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Pilon Fracture Rehabilitation Exercises Program Outcome

Faisal Fahmy Adam, Amna Abdullah Desouky , Esmat Sayed Abd-Elmeegeed
American Journal of Nursing Research. 2018, 6(5), 222-228. DOI: 10.12691/ajnr-6-5-2
Published online: June 13, 2018

Abstract

Pilon fractures often involving a lengthy, sometimes painful recovery time. Aim; to evaluate the effect of rehabilitation exercises program on Pilon fracture outcome. Research hypothesis; the outcome of study group patients will be better than the outcome of control group. Patients and Methods: A quasi – experimental research design was utilized. Setting; the study was conducted in Traumatology Department of Assuit University Hospital. A convenience sample of sixty patients diagnosed with Pilon fracture divided into study and control group (thirty for each). Tools; tool I Patient assessment sheet, tool II “Modified Mazur scale [1]. The control group exposed to routine hospital care while study group patients received the rehabilitation exercises program. Results revealed better outcome among study group patients than control group; Mazur score (85.27 ± 8.69 vs. 72.57 ± 13.43), and marked reduction in postoperative complications rate. Conclusion: This study proved that; application of rehabilitation exercises program had a statistically significant improvement on Pilon fracture outcome that was apparent in fewer postoperative complications rate and raised level of Mazur score among study group. Recommendation: Rehabilitation exercises program for Pilon fracture should be carried out on an individual basis from beginning of this fracture to prevent postoperative complications and achieve better outcome.

1. Introduction

Pilon fracture is a type of fracture that occurs at the distal part of the tibia and involves the weight-bearing surface of the ankle joint. The word Pilon, which is derived from the French language, was introduced by Destot in 1911; it refers to a pestle, which is a club-shaped tool for mashing substances in a mortar or using a large bar to stamp or pound vertically 2.

The ankle joint is formed by the tibial plafond superiorly, the talus inferiorly and malleoli medially, laterally, and posteriorly 3. The planfond articulates with the talus and together; the plafond & talus distribute stress of weight bearing through the ankle joint. The ankle carries up to four times an individual body weight. The motion of the talus acting like a hammer or pestle as it crashes into the tibial plafond. With this type of injury, the other bone in the lower leg, the fibula, is frequently broken as well 4.

Pilon fractures often result from high-energy trauma such as a car or motorcycle accident, fall from height, or skiing accident or low energy force. High velocity trauma is often associated with intra-articular comminution, multiple metaphyseal fragments and soft tissue injuries, making their management challenging 5.

All Pilon fractures require surgical management. Perioperative complications may occur preoperatively, intraoperatively, or postoperatively. Intraoperative complications depend mainly on the technical procedure while post-operative complications may be either early or late. Early complications as wound complications can lead to deep infection with potentially catastrophic consequences. Stiffness, posttraumatic arthritis, and loss of ankle motion can develop in the late postoperative period 6.

Rehabilitation exercises of the foot and ankle is an important part after pilon fracture, the best results are seen when physicians, the physiotherapists, nurses, and patients work together in an open, communicative and coordinated way towards achieving similar and attainable goals 7.

2. Significance of the Study

Pilon fractures constitute 1% of lower limb fractures and 7% of tibial fractures. This type of fracture requires long postoperative rehabilitation time than basic ankle fractures 8. Patients with Pilon fractures are liable for developing many complications that result from long period of immobilization as well as from the nature of injury. Considering all these facts; this study was conceived and designed so to evaluate the outcome of rehabilitation exercises program on Pilon fracture.

3. Aim of the Study

To evaluate the effect of rehabilitation exercises program on Pilon fracture outcome.

4. Hypothesis

The outcome of the study group patients will be better than the outcome of control group.

5. Operational Definition

5.1. Pilon Fracture Outcome

It means clinical outcome in the form of ankle range of motion, ankle pain, swelling, and gait that was assessed by Mazur scale 1. As well as the complications associated with Pilon fracture.

6. Patients and Methods

6.1. Study Design

A quasi – experimental research design was utilized in this study.

Variables

The independent variable in this study was the rehabilitation exercises program. While the dependent variable was the Pilon fracture outcome.

Setting

The study was conducted in Traumatology Department and follow up was conducted in the Orthopedic Outpatient Clinics, Assuit University Hospital- Eygpt.

Sample

A convenience sample of sixty adult patients divided into study group (30 patients) and control group (30 patients) admitted in Traumatology Department at Assuit University Hospital and followed in Outpatient Clinics. Patients were selected according to the following criteria: oriented, male and female patients, their age from 18 to 65 years old, and diagnosed with Pilon fracture that may be either open or closed. Patients who had bilateral injury, osteoporosis, previous orthopedic operation in the same affected side, presence of neurologic disease, decompensated organ failure, psychiatric disease, inability to understand or follow the prescribed exercises, and patients who had co-morbid conditions were excluded from this study.

6.2. Tools for Data Collection

Tool I: Patients' structured assessment sheet:

This tool was developed by the researchers to assess the patients' condition, it consisted of three parts:

Part one: patients’ demographic profile:

This part assessed patients' demographic characteristics as (name, age, gender, occupation, marital status, residence, and level of education, etc………).

Part two: current health history

This part included data about; mechanism of injury, affected side, diagnostic imaging, duration of immobilization, neurovascular status of the affected extremity, starting time for weight bearing, and expected postoperative complications.

Part three: Patients’ knowledge about rehabilitation exercises program:

This part assessed patients' knowledge about rehabilitation exercises program. It consisted of fifteen open ended questions. Correct and wrong answers were scored as 1 and 0 respectively, leading to a total score ranging from 0 to 15. The total score of each patient was then converted into a percentage, where a cut-off score of 60% indicated acceptable knowledge (good knowledge).

Tool II: Modified Mazur classification: Clinical rating scale 1

The outcome was measured at 6th follow-up using a modification 16 of the system proposed by Mazur 1. This scale was adopted in this study to assess the clinical & functional outcome for Pilon fracture. It contains four items scored in a Likert response format with the following point ranges for each item: pain (0-50 points), gait (0-30points), swelling (0-10 points), and range of motion (0-10 points). The range of motion was assessed by using a universal goniometer with the patient seated and the knee bent for planterflexsion and dorsiflexion. Values for each of these items are combined with a higher score representing a higher level of function. Clinical results were graded as excellent, good, fair, or poor.

Tool III: Rehabilitation Exercises Program for Pilon Fracture

This tool was developed by the researchers after reviewing current national and international literatures. It included knowledge about rehabilitation exercises as preparation for doing the exercises, types of exercises that can be done, frequency, precautions that can be taken. 7, 9

6.3. Ethical Consideration

Permission to carry out the study was obtained from the institutional review board. Written informed consent was obtained from patients included in the study.

6.4. Operational Design

It included preparatory phase, field work phase, implementation phase, and evaluation phase.

Preparatory phase

This phase started by review of current and past, local and international related literatures as text books, articles, journals, periodicals and magazines, study tools were formulated, and this phase ended by content validity and pilot study.

Content validity

It was done by five expertise (two nursing staff) from the Medical Surgical Nursing field and (three orthopedic surgeons & physiotherapist) from the medical field to test contents, clarity and comprehensiveness of the tools. Minor modifications were required.

Pilot study

It was conducted on 10% (6 patients) of sample to evaluate the applicability and clarity of the tools, estimate the time needed for data collection, and test the feasibility of conducting the research after analyzing the pilot study results. Patients included in the pilot study were excluded from the current study sample.

Field work phase “implementation phase

Patients’ recruitment started in January 2017 and final data collection procedure was performed in January 2018. All Patients were interviewed and assessed two times.

First assessment was done for all patients during admission as a base line data by using tool one.

Second assessment was done after six months for all patients by using tool I (some points of part two & part three) and tool II.

The control group patients had exposed to routine hospital care. While study group exposed to the rehabilitation exercises program which carried out on an individual basis from the second postoperative day and continued according to the patient condition. Patients’ families had been involved to ensure patient support and facilitate achieving the goals.

The researchers explained and applied the rehabilitation exercises program preoperatively on the second day of admission in the Traumatology Department in two sessions. Each session taked about 45 minutes.

All study group patients already started warm up exercises, gentle ROM exercises of the knee joint on the second to the fifth postoperative day. And toes mobilization was then started, then upper extremities exercises were done for strengthening the muscles of the upper limbs to rehabilitate it for crutch using, then non-weight bearing crutch walking was continued six weeks postoperatively.

On the end of six weeks; the patients were allowed to start gradually increasing weight bearing using two crutches to achieve partial weight-bearing. Full weight bearing is generally delayed for approximately 12 weeks postoperatively. The researchers ensured patients’ commitment to implement the rehabilitation exercises program weekly by telephone.

Evaluation phase

To distinguish between the initial assessment of studied patients and their assessment at the time of follow up after six months. Evaluation phase was carried out through using tool I “some items of part two and part three” , and tool II for all studied sample “both control and study groups” in Orthopedic Outpatient Clinics.

6.5. Statistical Design

Date entry and data analysis were done using SPSS version 19 (Statistical Package for Social Science). Data were presented as mean and standard deviation. Chi-square and Fisher Exact tests were used to compare between qualitative variables. Mann-Whitney test was used to compare between two quantitative variables in case of non-parametric data. P-value considered statistically significant when P < 0.05.

7. Results

Table 1 shows that male patients were the predominance in both study and control groups (70% & 66.7% respectively) the mean ages of both study and control groups were (33.50 ± 11.94 & 35.97 ± 12.80 respectively). According to occupation; the highest percent their work was machinery work in both study & control groups.

Table 2 reveals that the left side was the common affected side in both study and control groups (60.0%, & 53.3 % respectively). The highest percent in both groups had Pilon fracture associated with other skeletal injuries (60.0%, & 70.0% respectively). Also this table indicates that; there was no statistical significant difference between the two groups regarding mechanisms of injury.

Table 3 illustrates that most of patients in both groups (study & control) were treated by two staged protocol (96.7% & 86.7% respectively). There was obvious improvement among the study group who applied the rehabilitation exercise program compared with the control group, where majority of the study group patients their duration of immobilization and the starting time for weight bearing were six weeks (80% & 86.7% respectively), while about half of the control group patients their duration of immobilization was more than six weeks and the starting time for weight bearing was more than twelve weeks.

Table 4 presents a marked reduction in the complications rate among the study group patients who received the rehabilitation exercise program than the control group patients, where 90% of the study group patients didn’t develop early complications nor late complications while 70% of the control group patients who didn’t develop early complications and only 36.7% who didn’t develop late complications. There were statistically significant differences between the two groups regarding most late complications

Table 5 clarifies that no statistically significant difference at the time of admission was found between the two groups (study & control) regarding their level of knowledge about the rehabilitation exercises program for pilon fracture. While there was a statistically significant difference in the time of follow up between the two groups (study & control) regarding their level of knowledge about rehabilitation exercises program for Pilon fracture.

Table 6 reflects that there was a statistically significant difference between the two groups (study & control) regarding Mazur score during the time of follow up.

Table 7 reveals that there were statistically significant improvements in the Mazur scores among the patients who didn’t develop complications neither early nor late complications than those who already developed either early complications or late complications.

8. Discussion

According to demographic profile of studied patients; the present study showed that male patients were the predominance in both study & control groups. The mean ages of both study & control groups were around thirty three & thirty five years old. This result can be attributed to the fact that men are more likely to exercise and perform physical activity than women.

These study findings are in the line with a study conducted at Trauma unit and Orthopedic Department of Assiut University Hospital by Amin 10 Entitled as “A thesis to compare the results of treatment to Pilon fracture with early internal fixation versus external fixation & delayed internal fixation” which revealed that more than half of patients were male and their mean ages were thirty seven years old.

Most of patients in both study &control groups treated by two staged protocol where external fixator applied for a period ranged from two to three weeks then the second stage “ open reduction & internal fixation” was done. Only a few number of patients who had type A pilon fracture, treated by one stage method (open reduction and internal fixation) this could be explained by that most of patients who had type B& C fracture had more comminution & soft tissues injuries which may need for external fixator alone first for a period from 2-3 weeks to allow swelling subside and then internal fixation later.

Similar to our results, Barei & Nork, 11 have reported that in the last two decades, more patients with Pilon fractures particularly type B&C fractures, are initially treated with spanning external fixation with or without fibular fracture stabilization and with or without percutaneous internal fixation. Also Gardner et al., 12 noted fewer complications using external fixation initially followed by staged (1-3wks) internal plating & grafting when patients present with type B&C Pilon fracture and bone loss.

According to mechanisms of injuries, the current study found that Pilon fracture mechanisms have changed from high energy injuries to low energy injuries. Also most of patients their fractures were associated with other skeletal injuries in the form of clavicle injuries or upper extremities injuries that were treated by conservative method. In a series of 50 patients studied by Meena et al., 8; they found that road traffic accident was most common mode of injury (56%) and associated upper limb injuries were present in 4patients and head injury was present in 8 patients. Associated fibular fracture was present in 88% of patients.

According to the patients’ knowledge about rehabilitation exercises program; the results of the present study revealed that there was a statistically significant difference in the time of follow up between the two groups (study & control) regarding their level of knowledge about rehabilitation exercises program for Pilon fracture. Lanyon 13 clarified in his study that exercises that introduce stress to the skeleton through ground-reaction forces e.g., walking and through joint-reaction forces (e.g., weight lifting) increase bone mineral density through remodeling.

Pamela, 14 stressed on the role of the nurse is to help patients understanding their injuries and educating on the rationale for weight-bearing restrictions as well as the exercises that they should follow and how to protect the ankle from further injuries.

As regard to Pilon fracture outcome during the period of follow up; the results of the present study showed a marked reduction in postoperative complication rates among study group patients than control group patients. This could be due to the effect of the rehabilitation exercises program which study group followed it where improved blood supply to the injured site & helped in normal fracture healing process. So the complication rate was fewer among this group than those who didn’t apply the rehabilitation exercises program.

Some complications can’t be measured in our study because it needs for longer time of follow up as complete union may need up to year & more to judge if complete union occurred or not; in our study the judgment of fracture healing process was based on callus formation which becomes evident on the radiograph which indicates that bone remodeling process are started & fracture healing process will continue.

American College of Sports Medicine 15 explained the relation between physical exercises and musculoskeletal health; it mentioned that; absence of typical forces on the body can cause degeneration, or deformity. For example, the absence of normal weight bearing associated with prolonged bed rest or immobilization weakens muscle and bone. Prolonged inactivity also leads to decrease efficiency of the circulatory and pulmonary systems.

Also the current study showed a marked improvement in the study group patients’ Mazur ankle score at 6th months follow up than control group patients which was apparent in decreased pain, swelling, better range of motion, and improved gait. This could be due to the effect of rehabilitation exercises program. This study finding was in a line with a study conducted by Jiang et al. 6 who retrospectively analyzed twenty two patients with Pilon fracture; their results showed that the ankle joint Mazur score was excellent and good in twenty patients. Also postoperative complications were statistically reduced compared with previous studies.

Finally; Puthoff and Nielsen 16 Pointed to; there was a link have been identified between decreased isometric strength of lower extremity musculature and difficulty stooping and kneeling as well as a link between decreased lower extremity peak power and reduced walking speed and difficulty moving from sitting to standing.

9. Study Limit

There was short period of follow up time and nursing literatures about this topic were rare.

10. Conclusion

Rehabilitation exercises program for Pilon fracture led to better outcome that was apparent in fewer complications rate, decreased pain, swelling, better range of motion, & improved gait which raised the level of Mazur score among the intervention (study) group.

11. Recommendations

Rehabilitation exercises program for Pilon fractures should be carried out on an individual basis from the beginning of this fracture to prevent postoperative complications and achieve better outcome. Simple charts including pictures and guidance about the rehabilitation exercises program for Pilon fracture should be available in Traumatology Department.

References

[1]  Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: Long-term follow-up with gait analysis. J. Bone Joint Surg Am. 61: 964-75. (1979).
In article      View Article  PubMed
 
[2]  Heim U. In Duparc J, editor: Fractures du pilon tibial. Conférences d’enseignement. Paris: Expansion Scientique Francaise;. 35-51. (1997).
In article      PubMed
 
[3]  Bible JE, Sivasubramaniam PG, Jahangir AA, Evans JM, Mir HR. High-energy transsyndesmotic ankle fracture dislocation-the Logsplitter injury. J Orthop Trauma. 28 (April (4)): 200-204. (2014).
In article      View Article  PubMed
 
[4]  Dujardin F., Abdulmutalib H., Tobenas A.C.,. Total fractures of the tibial pilon Review article, Orthopaedics & Traumatology: Surgery & Research, S65-S74, (2014), Available online at www.sciencedirect.com
In article      View Article  PubMed
 
[5]  Wei SJ, Han F, Lan SH, Cai XH. Surgical treatment of pilon fracture based on ankle position at the time of injury/initial direction of fracture displacement: a prospective cohort study. Int J Surg.; 12(5): 418-425. (2014).
In article      View Article  PubMed
 
[6]  Jiang Liangjun, Zheng Qiang, Li Hang, Pan Zhijun; Injury mechanism, fracture characteristics and clinical treatment of pilon fracture with intact fibula A retrospective study of 23 pilon fractures, Journal of Clinical Orthopaedics and Trauma 8S (2017) S9-S15 available at : www.elsevier.com/locate/jcot
In article      
 
[7]  Kisner C. & Colby L.: Therapeutic exercise: foundations and techniques, ch. (3; 22) 6th ed, Davis Company, Philadelphia, 883-890; 59-62. (2012).
In article      View Article
 
[8]  Meena U. Kumar, Bansal M. Chand, Prateek Behera, Rahul Upadhyay,Gothwal G. Chand: Evaluation of functional outcome of pilon fractures managed with limited internal fixation and external fixation: A prospective clinical study, Journal of Clinical Orthopaedics and Trauma 8S S16-S20. (2017), available at: www.elsevier.com/locate/jcot.
In article      View Article  PubMed
 
[9]  Moseley AM, Beckenkamp PR, Haas M, et al: Rehabilitation after immobilization for ankle fracture: the exact randomized clinical trial. JAMA; 314: 1376-1385. (2015).
In article      View Article  PubMed
 
[10]  Amin W. Tammam; A thesis to compare the results of treatment to pilon fracture with early internal fiation versus eternal fixation & delayed internal fixation, Master thesis, faculty of medicine, Assiut University, Egypt, p. 63. (2013).
In article      
 
[11]  Barei, D., & Nork, S.. Fractures of the tibial plafond. Foot and Ankle Clinics of North America, 13, 571-591. (2008).
In article      View Article  PubMed
 
[12]  Gardner, M., Mehta, S., Barei, D., & Nork, S.. Treatment protocol for open AO/OTA type C3 pilon fractures with segmental bone loss. Journal of Orthopaedic Trauma, 22(7), 451-457. (2008).
In article      View Article  PubMed
 
[13]  Lanyon LE.. Bone remodeling mechanical stress and osteoporosis. In: DeLuca HF, Frost HM, Jee WSS, editors. Osteoporosis: recent advances in pathogenesis and treatment. Baltimore (MD): University Park Press, 129. (1981).
In article      
 
[14]  Pamela L.Matthew C. Scott E.: Orthopaedic Trauma Pilon Fractures Orthopaedic Nursing, 30 (5) 293-298. (2011).
In article      
 
[15]  American College of Sports Medicine: ACSM’s Guidelines for Exercise Testing and Prescription, ed. 8. Philadelphia: Wolthers Kluwer/Lippincott Williams & Wilkins, 2010.
In article      
 
[16]  Puthoff, ML, and Nielsen, DH: Relationships among impairments in lower extremity strength and power, functional limitations, and disability in older adults. Phys Ther 87(10):1334-1347. (2007).
In article      View Article  PubMed
 
[17]  Barei, D.: Pilon fractures. Philadelphia: Lippincott, Williams & Wilkins. 1928-1974. (2010).
In article      
 
[18]  Egol, K., Koval., & Zuckerman, J. (Eds.), Handbook of fractures. Philadelphia: Lippincott, Williams & Wilkins, (2010).
In article      View Article
 

Published with license by Science and Education Publishing, Copyright © 2018 Faisal Fahmy Adam, Amna Abdullah Desouky and Esmat Sayed Abd-Elmeegeed

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Faisal Fahmy Adam, Amna Abdullah Desouky, Esmat Sayed Abd-Elmeegeed. Pilon Fracture Rehabilitation Exercises Program Outcome. American Journal of Nursing Research. Vol. 6, No. 5, 2018, pp 222-228. http://pubs.sciepub.com/ajnr/6/5/2
MLA Style
Adam, Faisal Fahmy, Amna Abdullah Desouky, and Esmat Sayed Abd-Elmeegeed. "Pilon Fracture Rehabilitation Exercises Program Outcome." American Journal of Nursing Research 6.5 (2018): 222-228.
APA Style
Adam, F. F. , Desouky, A. A. , & Abd-Elmeegeed, E. S. (2018). Pilon Fracture Rehabilitation Exercises Program Outcome. American Journal of Nursing Research, 6(5), 222-228.
Chicago Style
Adam, Faisal Fahmy, Amna Abdullah Desouky, and Esmat Sayed Abd-Elmeegeed. "Pilon Fracture Rehabilitation Exercises Program Outcome." American Journal of Nursing Research 6, no. 5 (2018): 222-228.
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  • Table 5. Percentage distribution of total level of knowledge about rehabilitation exercises program for pilon fracture among study & control group patients
  • Table 7. Relation between developed complications among study and control group patients and Mazur scores at 6th months follow up
[1]  Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis: Long-term follow-up with gait analysis. J. Bone Joint Surg Am. 61: 964-75. (1979).
In article      View Article  PubMed
 
[2]  Heim U. In Duparc J, editor: Fractures du pilon tibial. Conférences d’enseignement. Paris: Expansion Scientique Francaise;. 35-51. (1997).
In article      PubMed
 
[3]  Bible JE, Sivasubramaniam PG, Jahangir AA, Evans JM, Mir HR. High-energy transsyndesmotic ankle fracture dislocation-the Logsplitter injury. J Orthop Trauma. 28 (April (4)): 200-204. (2014).
In article      View Article  PubMed
 
[4]  Dujardin F., Abdulmutalib H., Tobenas A.C.,. Total fractures of the tibial pilon Review article, Orthopaedics & Traumatology: Surgery & Research, S65-S74, (2014), Available online at www.sciencedirect.com
In article      View Article  PubMed
 
[5]  Wei SJ, Han F, Lan SH, Cai XH. Surgical treatment of pilon fracture based on ankle position at the time of injury/initial direction of fracture displacement: a prospective cohort study. Int J Surg.; 12(5): 418-425. (2014).
In article      View Article  PubMed
 
[6]  Jiang Liangjun, Zheng Qiang, Li Hang, Pan Zhijun; Injury mechanism, fracture characteristics and clinical treatment of pilon fracture with intact fibula A retrospective study of 23 pilon fractures, Journal of Clinical Orthopaedics and Trauma 8S (2017) S9-S15 available at : www.elsevier.com/locate/jcot
In article      
 
[7]  Kisner C. & Colby L.: Therapeutic exercise: foundations and techniques, ch. (3; 22) 6th ed, Davis Company, Philadelphia, 883-890; 59-62. (2012).
In article      View Article
 
[8]  Meena U. Kumar, Bansal M. Chand, Prateek Behera, Rahul Upadhyay,Gothwal G. Chand: Evaluation of functional outcome of pilon fractures managed with limited internal fixation and external fixation: A prospective clinical study, Journal of Clinical Orthopaedics and Trauma 8S S16-S20. (2017), available at: www.elsevier.com/locate/jcot.
In article      View Article  PubMed
 
[9]  Moseley AM, Beckenkamp PR, Haas M, et al: Rehabilitation after immobilization for ankle fracture: the exact randomized clinical trial. JAMA; 314: 1376-1385. (2015).
In article      View Article  PubMed
 
[10]  Amin W. Tammam; A thesis to compare the results of treatment to pilon fracture with early internal fiation versus eternal fixation & delayed internal fixation, Master thesis, faculty of medicine, Assiut University, Egypt, p. 63. (2013).
In article      
 
[11]  Barei, D., & Nork, S.. Fractures of the tibial plafond. Foot and Ankle Clinics of North America, 13, 571-591. (2008).
In article      View Article  PubMed
 
[12]  Gardner, M., Mehta, S., Barei, D., & Nork, S.. Treatment protocol for open AO/OTA type C3 pilon fractures with segmental bone loss. Journal of Orthopaedic Trauma, 22(7), 451-457. (2008).
In article      View Article  PubMed
 
[13]  Lanyon LE.. Bone remodeling mechanical stress and osteoporosis. In: DeLuca HF, Frost HM, Jee WSS, editors. Osteoporosis: recent advances in pathogenesis and treatment. Baltimore (MD): University Park Press, 129. (1981).
In article      
 
[14]  Pamela L.Matthew C. Scott E.: Orthopaedic Trauma Pilon Fractures Orthopaedic Nursing, 30 (5) 293-298. (2011).
In article      
 
[15]  American College of Sports Medicine: ACSM’s Guidelines for Exercise Testing and Prescription, ed. 8. Philadelphia: Wolthers Kluwer/Lippincott Williams & Wilkins, 2010.
In article      
 
[16]  Puthoff, ML, and Nielsen, DH: Relationships among impairments in lower extremity strength and power, functional limitations, and disability in older adults. Phys Ther 87(10):1334-1347. (2007).
In article      View Article  PubMed
 
[17]  Barei, D.: Pilon fractures. Philadelphia: Lippincott, Williams & Wilkins. 1928-1974. (2010).
In article      
 
[18]  Egol, K., Koval., & Zuckerman, J. (Eds.), Handbook of fractures. Philadelphia: Lippincott, Williams & Wilkins, (2010).
In article      View Article