Physiotherapy Protocol — Distal Femur Fracture Post-ORIF (Elderly Female)

Clinical Summary of the Presentation

Hard end-feel at 45° flexion is a red flag. This suggests a bony or hardware block, not simply soft-tissue/capsular stiffness. Before progressing with aggressive mobilisation, you must liaise with the orthopaedic surgeon to rule out:

• Malunion / callus impingement in the intercondylar notch
• Hardware impingement (screw prominence, plate position)
• Heterotopic ossification
• X-ray / CT review is strongly recommended before forceful joint mobilisation

Phase-Based Physiotherapy Protocol

Phase 1 (Current Phase — Weeks 0–6 Post-Op Reference / Active Now)

Electrophysical Modalities (Pain & Inflammation)

• TENS (conventional, 80–100 Hz) around the knee — 20–30 min/session for pain relief
• Ultrasound therapy (1 MHz, pulsed 1:4, 0.5–1.0 W/cm²) over periarticular soft tissues — 5–7 min
• IFT (Interferential therapy) for deeper pain modulation and muscle stimulation
• Cryotherapy / Ice pack over knee — 15–20 min post-session to manage post-exercise soreness
• Elevation of the limb to reduce oedema

Range of Motion (ROM) Exercises

• Passive ROM — therapist moves knee through available range (0°–45°) with no overpressure; do NOT force beyond hard stop
• Active-assisted knee flexion in supine: heel slides on a smooth surface (or using a sliding board)
• Gravity-assisted flexion (seated dangling): sit at edge of bed/chair, let gravity gently flex the knee — hold 30–60 seconds
• Prone hanging (if tolerated by elderly patient): lie prone, let knee flex passively via gravity
• Patellar mobilisations — superior/inferior and medial/lateral glides: critical as patellar adhesions restrict flexion significantly
• Scar tissue/soft tissue mobilisation around the surgical incision if scar tethering is present

Strengthening

• Isometric quadriceps sets (quads tightening in extension): 10 reps × 3 sets
• Straight leg raises (SLR) — 4 planes (flexion, extension, abduction, adduction): 10 reps × 3 sets
• Ankle pumps — dorsiflexion/plantarflexion for circulation: 20 reps × 3 sets
• Gluteal sets — isometric glute contractions in supine: 10 reps × 3 sets

Mobility & Weight Bearing

• Confirm weight-bearing status with the surgeon (typically NWB → PWB at 10–12 weeks for ORIF)
• At 5 months post-op, if the surgeon has cleared weight bearing, progress to full or partial weight bearing with a walker/crutches as tolerated

Phase 2 (Weeks 6–12 Post-Op Reference / Overlap With Current Presentation)

ROM Progression

• Low-load prolonged stretch (LLPS): Apply a light overpressure hold at the end of available range (approaching 45°) for 10–15 minutes — this is the most effective technique for stiff joints. Do NOT apply sudden force
• Joint mobilisation (Maitland Grade I–II): Gentle tibiofemoral posterior glides in resting position to reduce pain and begin loosening the capsule — escalate to Grade III only if soft tissue end-feel confirmed
• CPM (Continuous Passive Motion) machine if available — set within pain-free range (0°–40° initially), advance by 5–10° per session
• Stationary cycling with elevated seat (reduces required flexion) — begin once 70–90° ROM is achieved
• Aquatic/hydrotherapy (if wound fully healed): warm water reduces pain, buoyancy assists ROM

⚠️ Important: If flexion is still <90° at 8–10 weeks post-op, or in this case has plateaued at 45° at 5 months, notify the surgeon immediately — Manipulation Under Anaesthesia (MUA) may be indicated, but only after ruling out a hard bony block.

Strengthening

• Short arc quads (SAQ): Flex knee to 45°, then extend — work within available range: 10 × 3 sets
• Terminal knee extension (TKE) with resistance band
• Mini squats / wall slides (within available ROM): 10 × 3 sets
• Hamstring curls (prone): 10 × 3 sets
• Hip abductor strengthening (side-lying leg raise): prevents Trendelenburg gait
• Calf raises (standing, supported): 10–15 × 3 sets
• PNF (Proprioceptive Neuromuscular Facilitation) patterns — D1/D2 lower extremity diagonal patterns

Gait Training

• Progress from walker → crutches → walking stick → unaided (as per WB status)
• Address any Trendelenburg gait pattern
• Stair training when quads strength and ROM permit

Phase 3 (Weeks 12+ / Functional Restoration)

• Closed kinetic chain exercises: leg press (limited range), step-ups, step-downs
• Balance and proprioceptive training: single-leg stance (with support), foam pad standing, wobble board
• Progressive resistance training: quads, hamstrings, glutes using resistance bands/weights
• Functional ADL training: sit-to-stand practice, toilet transfer, stair climbing
• Community mobility: walking distances, uneven terrain

Special Considerations for Elderly Patients

Home Exercise Program (HEP) — Daily

1. Ankle pumps — 20 reps, 3–4× daily
2. Quads sets (isometric) — 10 reps × 3 sets
3. Heel slides in supine — 10 reps × 3 sets
4. Seated gravity-assisted flexion (dangling) — 3 × 30-second holds
5. SLR (flexion + abduction) — 10 reps × 3 sets
6. Ice pack after exercise — 15 min

Urgent Action Required

1. Contact the treating orthopaedic surgeon — share ROM findings and end-feel character
2. Request X-ray / CT of the knee to assess hardware position, callus, or heterotopic ossification
3. Do NOT apply aggressive forced mobilisation (Grade IV Maitland or manipulation) until bony block is excluded
4. If imaging is clear and stiffness is purely periarticular/capsular, escalate to MUA discussion — this is a recognised complication at 5 months post-ORIF with <90° flexion