I have meant to write this blog for a very long time and the final nudge was our journey with the wonderful Ms. R, who was kind enough to lend her body for a few illustrative photos of her recovery after a hideous car accident.

One of the privileges of 25+ years in practice in the same location is that you can follow people over time and see some strong patterns emerge. One such pattern is the complexity of seeing patients deal with the long lasting domino effect of major lower extremity fractures and learning from those observations to be much more proactive about what to look for and how to intervene to optimize recovery, rather than the “wait and see“ approach, which often leads to predictable and unmitigated complications. Below is an outline of the steps I take when I work with a patient recovering from a severe lower extremity trauma.

I would define a severe lower extremity trauma as one that requires surgery, no weightbearing, and prolonged immobilization for at least 6 weeks. Obviously you can still have a lot of problems if your immobilization is less than 6 weeks or if you are allowed partial weightbearing, but the combo of the three is usually the perfect storm. I have seen just about every fracture you can imagine, and a few more in the last 27 years, but the most common one is a fracture dislocation combination of the ankle and foot, which requires requires surgical stabilization with hardware, prolonged time off the leg, and bracing or boot walking for several more weeks.

Week 1-6

Manage the post trauma and post surgical pain. The pain can be brutal and the risk is to reach high levels of prescription medications to deal with it. I find that using a combination of plant based anti-inflammatory botanicals (tumeric, white willow, and boswellia for ex), mild muscle relaxers (magnesium, valerian root), topical agents (CBD, menthol), and sleep support supplements (kava, California poppy) can help the patients minimize the use of prescription agents for episodes of breakthrough pain rather than as a base. Physical and mechanical agents such as ice and TENS units, can also be useful.
Address the beginning of compensatory injuries before they become a new problem. The use of crutches and walkers can easily cause shoulder injuries. If you cannot fully eliminate stress to the area, you need to be sure to get those minor injuries treated before they become major.
Stimulate strong bone and connective tissue healing: make sure patients are engaging in activities that get their heart rate up and push oxygen to surgical sites (yoga breathing, upper body exercises). Consider a good supplement of collagen and bone matrix. Use infrared therapy pads to stimulate repair.

Week 6-12

Somewhere in that vicinity patients will start doing partial or full weightbearing on the affected limb. The compensatory stress will shift from the shoulder to the pelvis and lumbar spine. Patient will often need to be checked and adjusted more frequently during that time frame.

Persistent swelling is a MAJOR problem in a high percentage of patients. It is often ignored although it can be very uncomfortable or frankly painful, and contrary to what patients are told, it does not always disappear over time. The reason is that trauma and surgery can create damage to the lymph system that needs to be properly treated and rehabilitated by a provider that is trained to do so (in our case, this would be Anne).
Scar tissue and contractures can be addressed as patients exit the cast and are allowed to increase movement. This mostly requires careful manual assessment of the layers of soft tissues that have started to form adhesions to each other, and treat it with a variety of methods: manual, instrument assisted, and cupping.

12 weeks and beyond

Lower extremity fractures can result in a new permanent leg length differential (longer or shorter than before). After 8-12 weeks of weightbearing, the leg will have fully “settled” and accommodated as much as it will. At that point, you can carefully evaluate for leg differential (visualization, physical, or X ray measurements) and fit the patient with the correct heel lift if applicable.
Ankle fracture and subsequent surgical stabilization will often result in a permanent change to the shape of the foot arch (surprisingly it is often higher). A standard shoe and insole may no longer work, and some patients require custom orthotics to spend any amount of time on their feet comfortably.
Prolonged immobilization and boot walking causes some persistent changes in the gait as well as a loss of position sense in the affected limb, which can result in poor balance. Gait retraining and balance exercises will be needed for most patients.