2.7 Fracture Rehabilitation & Immobilization Complications

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

2.7 Fracture Rehabilitation & Immobilization Complications

Key Takeaways Explain This Topic AI

Rehabilitation after fracture balances protection of healing bone against the morbidity of immobilization; staged progression from non-weight-bearing to protected, then full weight-bearing follows fracture stability, fixation method, and biologic healing phases (inflammatory, reparative, remodeling).

Common immobilization complications include disuse osteopenia, joint contracture, muscle atrophy, deep vein thrombosis, heterotopic ossification, and pressure injuries; early mobilization and judicious loading mitigate these.

Cast/wedge correction and surgical fixation (ORIF, intramedullary nail, external fixation) dictate weight-bearing timing: intramedullary nails often permit early weight-bearing, while articular fractures require delayed protected loading.

Red flags during fracture rehab include compartment syndrome (pain out of proportion, paresthesias, pallor), implant failure, and infection; a drop in pain followed by recurrence suggests refracture or hardware complication.

Last updated: July 2026

Fracture Rehabilitation & Immobilization Complications

Fracture care is a shared Domain D topic spanning orthopedic surgery and physiatry. The rehabilitation physician must understand fracture healing biology, fixation stability, and the systemic/musculoskeletal consequences of immobilization to design safe, progressive loading programs.

Fracture Healing Phases

Phase Time Frame Biological Events Rehab Implication

Inflammatory 0-7 days Hematoma, granulation, inflammatory cells Splint/immobilize; control edema/pain; DVT prophylaxis.

Reparative ~1-6 weeks Soft then hard callus (woven bone) Begin protected ROM/AAROM adjacent joints; isometrics.

Remodeling Weeks-months-years Lamellar bone replacement, medullary canal restoration Progressive weight-bearing, strengthening, return to function.

• Fixation-Specific Weight-Bearing Progression Undisplaced/Stable Cast ──► Delayed Weight-Bearing Until Callus
• Intramedullary Nail ──► Early Weight-Bearing (Load-Sharing Device)
• Plate/Screw (ORIF) ──► Variable; Depends on Comminution & Bone Quality
• External Fixator ──► Protected; Pin-Site Care Paramount
• Articular (ORIF Joint) ──► Delayed, Protected Loading to Preserve Cartilage

Intramedullary nails are load-sharing devices that frequently permit early, even immediate, weight-bearing in long-bone shaft fractures. Articular fractures (tibial plateau, acetabulum, pilon) require delayed, protected weight-bearing to allow subchondral bone and cartilage recovery. Periarticular locking-plate constructs depend on fracture comminution and bone quality.

Immobilization Complications

Disuse osteopenia and muscle atrophy : Rapid within weeks; mitigate with isometrics of immobilized muscles, electrical stimulation, and early mobilization of adjacent joints.

Joint contracture : Prolonged immobilization shortens capsule and ligaments; prevent with early AAROM/ROM of uninvolved joints and guarded ROM of the fracture site once stable.

Deep vein thrombosis : Lower-extremity fractures and immobility confer high VTE risk; chemoprophylaxis (LMWH, apixaban) per Caprini/trauma protocol.

Heterotopic ossification : Particularly after elbow fracture, SCI, or TBI; presents with pain, decreased ROM, erythema; prophylaxis (indomethacin for elbow, radiation) and early ROM.

Pressure injuries and cast complications : Padding, skin checks, and prompt cast windowing for localized pain prevent skin breakdown.

Reflex sympathetic dystrophy / CRPS : See chronic pain chapter; early protected motion and desensitization help.

Red Flags & Compartment Syndrome

Compartment syndrome is a surgical emergency. The classic "5 Ps"—pain out of proportion to injury, paresthesias, pallor, pulselessness (late), and paralysis—are unreliable in sequence; pain out of proportion and pain with passive stretch are the earliest. Increased analgesic requirement is a sentinel sign. Compartment pressure measurement (> 30 mmHg or within 30 mmHg of diastolic) confirms; urgent fasciotomy prevents Volkmann ischemic contracture.

Pediatric & Special Considerations

Children's fractures remodel well due to thick periosteum; Salter-Harris classifications guide management (Type II most common; Type IV intra-articular, prone to growth arrest; Type V compression, occult). Greenstick and torus (buckle) fractures are incomplete and stable. Pathologic fractures from osteogenesis imperfecta, malignancy, or metabolic bone disease require etiologic workup.

Pediatric Fracture Considerations

Children's fractures remodel well due to a thick, osteogenic periosteum and growth potential. Salter-Harris classification guides management and prognosis:

• Type Description Significance
• I Physis separation Good prognosis; often occult clinically
• II Through metaphysis Most common; generally good prognosis
• III Through epiphysis (intra-articular) Requires anatomic reduction; growth-plate related
• IV Through epiphysis, physis, metaphysis (intra-articular) High growth-arrest risk; needs ORIF
• V Physis compression Occult; growth arrest common

Greenstick (incomplete, one cortex) and torus/buckle (compression, no displacement) fractures are incomplete, stable, and managed briefly. Remodeling is greatest in fractures near the physis, in the plane of joint motion, and in younger children; angulation outside the plane of motion or rotational malalignment remodels poorly and requires reduction.

Pathologic Fractures & Bone Health Workup

A fracture from minimal trauma, or a fracture in an atypical location, prompts evaluation for pathologic causes: metastatic disease (breast, prostate, lung, thyroid, kidney, myeloma), primary bone tumor (osteosarcoma, Ewing), osteogenesis imperfecta, metabolic bone disease, or chronic steroid/immobility bone loss. Imaging (lytic/sclerotic lesions, MRI for marrow involvement), labs (calcium, SPEP/UPEP, PSA, TSH, vitamin D), and biopsy when indicated establish etiology. The physiatrist should suspect pathologic fracture when pain precedes trauma or when imaging shows an aggressive lesion.

DVT Prophylaxis & VTE Risk in Fracture Patients

Lower-extremity fracture and immobility confer high venous thromboembolism risk. Risk stratification (e.g., Caprini score, Rogers score for trauma) guides prophylaxis: pharmacologic (LMWH, apixaban) plus mechanical (intermittent pneumatic compression) when not contraindicated. Pelvis/acetabulum, hip, and multiple long-bone fractures are highest risk. Balancing fracture bleeding against VTE risk, prophylaxis is typically initiated within 24-72 hours once hemostasis is secure.

Functional Outcome Priorities

Rehabilitation after fracture targets restoration of range of motion, strength, gait/balance, and return to work/sport. Outcome measures (e.g., DASH/QuickDASH for upper extremity, LEFS, KOOS/HOOS for lower extremity) quantify function. The physiatrist sets weight-bearing progression, monitors for complications, coordinates therapy, and times return to sport/work based on radiographic and clinical healing rather than a fixed calendar.