Today, we’re continuing with Mareike’s question dealing with a character who has several medical complications from a broken leg as a result of a physical assault. You can read Part I here.

Today, I’m hosting Tim B. (my own physical therapist!) If you’re south of Denver and need an excellent physical therapist I’d be happy to refer you.

Here are Tim’s thoughts on the rehab aspects of this character. He also gives great insight into the medical treatment of such a fracture.

Welcome, Tim!

If a person has a compound, open, major fracture of the leg (the part between the knee and ankle), then the most likely treatment would be an ORIF (open reduction, internal fixation), or plates and screws. People with ORIF are then not given a cast.
If the fracture was comminuted (bone is fragmented versus a straight fracture), the typical treatment might be ORIF or an external fixator (halo). You can view this link for photos.

That person would then be non-weight bearing for at least 6 weeks (or more, depending on radiographic evidence of healing), then transitioned into partial weight bearing. They would use crutches or a wheelchair during the non weight bearing phase. The weight bearing phase would progress according to radiographic healing, more than anything else. There is no protocol, per se.

If a person is casted all the way to the hip, then there most likely would have been a fracture extending into the knee joint line, such as a tibial plateau fracture—which could be one of several fractures, including a compound fracture let’s say in the mid-shaft of the tibia/fibula.

Sometimes, an external fixator is applied (in the case of badly damaged and very swollen surrounding soft tissues). After swelling decreases, another procedure could take place (removal of external fixator and placement of internal plates/screws). A cast to the hip would not be used for a fracture below the knee, most likely. So the knee must be involved somehow for the cast to need to go all the way to the hip. Most people are issued a knee immobilizer after these fixation procedures. Perhaps in regions/countries where immobilizers and braces are not commonly found a person could be casted.

Compartment syndrome could be a result of the initial mechanism of injury—lots of soft tissue damage along with bleeding from the fracture—causing compression of the nerves and blood vessels of the leg. Or compartment syndrome might result from a cast that is too tight. Or a bedridden person who doesn’t move at all (same mechanism as a person developing a DVT due to lack of movement).

If blood vessels and/or nerves are compromised in the initial injury or by permanent damage from compartment/compression, the first attempt would be microsurgery by vascular/neurosurgeons to try and repair. Also, a release of the compartment would most likely take place.

Compartment releases are left open and frequent dressing changes take place until swelling comes down. It leaves a wide and long scar in the long run. It takes a little time to realize if it was successful or not (nerve and vessel repair). Perhaps a week later it would really be evident if the correction was successful, or if the leg/foot was “dying” due to lack of blood supply. Those dead areas would not be able to bleed, would probably start turning color, would start to smell, and might be numb.

PT would vary greatly.  Typically, non weight bearing to partial with appropriate crutch use while working the regions of the body surrounding the leg, including even the upper body for strengthening. Progression depends upon radiographic evidence of bone healing for the most part. Range of motion of the knee, ankle, and hip would be emphasized (for most people who have immobilizer but not casts).

Hope this helped and best of luck with your story!