracture with depression.
The surgical treatment was performed in the same day of the fracture - open reduction and internal fixation with
screw.
Sutures are removed after 14 days. Post operative period was uneventful. The patient was kept on knee leg cast for
6 weeks and was allowed to bear weight with the help of crutches only after 3 months.
SA is coming in our department to perform and to teach the rehabilitation measures for regain her gait and her
independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. Why is the lateral tibial condyle fracture more frequent compare with the medial tibial condyle?
a. It is indifferent
b. Due to the anatomical features of bones
c. Due to muscle attach around knee
R=b

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 can we explain the type of knee fracture and the mechanism of injury in our patient?
a. Valgus force on the knee in a female with postmenopausal osteoporosis
b. History of osteoarthritis
c. Varus force on the knee in a young female
R=a
 Personal data
Questions` answers

1. Why is the lateral tibial condyle fracture more frequent compare with the medial tibial condyle?
The knee is a complex joint, exposed to forces that can exceed five times the weight of the body. The normal
knee is in physiologic valgus alignment. Most of the load transmitted across the knee is medial to the eminence,
and therefore, the knee has stronger cancellous bone. The medial plateau is generally larger than and rounded as
compared with the lateral condyle. So, during extension some of the anterior articular surface of the lateral
plateau is exposed. All these anatomical and biomechanical features cause the lateral plateau to be more
susceptible to bone injury and fracture.

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

Yes. Restoration of the functional integrity and strength of the knee in our patient is essential for gait and
performing the daily activities. The tibial plateau is one of the most critical loadbearing segments in the human
body; fractures of the tibial plateau affect knee alignment, stability, and motion of the entire lower limb. Early
detection and appropriate treatment of these fractures are very important for minimizing patient disability .

3. How we can explain the type of knee fracture and the mechanism of injury in our patient?
This is a combined cleavage and compression fracture and involves vertical split of the lateral condyle combined
with depression of the adjacent load bearing part of the condyle. Caused by a valgus force on the knee; it is a low
energy injury, typically seen in individuals of the 4th decade or older with osteoporotic changes in the bone
density. Most common, and make up 75% of all tibial plateau fractures. Approximately half of the patients who
sustain a tibial plateau fracture are aged over 50.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

SA is 1.67 m height and a weight of 73 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis, cervical and back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with hip and ankles joints in normal limits.
Left (broken) knee
range of motion - active flexion (10 to 50), passive flexion (10 to 70), complete extension was limited as a
result of pain, swelling and scar tissues,
all muscles around knee had value 3 on the manual muscular testing; 4 for great gluteus, 4 for hip stable muscle.
Right knee primary osteoarthrosis, without malalignment
active flexion is 70, passive flexion is 100, minimal deficit of extension 5, no pain during passive movement.
manual muscular testing: 4 for great gluteus, +4 for hip stable muscle, 4 for quadriceps and 4 for posterior limb
muscles.
Weakness of the knee muscles was noted and the ability to stand and balance on left knee is significantly diminished.
Gait is possible with two crutches (partial weightbearing gait on the left lower extremity). The patient complained of
left knee pain when she got up from a chair and walked.
Neurovascular status of lower limbs is intact.
Vital Signs: temperature 36.7C, blood pressure 140/80 mmHg, rhythmic pulse 72 b/min, 16 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 patients left knee?
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. It is important for gait rehabilitation to examine the proprioception and balance?

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

3. Why is it important to perform complete physical examination in our patient?

a. To establish the affected tibial condyle
b. To establish the all injured structures of knee
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 knee pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the loss in range of motion in our patients left knee?
The fractures of tibial plateau significantly affect the biomechanics, stability and range of motion of the knee
joint. Also, ligamentous and menisci injuries may be present in tibial plateau fracture.

2. It is important for gait rehabilitation to examine the proprioception and balance?

Yes. The patient has to regain her optimal gait, only after all her lower limb functions are recovered. So, we
assess the patients ability to maintain balance with NWB using an assistive device, the balance on the involved /
uninvolved leg as appropriate when the fracture is healed and weight-bearing status is progressed.

3. Why is it important to perform complete physical examination in our patient?

Full clinical assessment is required, including evaluation of the soft tissues to determine whether a compartment
syndrome is present and whether the patient has sustained a neurovascular injury. Gentle stress testing can be
performed with the leg in extension to evaluate the stability of the ligaments. Because of the valgus stress at the
moment of impact, the medial collateral ligament is at greater risk than the lateral collateral ligament; however,
disruption of the lateral collateral ligament is of grave concern because of possible injuries to the peroneal nerve
and the popliteal vessels.

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patient with knee fracture take into consideration the global kinetic
exercises, after analytic kinetic program. Muscles atrophy after any fracture can make moving around painful
and slow. The kinetic muscle chains of the lower limb for extension and for flexion are very important for
independence in ambulation, so previous kinetic programs 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).
Most tibial plateau fractures are easy to identify on standard anteroposterior (AP) and lateral projections of the knee.
Lateral views should not be considered adequate if a rotational component obscures the visualization of the femoral
condyles as a single unit. Oblique projections should be added if a nondisplaced tibial plateau fracture is suspected but
not seen on the standard projections. After surgery, it can monitor the callusin time.

Computed tomography (CT) scan.

This type of scan can create a cross-section image of the knee. Three-dimensional spiral CT reconstructions yield a
better and more accurate demonstration of the tibial plateau fracture. They present the anatomy in the view the surgeon
will see when surgery is performed. The data obtained from a CT scan can orient the best surgical approach based on
the fracture planes seen on the computer images.

Magnetic resonance imaging (MRI) scan.

This type of scan provides high resolution images of bones (identifying occult fractures of the tibial plateau) and soft
tissues of the knee (meniscal, collateral, and cruciate ligamentous structures).. Plateau fractures and other pathologic
aspects (edema, hyperemia, hemorrhage) may be visualized on MRIs, even when plain film radiographs are normal.
Imagistic data
Questions (for assessment detailed answers see next page)

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

a. Fixation with biological buttress plating
b. Fixation with percutaneous elevation and cannulated cancellous screw
c. Fixation with cannulated screw
R=c

2. The imagistic findings of X-ray left knee 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. The ORIF can suggest the type of optimal management performed in our patient?
a. No
b. Yes
c. It is important to be performed in the future
R=b
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 screws. Generally, orthopedic management of tibial plateau fractures varies from conservative
non-operative treatment to open reduction and internal fixation (ORIF - for fractures that show greater than 5 mm of
depression or 1 mm displacement). ORIF with the restoration of the articular surfaces will promote the best
outcomes, with satisfactory results in 75% of cases.

2. The imagistic findings of X-ray ankle can suggest the mechanism of injury suffered by our patient?
A Schatzker type III fracture is a pure compression fracture of the lateral tibial plateau in which the articular surface
of the tibial plateau is depressed and driven into the lateral tibial metaphysis by axial forces, without the wedge
fracture . Our patient had central depression (type IIIB - the depressed portion of the plateau is typically elevated by
means of a submetaphyseal cortical window and may result in joint instability). These fractures represent more than
35% of all tibial plateau fractures and are more frequent in the older age groups (the 4th and 5th decades of life), in
whom some degree of osteopenia is more likely to occur, like in our female patient.

3. The ORIF can suggest the type of optimal management performed in our patient?
Yes. Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Anterolateral and
anteromedial surgical approaches do not permit adequate reduction and fixation of depressed portion. To achieve this,
it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal
reduction and screw placement.
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 (special for quadriceps muscle);
changes in body structures tibial plateau 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 knee 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 = 8 before, 3 after rehabilitation program;
6 Minute Walk, with cane = 140 meters before; 280 meters after rehabilitation program;
Timed Up and Go, with cane = 38 seconds before; 25 seconds after rehabilitation program;
scales for condition-specific health status measures
The Lower Extremity Functional Scale (LEFS) (a self-reported questionnaire intended for use on adults with lower
extremity conditions; it is a 20-item questionnaire assessing patient relevant outcomes of lower limb function; the
maximum possible score is 80 points, indicating very high function.; the minimum possible score is 0 points,
indicating very low function) = 41 before rehabilitation; 52 after rehabilitation program.
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 Lower Extremity Functional Scale (LEFS) and SF-36
are in concordance for disability status ?
a. Yes
b. No
c. It is no possible 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. Initially, in the nonweightbearing period, functional assessment will be
limited and will focus on activity of daily living modification, transfers and short distance ambulation and stairs.
Once weight-bearing is allowed, the therapist will need to reassess gait, balance activities, and higher-level functional
activities as appropriate. Outcome measures such as the Lower Extremity Functional Scale may be helpful in tracking
and documenting progress.

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. This aspect has a great impact on the different parameters like lack of
extension, range of movement, instability, walking distance and pain score.

3. The final score of the two scales used for our patient The Lower Extremity Functional Scale (LEFS) and SF-36
are in concordance for disability status ?
Yes. The both scales contain the items for quality of life and various daily activities in which the lower limb, knee
especially, is responsible for balance and gait. These measurement instruments, based on scoring systems, are applied
so as to assess the benefits achieved by the surgical procedure and rehabilitation measures.

4. How can explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients recovering from knee 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. Lateral left tibial condyle Schatzker type III fracture (operated 3 months ago, open reduction and internal
fixation surgery with the iliac graft)
2. Primary knee osteoarthritis
3. Cervical and lumbosacral spondylosis.
4. Postmenopausal osteoporosis (medication controlled)
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the arguments for a low energy injury on the knee in our patient?
a. Osteoporotic status
b. Bilateral knee osteoarthritis previous diagnosis
c. Spondylosis
R=a

2. The following diagnosis can we take into consideration for possible complications in our patient?
a. Knee stiffness and instability and angular deformities
b. Malunion or nonunion of the fracture site
c. Osteoarthrosis
R = a, b

3. We must mention a complete diagnosis for all patients 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?
Our patient was diagnosed with type III Schatzker tibial fracture. This type of fracture is a focal depression of
articular surface with no associated split. This is a pure compression fracture of the lateral or central tibial plateau in
which the articular surface of the tibial plateau is depressed and driven into the lateral tibial metaphysis by axial
forces. A low energy injury, these fractures are more frequent in the 4th and 5th decades of life in females with
osteoporotic changes in bone.

2. The following diagnosis can take into consideration for possible complications in our patient?
Our patient was previous diagnosed with osteoarthritis, so this diagnosis had not be take into consideration for late
possible complication. Other, late complications are often associated with mechanical problems like knee stiffness
and instability and angular deformities or malunion of the fracture site.

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

Rehabiliation program typically reclaims kinetic exercises. In older patients all kinetic program must respect the
intensity, duration and frequency in accordance with cardiac and respiratory status. Also, the back pain and
dysfunction of any lower limb joint represent real milestones 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 knee 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,
- 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 both knees,
- kinetic
- early rehabilitation includes gait training with assistive devices, crutches first, cane after; ankle pumps, knee
range of motion (active flexion and passive extension), isometric contraction of all muscles of lower limbs;
- stretching and thera-band exercises for knee (flexion, extension), balance and progressive knee weights as
indicated and tolerated by the individual;
- knee strengthening exercises, leg, calf, hip exercises (to help improve waling ability), balance and
proprioception exercises, global exercise to improve functional mobility and walking ability;
- for gait training we performed progressive exercise program consisting of strength training, stabilization
exercises and coordination exercises; the gait training progressed increasing the weight, speed and duration.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why it is 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 we should 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 weight bearing 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 it is important to perform a rehabilitation program 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 contributing 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 we should 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, at 12 weeks after intervention. The
goals of the rehabilitation program are: continuing healing of the 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 falls.

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

Yes. Everyone heals differently, and everyone's knee 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 one crutch, a standard cane when our patient went home. We
recommended a home-training program for both knees (muscles can gain both the endurance and the strength needed for
everyday activities through controlled exercises), so our patient will maintain an optimal function of both lower limbs.