Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in patient
with medial malleolar fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
IM, 68 year old woman with recent history of
right medial malleolus fracture and
postmenopausal osteoporosis

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Severe pain and stiffness in right ankle, swelling and tenderness of the ankle, moderate disability in gait
Post surgical (internal fixation of the right medial malleolus fracture) rehabilitation status

ANAMNESIS (history)
Our 68 year old woman suffered, two months ago, an isolated medial malleolus fracture after twisting her ankle
while walking down a flight of five stairs, and has underwent surgical treatment.
She has previous history of postmenopausal osteoporosis, bilateral hip arthrosis and lumbar spondylosis.
She performed daily activities in standing postures in her professional life.
Her history reveals previous fractures of both upper limbs, after menopausal status. After injury, IM was unable to
stand and bear weight on her own immediately following the falling. She presented to emergency department after
two days, with significant ankle swelling and difuse pain in foot and ankle, predominant in medial side. After
orthopedic examination, she was diagnosed with right medial malleolus fracture. The surgical treatment was
performed in the same day for fracture - open reduction and internal fixation with screw. Sutures are removed at 14
days. Post operative period was uneventful.
The patient was kept on short leg cast for 6 weeks and was allowed to bear weight with the help of crutches only
after 2 months.
IM is coming in our department to perform and learn the rehabilitation measures for regain her gait and her
independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. Is a surgical intervention a correct indication for our patient?

a. Yes
b. No
c. Probably
R=a

2. The intervention in our patient is important for regaining functional status of the lower limb?
a. No
b. Yes
c. It is indifferent
R=b

3. How can we explain the type of ankle fracture (only medial malleolus) in our patient?
a. In pronation-abduction or eversion the transverse fracture of medial malleolus is occurred in the first stage
b. In supination-adduction, near vertical fracture of medial malleolus is occurred in the second stage.
c. In supination-lateral rotation, fracture of medial malleolus is occurred in the third stage.
R=a
 Personal data
Questions` answers

1. Is a surgical intervention a correct indication for our patient?

Yes. Indications for operative treatment of ankle fractures are dictated by the stability of the ankle joint. All
malleolar fractures are intraarticular injuries, with variable affected soft-tissue. In literatura data it is mentioned
that indications for surgery are: articular / unstable / displaced fractures. Open reduction and internal fixation
(ORIF) are the components of the surgical intervention.

2. The intervention in our patient is important for regaining functional status of the lower limb?
Yes. Surgical treatment for medial malleolus fracture consists in a medial approach and fixed with either single
malleolar screw, k-wire or with tension band wiring with 2 screws or k-wires. This anatomical reduction and
satisfactory fixation usually leads to a rapid return of function - sufficient stability to allow full mobility at the
ankle joint.

3. How can we explain the type of ankle fracture (only medial malleolus) in our patient?
In various injury, the foot in a pronated and abduction attitude, the talus is abducted in the ankle mortise resulting
in traction on the medial ankle structures and compression laterally. The bones and ligaments of injuried ankle
are affected in the following order: stage I - transverse fracture of medial malleolus or rupture of deltoid
ligament; stage II - rupture of both anterior and posterior tibiofibular ligaments with fracture of posterior tibia. In
supination attitude, first appeared the injury of lateral malleolus or fibula, than of the medial malleolus.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

IM is 1.62 m height and a weight of 69 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with bilateral coxarthrosis , without significant complaints, and knee joints in normal limits.
Left ankle
range of motion - passive dorsiflexion (10), passive plantar flexion is 40, passive inversion is 25 and eversion
is around 10, no pain during passive movement.
we palpated the body and tendon of the tibialis anterior, extensor hallucis longus, and extensor digitorum longus;
the peroneus longus and brevis tendon are palpated as it passes posterior to the lateral malleolus; on the medial
aspect, posterior to the medial malleolus, we palpated of the posterior tibialis, flexor digitorum longs, and flexor
hallucis longus. Manual muscular testing is normal, in accordance with her age.
Right (broken) ankle
range of motion - all motions were limited as a result of pain, swelling and scar tissues, especially eversion
all muscles around had value 3 on the manual muscular testing.
Weakness of the ankle muscles was noted and the ability to stand and balance on right leg is significantly diminished.
Gait is possible with one crutche , on the left side (partial weightbearing gait on the right lower extremity). The patient
complained of right ankle and foot pain when she got up from a chair and walked.
Neurovascular status of lower limbs are intact.
Vital Signs: temperature 36.7C, blood pressure 140/80 mmHg, rhythmic pulse 74 b/min, 20 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. How can we explain the loss in range of motion in our patients ankle?
a. Because the cartilage is destroyed
b. Because concomitant damage to the soft tissue around bones
c. Because our patient is female in menopausal status
R = a, b

2. Ankle range of motion is important for gait rehabilitation ?

a. No
b. Yes
c. It is a biomechanical parameter that can be ignored in gait rehabilitation program
R=b

3. Why is it important to perform ROM in our patient?

a. To establish the extension and flexion mechanisms of foot and ankle
b. To complete the physical examination
c. To monitor the pain of lower limb
R=b

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the ankle pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the loss in range of motion in our patients ankle?
The broken ankle will never return to the pre-injury level of function. Even with an ideal fracture reduction, the
concomitant damage to the soft tissue and cartilage causes some pain and loss of range of motion.

2. Ankle range of motion is important for gait rehabilitation ?

The ankle joint is composed of 2 joints: the true ankle joint and the subtalar joint. Ankle fractures refer to
fractures of the distal tibia, distal fibula, talus, and calcaneus. The true ankle joint allows dorsiflexion and plantar
flexion or the "up and down" movement of the ankle. The foot can be made to point toward the floor or toward
the ceiling via the true ankle joint. The subtalar joint allows the foot to be inverted or everted, that is, the sole of
the foot can be made to face inward (inverted) or face outward (everted) through the subtalar joint. So, normal
gait is possible only if the two joints of the ankle are functional and without pain.

3. Why is it important to perform ROM in our patient?

A systematic ROM examination revealed a restricted motion in ankle joint and foot, altered gait and poor
balance, quite common after a period (almost 2 months) of immobilization. After an ankle fracture, the
biomechanics of the ankle may affect: loss of range of motion, especially dorsiflexion, with a significant effect
on gait and increases forefoot loading alteration in contact area. These aspects can promote post traumatic
arthritis.

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patient with ankle fracture take into consideration the global kinetic
exercises, after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for
flexion are very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X-rays.
This type of scan is the most common and widely available diagnostic imaging technique.
X-rays can show if the bone is broken and whether there is displacement (the gap between broken bones).
The standard plain radiographic views of the injured ankle are the mortise view (a modified AP with the ankle
internally rotated so that the malleoli are in the same horizontal plane and the joint space is seen evenly on both sides
of the ankle) and lateral (is very valuable in assessing congruence and posterior malleolar fractures). After surgery, it
can monitor the callus, in time.

!! Stress test - the physician may put pressure on the ankle and take a special x-ray,
called a stress test; it is done to see if certain ankle fractures require surgery.

Computed tomography (CT) scan.

This type of scan can be useful in assessing more complex fractures. CT changed management in 40% of
syndesmotic injuries, 31% of fracture-dislocations and 29% of trimalleolar fractures. Scans influenced fixation of
medial and posterior malleolar fracture elements.

Magnetic resonance imaging (MRI) scan.

This type of scan, rarely indicated, provides high resolution images of both bones and soft tissues, like ligaments. For
some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the type of internal fixation performed in our patient?

a. Fixation of medial malleolus
b. Fixation of high fibular fracture
c. Fixation of metal plate and external fixation
R=a

2. The imagistic findings of X-ray ankle can suggest the mechanism of injury suffered by our patient?
a. No
b. Yes
c. It is a MRI image of ankle
R=b

3. Is arthroscopic examination essential for our patient when we start the rehabilitation program?
a. Yes
b. No
c. It is important to be performed in the future
R = b, c
 Imagistic data
Questions` answers

1. What is the type of internal fixation performed in our patient?

Postoperative anteroposterior and lateral x-rays of our patient who underwent open reduction demonstrate the
internal fixation with screw of the medial malleolus fracture. It can observe in both scanned bones (tibia and fibula)
osteoporosis (our patient is diagnosed with postmenopausal osteoporosis). The porosity of these bones may increase
the risk of fixation failure and thus preclude early mobilisation.

2. The imagistic findings of X-ray ankle can suggest the mechanism of injury suffered by our patient?
By using the algorithm based on the experimental work of Lauge-Hansen, the radiologist can quickly diagnose the
mechanism of injury and the degree of completeness. Ligamentous tears are recognized as easily as the malleolar
fractures. Using radiographic information, it is possible to assess the mechanism of injury and the stage at which each
force arrested. Evaluation of the medial malleolus or width of the medial side of the ankle mortise assesses the injury
to the medial aspect of the ankle and is the second determining factor in establishing the type of force. A more
rehabilitation treatment of the injury can be instituted on the basis of accurate information afforded by the
radiographic examination alone.

3. Is arthroscopic examination essential for our patient when we start the rehabilitation program?
Posttraumatic arthritis has been described in 14% of patients with broken ankle. despite an anatomic reduction, most
likely as a result of chondral injury sustained at the time of initial injury. The arthroscopic examination can found that
more patients have some degree of chondral injuries, in time.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness;
changes in body structures medial malleolus fracture;
activity limitation - limited walking ability and problems with ADLs;
participation restrictions - reduced participation in leisure activities and in household chores.
The primary ICF activities and participation codes associated with ankle stability and movement coordination impairments
are d450 walking, d4552 running, d4553 jumping, d4558 moving around, specified as direction changes while walking
or running.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 8 before, 4 after rehabilitation program;
6 Minute Walk, with crutches = 110 meters before; 200 meters after rehabilitation program;
Timed Up and Go, with crutches = 38 seconds before; 26 seconds after rehabilitation program;
scales for condition-specific health status measures
The Foot and Ankle Outcome Score (FAOS) is a self-reported questionnaire and was developed to assess function in
a variety of foot and ankle-related problems; it is a 42-item questionnaire assessing patient relevant outcomes in five
separate subscales (Pain, other Symptoms, Activities of daily living, Sport and recreation function, foot and ankle-
related Quality of life); Sum up the total score of each subscale and divide by the possible maximum score for the
scale;100 indicates no problems and 0 indicates extreme problems. FAOS = 27 before rehabilitation; 35 after.
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 37 before rehabilitation; 43 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to assess the functional status in our patient ?

a. Yes
b. No
c. Is no important to mention
R=a

2. The changes in body structures that appeared from surgery may explain?
a. Back pain and lumbar stifness
b. A further disturbance in the neuromuscular status
c. Optimal balance and gait
R=b

3. The final score of the two scales used for our patient The Foot and Ankle Outcome Score (FAOS) and SF-36
are in concordance for disability status ?
a. Yes
b. No
c. It is no possibility to compare the two score scales
R=a

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for muscular joint status takes a few weeks after intervention
R=c
 Functional data
Questions` answers

1. It is important to assess the functional status in our patient ?

Yes. Many investigators have evaluated both short- and long-term results after surgery, to establish the complete
clinical and functional status of patient. Today, it is used patient-reported scores to evaluate functional results, as has
been done in almost studies. In accordance with the International Classification of Functioning, Disability and Health
(ICF), the degree of impairments, disabilities, participation problems and health related quality of life should be
described from the patients perspective.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further
disturbance in the neuromuscular status.

3. The final score of the two scales used for our patient The Foot and Ankle Outcome Score (FAOS) and SF-36
are in concordance for disability status ?
Yes. The both scales contain the items for quality if life and various daily activities in which the lower limb, ankle
especially, is responsible for balance and gait. The gait scheme is disturbed in isolated fracture of the medial
malleolus that occurs when the foot is forcefully rolled inwards or outwards; when the foot rolls out, this pulls
tension on the medial malleolus, and cause its fracture.

4. How we can explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients' recovering from ankle fracture reclaim 2 3 months for plateau in strength and functional gains. The
outcome measures chosen for our patient study are common clinical measures and their associated impairments are
theoretically addressable by targeted rehabilitation techniques, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Medial right malleolus fracture (operated 2 months ago, open reduction and internal fixation surgery),
type A after Herscovici classification of medial malleolar fractures by level
2. Postmenopausal osteoporosis (medication controlled) with previous upper limb fractures
3. Bilateral primary coxarthrosis
4. Mechanical low back pain. Lumbosacral spondylosis.
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the imagistic arguments for our patients complete diagnosis?
a. Diffuse osteoporosis in both bone segments
b. Distal extent at the level of the talar dome
c. Medial malleolus fracture
R = a, c

2. The following diagnosis can be taken into consideration for possible complications in our patient?
a. Reflex sympathetic dystrophy (RSD)
b. Posttraumatic Arthritis
c. Malunion or nonunion of the fracture site
R = b, c

3. We must mention the complete diagnosis for all patients disorders? Why?
a. No, it is not an important aspect
b. Yes, because the disorders have an important conditioning for rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b
 Complete diagnosis
Questions` answers

1. What are the imagistic arguments for our patients complete diagnosis?
The medial side is normally stabilized using screw. This fracture has indication to operate on a displaced ankle fracture
because of a perceived risk of symptomatic medial malleolar non-union, especially in female patient, with osteoporosis
like our patient.

2. The following diagnosis can be taken into consideration for possible complications in our patient?
The reflex sympathetic dystrophy (RSD) generally precede ankle fractures. Our patient is female with postmenopausal
osteoporosis, so her ankle fracture may consider a complication or manifestation of her basic bone disorder.
Posttraumatic arthritis complicates 20-40% of ankle fractures. When the fracture is more severe, the risk of this
complication is the greater . Older females have an increased risk of arthritic complications.
Malunion or nonunion of the fracture site can occur more frequently in older female patient. Malunion has potentially
proceeds to degenerative changes of the joint. Chronic persistent symptoms such as pain, weakness, and instability of
the ankle may develop.

3. We must mention the complete diagnosis for all patients disorders? Why?
Recovering program typically reclaim kinetic exercises. In older patient all kinetic program must respect the intensity,
duration and frequency in accordance with cardiac and respiratory status. Also, the back pain (lumbosacral
spondylosis) and bilateral hip degenerative arthritis are real stones in rehabiliation program goals and sessions.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
controlling the residual inflammatory process;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the ankle in the economy of the limb biomechanics;
maintenance of normal daily activities and maximization of quality of life.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, biphosphonate drugs, vitamin D3 and calcium carbonate oral
non-pharmacological modalities:
- educational, dietary and hygienic,
- posture (activity modification), protective boot and ankle brace,
- physical (thermotherapy ice-pack to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased joint
swelling and pain will reduce chances of developing complications during the rehabilitation process;
- massage classic and special massage (Cyriax) of ankle and foot,
- kinetic
- early rehabilitation includes gait training with assistive devices, crutches first, cane after; ankle pumps, ankle
range of motion (foot and ankle up and down, in and out, circles), isometric contraction of all muscles of lower
limbs;
- stretching and thera-band exercises for ankle (dorsiflexion, plantarflexion, inversion, eversion in this order),
heel and toes rises, single leg balance and progressive ankle weights as indicated and tolerated by the individual;
- ankle strengthening exercises, calf, hip and knee exercises (to help improve waling ability), balance and
proprioception exercises, global exercise to improve functional mobility and walking ability.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why it is important to perform a rehabilitation program (RP) in our patient?

a. Because the RP improves only the ankle ROM
b. Because the RP improves the upper limb function
c. Because the RP improves the lower limb function
R=c

2. Why should we respect the kinetic algorithm program in our patient rehabilitation ?
a. Because ROM exercises must preceded the strength exercise
b. Because it is the patient option
c. Because it is performed open reduction and internal fixation (ORIF)
R=a

3. What are the goals of RP in our patient, when she presented in our department ?
a. Initiate functional weightbearing exercises , open kinetic chain AROM and isotonic strengthening exercises
b. Initiate proprioception and gradual gait exercises
c. Restoration of strength, power, and endurance
R = a, b

4. The dysfunction in lower limb is optimally controlled in our patient?

a. Yes
b. No
c. It is no important
R=a
Rehabilitation program
Questions answers

1.Why it is important to perform a rehabilitation program (RP) in our patient?

The complex goal of rehabilitation is to restore range of motion, strength, proprioception, and function. Anatomic
reduction is necessary to restore the normal anatomy of this weight bearing joint. Earlier and well controlled RP may
prevent stiffness and lead to faster recovery and joint motion contributes to cartilage health. Our patient should advance
weight bearing as tolerated but limit activities such as heavy lifting and running. An exercise conditioning program will
help the patient return to daily activities.

2. Why should we respect the kinetic algorithm program in our patient rehabilitation?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and progressed
as indicated and tolerated by the individual. The rehabilitation program is adapted to the surgical intervention performed
for our osteoporotic patient, who has a risk of developing painful non-union status.

3. What are the goals of RP in our patient, when she presented in our department?
The patient is coming in our department after she removed the knee cast, after 8 weeks after intervention. The goals of
rehabilitation program are: continuing healing of fracture site, normalizing AROM and impaired proprioception, initiate
gradual return to functional activities and light work activities. All rehabilitation has to respect the progression for
optimal control of patients impairments and functional limitation, to prevent the falls.

4. The dysfunction in lower limb is optimally controlled in our patient?

Yes. Everyone heals differently, and everyone's ankle fracture injury is different. After RP performed, our patient had
optimal gait training. She was help to progress from using an assistive device to walking independently; applied
progression for walking included: using one crutch and a standard cane when our patient went home. We informed our
patient that it may take several weeks for the muscles around her ankle to get strong enough for normal walking and to
return to your regular activities.