post tibia # and IM nail fixation- rehab

male with IMnail fixation to tibia with distal and prox 3rd fractures 12/52 ago. delayed rehab due to skin necrosis. Now green light surgeon. objective fwb with no crutches return to sport. Callus formation is very slow
He lacks knee extension and has tibfem pain on WB . Not the nail - directly over the incision through the Patella tendon.
1. can I mob the tib fem joint?
2. exs to avoid for strengthening. i am looking closed chain, cocontraction and balance through out the leg. Leg press, bike, hip work, stp ups, wt transfer work and stretching, proprioception. I am avoiding resisted knee extension as in on a cybex machine. I assume that is right.
Chances are i am not going to bother the fracture and that ultimately I am looking for co contraction/stability /wb loading with no shear forces to facilitate the # consolidation etc.

PLease comment. I am just returning to practice

[Physiobase]

Was there any injury to the tibial plateau or is this now simlpe a surgical site? If no injury then I cannot see any reason why you can't mobilise the knee joint and in fact this might be something I would do during the first session.

You need to keep in mind that the leg suffered a brutal injury to fracture in two places and that often the "fixation" or focus of the acute medical team is the fracture.

Yet to fracture the clients leg probably took a huge force across the knee joint itself. This may well mean that there is soft tissue damage at the knee as well. Assess the knee joint for specifc knee injury and treat as applicable.

Most of your exercises seems fair and well thought out. Graded additions of these though as callous formation becomes more ossified. It is likely that the ankel could well do with some mobilisation and the calf and peroneals with some gentle soft tissue work to restore tissue balance, blood flow, nerve elasticity etc. The fracture itself and the subsequent immobilisation would have had an effect on those areas.

I would say don't do to much to soon. Keep it simple, standardised, work on two legs together initially before challenging balance on one (as they might not have had great balance prior to the injury). Walking alone will be enought for the fracture to heal so you don't need to consider exercises to compress things anymore than that in terms of ossification.

Good luck and keep us posted with problems. How did the injury occur? 8o

No injury to tib plateau and the surgeon has checked all the ligts etc.
He was a keen sledger who missed the up and coming large tree. He hit the tree directly with his R tibia.
INterms of # movement, I was reluctant to get in and check TF joint and other structures for fear of displacing the prox fracture site. How realistic is it that despite fixing the tibia well with my hands that I will create any shear at the #site. He has very slow callus formation at both sites, the proximal being the slowest.
I used this same thought process when deciding to avoid any open chain resisted through range knee work. Am i sound in that judgement. If this is good at what point would I be able to consider this kind of ex?

Thank you for your advice. I have super seniors when i graduated and for the first 4 yrs of my career but have since then not lived in my home country and have been unable to practice. Now I work on my own in a european country but there is no support mechanism as an employee so since the pay does not cover the child care I have had to jump in to private parctice. I want however to give great treatments and have never stopped eating textbooks since graduation. However it must be said, eating research/books / attending courses does not prepare you for the very surprisig lack of confidence you feel when faced with patients again.

I hope that I can get back the confidence soon- I am motivated.. i guess i was just spoilt in the hospitals where I have worked in the UK and the training/ support that I received. I miss it so much!!

[Physiobase]

You mentioned in the first post that it was the tib/femoral (knee joint) that you wanted to mobilise? Is it in fact the proximal tib fib joint? I would take it easy on that one although the movement is so small in real terms and mobilisation of this joing in an anterolateral direction with a flexed knee does help often with some forms of knee pain.

If the client is full weight bearing then the surgeon must be pretty happy with the ability of the tibia to take some force. Anterior draws with the patient in supine and the knee in various ranges of flexion should not pose any real problem for the fracture site. I would use pain a a guide there (providing sensation is fully intact).

Exercise bike riding and walking are going to be a simple way forward. If he can tolerate it some swimming (front crawl) could provide some bening type forces across the site. It tolerated progressing that to short flippers on the feet and a kick board to hold onto could also assist.

At the end of the day it is a broken bone. If the joints are intact, the blood supply and nerve structure intact and the muscles working then the recover should be progressive and uncomplicated. Physio is mainly acting as a guide to the appropriate starting point and subsequent progression. 8o

yup sorry I meant tib fem and not tib fib
thanks for your help