Ankle fracture rehabilitation training

- Dec 31, 2019-

The ankle joint is composed of the lower end of the tibia and fibula and the talus. It is the pulley joint with the largest weight of the human body. When standing, the whole body weight falls on the ankle joint. The load value when walking is about 5 times the weight. Walking and jumping movements in daily life mainly depend on Ankle dorsiflexion and toe flexion exercise.


Ankle fracture refers to the fracture of the internal and external ankle of the distal tibia and fibula. It is one of the common fractures in orthopedics. It usually occurs after ankle sprain caused by indirect violence. Different types of fractures can be caused depending on the direction and size of the violence and the position of the foot at the time of the injury.


Clinical manifestation

After ankle trauma, the ankle is painful and swollen, and bruises and bruises may appear under the skin. They are afraid to move the ankle and cannot walk. Examination revealed ankle deformities, marked tenderness on the medial or lateral malleolus, and bone fricatives.


X-rays of the ankle joint should be taken in ortho, lateral and ankle points, and fractures should be diagnosed according to the history of trauma, ankle pain swelling and deformity, and X-ray manifestations. When the ankle joint is injured, high fibula neck fractures sometimes occur. Care should be taken to avoid missed diagnoses.


For high lateral malleolus or fibula fractures, care should be taken to evaluate the possibility of lower tibiofibular joint injury. In addition, you should pay attention to check other concomitant injuries, such as injury of the peripheral ligament, injuries of fibula tendon, Achilles tendon, posterior tibialis tendon, talar osteochondral injury, nerve, and vascular injury, etc., if necessary, MRI examination.


Fracture of the fibula combined with the ligament (type A ankle fracture):


A transverse avulsion fracture below the level of the tibiotalar joint, the tibiofibular ligament is intact, and it is related to the position-force direction when the foot is injured, and the stability of the ankle points is supination-abduction. The lateral malleolus avulsion fracture is accompanied by a transverse fracture line. After the fracture is reset, it can be fixed with steel plates. If the lateral injury is an avulsion fracture piece with ligaments attached, it can be fixed with screws or tension bands.


Trans-ligament joint fibula fracture B-type ankle fracture):

Spiral fractures begin at the level of the tibiofibular joint and show supination. The proximal interosseous ligament is usually intact, and the anterior and posterior inferior tibiofibular ligaments may be torn. The major deformities of the lateral malleolus type B fractures are external rotation, posterior displacement, and shortening. They are fixed with plate screws after reduction.


Fracture of the fibula of the combined ligament (type C ankle fracture):


Fractures are above the tibial commissural ligament, the avulsions of the combined ligament, the ankle joint is unstable, pronation-valgus, or pronation-abduction. Type C fractures also require treatment of the fibula, and open reduction and internal fixation are required to reconstruct the ankle Acupoint stable.


Postoperative rehabilitation

Routine care


(1) Pain Nursing: After supine or hard anesthesia, go to the pillow and lie supine for 6 hours, fast for 6 hours after the operation, monitor changes in vital signs, and do psychological care. Lift the affected limb 20-30cm, keep the incision clean, and remove the sutures after 2 weeks. Toe to the surgical site was compressed with a sterile cotton pad. Keep the incision dressing dry and apply dressing in a timely manner when there is exudation.


(2) Pain care: Postoperative patients have varying degrees of pain. Care should be taken to properly protect the affected area, brake the limbs, avoid wound contamination and prevent re-injury. Patients complaining of pain should strengthen observation, timely treatment, and use painkillers as prescribed by the doctor. When the patient has abnormal pain, observe the pain-causing factors and pay attention to find out whether other complications occur.


(3) Infection care: Monitor the patient's body temperature changes, superficial infections on the wound surface can be treated by drainage, dressing change, rational application of antibiotics and other measures; deep infections need to be re-planned, closed drainage, internal fixation, but not Need to be removed and fixed.


2. Rehabilitation assessment


The assessment must be performed on the basis of a detailed understanding of the medical history and a comprehensive examination of the patient. A brief understanding of the patient's surgical situation is required, and the content of the rehabilitation assessment must be focused and adjusted.


(1) Limb length measurement: The length of the lower limbs is measured with a tape measure from the anterior superior iliac spine through the midpoint of the sacrum to the medial malleolus. The thigh-length is the distance from the anterior superior iliac spine to the medial space of the knee joint, and the calf-length is the distance from the medial space of the knee joint to the medial malleolus.


(2) Measurement of limb circumference: In order to understand the muscle atrophy, it is better to measure the skin part. When measuring, use a tape measure to surround the determined part of the limb for one week, and record the circumference of the limb. The affected and healthy limbs were measured and compared at the same time, and the measurement date was recorded for comparison before and after rehabilitation. A common part of lower limb measurement is to take 10cm above the sacrum when measuring the thigh, and 10cm below the sacrum when measuring the circumference of the calf.


(3) Muscle strength assessment: After the fracture, muscle atrophy and muscle strength often occur due to reduced limb movements. Freehand muscle strength assessment (MMT method) is commonly used to mainly check the quadriceps, hamstring, tibialis anterior muscle, and calf. Triceps, varus, and foot varus muscle strength.


(4) Evaluation of joint mobility: The protractor method is commonly used as the inspection method to measure the active and passive joint mobility of hip, knee and ankle joints in all directions.


(5) Gait analysis: After ankle fracture, it is very easy to affect the walking function of the lower limbs. Gait analysis should be performed on patients. The clinical analysis uses observation methods, measurement methods, etc .; laboratory analysis includes kinematic analysis and dynamic analysis.


(6) Evaluation of lower limb function: The focus is on assessing functions such as walking and weight-bearing.


(7) Nerve function evaluation: including sensory function test, the reflex test, and muscle tension evaluation.


(8) Pain assessment: The degree of pain is usually assessed by the VAS method.


(9) Evaluation of balance function: commonly used scales include the Berg balance scale, Tinetti scale, and "stand and go" timing test.


(10) Assessment of activities of daily living: commonly used modified Barthel index and functional independence assessment.


(11) Fracture healing: including fracture alignment, epiphyseal growth, and delayed or non-union or malunion, mainly through X-ray examination and CT examination if necessary.


3. Rehabilitation training


Surgical treatment has become a conventional treatment method for ankle fractures, but if it is not coordinated with postoperative system rehabilitation, it will inevitably lead to muscle atrophy, tendon adhesions, and joint stiffness, which will affect the long-term efficacy of the ankle joint. Therefore, surgery can restore the ankle anatomical alignment, and rehabilitation training is the key to treating ankle fractures, maximizing ankle function and reducing complications.


Postoperative rehabilitation of ankle fractures can be divided into three segments: early, intermediate, and late stages. During the rehabilitation of ankle fractures, follow the step-by-step rehabilitation principles and follow the principle of gradual treatment. Early passive activities should be supplemented by active activities, and later active activities should be supplemented by passive activities. Actively perform toe activities, passive flexion and extension of the ankle joint, active flexion and extension of the ankle joint, functional activities of the hip and knee joints, and weight-bearing functional activities of the affected limb in order to restore health as soon as possible and walk with full weight.


(1) Early-stage: 1-3 weeks after the operation

In order to make the ankle joint heal firmly, some patients need plaster casts or ankle braces to be fixed for 2-4 weeks. During the fixation period, they should follow the doctor's advice. They should not move blindly and cause injury.


1-7 days after the operation, you can do active activities of the toes with pain, move the toes as hard, slowly, and as widely as possible, and place the ankle joint at plantar flexion less than 10 °, close to the vertical position, and must not cause ankle movement . 5 minutes/group, 1 group/hour, can not only promote swelling but also prepare for future exercise.


Straight leg lifting exercises include lateral leg lifting inward and inward and lateral leg abduction in abduction, and rear leg lifting exercises to strengthen the muscles on the front, back, and inside of the thighs to avoid excessive atrophy. 30 times/group, rest 30 seconds between groups, 4-6 groups each time. Train 2-3 times a day. If the plaster is too heavy, it may not be completed.


One week after surgery, knee flexion and straightening exercises are performed, 15-20 minutes/time, once a day. Thigh muscle exercises include resisting knee extension and resisting knee flexion, practicing the absolute strength of the thighs, medium load (when performing 20 movements, that is, the fatigue-bearing weight), 20 times/group, 60 seconds rest between groups, 2-4 groups/day.


After 2 weeks, the local pain was relieved and the trauma inflammation began to subside. The patient could do the toe movements while doing passive ankle flexion and extension exercises and varus and varus exercises. If the patient's ankle joint is not fixed with plaster, you can start the following exercises. If you wear plaster, you need to check with your doctor. After the plaster or brace is removed, you can practice the ankle movement. After the exercise, continue to wear the plaster or brace.


① Active ankle joint: including flexion and extension and varus. Work slowly and to the maximum extent, but it must be painless or slightly painful to prevent adverse consequences caused by excessive pulling. 10-15 minutes/times, 2 times a day. Hot water soaks your feet for 20-30 minutes before training or if conditions permit, water acupuncture with an intensity of no more than 6 can improve the ductility of the tissue and facilitate the practice.


② Passive ankle flexion and extension exercises: Hold the ankle joint with one hand and hold the front of the foot with the other to do ankle flexion and extension. At the same time, instruct the patient to perform corresponding muscle contraction exercises. Exercise 50-100 times each morning and evening, 2-3 Consistent with the healthy side during the month.


③ Eversion exercises: increase the range of motion and strength of the joints within the range of no pain or slight pain. Because the tissue healing has not fully healed, do not stretch excessively, 10-15 minutes/time, twice a day. Before training, you can soak your feet in hot water for 20-30 minutes or water acupuncture for 20 minutes, and control the intensity to within 6.


In addition, infrared light therapy can relieve muscle spasm and promote the absorption of exudation. It also has a good effect on inflammation, pain, edema and local blood circulation disorders.


(2) Mid-term stage: 4-6 weeks after surgery

Within 4-6 weeks after the operation, the fracture was basically stable, and the fibrous tissue had adhered to the original epiphysis. At this stage, plaster or braces can be removed for fixation.


The ankle joint gradually transitioned from passive activities to passive activities. Patients should be encouraged to do active flexion and extension of the ankle joint while supplementing external forces to increase the range of ankle joint motion. Exercise every morning, middle and evening, about 100 times each time. At the same time, patients are encouraged to do functional activities of the hip and knee joints, which last until 6-8 weeks after surgery, so that the ankle joint activities are basically normal.


Strengthen the muscle strength around the ankle joint, can perform anti-hook feet, anti-blocking feet, anti-inversion and eversion exercises, 30 times/group, 30 seconds rest between groups, 4-6 groups, 2-3 times a day.


(3) Late-stage: 6-12 weeks after the operation

6-12 weeks after the fracture, the fracture is already in the clinical healing period. The patient should follow the doctor's advice to get out of bed to do weight-bearing exercises for the affected ankle and lower limb, such as anterior step, posterior step, lateral step, etc., requiring slow movement, Have control, do not shake the upper body. 20 times/group, 30 seconds rest between groups, 2-4 groups/times, 2-3 times a day. Gradually increase the weight of the load, you can carry heavy weights until you can walk away from the crutches completely after 12 weeks.


Exercises that strengthen the muscles of the ankle and lower limbs include ① Squat: 2 minutes/time, 5 seconds rest, a total of 10 minutes, 2-3 times a day; ② Lift: transition from two legs to one leg; ③ Exercises before lifting your feet: slow and controlled, without shaking your upper body. 20 times/group, with 30 seconds rest between groups, 2-3 times a day.


Strengthening the ankle motion can practice full squatting to protect the legs, and evenly distribute the strength of the legs, making the hips contact the heel as much as possible, 3-5 minutes/time, 1-2 times/day.


Note that exercises should be done step by step, not forced or blindly, strengthen muscle strength to ensure the stability of the ankle joint in the exercise, and pay attention to safety to avoid falling.


(4) Guidance for discharge:

Postoperative rehabilitation exercise guidance is very necessary and should be adjusted in time according to the patient's rehabilitation progress, so as to improve the rehabilitation effect after surgery. Discharged patients should continue to exercise and gradually reach their rehabilitation goals.


① March-April: After 3 months, you can start the transition from slow walking to brisk walking, and practice strengthening the calf triceps strength, and perform balance training; ② April-May: the affected limb can adapt to easy physical activity; ③ May-July: Normal physical work and exercise can resume after 6 months.


(5) Ligament training

The following methods can improve the protective function of ankle ligaments by insisting on daily exercise:


In-situ top feet: feet upright 30cm apart, with the heels raised and the forefoot of the feet not separated from the ground, mentioned and released for 50 times in a row.


Rotating motion: The left foot is standing, the right toe is on the ground, the heel is rotated 10 times from left to right, and then 10 times from right to left. Repeat 5 times, and then change the right foot to stand and rotate the left foot. The method is the same.


Elevator movement: Take a seated position with both feet flat, hold both toes with both hands, and slowly pull back to keep the ankle sore for 1 minute, then relax, repeat after 10 seconds, 20 times in a row. After the exercise, do a relaxing exercise and gently massage the ankle for 2 minutes.