Physiotherapy Surgery

The Physiotherapy Surgery department is assigned to the Clinic for Trauma Surgery, Plastic and Reconstructive Surgery.

The physiotherapists look after both intensive care units and intermediate care 365 days a year.

One of our tasks is to maintain and promote the patient's movement system and movement behaviour.

The aim is to actively and independently support the healing process.

The therapists prepare patients individually for the time after hospitalisation by helping them to continue to be independent.

The physiotherapy surgery team is constantly undergoing further training and works according to the latest medical standards.

In addition to inpatient care, our colleague Adalbert Stegmaier (0731-500-54590) also offers physiotherapy on an outpatient basis.

Therapies

Conservative treatment (stable fractures: fracture classification A1)

Bed rest 5 days post-traumatic
  • Trunk isometry (e.g. Brunkow), en bloc rotation in SL, stroke-free / arm movement in lateral flexion (pain-orientated)
  • Flexion / extension (max 30 degrees flex measured from the horizontal)
  • Isotonic exercises of the extremities in a stable position
5th day to 8th week post-traumatic
  • Mobilisation with 3-point support corset if necessary
  • With straightened CLA, lift-free / low-lift movement in rotation
  • Movement into extension against dosed resistance on the pelvis / sacrum
From week 8: (X-ray)

Muscular build-up training (also with training equipment) without movement limits (orientated to the patient's performance and symptoms)

Fractures treated with dorsoventral spondylodesis and dorsoventral stabilisation with ventral instrumentation

Follow-up treatment as described for conservative treatment, but

  • without corset
  • Flexion limit for 4 weeks only
  • Mobilisation on the 5th postoperative day
Fractures with dorsoventral stabilisation without instrumentation (ventral bone chip)

Corset for 8 weeks bed rest until day 5 postoperatively:

  • Trunk isometry
  • Stabilised turning in SL
  • Stroke-free / arm movement in lateral flexion (pain-orientated)
  • Flexion / extension 30/0/10 (from the vertical)
  • Isotonic exercises on the extremities in a stable position (e.g. PNF)

5th postoperative day to 8th week:

  • Mobilistaion with corset
  • Stimulation of flexion / extension (30/0/10) via guiding resistances (e.g. on the sacrum, iliac crest)
  • Practising in other starting positions

8th week to 12th week:

  • Additional pain-orientated rotation
  • Three-dimensional movement in the above movement limit against guiding resistance

From week 12: (X-ray)

  • Start with muscular strengthening training (including equipment)
  • The limit should be based on the symptoms reported by the patient and their ability to perform
1st week: After predetermined immobilisation, adapted pain treatment.
  • Start therapy with lymphatic drainage to decongest the tissue.
  • Thermotherapy: Relief of pain through appropriate heat or cold, depending on how the patient feels.
  • Electrotherapy with Tens: the patient can treat themselves independently under the guidance of the therapist.
  • Classic massage via the characteristic muscles of the upper extremity.
  • Connective tissue massage as vegetative re-tuning therapy.
Week 2: In addition to pain therapy: muscular stability and reduction of relieving posture, training of coordination and proprioception.
  • Tension exercises for the dorsal and ventral neck muscles.
    • Diagonal lines of vision with holding exercises for the dorsal neck muscles.
    • Tension exercises with the tongue alternating diagonally against the soft and hard palate for the ventral neck muscles.
  • Brunkow in supine position to improve muscle tension.
  • Rhythmic stabilisation from PNF in the seated position. In this phase, leave out the head component.
Week 5 - 7: Increase proprioception and coordination. Integration of everyday movements (ADL).
  • Brunkow tension translation of the cervical spine dorsally, taking pain into account.
  • Joint mobilisation, related to cervical spine only manual traction level 1.
  • Working on straightening up and reducing the posture of rest using the shoulder pattern from PNF.
  • Rhythmic stabilisation from PNF with head component, naturally taking pain into account.
  • Foam ball exercises standing against the wall. Describing a figure eight with the forehead or occiput.
  • Instructions for standing on four feet, translation dorsal to the cervical spine head against gravity.
  • Exercises with the Swingbow. Reduction of the protective posture and proprioceptive training. Increase by changing the surface.
  • Same goal as above, using the Posturomed and throwing a ball with a change of direction.
A homework programme should run through the entire course of therapy. Very simplified examples:
  • Bend the chin to the chest and the neck forwards, bend the neck back again and the chin back to the starting position.
  • Tilt the neck backwards, look up to the ceiling and back to the starting position
  • Tilt your neck to the side so that your ear is pointing towards your right shoulder. During this movement, direct your gaze to a specific point at eye level. Return to the starting position.
  • Brunkow tension dorsally while sitting on a chair or pezzi ball as instructed by the therapist.
What is a functional hand?

If finger function is lacking (e.g. in the case of tetraplegia), the aim is to train the still innervated muscles and learn trick movements to create a substitute form of grasping.

How is this achieved?

A deliberate shortening of the finger flexor tendons should be induced through targeted positioning. If the fingers are not positioned correctly, they either remain stretched or become deformed into a clawed hand, increasing the risk of injury and considerably limiting or even eliminating the possibility of regaining independence.

The principle of the functional hand
  1. Active functional hand
    In tetraplegia above C 5/6, all finger and thumb muscles are lost, with partial or complete preservation of the extensor function in the wrist by the extensor carpi radialis muscle. Passive flexion of the wrist in the pronated position and utilisation of gravity leads to an opening of the hand with slight passive extension of the fingers in the metacarpophalangeal joints. Through the voluntary active use of wrist extension by the extensor carpi radialis muscle, the hand closes in the form of a fist closure (flexor tendons of the fingers come under tension).
    The thumb lies firmly against the flexed index finger in the form of a lateral grip.
    This enables a targeted holding and gripping function. (The strength of this fist closure is determined by the extent to which the finger flexor tendons are shortened. The prerequisite for this is also the preservation of joint mobility).
  2. Passive functional hand
    In the case of complete tetraplegia below C4/5, all muscles that act on the fingers and wrist are paralysed. The wrist is stabilised in 30° dorsiflexion using specially manufactured splints. With innervated biceps muscles, these tetraplegics are able to become independent in some areas.
Treatment of the tetraplegic hand

The functional hand can only be achieved by consistently positioning the hands from day one in every position (supine, lateral, prone) for at least three months. The positioning may only be removed for nursing measures and for movement (contracture prophylaxis).

Training of the functional hand through
  1. Functional hand splint (this is individually adapted by occupational therapists in the further course)
  2. Taping and positioning
    Position of the hand during taping and positioning (functional position):
    - 30° dorsiflexion (extension) in the wrist
    - 90° flexion (bending) in the MCP (metacarpophalangeal joint)
    - 90° flexion (bending) in the PIP (proximal interphalangeal joint)
    - full extension in the DIP (distal interphalangeal joint)
    a. The hand is held manually in the functional position. A small roller is inserted into the inner surface from the side of the little finger. The roll consists of a gauze bandage (with a small diameter) that is covered with a tubular bandage.
    The length of the roll is based on the width of the palm at the level of the metacarpophalangeal joints. The thickness of the roll depends on whether the fingers can be brought into a functional position when the roll is wrapped around them.
    b. Leukofix is particularly suitable for gluing.
    The Leukofix strip is applied below the respective PIP (middle joint) of the four long fingers.
    It is glued beyond the extended DIP (end joint) and wrist.
    It is glued in a radial pattern to one point.
    This should vary to protect the skin.
    The fingers must not be placed on top of each other.
    c. The thumb is fixed in an outstretched position in the area of the PIP (metacarpophalangeal joint) with adhesive strips. If possible, do not tape over any joints.
    d. Apply 30° dorsiflexion to the wrist.
Variants depending on the findings:
  • If the fingers overlap, the adhesive strip can also be applied parallel to the fingers instead of in a radial pattern.
  • In the case of reddened end joints, apply adhesive tape from the fingernail. Caution: Claw hand
  • If there is a lack of stability, the adhesive strip can also be applied circularly to the thumb.
  • Etc.
Please note:
  • The fingers must never be stretched with simultaneous dorsiflexion (extension in the wrist)! During palmar flexion (flexion in the wrist), the PIP and DIP finger joints (base and end joints) should be fully extended.
  • The metacarpophalangeal joint of the thumb in particular must not be moved in an uncontrolled manner, as good stability of the thumb means better function
  • The wrists are free to move
This means the following for care

Care measures on the hands should only be carried out with palmar flexion!
The fingers must not be abducted (spread apart). Wash the spaces between the fingers carefully!

Positioning

 

1. positions that facilitate breathing

The positions shown have one thing in common:

  • relieving the chest from the weight of the shoulder girdle
  • the abdomen slopes forwards
  • Easing the movement of the ribs backwards (except in the supine position)
  • Improved use of the auxiliary respiratory muscles, as the punctum fixum and punctum mobile are interchanged
2. stretching positions in general

For example, the supine position with arms in a U-shape or lateral position with bent arm (stretching over elbow).

Objectives:

  • To reduce increased elastic resistance in the skin and muscle tissue of the upper body
  • Maintaining/improving thoracic mobility

To reduce breathing-inhibiting resistance in the entire thorax!

3. drainage positioning

Indications:

  • Generally for chronic obstructive pulmonary diseases
  • Bronchiectasis
  • Chronic bronchitis
  • Acute bronchial obstruction
  • Postoperative atelectasis
  • Paralytic conditions of the respiratory muscles


Dosage:
Each position must be held for at least 3-5 minutes. It should be performed between 2-4 times per day. Duration and repetitions depend on the efficiency of the expectoration! Aerosol therapy can be carried out before (to open the bronchial tree and improve drainage) or (possibly also and) after the drainage position, so that areas previously filled with secretions are now also reached by the aerosol.

Many selective drainage positions are associated with rotation of the chest and are therefore contraindicated in cardiac surgery with opening of the sternum.

As a general guide:

1. supine position, possibly combined with head-down position as drainage for the right middle lobe and the lower parts of the left upper lobe (segments 4, 5).

2. prone position, possibly oblique prone position on the opposite side of the part of the lung to be drained, possibly head-down position as drainage for the upper (and middle) parts of the two lower lobes (segments 6, 10).

3. lateral position on the opposite side of the part of the lung to be drained, possibly head-down position as drainage for the lower (and outer) parts of the two lower lobes (segment 8,9).

4. upright position / elevated upper body as drainage for the upper segments

Additional respiratory therapy measures

1. passive measures

Features:

  • Variable use
  • Independent of the patient's ability to exercise
  • Includes diagnostic and therapeutic grips
  • Can be used independently or in harmony with the breathing rhythm
  • for preparing active measures
  • Can be combined with stretching and drainage positions
  • are perceived as very relaxing, calming and often also pain-relieving


a) Stroking the intercostal spaces

Always from lateral to medial
Always following the ribs

effect:

  • Detonating and tissue loosening
  • Increases circulation
  • Training the direction of breathing
  • Pain-relieving
  • Increases the breathing rate when stroking during exhalation Reduces the breathing rate when stroking during inhalation

But also possible as hand-over-hand stroking independent of the breathing rhythm

b) Stroking the intercostal spaces in conjunction with vibrations Apply 2-3 fingers, strengthen the effect with the other hand

effect:

  • Stimulation of breathing
  • Mobilisation and transport of secretions


c) Pack grips
Grasping, pulling off and holding a skin fold in the thoracic region

Techniques:

  • Holding the grip over several breaths (grasping during exhalation)
  • Grip during the exhalation, at the end of the exhalation possibly apply a stretch (as a stimulus for the next inhalation)
  • Move with the breath
  • Breathe away the skin fold


Effect:

  • Release subcutaneous adhesions, reduce skin turgor
  • Promotes blood circulation
  • Breathing direction training


d) Skin fold displacement, skin rolling
Gripping a skin fold and "rolling out" over the thumb tips

Effect:

  • Lowering the skin turgor
  • Promotes blood circulation


e) Thoracic compression
Place both hands laterally-medially on the thorax, direction of pressure: medial, dorsal, caudal

Techniques:

  • Uniform compression
  • Compression with simultaneous shaking/vibrations
  • Compression with simultaneous stretch at the end of exhalation


Effect:

  • to support exhalation
  • strong respiratory stimulus
  • Mobilise and transport secretions
  • Cough provocation


Actually contraindicated after thoracic surgery! In a weakened form, more possible in the sense of "guiding the lower ribs in the respiratory rhythm".

f) Tapping, hacking, clapping

g) Physical measures

e.g. hot roll

2. Active measures

a) Lip brake (exhalation technique)
After the inspiratory phase is completed, the breathing stops briefly; exhalation takes place against the resistance of the lips, which are slightly pressed together and moistened.
Dosage:
3 x 2-5 breaths, pausing for 2-5 breaths in between

Effect:

  • Prolonged expiration, followed by prolonged inspiration
  • Reduction of the respiratory rate
  • The slowed intrabronchial pressure drop keeps the bronchi wide and less compressible. More air can be exhaled. The collapse phenomena are reduced and the lungs are less over-inflated.

b) Nasal stenosis (inspiration technique)
Press on one nostril, adjust the degree of constriction to the individual possibilities! Trace the path of the airflow. If the idea of a liberating "ah" is used for the inflow, a favourable setting is also achieved in the throat and in the deeper airways. The mouth is closed.

Variations:

  • Press both nostrils slightly inwards
  • Pull the tip of the nose long
  • Dabbing the nose while inhaling

Effect:

  • Intensive deepening of the breath
  • Unfolding of poorly ventilated alveolar sections


c) Contact breathing Breathing work by placing the hands and/or resistance to inhalation as a breathing stimulus

Effect:

  • Draw attention to breathing
  • Breathing direction training, change of conspicuous breathing form
  • Relaxing, calming

A distinction is made between pelvic fractures that do not affect the stability of the pelvis. (As they have no influence on the load-bearing function and the overall statics).

  • Pelvic blade fracture
  • ischial fractures
  • Coccyx fractures and avulsion fractures of muscle insertions (SIAS, SIAI and tuber ischadicum)
Pelvic ring fractures

Anterior pelvic ring fracture = fracture of Os ischii and Os pubis
Posterior pelvic ring fracture = fracture of Os illium

Functional categorisation
  • Type 1 Stable pelvic ring fractures
    e.g. isolated, unilateral, but also fds. non-displaced anterior pelvic ring fracture.
  • Type 2 Pelvic ring injury with instability in rotation of the pelvis, but not necessarily in the vertical plane.
    Dislocated double-sided anterior pelvic ring fracture with or without symphysis rupture, or unilateral anterior pelvic ring fracture with symphysis rupture.
  • Type 3 pelvic ring injury with instability for rotation and vertical direction, i.e. always unstable for weight-bearing on at least one side.
    e.g. posterior pelvic ring fracture with symphysis fissure or anterior pelvic ring fracture with SI joint fissure, etc.

Other names:
Butterfly fracture (bds. pelvic ring fracture)
Malgaigne fracture (anterior and posterior pelvic ring fracture on one side)

Medical therapy

Conservative treatment is generally favoured for type 1 fractures. Surgery is indicated in cases of major dislocation and instability, especially in the vertical direction.

Surgical therapy

Plate osteosynthesis
Wire fixation (for symphysis rupture)
External fixator
Traction screw for dislocated bone fragments (see pelvic ring fractures)

Treatment-relevant aspects and special features

Additional injuries to vessels (iliac artery, femoral artery), nerves, intestines and ureters possible. Depending on the type and corresponding treatment, movements of the upper limb (e.g. rotation) are contraindicated. Always observe the statics!

PT treatment and progression

In the case of generally stable pelvic fractures, mobilise as early as possible;
keep the humerus and lumbar spine free, work to stabilise the lumbar region if possible.
In the case of existing instabilities, take these into account in the treatment, i.e. observe ongoing movements, appropriate relief during mobilisation (between 4 and 12 weeks, depending on the case)

In patients with complex pelvic injuries and with increasing age, a wide range of complaints can be expected:

HG osteoarthritis (especially with HG involvement of the pelvic fracture)
Back pain (e.g. due to too much stability of the pelvis after healing)
Menstrual cramps
Injuries to the urogenital tract
etc.

This results in further physiotherapy measures:

  • Electrotherapy
  • BGM
  • traction
Conservative

Only for non-displaced fractures without dislocation

Surgical

For dislocation in dorso-cranial, dorso-medial, ventral-medial and central direction (mostly combined injuries)
Plate osteosynthesis
Screw osteosynthesis

Special features

Ischiadicus lesion = failure of the foot lifters, foot countersinks and ischiocrural muscles
Sitting is permitted
Acetabular fractures favour early coxarthrosis

Treatment

Axial movements for flex/ext, ABD/ADD, IR/AR
Movement in PNF patterns
Quadriceps training
Sling table BÜ in RL and SL
Functional hip extension exercises
Stemming
Mobilisation and gait training with floor contact (approx. 10 kg) for 10-12 weeks

For sciatic nerve lesions

Electrotherapy
Ice
Tapping
Functional innervation training

Surgical

Plate osteosynthesis
Intramedullary nail (locked/unlocked)
External fixator for open fractures
Ilizarov for large soft tissue damage

Aspects relevant to treatment

Unlocked intramedullary nail = full weight-bearing
Locked intramedullary nail = partial weight-bearing with dynamisation, then full weight-bearing
Plate osteosynthesis = partial weight-bearing
External fixator + Ilizarov = full weight-bearing

Special features

Watch out for signs of infection with Ilizarov and external fixator! The skin on the pins is stretched during exercise! Attention pain!!! Fracture end and bench edge should not be at the same height (shearing forces!)

Treatment and course

1st day
Respiratory gymnastics
Thrombosis prophylaxis
Isometry

2nd day after Redon train
Thrombosis prophylaxis
Isometrics
Movement exercises in the foot and hip joint in all directions (pain-dependent)

From day 3:
Mobilisation see above
Stretching the ischios, quadriceps, adductors
PNF (short lever, dosed rotation)
Also the arms and the contralateral leg

Possible causes
  1. Advanced coxarthrosis
  2. Traumatic destruction of the hip joint (acetabulum, head, SH)
Various Types and loading
  • cemented: stem and cup fixed with pallacos, relatively smooth prosthesis surface, patients usually older than 70 years, immediate VB
    usually VB from 1st postop. day, but pain-dependent. day, but dependent on pain
  • Cementless: rough, partly thread-like surface, should grow in, younger patients, longer durability, first TB for approx. 6 weeks, later VB TEP starting with foot sole contact, slowly increasing to 20 kg for 6 weeks until VB (12th week) depending on pain.
  • "Hybrid TEP": mixture of a) and b), cup cementless, femoral shaft cemented or vice versa.
    20 kg partial weight-bearing for 6 weeks.
  • Duo head prosthesis: cemented ? Full weight bearing, depending on wound healing
Avoid:
  • Rotations
    with anterior approach: no Aro! For surgery, patient lies in supine position and leg in external rotation
    with posterior approach: no Iro! Surgery in lateral position in internal rotation for TEP replacement, cementless socket
    Rotation correction up to the 0 position is permitted!
  • Adduction (neither in flexion nor extension position!) (expansion splint for 5 days)
  • Flexion in combination with add. or rotation
  • Axial flexion/extension is possible and necessary!
  • Flexion and abduction with a long lever during the early phase = first 6 weeks
Dangerous situations

Crossing or crossing legs, caution with carpets and rugs, standing up or sitting down from low armchairs, chairs or the toilet, SL on the opposite side with poor positioning (affected, upper leg falls into add., SL not possible on affected side due to soreness), turning over while lying down, turning over while walking without step sequence
Without complication, this applies for 1/2 year

Therapy

From 1st postop. Get up on the affected side

- Lymphatic drainage, breathing therapy, hot roll, connective tissue massage
- detonation of the tonic muscles
- rapid mobilisation, posture training and extension of movement

Complications

TEP - dislocation, periaticular ossification, TEP - loosening, sepsis

Therapy
  • Bedside table Front access same side
  • Rear access opposite side
  • Movement behaviour Back section of bed not over 70°
  • In lateral position, secure abduction by positioning the leg in between (pillow)
  • Promotion of resorption Lymph drainage
  • Short-term ice
  • Passive - assistive movement exercises
  • Detonation soft tissue techniques (e.g. classic massage)
  • Hot roll
  • Connective tissue massage
  • Strengthening isometrics
  • Brunkow
  • Therraband
  • PNF over flow
  • Gait training Load-dependent point gait (three-point gait - partial load, four-point gait - full load)
  • Stairs 4 - 6 days after surgery
  • ADL functional behaviour training in everyday life
Forms

Supracondylar = extra-articular fractures
Ligamentous medial fracture
Monocondylar fracture
Lateral joint fracture
Y-joint fracture
Joint comminuted fractures

Surgical therapy
  • Condylar plate
  • Cancelliosaplasty with special plate
Treatment-relevant aspects and special features
  • Often high blood loss (haematoma / hypovolaemia, circulation !!)
  • Nerve injuries (peroneal nerve)
  • Haemarthrosis in intra-articular fractures easily leads to adhesions of the capsule
  • Risk of arthrofibrosis
  • Severe swelling and joint effusion
  • Positioning on gable splint
  • Adhesion of soft parts of the thigh
Treatment and progression
  • Haematoma resorption
  • Decongestion with short-term ice, quadriceps tension, lymph drainage
  • Active movement up to the pain threshold
  • Pay attention to surrounding joints
  • Motorised splint
  • Gait training according to Redon train with rolling, possibly 20 kg partial load
  • Strength maintenance and strengthening of the entire leg in the open and closed system.
Surgical therapy

Transverse fracture (tension banding or screw osteosynthesis; always surgery)
Longitudinal fracture (tension banding or screw osteosynthesis; rarely surgery)
Multiple fragment fracture (tension banding with crib wires)
Comminuted fracture (tension banding, possibly resorbable pins
If reduction is not possible, a patellar release is performed

Note:
Free patellar mobilisation is not possible with tension banding osteosynthesis

PT treatment and progression

Until approx. 4th day post-op
Pain-dependent exercise of knee flexion up to max. 60°
Isometric quatricep training
Thrombosis prophylaxis
Circulatory training
Cold treatment (Cryocuff)
Exercise of OSG, USG, toes
PNF with healthy leg
Motorised splint (60/0/0)

from day 4 to week 4 (relief) .day to 4th week (unloading)
See above
After 2 weeks, practise extension unloaded
Practise flexion up to 90 degrees (also active)
Gait training
Slowly increase motorised splint

4th-6th week load build-up
All the points listed above

6th-7th week full load !

Complications
  • Material breakage
  • Step formation (primary or secondary)
  • Cartilage damage
  • Retropatellar arthrosis
  • Pseudarthrosis
Surgical therapy

Transverse fracture (intramedullary nail locked)
Oblique fracture (intramedullary nail locked)
Comminuted fracture (intramedullary nail locked)
In case of soft tissue damage (external fixator)
Open fracture (no intramedullary nail due to intramedullary infection or intramedullary phlegmon)

Static locking = top and bottom locked
Dynamic locking = bottom locked only

Progression and treatment

After Redon traction and X-ray control, 20 kg partial weight-bearing, then slow increase in weight-bearing.

PT treatment

Thrombosis prophylaxis
Muscle pump
Circulatory stimulation
Isometry
PNF (only with proximal resistances)
Exercise OSG, as PF is often restricted
Maintain knee mobility
Strengthening of the arms (PNF, Theraband...)
Gait training

Once the fracture has healed, distal resistances are permitted again!

If treated with an external fixator

There is often a great deal of swelling
Poor soft tissue situation due to haemorrhaging into the muscle belly
The ankle joint and toe mobility is usually poor (contracture)

Treatment

Contracture prophylaxis
Pointed foot prophylaxis (exercise and positioning)
Fixator must always be positioned freely

General

The leg should be elevated on the fixator
It is also possible to change the procedure from fixator to intramedullary nail

Surgical therapy

Partial resection (e.g. basket handle tear)
Meniscectomy (in case of complete destruction)

Treatment-relevant aspects and special features

The medial meniscus is more frequently affected than the lateral meniscus because it is fused to the medial collateral ligament and the capsule and is therefore more immobile. Degenerative processes are more common in the lateral meniscus.

Treatment and course

Day 1
Thrombosis prophylaxis
Isometry
Movement 0/0/60
Positioning in a foam splint

Day 2 post-op:
Redon traction (=> 2 hours bed rest)
Motor splint (pain-dependent or 0/0/60)
Mobilisation under partial weight-bearing 20 kg
Quadriceps training

From day 4 post-op: Anesthesia with a foam splint. Day 4 post-op:
Aim for a range of motion of 0/0/90 through active exercise
Motorised splint
Stretching of the ischiocrural group, quadriceps, popliteus muscle, triceps surae
Climbing stairs

Day 10-14:
Increasing weight-bearing

Fitness for sport is only restored when the muscles are fully rebuilt.

Surgical therapy

Smoothing of the cartilage surface
Rinsing of cartilage flakes
Redon
Bandage (Nodge plastic)

PT treatment and course

1st day post-op:
Thrombosis prophylaxis
Isometry
Positioning in a foam splint

2nd day post-op:
After Redon traction, 2 hours bed rest and intensive ice therapy for vasoconstriction
Free-functional movement exercises in the pain-free area
Mobilisation and gait training under pa rtial weig ht bearing 20 kg

5th - 6th day post-op: Dosage 6th day post-op:
Dosed load build-up

Fitness for sport is restored when the muscles are fully rebuilt!

Tips:


Knee flexion should not exceed 90 degrees under load Swimming, cycling and cross-country skiing are recommended sports.

Post-treatment programme after cruciate ligament surgery with semitendinosus/gracilis and stabilisation with Transfix system

1st-5th day:

  • Relief
  • Movement 0-0-30° (Mecron splint)
  • Isometric exercises
  • PNF contralateral leg, arms

6th-14th day:

  • 20 kg partial weight bearing (up to half body weight with complete freedom from pain)
  • Donjoy splint 0-0-90°
  • CPM pain-adapted up to max. 0-0-90°
  • Passive and active patella mobilisation
  • Traction in the current resting position
  • Lymphatic drainage
  • Start proprioceptive training

3rd week:

  • Full weight bearing at 0-0-90° in Donjoy splint
  • Co-contractions, isometric exercises, ischiocrural muscle training
  • Active and passive patella mobilisation
  • PNF (initially proximal resistance, later also distal)

4th-6th week:

  • 0-0-90° (Donjoy splint)
  • Co-contractions, isometric exercises, training of ischiocrural muscles
  • Cycling (high number of pedal revolutions), stepper training
  • Swimming (leg paddle stroke)
  • Proprioceptive training with tilting board, gyroscope, etc.
  • PNF (initially proximal resistance, later also distal)

from the 7th week:

  • No limitation of movement
  • Intensification of the above mentioned KG exercise programme
  • Additional manual therapy measures
  • Isokinetic training of the extensor and flexor muscles (angular velocity 150°/s, extension limit 20° for 6 weeks). Optional training in a closed system (shuttle).
  • Coordination training
  • Intensification of independent muscle building training with e.g. leg stepper, cycling (high pedal stroke rate), jogging on flat ground, swimming (leg paddle stroke)

from week 12:

Sport-specific build-up training possible

Full fitness for sport after 6 months!

Quadriceps tendon

Selection of applications depending on training status

0-6th week:

  • Passive and active movement exercises after drainage (0/0/90
    Degree to be aimed for
  • Motorised splint (CPM) pain-orientated in the knee (0/0/90) Gard postoperative
  • Active knee extension after secure wound healing up to 0 degrees
  • Passive and active patella mobilisation
  • Co-contraction, isometric exercises, ischiocrural muscle training
  • PNF (initially proximal resistance, later also distal)
  • Successive full weight-bearing and free-functional movement exercises with freedom from effusion and pain. (Full weight bearing not with extension deficit > 10 degrees)
  • After reaching full weight-bearing => stepper training, cycling (high number of pedal revolutions), swimming (leg paddle stroke)

from week 7:

  • Full weight bearing should be achieved!
  • No limitation of movement
  • Intensification of the above mentioned KG exercises
  • Additional manual therapy measures
  • Isokinetic training of the extensor and flexor muscles (angular velocity 150 degrees /s, extension limit 20 degrees for 6 weeks) Optionally also training in the closed system.
  • Proprioception training (e.g. soft surface, rocking board, mini trampoline)
  • Intensification of independent muscle building training with e.g. leg stepper, cycling (high number of pedal revolutions), jogging on level ground


from week 12

  • Sport-specific build-up training possible
  • Accompanying injuries from cruciate ligament injuries
  • Meniscus resection: no change to the programme required
  • Meniscus refixation: until the 7th week only partial weight bearing with 20-30 kg
  • Internal ligament lesion: grade 1 & 2 no change Grade 3 (surgical reconstruction): additional knee joint orthosis for 6 weeks
  • External ligament lesion: knee joint orthosis for 6 weeks
For quadriceps or semitendinosusplasty

Full weight bearing only from the 4th week
Knee joint orthosis for 6 weeks

Causes
  • endogenous (haematogenous spread of pathogens e.g. a phlegmon)
  • exogenous (after open fractures or operations)


Dependence. On number + virulence of pathog. Germs

Constitutional factors that contribute to the suppression of the patient's general defence system.

Frequency
  • 0.5 - 2 % with asept. Bone surgery
  • between 1-5 % after surgical treatment of closed fractures
  • up to 25 % for open fractures
Symptoms
  • General signs of inflammation (redness, swelling, fever,...)
  • Fistula formation
  • Secretion
  • Function. Disorders
Complications
  • Deformities
  • Recurrences
  • Pathological fractures
  • Growth disorders in children
  • Nerve damage due to positioning + pressure
  • Vascular damage
  • Axial deviations
  • Joint dislocations
  • General problems ?
Therapy
  • Immobilisation
  • Positioning + mobility after consultation with doctor
  • System. Antibiosis
  • Suction / irrigation drainage
  • OP evacuation
  • Fix. External
    For multiple fractures Fractures for rod.
    For arthrodesis
  • Ilizarow
    For rod after removal of a bone segment
    For bone lengthening by segment grafting
KG Problems & treatment

1. pain:

  • OP trauma: analgesia, ice, positioning
  • Implant: care measures Measures, soft tissue mob.
  • Soft tissue stretching: small acl. Exercises, isometry
  • Muscle tone: positioning, ice, transverse friction, anchoring grips, acl. exercises Stirrups


2. swelling:

  • OP trauma: positioning, ice, active exercises
  • Hydrostatic: see above, muscle pump
  • Infections: local / system. Measures

3. muscle atrophy: (prophylaxis)

  • Pain
  • Inactivity ® Strengthening, mobilisation, gait training
  • Musc. Imbalance


4. muscle contracture:

  • Pain-related relieving posture: pain relief, positioning, gait & posture training
  • Musc. Dysbalance: Relax. Techniques, stretching techniques
  • Immobility: active exercise in different positions, change of position, mob. double-jointed muscles are more affected than single-jointed muscles and must therefore be included in the therapy as functionally as possible.

5. capsule / ligament shrinkage:

  • Pain-induced relieving posture
  • Immobility ® Manual therapy
Surgical therapy
  • Plate osteosynthesis S
  • screw osteosynthesis
  • Tension strapping
  • Set screw for syndesmosis rupture (removal after 6 weeks)
Treatment-relevant aspects and special features
  • Depending on the injury mechanism, no pro / sup in the first 6 weeks
  • PT treatment
until Redon traction
  • Move toes, forefoot, knee and hip
  • Strengthen arms (support walking)
  • elevate to reduce swelling
after Redon train until 6th week
  • Practise dorsiflexion / plantar flexion
  • PNF with proximal resistance
  • Gait training on crutches, possibly 20 kg partial weight bearing
from the 6th week
  • Full weight bearing
  • Exercise pro/sup
Cause

Consequence of a compression in the longitudinal axis of the body or a fall from a great height

Surgical therapy

Extra-articular fractures without dislocation => conservative therapy Joint fractures and unclassifiable fractures => plate-screw osteosynthesis
Open fractures 1st and 2nd degree => plate-screw osteosynthesis, 3rd degree => external medial fixator

PT treatment and progression

Preoperative decongestion measures !!!

Postoperative:

Elevation of the leg in a US splint (reduction of soft tissue swelling)
Free positioning of the calcaneus

Treatment
  • Thrombosis prophylaxis
  • Circulatory stimulation
  • Isometry
  • Immediate exercise of the USG/OSG


After Redon traction, additional X-ray control:

  • Mobilisation with unloading of the calcaneus for 10-12 weeks
  • PNF (proximal resistance)
  • Triceps atrophy prophylaxis
  • KG mobilisation, patella, metatarsals and toes
  • Calf stretching (decongestion, TP)
  • Soft tissue techniques
  • PNF arms and healthy leg


Slow load build-up after 10-12 weeks. Gait training with special attention to the rolling movement!

Definition: Intra-articular compression fracture of the distal tibia with
cancellous bone effect; usually comminuted # with extensive joint destruction.

Cause

Axial force on the distal end of the tibia, e.g. fall from a great height.

Conservative treatment

Rather rare

Surgical indications
  • Always for displaced fractures. However, due to poor soft tissue coverage, definitive surgical treatment should be secondary.
  • In the case of massively dislocated fractures, a joint-bridging external fixator osteosynthesis is required to ensure adequate immobilisation and reduction.
  • After the soft tissue has subsided, the patient is switched to an internal plate osteosynthesis.
  • A free flap arthroplasty must often be planned at an early stage.
KG treatment
  • Prophylaxis programme (DP, TP, PT)
  • Immediate mobilisation with unloading
  • Gait training
  • Keeping neighbouring joints free / pointed foot prophylaxis
  • Manual therapy in the entire foot area (toes, metatarsophalangeal joints, metatarsus)
  • MLD
  • Full weight-bearing capacity not before 12 weeks ME after 12-18 months
Possible causes
  • Advanced coxarthrosis
  • Traumatic destruction of the hip joint (acetabulum, head, SH)
Different types and loading
  • cemented: stem and cup fixed with pallacos, relatively smooth prosthesis surface, patients usually older than 70 years, immediate VB usually VB from 1st postop. day, but pain-dependent. day, but dependent on pain
  • Cement-free: rough, partly thread-like surface, should grow in, younger patients, longer durability, first TB for approx. 6 weeks, later VB TEP starting with contact with the sole of the foot, slowly increasing to 20 kg for 6 weeks until VB (12th week) pain-dependent
  • "Hybrid TEP": mixture of cemented and cementless, cup cementless, femoral shaft cemented or vice versa.
    20 kg partial weight-bearing for 6 weeks.
  • Duo head prosthesis: cemented ? Full weight bearing, depending on wound healing
Avoid
  • Rotations:
    with anterior approach: no Aro! For surgery, patient lies in supine position and leg in external rotation
    with posterior approach: no Iro! Surgery in lateral position in internal rotation for TEP replacement, cementless socket
    Rotation correction up to the 0 position is permitted!
  • Adduction (neither in flexion nor extension position!) (expansion splint for 5 days)
  • Flexion in combination with add. or rotation
    Axis-appropriate flexion/extension is possible and necessary!
  • Flexion and abduction with a long lever during the early phase = first 6 weeks
Dangerous situations

Crossing or crossing legs, caution with carpets and rugs, standing up or sitting down from low armchairs, chairs or the toilet, SL on the opposite side with poor positioning (affected, upper leg falls into add., SL not possible on affected side due to soreness), turning over while lying down, turning over while walking without step sequence
Without complication, this applies for 1/2 year

Therapy: from 1st postop. day, standing up over the affected side. Standing up on the affected side

  • Lymphatic drainage, breathing therapy, hot roll, connective tissue massage
  • Detonisation of the tonic muscles
  • Rapid mobilisation, posture training and extension of movement

Pathologically increased inflammation of the distal joints as a result of trauma or surgery, especially in vegetatively unstable patients

Staging in terms of duration is no longer recommended.
SRD can begin with a cold, cyanotic extremity as well as a warm and swollen one and persist for years.
Trophic disorders can also occur if the extremity is too warm or too cold and swollen.

The primary lesion and the current SRD findings are important for therapy

  • Spontaneous pain
  • Active and/or passive restriction of movement
  • Permanent or only load-dependent swelling
Pathogenesis

Pain caused by the triggering event leads to excitation of the nociceptors
which results in a reflexive disturbance of sympathetic vascular innervation,
which in turn has a negative effect on blood flow.
A change in the activity of the sympathetic vasoconstrictor neuromas causes an
increased venous tone, resulting in an obstruction of drainage from the capillary area with subsequent oedema.
This in turn leads to spontaneous pain and pain on movement, which excites other nociceptors.
The result is a vicious circle with restriction of movement and even fibrosis.

Symptoms

Three areas can be categorised according to clinical neurological criteria:

  • Autonomic (sympathetic) disorders consisting of generalised swelling and altered skin temperature
  • Motor disorders in the form of restricted mobility and reduced strength
  • Sensory disorders, which include altered skin sensitivity and diffuse, deep spontaneous pain.
Physiotherapeutic therapy

Only what is good for the patient is justified, no passive exercises, daily treatment.

  • Splints, gloves/stockings made of stretchable but compressive material in the case of pronounced oedema.
  • Gradual ice treatment, if the after-effect is well tolerated
  • Descending cool partial ice bath, whereby an indifferent temperature is often sufficient. Reactive, pain-intensifying hyperaemia should be avoided.
  • Lymphatic drainage
  • stretching massage techniques
  • elevation when pain relief is achieved.
  • active/assisted movement of all joints, only low-pain to pain-free from the shoulder joint to the elbow to the wrist
  • decongestive tensing/relaxing or isometrics
  • Movement in a partial bath/movement bath, whereby the buoyancy forces promote venous drainage.
  • Manual therapy
  • Posture correction
  • Splint postop. Wear day and night for 6 weeks, then for a further 2 weeks only at night without reins.
  • During these 6 weeks no active flexion, no stretching and no resistance (no carrying heavy loads)
  • Physiotherapy 2-3 times a week without a splint: passive stretching of the fingers from an approximated starting position. Passive flexion of the fingers and movement of the wrist with flexed fingers.
  • After removal of the splint (week 7). Start with active flexion of the long fingers. The aim is free extension and flexion up to fist closure without strain. Physiotherapy continues 2-3 times a week.
  • From the 9th postoperative week, increasing weight-bearing until full weight-bearing from the 12th week. Therapy ends around the end of the 12th week.
Scar treatment

After approx. 14 days, the stitches are removed from the wound, and once the last crusts on the wound have fallen away, care of the scar must begin, preceded by a 10-minute camomile bath if necessary. Then massage the scar with your thumb or thumb and forefinger twice a day for 10-15 minutes and apply a moisturising cream.

Post-treatment programme after shoulder surgery for functional problems

  • No active abduction over 90°

  • Isometric muscle strengthening exercises in individual directions of movement

  • Keeping the thoraco-scapular gliding plane free, posture training

  • Capsular toning and stretching measures, treatment of tendo-myotic changes

  • Passive/assistive movement exercises

  • Motorised splint (CPM)

in the absence of pain:
  • Isotonic movement exercises (also against resistance)
  • PNF
  • Muscle strengthening with Theraband, MTT or similar
  • Backstroke

Post-treatment programme after reconstructive shoulder surgery

0-3rd week
  • Immobilisation with TG tube bandage
  • Passive/assisted movement exercises up to 60° abduction (Abd) and elevation (Elev)
  • No external rotation (AR)!!!, but AR from internal rotation position to neutral 0 position possible
  • Decongestive measures (e.g. foam ball)
  • Keep the thoraco-scapular gliding plane free, posture training
4th-6th week
  • Removal of the shoulder bandage
  • Passive/assistive movement exercises up to 60° abdomen/elevation
  • Still no AR above neutral 0 position!
  • Otherwise as 0-3rd week
From week 7
  • Free-functional follow-up treatment, gradual increase in AR
  • Pain-dependent active movement exercises
  • Muscle strengthening with Theraband, MTT or similar
  • PNF
  • Manual therapy

Follow-up treatment programme after reconstructive rotator cuff suturing

0-6th week:

  • Immobilisation with abduction cushion
  • Passive/assistive movement exercises from 30° abduction (Abd) and elevation (Elev)
  • No zero position (hanging arm) in abduction.
  • Rotational movements in abduction from 30° depending on the injured zone
    Zone A: avoidance of external rotation beyond the 0 position
    Zone B: no restriction of rotation
    Zone C: avoidance of internal rotation
  • Decongestive measures (e.g. foam ball)
  • Keeping the thoraco-scapular gliding plane free, posture training

From week 6:

  • Removal of the abduction cushion
  • Passive/assistive movement exercises from 0° Abd/Elev

From week 7:

  • Free functional follow-up treatment
  • Pain-dependent active movement exercises
  • Manual therapy

From week 12:

  • Muscle strengthening with Theraband, MTT or similar.
  • PNF