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Author Topic: Tibial Plateau Fracture - When to start bending knee  (Read 13863 times)

Offline tpfskiing

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Tibial Plateau Fracture - When to start bending knee
« on: April 23, 2008, 06:00:01 AM »
Hello,

I have the following fractures to my left tibia as a result of a skiing accident 6 weeks ago:
1) avulsion fracture to the tibial spine
2) depressed fracture of the lateral tibial plateau
3) vertical epiphyseal fracture

I had surgery and the surgeon inserted 2 screws.  I now have a T-ROM brace, but I can only bend the knee to 30 degrees and have not started physical therapy yet.  Am I far behind on my therapy?  I have been reading that most people are flexing the knee up to 90 degrees only a few weeks after surgery with this type of fracture.  What can I do to get the knee to bend more?  I go to the Dr. again tomorrow, so just thought I'd get some input before seeing him.  Thanks for your comments.

Offline maryc

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #1 on: April 23, 2008, 06:45:40 AM »
Every injury is different, but do ask you OS about your ROM.  Also ask when you will be starting PT.  I would look at the exercises on the knee rehabilition page http://www.kneeguru.co.uk/KNEEnotes/node/1118.  Check with your Dr if you can begin these exercises.
8/4/07 fell
8/5 diagnosed TPF
8/6 surgery plate and 6 screws
8/12 out of hospital NWM
8/21 staples removed
9/18 OS appt - WBAT with crutches
10/10 - WBAT with cane
10/27 - back to work w/cane
12/26 - no cane, slight limp when tired
1/25/08 - released from PT, no limp
2/3/09 - Released by OS

Offline aislyn

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #2 on: April 23, 2008, 01:20:35 PM »
TPF's are such tricky injuries. Mine happened on 1/28/08. No surgery, but had an immobilizer for 8 weeks, NWB, and than PWB for 2 weeks doing 90 minutes of rehab daily. When I first got my immobilizer off I had 0 ROM, but as of yesterday, was released from my OS with a full 180 degrees and FWB with slight limp. Do check the exercises  on this site, they are great and I used them all over the course of my rehab, but do check with you OS. I also think that bending that knee has a high fear factor. It certainly did for me. I was so worried that I would injure myself again. Best of luck and keep us posted.

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #3 on: May 02, 2008, 04:45:41 AM »
maryc, thank you so much for your suggestions!  It's great to have some new exercises that I can work on!

aislyn, thank you for your personal story... it is encouraging to hear that after 8 weeks with an immobilizer you are now at 180 degree ROM!

I am scheduled now for 8 weeks of physical therapy (non-weight bearing) and had my first session this week!  The therapist took some measurements of my leg (to check muscle loss, ROM - still at 30 degrees), said that I have lots of fluid in the knee, started me with some muscle contractions using electric stimulation, and had me walking around on the crutches.  Now I just have to get this knee to bend!

Thanks again! ;-)

Offline maryc

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #4 on: May 02, 2008, 05:23:06 AM »
TPF - with your PT's ok try letting gravity help with your ROM.  Sit in a chair with your knee on the edge of the chair, let gravity pull you leg down while trying to keep the back of your knee pressed into the chair.  Although it sounds simple it worked for me.
8/4/07 fell
8/5 diagnosed TPF
8/6 surgery plate and 6 screws
8/12 out of hospital NWM
8/21 staples removed
9/18 OS appt - WBAT with crutches
10/10 - WBAT with cane
10/27 - back to work w/cane
12/26 - no cane, slight limp when tired
1/25/08 - released from PT, no limp
2/3/09 - Released by OS

Offline fuzzybob

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #5 on: May 02, 2008, 12:59:43 PM »
Whilst the cause of my TPF is different from most, to reassure you my ROM is recovering well after 6 weeks immobilised and NWB.

I suffered a lateral TPF during surgery on 12/03/08! I was in for a high tibial osteotomy (HTO) and posterolateral corner (PLC) ligament reconstruction. During the HTO, as my OS was placing the final screw (had a puddu plate and 4 screws) noticed my tibia fracture from osteotomy site up to the joint line through the tibial plateau. He did not proceed with the PLC reconstruction due to this rare complication and had to place extra long screws to try to stabilise the fracture. I had a slight step (depression).

Immediatly post op I was placed in a full length back slab plaster cast and confined to complete bed rest for 48 hours. Not allowed to move! Re-X-rayed and as bones and metal work still insitu, my OS removed the cast and replaced it with a Donjoy T-ROM immobiliser locked at 0 degrees, NWB for 6 weeks. Not allowed to moved around apart form getting up to go to bathroom for 2 weeks post op, then allowed to get up and move around a bit more, but not allowed to bed the knee at all.

X-rays at 1, 2, 4 and 6 weeks postop. At 6 weeks OS unlocked the brace and has allowed me to start gentle flexing and gentle weight bearing. I am now 7 weeks post op. 1 week with my new freedom to move.....and had my first PT session yesterday. Amazingly I have 0 degrees extension and can just get to 90 degrees flexion. Swelling stopping me from going any further.

PT, OS and me really please with progress so far at this early stage. So I hope this gives you some encouragement and re assurance getting ROM back after so long immobilised is possible.

Good luck with your recovery.

09/06 bad hamstring tear/undiagnosed knee injury
03/07 >6 months PT.OS referral
05/07 OS#1 diag. old age
07/07 OS#2 scope/EUA. Diag.LCL/PLC/ACL laxity, Grade3 medial femoral condyle damage, medial meniscus displaced
12/03/08 HTO,TPFx in surgery!
04/09 hardware out scope/EUA.PLCr not needed
ACI?

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #6 on: June 08, 2008, 05:48:39 PM »
Thank you all for your replies... it's nice to have a community of people who understand what it's like to go through a TPF!

I am now 12 weeks post-op and started weight-bearing this week.  The problem is I still cannot get my knee to bend past 30 degrees flexion!  Do you think I may have arthrofibrosis (stiff knee syndrome) from too much scar tissue?  I have been in physical therapy for the last 6 weeks, but my doctor has not given the therapist permission to actively bend the knee, and I cannot bend it myself past 30 degrees.

I had a CPM machine for a month, but that didn't get it past 30 degrees, and two visits with an acupuncturist did not get it bending either.  I have an appointment with a medical massage therapist on Monday and with my doctor on Tuesday.  I plan to ask my doctor about arthrofibrosis and manipulation, and I will ask him to give my therapist permission to actively bend it.  Will a CT scan show how much scar tissue I have?

Oh and by the way, for any of you reading this who is on crutches, be careful not to overdue it... I developed Guyon's Canal Syndrome in my right hand from putting too much pressure on the palm of my hand and have been in a wheelchair for the past month (symptoms are numb pinkie and ring finger and it's 6 weeks or more in a wrist brace for it to hopefully go away)!

Thanks for your thoughts!

Offline fitnesskitty

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #7 on: June 09, 2008, 06:30:58 PM »
Hi there,

I would not panic about the flexion yet, but as someone that did have a frozen knee from scar tissue, I would be happy to listen and answer any questions you may have if it does come down to that. The first point I want to make is, wait until your therapist is allowed to begin helping you push your flexion.  This will hurt some, but you will get through it.  If he or she cannot help you gain ROM after a few sessions, then I would be more likely to go back to the OS.  Mine was completely frozen and got to the point where I was actually losing flexion.  I had a second surgery a little more than three months after the first: a scope LOA (lysis of adhesions) to remove the scar tissue and an MUA (manipulation under anesthesia).  My OS does gentle MUAs so as not to damage the knee.  My original injurt was a dislocation of the patella, a partially torn tendon and bone fragments from a fall down just a few stairs in my house.  First surgery was performed six days after my injury, to allow some swelling to go down.

Second, CPM machines are not ment to increase ROM, but to get the joint lubricated and help keep it lubricated.  It is less about ROM and more about keeping the joint "warmed up."  I would not fret over that.  Mine went up to 120 degrees max, and I could get mine all the way through the machine's range of motion, and then go to PT, and have just 90 - 100 degrees of flexion.  It was highly inaccurate, and could be inaccurate in either direction, especially if you are not on a really flat surface, such as the floor.  On my bed, mine was off by at least 30 degrees.

Anyway, keep us posted on your progress!  Please feel free to message me if you would like to ask questions or vent!

Take care!

Sarah


Aug 17 07 Injured
Aug 23 07 Open surgeryOct 18 07 No progress made at PT for awhile - stuck 52/53 degrees
Oct 23 07 Saw OS, wants second opinion from partner-ROM stuck 30-35
Nov 1, LR, LOA, MUA
PT 2X/week now, was 3X
Jan 8: ROM 134
Rest In Peace, Lucky!  I love and miss you so much!!!!!!!!

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #8 on: August 11, 2008, 08:34:54 AM »
Hello all,

I am now 5 months post-op and I have had 6 weeks of very active (and painful) physical therapy and my knee will still not bend past 45 degrees!

The orthopedic surgeon gave me 4 more weeks of therapy to get the knee to bend, but if it is not past 90 degrees by then, he plans to operate.  He described the surgery as orthoscopic with 3 holes and a rotating blade that will cut out the scar tissue and cut small incisions into the muscle above the patella.  This sounds like it could do more harm than good to me, but what are my other options?

Thanks for your advice!

Offline favouritesearcher

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #9 on: August 12, 2008, 08:28:26 AM »
Hi TP,

I would say that surgery is your only option unless you want to be stuck with a leg which won't bend.  I was in a similar situation to you, range of motion 20-75 after working at it for 5 months.  The arthroscopic surgery hurts a bit and you need to spend a lot of time afterwards on the correct exercises (making the leg fully extend straighten, keeping the kneecap mobile, keeping the knee bending so that the scr tissue can't come back).  Really, for me it was when y real recovery bagan and I was looking forward to it.

FS
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #10 on: August 19, 2008, 04:08:08 PM »
Thank you FS for your post.  How long after the arthroscopic surgery were you up and walking again?  Did you try manipulation under anesthesia before surgery?  What kind of fracture did you have?  How long after your first surgery did you start bending your knee?  Thanks!  TP

Offline favouritesearcher

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #11 on: August 22, 2008, 07:53:07 AM »
Hi TP,

I had a tibial spine avulsion fracture, where the ACL ripped out the bit of bone it attaches to in the centre of the tibia.  That was the only damage done in the accident (no meniscal damage, ligament damage or other breaks).

After the first surgery my knee was in a fixed brace for 2 weeks, then I was allowed to bend it to 30 degrees for 4 weeks, then to 60 for 4 weeks, then to 90.  That was the theory but I think that my leg was actually bent at 15 degrees inside the brace, so it was never straight.  When I was still stuck at 60 degrees after 10 weeks they threw the brace away and said to get it bending no matter what.  It only moved twice – once from 45 to 60 degrees, and the second time from 60 to 75 degrees.  I think that having the knee bending immediately after surgery for a broken bone is at the cutting edge and not quite thought of as the best way of doing things, especially for a tibial spine avulsion fracture where the screw goes vertically down into the bone rather than horizontally across it to reattach the ACL.

After the arthroscopic surgery I used my crutches for about another 2-6 weeks and gave up the walking stick about 5 months later.  I would say that rehab after the second surgery took about a year.  I was able to drive about a week after the surgery and could sit in a chair normally the next day.  Its important to make sure that the surgeon has a PT protocol lined up for you because a lot of surgeons don’t pay much attention to this (straightening the leg, doing patella mobs and bending the knee passively in a CPM machine to get rid of the debris and lubricate the joint).

An MUA was not really an option for me because my leg wasn’t straight, and no amount of forcing a leg straight will fix that problem because the scar tissue was probably stuck under the patellar tendon and probably also stopped the ACL going into the notch properly.  I thought about an MUA but since it was 5 months since the first surgery and accident I decided that there was too much risk, because the scar tissue has usually hardened up by then.

FS
Mar 04 - Tibial spine avulsion fracture (skiing). Open surgery to fix, 1 screw.  Max passive ROM 20-75, active ROM 30-45
Aug 04 - Diag. severe arthro. Scar tissue clean up (LOA, removal of scar tissue).
Feb 05 - Discharged from surgeon's care. ROM 3-125.
Apr 05 - Discharged from physio. Same ROM

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #12 on: November 02, 2008, 04:05:08 AM »
Hi all,

At 7 months postop and after 4 months of aggressive PT my knee would only bend to 75 degrees, so I had a second surgery 2 weeks ago. They did an arthroscopic surgery to remove scar tissue and got me to 115 degrees in the OR. With daily PT, my ROM is now up to 90-100 degrees, but I was told I need to come back again in 3 months for another surgery. Is it normal to need so many surgeries? I am using a CPM machine for 6 hours a day, on crutches for one more week, and doing PT a few times a week.  The surgery was not bad compared to the first, but now I am waking up sometimes at night with throbbing pain by the patella. Just curious how long this ordeal will continue until I can bend my knee enough to run again (if ever).

Thanks!

Offline maryc

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #13 on: November 02, 2008, 04:50:44 AM »
http://www.kneeguru.co.uk/KNEEnotes/node/753  check out this link on arthrofibrosis I think you may find it helpful
8/4/07 fell
8/5 diagnosed TPF
8/6 surgery plate and 6 screws
8/12 out of hospital NWM
8/21 staples removed
9/18 OS appt - WBAT with crutches
10/10 - WBAT with cane
10/27 - back to work w/cane
12/26 - no cane, slight limp when tired
1/25/08 - released from PT, no limp
2/3/09 - Released by OS

Offline tpfskiing

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Re: Tibial Plateau Fracture - When to start bending knee
« Reply #14 on: May 01, 2009, 12:05:55 AM »
Hello all,

I just thought I would update my post since it's been a while...

After my 2nd surgery in October 2008, I went back in February 2009 and had a 3rd surgery.  My ROM was at 120 degrees maximum pre-op and they decided to operate because I still had stiffness around the patella, particularly under the patellar tendon.

I did not receive a nerve block pre-op, but I requested and received one post-op, after waking up from the surgery with pain.. I will get one every time from now on!

The good news is... in the OR, after scar tissue was removed, my ROM increased to about 135 degrees.  It further improved during therapy, and I am now almost at full range of motion!!

The bad news is... during this 3rd surgery they found a hole in my cartilage down to the bone (grade 4 changes on the lateral femoral condyle) that will require a microfracture surgery in one year.  The cause of the hole is unknown and this was the first time I heard of the problem.  I wonder if the surgery caused the problem.

I am now 3 months post-op and although my flexion is mostly back, my knee is still stiff, crunches / cracks loudly when it bends, and feels sore / painful with active use.  I still need to bring an ice pack to work every day as my knee constantly feels hot.  Also, the top of my shin from my knee to my ankle is still numb, which the anesthesiologist says is not from the nerve block (but which may resolve by itself after 6 months, as nerves take a while to heal).

I consider myself to generally be a happy person, but recently I feel like crying a lot and I don't know why.  I assume it is just built up frustration from this ongoing injury.  I am finding it so much more difficult to be patient and let the knee heal this 3rd time around.  I keep trying to get back to my normal life, but I am limited in the things I can do (I used to be very physically active).

But despite all of this, and the fact that I will need a 4th surgery next year, I am happy that I can finally bend my knee.  Also, the doctors, nurses, and PT staff at the Clinic were all amazing, and I feel really lucky to have discovered them by reading all of your posts on this website.

So, thanks for your support and wishing you all the very best with your surgery/recovery/healing!

;)