Southern Illinois University School of Medicine

Fracture Treatment Protocols

Table 1. Upper Extremity
Fracture	X-rays Needed	Immobilization	Fixation	Mobility Precautions
Scapula
scapular body acromion process coracoid process glenoid neck glenoid fossa	AP/axillary/scapular shoulder	sling	screws reconstruction plates tubular plates mini T-plates	Stable: WBAT Unstable: protected weight-bearing 2-3 months no deltoid isometrics until 6 weeks post stabilization sling immobilization as needed
Clavicle
displaced	AP/axillary Shoulder	Sling or Figure of 8 Strap	reconstruction plates	Stable: WBAT Unstable: PWB-NWB 6-8 weeks postinjury sling, figure 8 immobilization as fracture/patient status dictates
nondisplaced	AP/axillary Shoulder	Sling or Figure of 8 Strap	dynamic compression plate (DCP)
Humerus
1. Proximal fractures greater tuberosity lesser tuberosity surgical neck anatomic neck	AP/axillary Shoulder AP/Lat Humerus	Coaptation Splint vs.Sling	plate wires (tension-band, K-wire) 2.5-mm Schanz pins screws external fixation hemiarthroplasty (elderly patient)	NWB 8-12 weeks sling, Neer protocol (circumduction, passive abduction & forward flexion, > 4weeks then aarom)
2. Humeral shaft	AP/Lat Humerus	Coaptation Splint	DCP locked IM nail	NWB-WBAT as fracture pattern dictates
3. Distal humerus	AP/Lat Elbow AP/Lat Humerus	Posterior Elbow Splint	reconstruction plates tubular plates screws tension-band wire for olecranon osteotomy	NWB 8-12 weeks Aarom as soon as soft tissues allow

Radius and Ulna
1. Olecranon	AP/Lat Elbow AP/Lat Forearm	Posterior Elbow Splint	tension-band wiring screw, wire fixation	Aarom as soon as soft tissues allow NWB
2. Radial head	AP/Lat Elbow AP/Lar Forearm	Posterior Elbow Splint	closed reduction mini-fragment screws mini T-plates	Aarom as soon as soft tissues allow NWB
3. Forearm isolated radius, ulna – both bones	AP/Lat Forearm	Sugar Tong Splint	closed reduction plates screws (rare) IM nail (rare)	Aarom as soon as soft tissues allow NWB 8-12 weeks
Monteggia/Glaeazzi	AP/Lat Forearm	Sugar Tong Splint
4. Distal radius	AP/Lat Forearm	Sugar Tong Splint	closed reduction external fixation ORIF	Aarom as soon as soft tissues allow NWB 8-12 weeks

Wrist & Hand
carpal	AP/Lat Hand	Dorsal-Volar Splint	closed reduction wires mini-plates	cast, splint immobilization NWB-PWB 8-12 weeks
MC	AP/Lat Hand & Fingers	Buddy Tape
phalanx
Terminology: (NWB) Nonweight-bearing – patient may not use extremity for any weight–bearing activity (TDWB) Touch-down weight-bearing – extremity may touch the ground just during rest, not during ambulation (TTWB) Toe-touch weight bearing – toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing – approximately 20-30 lbs. (PWB) Partial weight-bearing – weight limit specified by M.D.

Fracture	Initial Physical Therapy Program	Advanced Physical Therapy**
Scapula
scapular body acromion process coracoid process glenoid neck glenoid fossa	Days 1-5: shoulder pendulum exercises elbow, forearm; wrist, hand AROM; grip strengthening Weeks 2-3: gentle PROM-AAROM shoulder; deltoid, rotator cuff isometrics If stable fracture pattern- shoulder PROM-AAROM initiated 1 week postinjury, ROM, strengthening progressed to tolerance	Stable: PROM/strengthening as tolerated Unstable: strengthening at 3 months; progress to isometrics, surgical tubing, and free weights
Clavicle
displaced nondisplaced	Stable Day 1 post-stabilization: early shoulder AROM-AAROM to tolerance; shoulder isometrics; elbow, forearm, wrist, hand AROM; grip strengthening Unstable: limit ROM as fracture pattern dictates	Stable: PROM/strengthening as tolerated Unstable: strengthening at 6-8 weeks; return to activity in 10-12 weeks

Humerus
1. Proximal fractures greater tuberosity lesser tuberosity surgical neck anatomic neck	Day 1 post-stabilization: elbow, forearm, wrist, hand AROM; grip strengthening Days 2-5: pendulum shoulder exercises Weeks 1-3: early gentle AAROM shoulder joint within mobility limitations; deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder	Week 12: begin strengthening; progress to isometrics, surgical tubing, free weights, isokinetics; scapular stabilization exercises are important
2. Humeral shaft	Day 1 post-stabilization: elbow, forearm, wrist, hand AROM grip strengthening Days 2-5: Pendulum shoulder exercises Weeks 1-3: Early gentle AAROM shoulder joint within mobility limitations: deltoid, biceps, triceps, isometrics Weeks 3-6: AROM, gentle PROM shoulder	Weeks 10-12: strengthening Week 12: progression the same as for the proximal humerus
3. Distal humerus	Day 1 post-stabilization: shoulder AAROM-AROM; wrist, hand active range of motion-CPM (elbow) as M.D. indicates Days 2-5: gentle elbow, forearm AROM; deltoid isometrics; grip strengthening Weeks 8-10: gentle PROM-AAROM elbow, forearm	Weeks 10-12: strengthening Week 12: isokinetics

Radius & Ulna
3. Olecranon	Days 1-7 post -stabilization: early gentle AAROM-AROM forearm, elbow (initiated after 2-3 days); shoulder, wrist, hand AROM; grip strengthening	Weeks 10-12: PROM; strengthening
4. Radial head	Days 1-7 post-stabilization: early elbow AROM shoulder, wrist, hand AROM; grip strengthening	Weeks 10-12: PROM;strengthening
3. Forearm isolated radius, ulna – both bones Monteggia/Glaeazzi	Days 1-5 post-stabilization: immediate shoulder, hand AROM; early, gentle AAROM forearm, elbow, wrist as fracture stability allows; grip strengthening	Weeks 10-12: PROM Week 12: strengthening
4. Distal radius	Days 1-5 post-stabilization: immediate AROM shoulder, elbow, fingers; initiation of gentle wrist AROM as immobilization allows (after cast removal than splint); grip strengthening	Weeks 8-10: PROM; light activity Weeks 10-12: strengthening

Wrist & Hand
carpal MC phalanx	Days 1-5 post stabilization: early AROM-AAROM fingers, wrist, forearm as fracture and stabilization allow; elbow, shoulder AROM; fine motor control, desensitization; techniques as indicated	Weeks 8-10: PROM; light activity Weeks 10-12: strengthening
6. (WBAT) Weight-bearing as tolerated – patient may bear weight through extremity as tolerated 7. (TKE) Terminal knee extension – short-arc quadriceps strengthening exercises 8. (SLR) Straight leg raises – isometric strengthening exercises with hip flexion Post-stabilization to healing *After fracture healing

Table Two: Lower Extremity: Acetabulum to Femur
Fracture	X-Rays Needed	Immobilization	Fixation	Mobility Precautions
Acetabulum
Posterior wall; posterior columns; anterior wall; anterior column; transverse; T-shaped; posterior column/posterior wall; transverse/posterior wall; both column; anterior column with posterior hemitransverse (Letournel classification)	AP Pelvis Judet Views CT San (3mm Cuts)	Distal Femoral Traction	Lag screws reconstruction plates	Kocher-Langenbeck approach: (posterior), avoid active hip extension rotation Ilionguinal approach: (anterior), avoid active hip flexion, vigorous trunk and abdominal flexion Extended iliofemoral approach: (posterolateral), no active hip abduction 6-8 weeks; weight-bearing; NWB 8-12 weeks; positioning ROM; posterior wall involvement – no hip flexion greater than 70 degrees for 6 weeks
Pelvis
1. Anterior ring public symphysis rami 2. Posterior Ring Sacrum SI fracture/dislocation iliac wing	AP, inlet & outlet Pelvis, CT scan	See pelvic fracture disruption protocol	plating external fixation lag screws screws plating	TDWB-WBAT 10-12 weeks postinjury (depends on associated, posterior ring involvement) TDWB-WOLWB 10-12 weeks

Femur
1. Femoral head	AP Pelvis AP/Lat hip	Distal Femoral Traction	Screw fixation hemiarthroplasty THA (in elderly patient as fracture dictates)	Toe-touch weight-bearing 8-12 weeks no straight leg raises (SLR) TTWB, WBAT dependent on prosthesis fixation (see femoral neck fracture)
2. Femoral neck	AP Pelvis AP/Lat both hips (uninjured side with templeates)	Buck’s Traction	screws dynamic hip screw endoprosthesis (elderly)	WB as necessary for balance for ambulation WB as necessary for balance for ambulation WBAT ROM precautions: avoid simultaneous/combination movements of the operative hip. Allow flexion, extension, abduction, adduction or rotation in cardinal planes of motion with no restriction; no SLR 6 weeks Posterior surgical approach: no hip flexion greater than 60 degrees, avoid hip adduction, internal rotation past neutral; no SLR 6-8 weeks
3. Interochanteric femur	AP Pelvis AP/Lat hip	Buck’s Traction or Pillow Splints	DHS or IM nail	WB as neccessary for balance for ambulation on walker or crutches
4. Subtrochanteric femur	AP Pelvis AP/Lat Femur	Distal Femoral Traction	DHS Blade plate IM nail	TTWB; no SLR; no active hip abduction with blade-plate fixation
5. Femoral shaft	AP/Lat Femur AP/Lat Knee AP Pelvis If severely comminuted get scanogram opposite femur	Distal Femoral or proximal tibilal Traction	IM nail	Interlocked nail/plate TTWB 6-8 weeks
6. Supracondylar, intracondylar femur	AP/Lat Femur AP/Lat Knee AP Pelvis	Knee Immobilizer	DCP, LC, DCP condylar blade plate; condylar buttress plate; screws	Note: Knee immobilizer, external support may be needed To allow early crutch training if quad control slowly achieved; DCP fixation same as IM nail protocol TDWB 10-12 weeks
Terminology: (NWB) Nonweight-bearing – patient may not use extremity for any weight–bearing activity (TDWB) Touch-down weight-bearing – extremity may touch the ground just during rest, not during ambulation (TTWB) Toe-touch weight bearing – toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing – approximately 20-30 lbs ( PWB) Partial weight-bearing – weight limit specified by M.D.

Fracture	X-rays Needed	Immobilization	Fixation	Mobility Precautions
Patella
Nondisplaced	AP/Lat Knee	knee immobilizer	cylinder cast,	Stable: WBAT
displaced			lag screw (s) tension-band wiring	Unstable: TTWB 4-8 weeks

Tibia
1. Tibial plateau	AP/Lat Knee CT Scan	knee immobilizer	buttress T-plate DCP screws	TDWB 8-12 weeks NO TKE exercise (avoid excessive end range anterior tibial glide)
2. Tibial Shaft	AP/Lat tibia	Cadillac Splint Walking boot	IM nail reamed and unreamed; plates and screws; external fixator	PWB 6-8 weeks TDWB 8-12 weeks PWB 6-8 weeks

Ankle
1. Pilon	AP/Lat Ankle Mortise View AP/Lat Tibia	Cadillac Splint Calacneal Traction	screws and plates	NWB 12 weeks
2. Medial malleolus, posterior malleolus, lateral malleolus (Weber A, B, C)	AP/Lat Ankle Mortise View	Cadillac Splint	screws, plates, and tension-band wiring	PWB 8-12 weeks

Foot
1. Calcaneus extraarticular intraarticular	Lat Foot Oblique Foot Harris Heel View CT Scan (3mm Cuts)	Cadillac Splint Use a lot of Padding to protect from Inevitable swelling.	Reconstruction plate H-plate; lag screw K-wires	NWB 12 weeks
2. Talus	Lat Foot	Cadillac Splint with toe plate	lag screws or K-wires (rare)	NWB 12 weeks
3 . Metatarsals and phalanx	Oblique Foot AP/Lat & oblique Foot	Cadillac Splint with toe plate	screws, wires, and pins	closed reduction immobilization
Terminology: (NWB) Nonweight-bearing – patient may not use extremity for any weight–bearing activity (TDWB) Touch-down weight-bearing – extremity may touch the ground just during rest, not during ambulation (TTWB) Toe-touch weight bearing – toe may touch ground just for balance (WOLWB) Weight-of-leg weight-bearing – approximately 20-30 lbs. (PWB) Partial weight-bearing – weight limit specified by M.D. 6. (WBAT) Weight-bearing as tolerated – patient may bear weight through extremity as tolerated 7. (TKE) Terminal knee extension – short-arc quadriceps strengthening exercise

Fracture

Initial Physical Therapy Program

Advanced Physical Therapy**

Nondisplaced;

displaced

Days 1: bilateral UE strengthening; ankle AROM;

knee CPM post-op if indicated

Days 2 to discharge: quad hamstring isometrics***; knee/AROM

as fracture pattern allows***; SLR***

Weeks 4-8 : strengthening; progress knee A/AAROM; begin quad

Isometrics and SLR if there was quad mechanism involvement

Week 8: WBAT, wean from crutches; concentrate on short arc/end range; quadriceps strengthening; closed kinetic chain activities (i.e., cycling, partial squats, leg press); balance proprioceptive training

1. Tibial plateau

2. Tibial Shaft

Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training

Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training

Day 1-discharge: bilateral UE & contralateral LE strengthening; AAROM, isometrics, AP involved LE; bed mobilization/transfer and ambulation training

Weeks 6-8: TKE initiated; A/AAROM operative LE; hip girdle, quad & hamstring strengthening; balance/proprioception training

Weeks 12-14: WBAT, wean from crutches, gait retraining; strengthen quads, hamstrings, abductors, flexors, extensors, and lower trunk muscles; initiate balance/proprioceptive awareness training; aerobic/fitness & functional training

1. Pilon

2. Medial malleolus,

posterior malleolus, lateral

malleolus (Weber A, B, C)

Immediate post-stabilization: bilateral UE strengthening; gluteal, quad, hamstring isometrics

Day 2 to discharge: hip, knee toe AROM; SLR, TKE

Week 2: ankle subtalar AROM; progressive hip and knee strengthening

same as pilon fracture

Week 12: PROM initiated; strengthening; balance/proprioceptive awareness training; WBAT, wean from crutches; closed kinetic chain program

Weeks 8-10: gait progression after fracture healing; AROM/PROM

ankle and subtalar joints; balance/proprioceptive awareness training

1. Calcaneus

extraarticular

intraarticular

2. Talus

3 . Metatarsals and phalanx

Preoperative: UE strengthening; uninvolved extremity strengthening

Involved extremity hip, knee isometrics; crutch training for short distance (primary elevation of extremity)

Day 1: UE strengthening; uninvolved extremity AROM strengthening involved extremity hip- knee isometrics; AROM, Toe AROM to tolerance

Days 2-3: crutch training, NWB involved extremity (limited time in dependent position)

Days 4-7: early ankle, subtalar AROM when surgical incision is sealed

Week 1 to month 3: continue early AROM ankle, subtalar, toes; gentle PROM toe dorsiflexion and plantarflexion; progress involved extremity; hip-knee conditioning

Same as calcaneus

Day 1 post-stabilization: biliateral UE strengthening; hip, knee

AROM, isometrics; ankle, subtalar, toe AROM as fracture pattern allows

Month 3: gradually increase weight-bearing starting at 20lbs to FWB

over 1 mo; gradually wean from assistive devise as patient tolerates; pool therapy if available; gait training, re-education; desensitization techniques as needed; ankle subtalar AAROM isometrics; low impact endurance training

Months 4-6: gait progression, advanced balance and proprioceptive activities; ankle, subtalar isometric, isotonic strengthening with tubing/theraband; no free weights; soft-tissue immobilization

Month 6: ankle, subtalar PROM; joint mobilization; isokinetic assessment, strength-endurance training; advanced balance, gait training as indicated

Same as calcaneus

Weeks 8-12: WBAT; wean from crutches; proprioceptive/balance training;; closed kinetic chain activities

8. (SLR) Straight leg raises – isometric strengthening exercises with hip flexion

9. (UE) Upper extremity

10. (LE) Lower extremity

*Post-stabilization to healing

**After fracture healing

***Note: No active quads if quadriceps mechanisms involved or disrupted

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