7.2 Fractures, Dislocations and Subluxations

7.2 Fractures, Dislocations and Subluxations

Quick Answer: Match load to healing stage and written medical precautions. Do not perform primary reduction of acute dislocations—protect the limb, check neurovascular status, and escalate to emergency/medical care. After reduction or fracture stabilisation, deliver progressive physiotherapy: protected motion when allowed, strength and control, gait or upper-limb function, and criteria-based return to work or sport.

Fractures, dislocations, and subluxations appear in APC cases across emergency discharge, orthopaedic wards, outpatient fracture clinics, sports, and community rehabilitation. The exam tests safety, scope, and progressive reasoning: know what you must not do, what precautions mean, and how to rebuild function without violating healing constraints.

Fractures: Clinical Picture and Physiotherapy Role

A fracture is a break in bone continuity. Presentations range from stable undisplaced fractures managed in cast or boot to complex multi-fragment injuries requiring open reduction and internal fixation (ORIF), external fixation, or joint replacement in some elderly hip fractures.

Healing stages (practical model)

Use stages as a loading framework, remembering exact biology varies by bone, age, comorbidities (diabetes, smoking, osteoporosis), fixation method, and nutrition:

1. Inflammatory / early — haematoma and early cellular response; pain and swelling common. Protection dominates; early medical-approved movement of adjacent joints often still essential.
2. Repair (soft then hard callus) — progressive bridging of the fracture. Loads increase only as stability and medical guidance allow; still vulnerable to shear or premature high-impact force.
3. Remodelling — callus remodels along stress lines over months. Progressive strength, impact, and sport-specific loads are usually introduced later with radiographic and clinical clearance as required.

Physiotherapy does not “speed biology with aggressive load” against medical advice. It optimises the environment: oedema control within limits, adjacent joint mobility, safe transfers and gait, isometric or open-chain work as allowed, education, and monitoring for complications.

Comorbidity modifiers that slow or complicate healing on exam stems: smoking, poorly controlled diabetes, osteoporosis, malnutrition, corticosteroid use, non-adherence to protection, and unstable fixation. Name these when explaining delayed recovery rather than blaming the patient for “not trying.”

Assessment after fracture

• Confirm weight-bearing status, range limits, sling/cast/boot rules, and review dates from the treating team.
• Inspect skin, swelling, cast edges, wound or pin sites when relevant; escalate infection or compartment concerns.
• Neurovascular screen: colour, temperature, capillary refill, sensation, motor, pulses as appropriate.
• Pain pattern: expected post-fracture pain versus red flags (increasing severe pain, tense compartments, new numbness, fever).
• Function: transfers, gait aid use, stairs, upper-limb ADLs, work demands.
• Psychosocial factors: fear of falling, low confidence, home setup—especially after hip or lower-limb fracture in older adults.

Protected rehabilitation principles

• Protect the fracture site according to orthopaedic protocol (NWB, TDWB, PWB, WBAT—know the abbreviations and teach them accurately).
• Mobilise what is allowed early — adjacent joints stiffen quickly; fingers, elbow, shoulder after distal radius cast; hip and knee after ankle immobilisation where permitted.
• Progress load with criteria when precautions change: controlled pain, adequate muscle activation, safe gait pattern, no wound complications, and team clearance for next stage.
• Strengthen progressively — isometrics → controlled range → closed-chain as permitted → power and impact later for athletes.
• Address the whole person — falls risk, bone health discussion referral pathways, cardiovascular deconditioning, return-to-drive and work planning within Australian legal and workplace contexts as appropriate.

Complications to recognise

• Compartment syndrome (pain out of proportion, pain on passive stretch, tense compartment—emergency).
• Complex regional pain features evolving after injury (disproportionate pain, autonomic changes—needs careful multidisciplinary management).
• Delayed union / non-union risk factors (smoking, poor fixation stability, inadequate protection, medical comorbidities).
• Secondary stiffness and muscle wasting from over-protection beyond protocol needs.
• Venous thromboembolism risk awareness after lower-limb injury/surgery—follow medical prophylaxis plans; escalate acute calf pain/swelling/breathlessness appropriately.

Weight-Bearing and Precautions: Implementation Skill

APC cases often hinge on whether you respect PWB versus WBAT, or whether you advance a patient to stairs without gait aid competence. Teach:

• Correct crutch or frame pattern for the prescribed status.
• How to negotiate steps and transfers without violating NWB.
• When to contact the clinic if the patient cannot maintain the status safely at home.

Never invent less restrictive precautions because the patient “feels fine.” Conversely, do not keep someone non-weight-bearing after the team has cleared progression without clinical reason—underloading also harms.

Practical exam vignette: After ankle ORIF the order is NWB 2 weeks then WBAT in boot. Day 5 the patient wants to “test a few steps without crutches in the supermarket.” Correct response: maintain NWB with aids, problem-solve supermarket logistics, contact the team only if the order is unclear—not liberalise precautions unilaterally.

Dislocations: Medical Reduction, Not Primary Physio

A dislocation is complete loss of joint surface congruence. Common APC-relevant sites include shoulder (glenohumeral), patella, elbow, and fingers; hip dislocation is less common but high-stakes after arthroplasty or major trauma.

Acute presentation priorities

1. Do not attempt primary reduction as the treating physiotherapist in standard emergency or community vignettes—this is a medical/emergency procedure with imaging, sedation/analgesia decisions, and complication management outside routine physio primary care.
2. Protect the limb in the most comfortable supported position; avoid forcing range.
3. Neurovascular assessment before and after any medical reduction (e.g., axillary nerve after shoulder dislocation; vascular status at elbow/knee).
4. Escalate to emergency or orthopaedic care urgently for unreduced dislocation, suspected fracture-dislocation, open injury, or neurovascular compromise.
5. Document mechanism, prior dislocations, and associated injuries.

Exam traps include options that ask you to “reduce now in the clinic gym” for a first-time traumatic shoulder dislocation without medical pathway—reject those.

Post-reduction physiotherapy

After confirmed reduction and medical instructions:

• Follow sling/immobilisation duration guidance (varies by age, direction of instability, first-time versus recurrent, associated fracture or labral injury).
• Begin protected active-assisted motion when allowed; avoid early aggressive end-range positions that recreate the dislocation mechanism (e.g., forced abduction–external rotation early after anterior shoulder dislocation—follow specific protocol).
• Progressive rotator cuff and scapular control (shoulder), quadriceps and hip control (patella), and global kinetic chain work.
• Proprioception and sport-specific drills later; return-to-contact or overhead sport is criteria-based (strength symmetry targets, apprehension control, task confidence) not calendar alone.
• Recurrent traumatic dislocations despite good rehab warrant orthopaedic discussion; first-time events in selected populations may also follow defined specialist pathways.

Subluxations

A subluxation is partial or transient loss of congruence—the joint surfaces lose optimal alignment temporarily and often spontaneously reduce. Patients describe slipping, shifting, or apprehension. Examples: multidirectional shoulder laxity with transient subluxation, patellar subluxation episodes, minor joint shifts in hypermobile individuals.

Reasoning

• Differentiate traumatic subluxation (clear injury event) from atraumatic symptomatic laxity.
• Assess apprehension tests carefully; stop if frank instability is imminent.
• Management overlaps hypermobility and instability care: motor control, graded exposure to previously provocative positions only when control is adequate, bracing or taping as temporary adjuncts in some sports cases, and activity modification during irritable phases.
• Recurrent symptomatic subluxations with functional failure need specialist review; do not endlessly stretch the joint.

Dislocation vs Subluxation vs Fracture–Dislocation (Quick Map)

Integrating Fracture and Dislocation Care Across Settings

Acute hospital: early mobilisation orders after hip fracture surgery, chest and DVT risk awareness, discharge planning, gait aid prescription, carer education.

Outpatient/private practice: post-cast stiffness programs, graduated return to running after ankle fracture, overhead athlete progression after shoulder dislocation, workplace rehabilitation with functional capacity rebuilding.

Rural/remote: clearer escalation thresholds when imaging or orthopaedic review is delayed; protect more conservatively when diagnosis is uncertain and transfer is required.

Criteria-Based Progression Examples

Rather than “week 6 equals full sport,” use markers such as:

• Adherence to weight-bearing status without compensatory collapse.
• Active range sufficient for gait or ADLs without protective spasm dominating.
• Strength adequate for controlled single-leg stance or elevation tasks as relevant.
• No increasing night pain, wound issues, or new neurovascular signs.
• Task-specific drills completed with acceptable symptom response and technique.

Communication and Shared Decisions

Explain healing stages in plain language: “The bone is knitting; your job is to protect the break while we keep the rest of you strong.” After dislocation: “The joint is back in place; we rebuild control so it is less likely to come out again—forced early extreme positions work against that.” Document precautions taught and patient understanding.

Pitfalls That Fail APC Items

• Attempting unsupervised reduction of traumatic dislocations.
• Ignoring neurovascular checks around elbow, knee, or shoulder injuries.
• Violating NWB status because the patient is impatient.
• Completely neglecting adjacent joint mobility during immobilisation when movement is allowed.
• Clearing contact sport after dislocation based only on “pain is better” without stability and strength criteria.
• Missing compartment syndrome after high-energy fracture or tight cast.

Sample Australian-Style Case Contrasts

Case A — distal radius fracture, cast, private practice: NWB on hand for loading tasks, fingers free to move. Plan: finger and shoulder/elbow mobility, oedema advice, cast-care education, monitor median nerve symptoms and cast tightness, prepare for post-cast stiffness program after removal—do not remove cast or invent earlier heavy gripping against orders.

Case B — first-time traumatic shoulder dislocation, ED discharge next day: reduced in ED, sling advice given, axillary sensation intact, apprehensive. Plan: follow immobilisation guidance; begin allowed protected motion; cuff/scapular activation when permitted; avoid early forced ABD-ER; explain recurrence risk; criteria-based return to contact/overhead sport; escalate recurrent events.

Case C — hip fracture pathway, older adult post-ORIF/arthroplasty (setting-dependent orders): early mobilisation as ordered, gait aid prescription, falls risk, discharge planning, carer education, DVT warning signs awareness per medical plan—not bed rest “until the bone feels perfect.”

Case D — recurrent patellar subluxation, adolescent netballer: slipping episodes with cutting, no osteochondral red flags currently, quads and hip control poor. Plan: progressive strength and control, taping/brace as temporary adjunct if helpful, movement retraining, specialist review if recurrent instability persists despite structured rehab.

Decision Table for APC Options

Self-check

1. Can I explain fracture healing stages as a loading framework with comorbidity modifiers?
2. Can I teach NWB/PWB/WBAT accurately and implement gait aids safely?
3. Do I refuse primary traumatic dislocation reduction and prioritise neurovascular status?
4. Can I outline post-reduction progressive stability rehab with criteria-based return?
5. Can I differentiate subluxation management from acute unreduced dislocation emergencies?

Master protected loading and escalation boundaries, and fracture–dislocation cases become structured rather than intimidating.