Physiotherapy management in fracture complications (Rsd/myositis ossificans)

1. PHYSIOTHERAPY MANAGEMENT
IN
FRACTURE COMPLICATIONS
(RSD/MYOSITIS OSSIFICANS)
Presented by-
Dr. Ashish Kumar Sharma
BPT 4th Year

2. FRACTURE
• A fracture is a discontinuity in a bone (or cartilage) resulting from mechanical forces that
exceed the bone's ability to withstand them.
• Most commonly fractures occur in the setting of trauma. Fractures can also occur,
however, in a variety of other settings –
a) The entire skeleton may be weak due to metabolic (e.g. osteoporosis) or less
frequently genetic abnormalities (e.g. osteogenesis imperfecta) and thus prone to
fractures from forces that would be insufficient to cause fractures in normal bones.
These are known as insufficiency fractures.
b) The protracted chronic application of abnormal stresses (e.g. running) can result in
the accumulation of microfractures faster than the body can heal, eventually resulting
in macroscopic failure. These are termed fatigue fractures. Together, insufficiency and
fatigue fractures are often grouped together as stress fractures.

3. c) The bone may have a lesion that focally weakens a bone (e.g. metastasis, or bone
cyst). These are known as pathological fractures.

4. TYPES OF FRACTURE

5. ROLE OF PHYSIOTHERAPY
• Doing an assessment for the patient is necessary also doing The problem-oriented
medical record (POMR) system ( is based on a data collection system that incorporates
the acronym SOAP:
a) Subjective – any information given to you by the patient: allergies, past medical
history, past surgical history, family history, social history (living arrangements, social
conditions, employment, medication), review of systems .
b) Objective – all information obtained through observation or testing, e.g. range of joint
movement, muscle strength .
c) Analysis – a listing of problems based on what you know from a review of subjective
and objective data.
d) Plan – this refers to the plan of treatment).

6. • The treatment will depend very much on the problems identified during your initial
assessment, but may include a mixture of the following –
i. Soft tissue manipulation, particularly to manage Edema and swelling
ii. Scar management if the patient had surgery to fix the fracture
iii. Ice therapy
iv. Stretching exercises to regain joint range of movement
v. Joint manual therapy and mobilizations to assist in regaining joint mobility
vi. Structured and progressive strengthening regime
vii. Balance and control work and gait (walking) re-education where appropriate
viii. Taping to support the injured area/help with swelling management
ix. Return to sport preparatory work and advice where required.

7. COMPLICATIONS OF FRACTURE

8. • Fractures are common: most people will experience at least one during a lifetime.
• With modern medical and surgical care most heal without problems or significant loss of
function. However, fractures are associated with a range of complications.
• Acute complications are generally those occurring as a result of the initial trauma and
include neurovascular and soft tissue damage, blood loss and localized contamination
and infection.
• Delayed complications may occur after treatment or as a result of initial treatment and
may include malunion, embolic complications, osteomyelitis and loss of function.
• The risk of complications varies with the particular fracture, its site, circumstances and
complexity, with the quality of management, with patient-specific risk factors such as age
comorbidities, and with post-fracture activities such as air travel and immobility.

9. RISK FACTORS
• Fracture complications are often variably defined, and there is a lack of consensus in their
assessment, which makes their incidence difficult to estimate. Complications clearly vary with
fracture site and nature and with quality of surgery but many also vary with patient attributes
such as:
a) Age.
b) Nutritional status.
c) Smoking status.
d) Alcohol use.

10. e) Diabetes (type 1 or type 2).
f) Use of non-steroidal anti-inflammatory drugs (NSAIDs) within 12 months.
g) A recent motor vehicle accident (one month or less prior to fracture).
h) Estrogen-containing hormone therapy (although this may be a proxy for osteoporosis).

11. • Prevention of complications as a result of fractures is the most important milestone in
successful management and early recovery.
• The complications are classified into the following three categories:
a) Immediate or early complications
b) Intermediate or delayed complications
c) Late complications

12. EARLY COMPLICATIONS
Hypovolemic shock
Injury to the nerves
Injury to the major blood
vessels
Injury to the muscles

13. DELAYED COMPLICATIONS
Adult respiratory distress
syndrome (ARDS)
Infection
Deep venous thrombosis (DVT)
Compartmental syndrome
Crush syndrome

14. LATE COMPLICATIONS
Delayed union
Non-union
Malunion
Joint stiffness
Reflex
sympathetic
dystrophy (RSP)
Late nerve palsy
Myositis
ossificans
Secondary
osteoarthritis
Avascular
necrosis
(AVN)
Limb length
disparity
Prolonged bed
immobilization
Volkmann
ischaemic
contracture (VIC)

15. BASIC PRINCIPLES OF PREVENTING
COMPLICATIONS FOLLOWING
FRACTURES
• Knowledge about the possible complication in relation
to the individual fracture and methods of its prevention.
• Early detection by skilled critical regular monitoring.
• Educating and guiding a patient on the expected early
signs and symptoms of the possible complications
related to a particular fracture, and to report
immediately. Volkmann ischaemic contracture

16. Compartment Syndrome Atrophic non-union.
Cubitus valgus deformity

17. NATURE OF INJURY AND THE POSSIBLE
COMPLICATIONS
Nature of Injury Possible Complication
• Violent trauma RTA, multiple fractures, compound fractures, fractures
of hip, pelvis, femoral head, neck; fractures of skull, spine or violent
visceral injuries
• Hypovolaemic shock
• Fracture of proximal humerus, through the waist of scaphoid bones,
injury to lunate bone, fracture of neck, head or posterior hip dislocation
• Avascular necrosis
• Supracondylar fracture of humerus or fracture of both bones of forearm,
elbow joint dislocation
• Volkmann ischaemic
contracture (VIC)
• Myositis ossification
at Elbow
• Fracture of both bones of the forearm or leg just proximal to the wrist
or ankle, respectively
• Compartmental
syndrome

18. • Nature of Injury • Possible Complication
• Fractures of radius and ulna at the same or close level to each other • Cross-union
• Colle's fracture or fractures at the distal end of radius • Reflex sympathetic
dystrophy (RSD)
• Major fractures around the hip – central dislocation, fractures around
the hip joint
• Deep venous
thrombosis (DVT)

19. IMMEDIATE COMPLICATIONS

20. HYPOVOLAEMIC SHOCK
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Severe trauma (road
traffic accident [RTA])
• Shock • Control bleeding • Limb supporting splint
• Multiple fractures • Coma • Restoration of
cardio respiratory
function
• Chest physiotherapy to
improve respiratory
function
• Fractures: pelvis and
long bones
• Cardiorespiratory
failure
• Catheterization of
urinary bladder
• Severe visceral
injuries
• Excessive external or
internal bleeding
(blood loss of >1500
mL)
• Measures to prevent
infection
• Renal failure • Instant splinting of
the injured limb

21. INJURY TO BLOOD VESSELS
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Blunt or sharp injury • Limb may be
cyanosed, cold and
pale at the distal end.
• Supportive splinting • Localized pressure at
the bleeding points
• There may be
pulselessness or feeble
pulse.
• Immediate
reduction of the
fracture
• Compression bandage
• Gradual onset of
ischemia may lead to
gangrene.
• Explore and repair
artery or vein and
improve distal
Circulation
• Limb support and keep
in elevation (no
thermotherapy)
• Early possible active, or
assisted movements to
distal joints

22. INJURY TO NERVES
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Nerve may be injured
by crushing,
stretching,
compression or by
division.
• Gradual sensory
impairment in its
distribution
Provide splint to
prevent overstretching
of the injured nerve
and contractures
• Provide suitable splint
(static)
• Paresis or paralysis in
the innervated muscle
groups
• Protect anesthetic
areas from heat,
cold or injury
• Continue distal
movements
• Cold limbs, of
associated vessel
injury
• Repair of the
severed nerve
• Re-education
• Biofeedback
• Functional restoration

23. INJURY TO MUSCLES
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Direct or indirect
injury
• Localized hematoma,
swelling over the
injured area with
redness, warmth and
tenderness
• Fast healing due to
abundant blood
supply
• Prevent contractions by
supportive splint.
• Painful isometric as
well as isotonic
contractions
• Rest and support to
the adjacent joint
• Muscle injury heals by
fibrosis and may form
adhesions. Early
movements are therefore
begun to prevent
contractures.
• Painful or lost function
of the injured muscle,
if cut
• Immobilization by
splint or bandage
• Nonsteroidal anti-
inflammatory drugs
(NSAIDs)

24. DELAYED COMPLICATIONS

25. ARDS
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Multiple fractures, or
fracture of pelvis, or
long bones
• Dyspnea with
increased rate of
respiration due to
• deficiency of gaseous
diffusion in the lungs
• Oxygen to restore
PaO2
• Concentrated chest
physiotherapy
procedures
• Inflammatory reaction
set up by micro emboli
of fat released from the
fracture (bone marrow)
• Multiple opacities in
the lung
• Pharmaceutical
drugs – steroids,
heparin, low-
molecular weight
dextran, antibiotics,
etc.
• Early mobilization with
monitored breathing
• Small patches on the
chest wall
• Definitive fracture
treatment

26. INFECTION
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• In open fractures • Healthy wound is
erythematous and
clean
• Antibiotics • Rest and proper splinting
• After surgical
operations
• If contaminated with
dead soft tissue, may
even destroy bone
(necrosis)
• Regular dressing • If the limb is
immobilized, vigorous
active movements are
given to the free joints to
augment circulation
• Neglected wounds • Wound care • IR, ultrasonics or UV
radiation or
hydrotherapy
• Irrigation
• Debridement
• Wound closure

27. DVT AND PULMONARY EMBOLISM
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Major fracture around
the hip joint, spine,
femur, tibia
• Delayed clinical signs
(by 4–8 days)
• Elastic compression
bandage
• Measures to reduce pain
(no thermotherapy)
• Thrombus formed in
the venous plexus may
lead to clot formation
which may get
detached and pass
onwards to the lungs
or brain with possible
fatal consequences
• Pain, redness, warmth
with oedema in the calf
muscles
• Anticoagulant
therapy
• Early pain-free active
limb movement
• Positive Hoffmann sign
(forced ankle
dorsiflexion produces
calf pain)
• Vigorous toe and ankle
movements with limb
well supported in
elevation
• Fever may be present

28. COMPARTMENTAL SYNDROME
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Vascular compromise
occurs in tight
compartment due to
tight bandage or POP
applied after an
injury
• Excruciating local pain
(poorly localized)
• Remove tight
bandage or POP.
Careful examination and
regular monitoring of the
immobilization
• Pale, cold distal part of
the limb, with reduced
or no pulsation
• Keep limb in
elevation and
observe for a few
hours.
• Vigorous active and
resisted fingers toe
movements
• Passive extensions of
fingers elicit pain due to
an ischemic necrosis of
the tissues contained
within the volar
compartment following
an improperly fitting
forearm splint/POP
• If no improvement,
perform surgical
decompression by
dividing skin and
fasciae.
• Early protected
functional use of the
related limb

29. VOLKMANN ISCHAEMIC CONTRACTURE (VIC)
Causes Clinical Features Therapeutic approach Specific
physiotherapy
measures
• Impaired vascular
integrity results in
muscular ischemia. The
ischemic muscles are
gradually replaced by
fibrous tissue which
progresses to fibrosis,
contractures and
shortening of the
muscles.
• Severe pain • If detected early, remove
compressive cause, begin with
vigorous physiotherapy with
dynamic orthosis – good results
• Early full
ROM
• Ischemia may damage
the peripheral nerve
• Gradually progresses
to sensory and motor
paresis to paralysis
• Late, moderate cases: Flexor-slide
operation
• Dynamic
VIC splint:
• Progresses to flexion
deformity at the wrist
and fingers
• Severe cases: Shortening of the
bones of the forearm, proximal row
of carpal bones with wrist
arthrodesis in functional position
• Active
mobilizatio
n

30. CRUSH SYNDROME
Causes Clinical Features Therapeutic approach Specific
physiotherapy
measures
• Massive crushing of the
muscle tissue following
violent direct trauma
• Muscular crushing
results in the release
of myohaemoglobin
into the circulation. It
spreads to the renal
tubules leading to
renal failure
• Catheterization • Superficial
thermotherapy to
lower abdomen
and deep pressure
massage
(kneading)
• May occur due to
inappropriate
application of
tourniquet, gas
gangrene or acute
compartmental
syndrome
• Acute renal failure • Immediate application of
tourniquet and its gradual
release to limit the entry of
deleterious substances in
circulation
• Early sustained
upright posture
• Haemodialysis • Counselling to
overcome
depression

31. PROLONGED BED IMMOBILIZATION
Causes Clinical Features Therapeutic approach Specific
physiotherapy
measures
• RTA, fractures of the
hip joint in elderly,
spinal head injuries or
operable cases, require
longer bed
immobilization or
unconsciousness
• Hypostatic pneumonia • Prevention of all these
complications is the major
need rather than treatment
• It can prevent, if
not, still play a
major role in
reducing the
gravity of such
complications if
and when they
occur.
• Deterioration of all
the vital functions
• Muscular, other soft
tissues weakness, and
bone demineralization
• Joint contractures and
stiffness
• Pressure sores

32. LATE COMPLICATIONS

33. PROLONGED BED IMMOBILIZATION
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Severe anaemia • Continued pain at the
fracture site with
stiffness in the
adjacent joint
• Extensive measure to
treat the underlying
disease causing non-
union
• Ensure correct
immobilization,
strictly preventing
stress on the fracture
site
• Localized bone
disease
• Crepitus at bony ends
with passive
movement
• If no signs of union:
Bone grafting with or
without internal
fixation
• Active resistive
exercises to improve
overall circulation of
limb
• Reduced blood supply
at the fractured site
• Radiological
investigation
confirms non-union
• Repetitive
movements of the
distal free joints
• Malnutrition

34. NON-UNION OF FRACTURE
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Extensive bone loss
due to injury
• Adequate
stabilization of the
fracture may occur.
• External fixation by
Ilizarov fixator
• Early graded
functional training,
with fixator
• Incorrect or
inadequate treatment
(e.g., reduction and
immobilization)
• Pseudarthrosis or a
false joint
• Bone grafting with or
without internal
fixation
• Early graded safe
weight bearing with
bilateral axillary
crutches
• Movement at the
fracture site is pain-
free and abnormal.
• Vigorous hip
movements in
supported standing
on the normal limb

35. MALUNION & DELAYED UNION OF FRACTURE
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Union of fracture
occurs in a
malposition like
angulation or rotation
• Obvious malposition
of the fractured bones
• Leave alone if the
function without
discomfort is retained
• Progressive
functional training
• Limb length disparity • Corrective osteotomy
with internal fixation
and bone grafting
• Assisted active
movements at the
initial stage
• After healing of
osteotomy, vigorous
functional training

36. STIFF JOINT
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Traumatic: when the
injury or fracture is
close to the joint
• Adhesion formation
taking place around
the joint
• Vigorous
physiotherapy
• Starting early
vigorous mobility
exercise
• Nontraumatic – when
the disease process
involves joint
• More susceptible
joints: shoulder,
elbow, hand and knee
• Wedge POP • Low-intensity, pain-
free, sustained
stretch and hold
• Initially painful
stiffness, later the
pain is reduced but
stiffness remains
• Manipulation under
general anaesthesia
• Continuous passive
motion (CPM)
• Surgical release of
adhesions

37. AVASCULAR NECROSIS
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• In certain fractures,
the blood supply to a
segment of bone is
deficient and is
susceptible to bone
necrosis
• Early aching type of
pain occurs on the
anterior aspect of hip
or thigh or groin –
even at rest.
• Core decompression
of femoral head by
vascularized bone
grafting and internal
fixation is performed.
• Maintenance of
functional ROM
• Prolonged steroid
therapy
• ROM of hip joint is
full, painful at the
extreme range.
• In extensive
destruction of the
head of femur, total
hip replacement
(THR) is advisable.
• Adequate support
(aid) to relieve
ambulatory body
weight or power
movements of upper
limp
• Alcoholism • Later on stiffness
develops and there is
more pain.
• In scaphoid bone
involvement, ORIF by
K wire is advisable.
• Renal dysfunctions • Use of hand is painful
in scaphoid
involvement.

38. SECONDARY OSTEOARTHIRITIS
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• History of
injury/fracture close
to the joint
• Pain on weight-
bearing or
pressurized power
hand functions
• NSAIDs to relieve
pain
• Deep heating
modality to relieve
pain
• Avascular necrosis
(AVN)
• Tenderness and
crepitus
• Arthroscopy • Exercises mainly to
retain full ROM
• Synovial
inflammation
• Osteotomy • Education of a
patient on proper
body mechanics in
functional activities
• Progressive stiffness
in the joint
• Gait training with
ambulatory aids
• Joint deformity

39. LIMB LENGTH DISPARITY
Causes Clinical Features Therapeutic approach Specific physiotherapy
measures
• Malunion overlapping
or angulation at the
fracture site
• Limp during
ambulation
• Growth stimulating
procedures
• Compensatory shoe
raise
• Loss of bone piece at
the time of injury
• Cosmetic deformity • Surgical distraction
technique following
osteotomy and
distracting bones and
applying external
fixator
• Functional training
ambulation
• Bone compression at
the cancellous bone
end
• Vigorous
strengthening exercise
including moving
operated leg
• Damage or bone
disease at the
epiphyseal plate
• Reduced blood supply,
e.g., post polio residual
paralysis

40. REFLEX SYMPATHETIC DYSTROPHY

41. INTRODUCTION
• Many names have been used to describe this syndrome such as; Complex regional pain
syndrome, causalgia, algodystrophy, Sudeck’s atrophy, neurodystrophy and post-
traumatic dystrophy. To standardize the nomenclature, the name complex regional pain
syndrome was adopted in 1995 by the International Association for the Study of Pain
(IASP).
• Complex regional pain syndrome (CRPS) is a term for a variety of clinical conditions
characterized by chronic persistent pain.

42. PREVALANCE
• CRPS affects approximately 26 out of every 100,000 people.
• It is more common in females than males, with a ratio of 3.5:1.
• CRPS can affect people of all ages, including children as young as three years old and
adults as old as 75 years, but typically is most prevalent in the mid-thirties.
• CRPS Type I occurs in 5% of all traumatic injuries, with 91% of all CRPS cases
occurring after surgery.

43. ETIOLOGY
• Sprains and strains
• Surgeries
• Fractures
• Contusions
• Crush injuries
• Nerve lesions
• Stroke

44. CLINICAL PRESENTATION
TYPE I TYPE II
Definition • Formerly "Reflex Sympathetic Dystrophy (RSD) "
• Occurs after a trauma remote from the affected
extremity, with or without minor nerve damage
• Formerly "Causalgia"
• Occurs after injury to a major
peripheral nerve
Sensory
Disturbances
• Allodynia and hyperalgesia
• Hypoesthesia and hypoalgesia
• Strange, disfigured, or dislocated feelings in limb
• Allodynia and hyperalgesia
• Hypersensitivity of the skin to
light mechanical stimulation -
some patients report
intolerance to air moving over
skin
Autonomic
disorders +
inflammatory
symptoms
• Swelling and edema
• Changes of sweating (especially hyperhidrosis)
• Abnormal skin blood flow
• Colour changes (redness or pale)
• Temperature changes
• Limb is cold and sweaty
• Distal extremity swelling
• Changes of sweating
• Abnormal skin blood flow
• Temperature changes

45. TYPE I TYPE II
Trophic
changes
• Thick, brittle, or rigid nails
• Increased or decreased hair growth
• Fibrosis
• Thin, glossy, clammy skin
• Osteoporosis (chronic stage)
• Smoothness and mottling of the
skin
• Acute arthritis
Motor
dysfunction
• Weakness of all muscles
• Inability to move the extremity
• Stiffness
• Tremor
• Reduced range of motion
• Severe impairment of complex movements
• Atrophy
• Inability to initiate movement
of the extremity
• Stiffness
• Tremor
• Dystonia
• Reduced range of motion

46. DIAGNOSTIC PROCEDURES
• CRPS diagnosis is mainly based on patient history, clinical examination, and supportive
investigations.
1. The Budapest Criteria – The Budapest criteria (also known as the IASP) has been
developed for the diagnosis of CRPS, but improvements still need to be made. Clinical
diagnostic criteria for complex regional pain syndrome are:
o Constant pain, higher than the normally perceived pain
o Minimum one symptom in three of the following four symptoms. Categories must be
reported –
a)Vasomotor: temperature asymmetry and/or skin colour changes/asymmetry
b)Sensory: hyperalgesia and/or allodynia
c)Sudomotor/edema: changes in sweating
d)Motor/Trophic changes.

47. o Additionally, the patient must also show signs of developing symptoms in at least
two symptom categories
o No other illness could explain the set of symptoms the patient is presenting with.
2. Other Tests –
o Infrared thermography
o Sweat testing
o Radiographic testing
o Bone scan
o MRI

48. MEDICAL MANAGEMENT
• Oral pain-relieving medications including corticosteroids and NSAIDs
• Intravenous immunoglobulin
• Hyperbaric oxygen therapy is an effective and well tolerated method for decreasing pain,
allodynia, oedema, increasing the range of motion in CRPS and also returning the skin
colour to a normal colour.
• Antidepressants may be utilised to treat associated depression
• A stellate ganglion block, or sympathectomy, blocks the nerve pathways causing pain.

49. PHYSIOTHERAPY MANAGEMENT
• The main goals of treatment are a reduction in pain, preservation of limb function and a
return to work.
• Comorbidities such as depression, sleep disturbance, and anxiety also need to be
addressed and treated concurrently in a patient-centred, multidisciplinary approach.
• A combination of physical and occupational therapy is effective in reducing pain and
increasing function in patients who have had CRPS for less than 1 year .
• Physical therapy focuses on patient education about the condition and functional
activities.

50. • Physical therapy intervention could include any of the following:
o TENS
o Aquatic therapy allows activities to be performed with decreased weight bearing on
the lower extremities.
o Mirror therapy
o Desensitisation
o Gradual weight bearing
o Stretching
o Fine motor control
• Other treatments - Whirlpool bath/ contrast baths, Vocational and recreational
rehabilitation, Psychological therapies: cognitive-behavioural therapy, Acupuncture,
Weight bearing, Ultrasound therapy, Kinesio taping

51. MYOSITIS OSSIFICANS

52. INTRODUCTION
• Myositis ossificans (MO) is the most common form of heterotopic ossification (HO),
usually within large muscles.
• Some doctors view MO and HO as two points on the same line. They are similar
problems that cause pain, local signs of inflammation, and loss of motion.
• In both cases, bone forms in and around soft tissue (usually muscle).
• Myositis ossificans (MO) occurs after trauma to the muscle or a broken bone. New bone
cells form between the torn muscle fibers. This happens most often around the elbow or
thigh. Children and young adults are affected most often.

53. EPIDEMIOLOGY
• Most cases of myositis ossificans occur as a result of trauma, and thus, the primary
demographic is young adults.
• Another group which is especially prone to myositis ossificans are paraplegics, usually
without evidence of trauma.

54. CLINICAL PRESENTATION
• Typically presents as a painful, tender, enlarging mass, which in 80% of cases is located
in large muscles of the extremities, often following recognized local trauma, although a
definite traumatic event is not always recalled.

55. PATHOLOGY
• Myositis ossificans is essentially metaplasia of the intramuscular connective tissue
resulting in extraosseous bone formation (without inflammation).
• Unfortunately, the histologically of myositis ossificans can appear similar
to osteosarcoma, and thus, can lead to inappropriate management.

56. DIAGNOSIS
• A thorough subjective and objective examination from a physiotherapist can usually
predict the likelihood of the presence of myositis ossificans.
• X-Ray
• MRI
• Ultrasound

57. PHYSIOTHERAPY MANAGEMENT
• The best strategy to manage this condition is to prevent its occurrence. Once myositis
ossificans is established, there is very little that can be done to accelerate the resorptive
process (i.e. the process of removing bone from the bruised region). Treatment will
usually focus on rest from aggravating activities and the implementation of gentle pain-
free range of movement exercises.
• No massage, or passive movements or manipulation is required.
• Post-surgery, concentrate on functional training emphasizing on achieving functional
ROM.

58. REFRENCES
• Orthopedics and advance physiotherapy (3rd Edition )
Jayant joshi & Prakash kotwal
• https://patient.info/doctor/complications-from-fractures
• https://www.physio-pedia.com/Complex_Regional_Pain_Syndrome_(CRPS)
• https://www.physio-
pedia.com/Myositis_Ossificans?utm_source=physiopedia&utm_medium=search&ut
m_campaign=ongoing_internal

59. THANK YOU