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LETTER TO EDITOR
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 133-134

Fractures: Avoidable complications of unsupervised knee manipulation


Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission15-May-2019
Date of Acceptance10-Jul-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Dr. Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani - 263 139, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_36_19

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How to cite this article:
Dharmshaktu GS. Fractures: Avoidable complications of unsupervised knee manipulation. Indian J Phys Ther Res 2019;1:133-4

How to cite this URL:
Dharmshaktu GS. Fractures: Avoidable complications of unsupervised knee manipulation. Indian J Phys Ther Res [serial online] 2019 [cited 2020 Feb 28];1:133-4. Available from: http://www.ijptr.org/text.asp?2019/1/2/133/273723



Physiotherapy following the posttraumatic care or surgery is an important tool to optimize strength, functioning, and range of motion of a joint. It must, however, be supervised and performed by a trained physiotherapist or allied professionals. Unsupervised efforts by patient, attendants, or even doctors are still prevalent practice, and these actions pose challenges that, at times, result in catastrophic outcome. This practice of performing physiotherapy by personnel without structured training and experience is not advocated, but many patients still engage themselves in unscientific form of self-directed physiotherapy against medical advice only to complicate their recovery. Fracture due to overenthusiastic effort is one complication that is not uncommon in this context. Two of our cases learnt these lessons the hard way, and their experiences have educative potential for other patients. One postoperative case of femur fracture managed with femoral nailing had concomitant soft tissue knee injury. He was advised regular physiotherapy to counter resultant knee stiffness. After 1 day of session, he discontinued the physiotherapy session and started his own set of exercises only to consult us after 3 weeks, with complaints of pain and swelling around knee joint. A friendly manipulation was done by another clinician to improve the range of motion few hours back. The radiographs showed undisplaced fracture over tibial tuberosity area, the pattern of which suggested that it resulted from overenthusiastic and uncontrolled knee flexion [Figure 1]a. He was again given plaster splint for 6 weeks till fracture was united [Figure 1]b before finally undergoing supervised therapy sessions. The incident prolonged the usually uneventful course of recovery. Another patient with soft tissue knee injury who was given plaster splint for 6 weeks developed knee stiffness and was advised gentle physiotherapy with graduated increase in intensity. She initiated physiotherapy on her own and consulted us after 4 weeks following an audible “snap” during one session followed by pain and disability to use the limb. The radiographs showed undisplaced patella fracture for which another plaster splint for 8 weeks was given until the union [Figure 1]c and [Figure 1]d. Above incidents and many more witnessed by doctors in daily practice not only prolong the recovery but increase healthcare expenditure and loss of human work hours. These are avoidable complications, and every attempt of educating patients in this regard is warranted to curtail their incidents. Acknowledging physiotherapy as an integral part of treatment by the public and healthcare personnel both can only minimize the recurrences of these unfortunate events that mar an honest and meticulous conservative or operative treatment.
Figure 1: The lateral image showing (a) fractured proximal tibia over tuberosity area following the physiotherapy denoted by an arrow (b) that was later united. The other case with (c) lower pole patella fracture denoted by arrow (d) that also required plaster immobilization before healing

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There is always a risk of iatrogenic fractures during knee manipulation, especially in the setting of underlying bone abnormalities such as osteoporosis or other systemic disorders.[1],[2] These usually result when done under anesthesia when the restrictive pain response is obtunded and inadvertent overzealous force may be used. Our cases were young with no underlying bone disorders and thus underlined the importance of cautious approach in any case. The fracture during manipulation have also been reported from smaller joints such as shoulder and better techniques are advocated to reduce the risk.[3] Besides the joints, spinal manipulation poses various challenges that may be grave to neurological status.[4] Manipulation thus has potential for complications, but situation may compound itself in the absence of professional help. There should be efforts to encourage professional help from the treating doctor as the patient is most loyal to their advice and the rehabilitation process should be given equal importance as part of initial dialogue about whole treatment plan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ipach I, Schäfer R, Lahrmann J, Kluba T. Stiffness after knee arthrotomy: Evaluation of prevalence and results after manipulation under anaesthesia. Orthop Traumatol Surg Res 2011;97:292-6.  Back to cited text no. 1
    
2.
Dharmshaktu GS. Physiotherapy-related impacted proximal tibia metaphyseal fracture in a child with myelomeningocele. J Health Res Rev 2017;4:40-2.  Back to cited text no. 2
  [Full text]  
3.
Magnussen RA, Taylor DC. Glenoid fracture during manipulation under anesthesia for adhesive capsulitis: A case report. J Shoulder Elbow Surg 2011;20:e23-6.  Back to cited text no. 3
    
4.
Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. Spine J 2005;5:660-6.  Back to cited text no. 4
    


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