Physiotherapeutic Rehabilitation of a Patient With a Comminuted Displaced Iliac Fracture and Superior and Inferior Pubic Rami Fractures: A Case Report

Ilium fractures, which commonly advance from the iliac crest to the greater sciatic notch, are high-energy pelvic fractures that are frequently unstable. The general course of management for this injury is conservative, although cases of substantially displaced have been described that warranted surgical intervention. Many conditions, including decreased mobility, structural alterations in the joints, and discomfort, might make people more vulnerable to falls while waiting for hip or knee surgery. This can have an effect on both preoperative and postoperative functioning. The goal of surgical treatment for these individuals is to return them back to their prefracture state. This article presents the case of a 30-year-old male who was obtained a dash injury while riding a motorbike. He was diagnosed by an orthopedic surgeon with right-sided iliac blade fracture extending towards sacroiliac joint with right-sided sacral ala fracture and superior pubic rami fracture extending toward iliopectineal line and right-sided inferior pubic rami fracture (Tile Classification Type B3). He was operated via open reduction and internal fixation (ORIF) with osteosynthesis plating was done. Following surgery, the patient was dependent and his daily living was hampered. However, physiotherapy intervention improved the patient's pain and physical functioning and he gained independence in carrying out daily activities.


Introduction
Slip-induced injuries account for 87% of hip fractures, which are expensive to treat and cause great suffering. These fractures commonly result in admittance to hospitals that provide specialized care [1]. Fractures resulting from accidents can cause in diminished freedom and functioning, limited mobility, lost confidence in one's ability to move, and lower quality of life [2]. Age-related bone resorption and trauma, most often from minor falls, are the main factors that lead to the majority of these fractures. Road accidents and falls from great heights are additional causes [3]. For the efficient eradication of infection, surgical excision of injured tissues and extraction of foreign particles is essential. Creating a stabilized fracture site, controlling the dead space, and systematic antibiotic therapy are equally important [4]. It is essential to properly realign and rebuild the shattered pieces. The best course of action for managing proximal tibia injuries is operative stabilization [5]. Intramedullary nailing, minimally invasive plate osteosynthesis (MIPO), open reduction and internal fixation (ORIF), and external fixation are among the prevalent surgical techniques [6]. The treatment's prognosis may be adversely affected by displacement, bone loss, soft tissue damage, infection, and related to numerous injuries [7]. The benefits of operational management include early mobilization and a shorter hospital stay. Additionally, it results in a decrease in systemic and local problems such as malunion and nonunion [8]. Following surgery, restricted weight bearing has indeed been linked to a longer healing time and a higher chance of developing postoperative problems. With the help of physiotherapy, early mobilization without limits and complete load bearing seems to enhance the adaptive postoperative result [9].

Patient information
This case report details the treatment and follow-up of a 30-year-old man who was rushed to the emergency department after he met with a road traffic accident while riding a bike. He sustained injuries on his face and right hip and was unable to bear weight on his right leg. The patient was managed with suturing over lacerated wounds at a primary care unit. Then he was immediately rushed to a hospital where X-rays and MRI were performed (axial sections of the hip joints were taken without administration of intravenous contrast), and on that basis, an orthopedic surgeon diagnosed the right-sided hip fracture. There he underwent an operative procedure in which open reduction and internal fixation with plate osteosynthesis were performed. Following this, the patient started complaining of aches and decreased mobility of his right lower limb. The patient had no history of chronic diseases or psychological impairments.

Findings and Impression of Investigations
X-ray and MRI examination revealed that there were displaced fractures of the right pelvic bone involving the ilium and pubic bone. Superiorly fracture line extended to the left iliac blade and medially it involved the iliac part of the right sacroiliac joint. Linear displaced fracture of the superior and inferior pubic rami on right side was seen. A comminuted, minimally displaced fracture of the right sacral body and sacral ala was present, with intra-articular extension into the right sacroiliac joint.

Diagnosis
The patent suffered from right-sided iliac blade fracture extending towards sacroiliac joint with right-sided sacral ala fracture and superior pubic rami fracture extending toward iliopectineal line and right-sided inferior pubic rami fracture (Tile Classification Type B3).

Clinical findings
The patient was alert and well oriented in place, person, and time during the general examination. The patient's hemodynamics were normal: he was afebrile, BP was 130/78 mmHg, pulse of 90 beats per minute, and a respiration rate of 22 cycles per minute. There was no cyanosis, clubbing, or icterus. The pain level was graded as 8/10 on the numerical pain rating scale (NPRS) on activity and 5/10 during rest.

Observational Results
The patient was evaluated while he was lying on his back with the right limb supported by a pillow and the hips and knees were extended. The patient was a 30-year-old man who has a mesomorphic built. Palpatory findings included the existence of Grade 3 tenderness and an increase in localized warmth. The table below mentions the range of motion (ROM) ( Table 1). Movements at left knee and both ankles were pain-free, but right knee and hip movements were painful. Because of the fracture and pain, a straight-leg raise could not be performed. On neurological evaluation, all superficial and deep senses and reflexes were intact. A written informed consent was obtained from the patient.

Right Left
Active Passive Active Passive

ABLE 1: Assessment on Day 1 of physiotherapy treatment
NA: not accessible

Postoperative Management
The short-term goals were to reduce edema and pain, improve joint ROM, improve cardiopulmonary fitness, stimulate early mobility, and prevent pressure sores. The long-term goals were walking re-education, gait and balance training, maximizing patient functioning in performing activities of daily living (ADLs) as independently as possible. Tables 2, 3, and 4 show week-wise management of the patient.

No Goal Intervention Regimen
Week

Follow up and outcome
Post conclusion of physiotherapy intervention, the patient returned optimal functioning without complain of pain not decrease ROM. Patient reported improved ROM and muscle strength hence returned back to his previous work schedules. Tables 5 and 6 show the outcome measures.

Discussion
In this case, the patient suffered from right hip pain, edema, limited ROM, and reduced strength. After assessing the patient, a treatment plan was created to address all of the symptoms. This plan included active and passive ROM exercises, muscular strengthening, and various modalities were used throughout the regime.
On the other hand, about 31% of the patients were using walking aids as a safety precaution, most of which consisted of canes. Additionally, many elderly people require some form of assistance [3]. Therefore, a conventional approach that emphasizes early weight bearing and ambulation in hip fractures is needed, which will compare how hip fractures are treated is reliable and effective. [9]. Following an iliac stress injury, using an antigravity treadmill for rehabilitation might assist in determining when it is safe to resume ground jogging [10]. In certain circumstances where it is preferable to have as minimal recovery time as possible, like in professional athletes and in individuals with extensively displaced fractures, surgical management may be necessary [11]. In my region, there are few studies looking at the critical role that rehabilitation intervention plays in fracture management. It is this gap that this study attempts to bridge. The patient was properly educated throughout the intervention with regard to what to expect, any probable difficulties, how to approach them, and the steps that would follow the surgery. To be better prepared to handle postoperative issues, the patient's psychological state should be improved. If the patient keeps a positive outlook, the chances of a timely return to normal activities and effective recovery enhances.

Conclusions
Physiotherapy aids in enhancing daily living skills, physical function, and patients' independence. The patient made good improvements in part as a result of his desire to keep up his physical treatment and adequate care. This study concludes that combining definitive surgical techniques with early physiotherapy intervention hastens the clinical recovery of patients with fractures by reducing pain, restoring range of motion and muscle strength and aiding early ambulation/loading of the fractured limb. Following committed effort from both the physiotherapist and patient, the patient was fully rehabilitated as he could ambulate unaided.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.