Post-Surgical Treatment and Rehabilitation: Tibial and Patellar Fractures

I. GENERAL IMMEDIATE POST-OP PRINCIPLES (Both Fractures)

1. Wound and Infection Surveillance

• Inspect the wound daily for signs of infection - swelling, erythema, discharge, warmth
• Monitor temperature and labs (WBC, CRP) in the early post-op period
• Open tibial fractures carry an infection rate of ~20%; higher with Gustilo type IIIB/IIIC injuries
• Perioperative antibiotics per protocol

2. Swelling and Vascular Monitoring

• Elevate the limb above heart level for the first 48-72 hours
• Ice packs to reduce local swelling
• Monitor for compartment syndrome - a 1.5-11% risk with tibia shaft fractures; watch for the "5 P's" (Pain out of proportion, Paresthesia, Pressure, Pallor, Pulselessness)
• DVT prophylaxis (anticoagulation per protocol)

3. Pain Management

• Scheduled NSAIDs (unless contraindicated) for the first 3-5 days
• Short-term opioids for breakthrough pain
• Nerve blocks or epidural analgesia where appropriate

II. PATELLAR FRACTURE - POST-OP REHABILITATION

Phase 1: Weeks 0-2 (Immediate Post-Op)

• For repairs with poor tissue quality, immobilization continues for 4-6 weeks before any ROM
• For repairs deemed strong intraoperatively, early protected ROM (0-30 degrees) begins within the first 1-2 weeks
• The goal is to prevent retinacular disruption that can progress to a significant extensor lag

"The postoperative rehabilitation regimen is based on the surgeon's assessment of the repair strength." - Rockwood & Green's Fractures in Adults, 10th ed. (2025)

Phase 2: Weeks 2-6 (Early Mobilization)

• ROM progression: Gradual increase toward 90 degrees of knee flexion; do not force
• Weight bearing advances from partial to full as fracture healing is confirmed on X-ray
• Exercises:
  • Straight leg raises (all planes)
  • Active-assisted knee flexion/extension
  • Mini-squats (0-45 degrees only)
  • Seated knee flexion exercises
  • Pool therapy (hydrotherapy) if wound is healed

Phase 3: Weeks 6-12 (Strengthening)

• Closed-chain exercises: leg press, step-ups, wall slides
• Open-chain resisted knee extension (start at 90 degrees, progress carefully)
• Stationary cycling (low resistance)
• Proprioception training - balance board, single-leg stance
• Full weight bearing expected by 6-8 weeks if healing is confirmed

Phase 4: Weeks 12+ (Functional Return)

• Isokinetic strengthening - must be regained before resuming high-risk activities
• Progressive jogging, then sport-specific training
• Return to competitive sports: not before 4-6 months to allow sufficient tendon healing and remodeling

"Isokinetic strength should be regained before resuming high-risk activities." - Rockwood & Green's, 10th ed.

III. TIBIAL FRACTURE - POST-OP REHABILITATION

Phase 1: Days 0-7 (Acute Phase)

• Ankle and foot exercises immediately post-op: pumps, circles, toe curls (prevent DVT and maintain distal muscle tone)
• Quadriceps and hip muscle isometrics
• Elevate limb; apply ice
• Knee flexion and extension exercises in bed (passive)
• Pain control optimized before physiotherapy

Phase 2: Weeks 1-6 (Progressive Weight Bearing)

• Weight-bearing protocol depends on fixation stability:
  • Stable fixation (reamed IM nail, interlocked): Partial weight-bearing with crutches from day 1-3; progress to full weight-bearing by 4-6 weeks as tolerated and per X-ray
  • Distal tibial fractures: coronal malalignment risk means weight-bearing restrictions must be followed until "significant fracture healing occurs"
  • External fixator: NWB until conversion to definitive fixation or confirmed bridging callus

"Weight-bearing restrictions must be followed until significant fracture healing occurs to prevent coronal malalignment." - Campbell's Operative Orthopaedics, 15th Ed. (2026)

• Active knee and ankle ROM exercises
• Calf raises with support
• Hip strengthening (abductors, extensors) - critical while restricted weight bearing
• Gait training with physiotherapist

Phase 3: Weeks 6-12 (Strengthening and Gait Normalization)

• Confirm callus formation on X-ray before advancing to full weight-bearing
• Progressive resistance exercises: leg press, heel raises, step-ups, lunges
• Stationary bike
• Proprioception and balance training
• Hydrotherapy if available
• Normalize gait pattern - address any Trendelenburg sign, antalgic gait

Phase 4: Weeks 12-24 (Functional Recovery)

• Running progression (walk-jog intervals)
• Agility drills
• Return to work assessment (occupational therapy if needed)
• Union expected at 16-26 weeks for closed fractures (open fractures take longer)

• Knee pain - common with IM nailing (knee is entry point); address patellar tracking and fat pad irritation
• Malunion - monitor alignment at every follow-up X-ray
• Nonunion - if no progress by 4-6 months, evaluate for augmentation (dynamization, exchange nailing, bone grafting)
• Symptomatic hardware - nail removal considered once fully healed if knee pain persists

IV. COMBINED TIBIA + PATELLA FRACTURE REHAB CONSIDERATIONS

1. The patellar repair dictates the knee ROM progression - do not push knee flexion beyond what the patellar fixation tolerates
2. Tibial fracture stability dictates weight-bearing - coordinate with surgeon on which limits the other
3. Use a hinged knee brace (locked at 0 degrees initially, unlocked progressively) to permit controlled motion while protecting both repair sites
4. Defer aggressive quad strengthening until both sites show radiographic healing
5. Physiotherapy should be supervised - unsupervised aggressive rehab is a known cause of fixation failure
6. Functional milestones are shifted 4-6 weeks later compared to isolated fractures

V. REHABILITATION GOALS SUMMARY BY TIMELINE

• Rockwood & Green's Fractures in Adults, 10th ed. (2025) - Patellar Fractures ch. 60, Tibial Shaft Fractures ch. 63
• Campbell's Operative Orthopaedics, 15th Ed. (2026) - Tibial fracture management
• Miller's Review of Orthopaedics, 9th Ed. - Periprosthetic knee fractures