Patellar Fracture: Open Reduction Internal Fixation (ORIF)

Physical Therapy Protocol

General Guidelines

• Weight Bearing: As tolerated in a locked ROM brace.
• Transfers: Assisted for the operative leg.
• Knee Extension: Avoid active knee extension for the first 2 weeks.
• Brace Settings:
  • Initially locked at 0° for the first 2 weeks.
  • Gradually unlock to 30° as tolerated for ambulation and ADLs.
  • Transition to full range by Week 6, based on quad control.
• Sleep: Brace should remain locked at 0° during sleep unless directed otherwise.
• Elevation & Cryotherapy: Elevate the leg and use cryotherapy to manage pain and swelling.
• Showering: Keep surgical incisions dry for the first 5 days. May shower after the first 5 days, with precautions to protect the incision.

Phase 1: Day 1 to Two Weeks After Surgery

Goals:

• Protect the fracture site.
• Begin gentle exercises to promote circulation and prevent stiffness.
• Initiate pain management and reduce swelling.

Interventions:

• Brace Use: Locked at 0°.
• ROM Exercises:
  • Ankle pumps
  • Straight-leg raises
• Pain Management: Cryotherapy, elevation, and prescribed pain medications.
• Mobility: Gait training with crutches, toe-touch weight-bearing.

Criteria for Progression:

• No significant pain or swelling.
• Maintain passive movement in distal joints (ankle, foot, toes).
• Tolerates early ROM exercises without discomfort.

Phase 2: Two to Six Weeks After Surgery

Goals:

• Gradually restore passive and assisted range of motion (ROM).
• Avoid excessive loading on the patella.
• Begin early quadriceps activation.

Interventions:

• ROM Progression:
  • Unlock brace to 30° as tolerated.
  • Gradual increase in knee flexion (goal: 90° by Week 6).
• Strengthening:
  • Isometric quadriceps activation
  • Straight-leg raises with brace locked
  • Hamstring and glute activation
• Aerobic Exercise: Non-weight-bearing exercises such as stationary cycling with minimal resistance.

Criteria for Progression:

• Gradual improvement in ROM
• No pain during controlled knee movement
• Ability to tolerate weight-bearing without increased swelling

Phase 3: Six to Twelve Weeks After Surgery

Goals:

• Initiate weight-bearing exercises as tolerated
• Continue progression of ROM and strengthening
• Begin returning to functional activities

Interventions:

• ROM Progression:
  • Continue unlocking brace to allow increased flexion
  • Full ROM by Week 12
• Strengthening:
  • Active-assisted range of motion (AAROM) for quadriceps
  • Isometric and isotonic strengthening
  • Begin light closed-chain exercises (e.g., partial squats, step-ups)
• Functional Mobility:
  • Controlled weight-bearing activities
  • Gradual reintroduction to daily activities

Criteria for Progression:

• Increased ROM without pain
• Tolerates strengthening and weight-bearing exercises
• No complications such as swelling or instability

Phase 4: Twelve Weeks to Six Months After Surgery

Goals:

• Restore full functional mobility
• Rebuild strength and endurance
• Prepare for return to activity

Interventions:

• Progressive Strengthening:
  • Continue building quadriceps, hamstrings, and glutes
  • Introduce resistance training
• Functional Exercises:
  • Squats, lunges, and step-ups
  • Low-impact sports drills if appropriate
• Neuromuscular Training: Balance and proprioception exercises

Criteria for Progression:

• Strength and ROM approaching pre-injury levels
• No pain or discomfort with daily activities
• Ability to perform functional movements safely

Phase 5: Six Months and Beyond

Goals:

• Full return to work and sports activities
• Advanced strengthening and impact training
• Prevention of re-injury

Interventions:

• Return to Full Activity:
  • Gradual reintroduction to work and recreational activities
  • High-impact training as tolerated
• Heavy Strengthening:
  • Resistance training for all lower extremity muscles
  • Plyometric and sports-specific drills
• Functional Testing: Assessment of strength, endurance, and agility before full clearance

Criteria for Full Return:

• Pain-free knee function
• Strength comparable to the uninjured side
• Ability to perform all activities with no discomfort

Patient Education and Red Flags

Key Reminders:

• Follow all rehabilitation guidelines carefully to prevent complications
• Communicate any pain, swelling, or difficulty progressing with your physical therapist or surgeon
• Stay consistent with your physical therapy schedule to optimize recovery

Red Flags:

• Persistent or worsening pain after prescribed exercises
• Significant swelling or bruising that does not improve with rest
• Difficulty moving the knee without significant discomfort
• Signs of infection at the surgical site (redness, warmth, discharge)