Start fracture rehabilitation today: reduce the risk of problem healing and CRPS. Jill Wigmore-Welsh MSc HCPC : Reading, London and web clinics.

Description

Fractures are among the most common injuries across the lifespan, accounting for 10 to 25 percent of all paediatric injuries and presenting in very different ways in children compared with adults. The fundamental distinction is biological: children’s bones are still growing, with active physes (growth plates) that are not present in adult bone, and a periosteum that is thicker, more biologically active, and considerably more capable of spontaneous remodelling. These characteristics mean that children can tolerate some degree of fracture displacement that would require surgical correction in an adult, and that the healing trajectory in healthy children is generally more rapid. However, they also mean that fractures involving the growth plate carry specific risks of growth arrest, angular deformity, and limb length discrepancy that require specialist paediatric orthopaedic assessment and ongoing developmental monitoring, not simply a period of immobilisation and discharge.

In adults, complex fractures include high-grade injuries involving comminution (fragmentation), bone loss, articular surface disruption, accompanying soft tissue damage, neurovascular involvement, or configurations that challenge fixation stability and compromise healing biology.

A complex fracture is not simply a fracture that is difficult to fix surgically. It is one in which the healing environment, the biological response, and the rehabilitation trajectory are all significantly altered from the straightforward case.

Across age groups, fractures in children should not be approached as miniature versions of adult injuries.

The developmental context — in terms of bone biology, growth implications, psychological impact, educational disruption, and family system effects — requires a specific and developmentally sensitive clinical framework.

Research published in the Special Issue on Paediatric Fractures confirms that despite the high prevalence of these injuries, comprehensive paediatric fracture rehabilitation remains under researched relative to adult orthopaedic rehabilitation, and that children with multiple or complex fractures derive particular benefit from early, structured physiotherapy addressing range of motion, alignment, abnormal movement patterns, and functional activity rather than simple immobilisation and waiting.

Effect

Child

For a child, a complex fracture interrupts the developmental trajectory. School attendance, physical education, social activity, peer relationships, and the developmental tasks of childhood — which include building confidence, competence, and physical self-concept — are all disrupted. For children with injuries involving the growth plate, the uncertainty about whether normal growth will be maintained creates a particular kind of sustained parental and individual anxiety that is not simply resolved at fracture union. For families, the organisational demands of managing a child through a complex recovery — including hospital admissions, outpatient appointments, therapy attendance, school liaison, and functional assistance — are substantial and frequently invisible in clinical assessments of impact.

 

Effect

Adult

For adults, complex fractures can be career-defining events. The typical presentation involves a working-age individual who sustains a high-energy injury that removes them from employment, disrupts their domestic roles, limits their independence, alters their sleep, and exposes them to sustained pain that is frequently disproportionate to what imaging findings suggest. Psychological factors — including acute stress responses, PTSD-type reactions, depression, anxiety, and pain catastrophising — are not incidental features of complex fracture recovery. They are robustly evidenced predictors of functional outcome. Research confirms that psychological factors, including pain catastrophising, depression, anxiety, and reduced self-efficacy, account for 15 to 25 percent of the variance in long-term functional outcomes after traumatic fractures, independent of injury severity.

Management

Rehabilitation for complex fractures in both children and adults must address the full biopsychosocial picture. For children, this means physiotherapy targeting age-appropriate functional recovery, developmental re-engagement, and correction of compensatory movement patterns; occupational therapy addressing return to school, daily activities, and participation; and psychological support where the injury or its treatment has been experienced as frightening, painful, or isolating. For adults, the scoping review by Silvester et al. — the most comprehensive synthesis of its kind — identified exercise-based physiotherapy delivered by physiotherapists as the primary intervention, but also found evidence for psychosocial interventions including cognitive behavioural therapy (CBT) in comparison to usual care, supporting the integration of psychological approaches into standard fracture rehabilitation.

In my practice, complex fracture rehabilitation is structured around the individual’s specific biological and psychological situation, their life context, their occupational and domestic goals, and the evidence base for their particular injury type. Trauma-informed approaches address the nervous system responses that frequently persist long after bone healing is complete. Pain neuroscience education reconceptualises the pain experience in ways that directly reduce kinesiophobia and catastrophising. Somatic psychotherapeutics address the physiological dimension of trauma response. And occupational therapy targets the functional milestones — from domestic independence to return to employment — that define genuine recovery.

References for Complex Fractures in Children and Adults: 

Description: (1, 2, 3) Effect: (4, 5) Management: (6, 7, 8)

Trauma-Related Compression Fractures

Description

Vertebral compression fractures (VCFs) are the most common fracture type associated with osteoporosis, but in younger adults they arise principally from high-energy trauma — road traffic accidents, falls from height, sporting injuries, and occupational accidents — producing injury to the anterior column of the vertebral body through compressive loading and flexion mechanisms. In older adults, the same fracture pattern may arise from low-energy incidents — a stumble, a missed step, bending forward — where underlying osteoporosis or osteopenia has substantially reduced the mechanical threshold required to produce structural failure. VCFs may also arise from neoplastic or pathological conditions that alter bone structural integrity. The resulting wedge deformity of the vertebral body causes pain, altered spinal mechanics, postural change, and — where multiple levels are involved — progressive kyphosis with significant functional and physiological consequences.

VCFs are frequently underdiagnosed. In the acute setting, back pain following trauma is not always investigated with sufficient imaging detail to identify vertebral fractures, and in older adults with existing spinal degeneration, the distinction between chronic degenerative change and acute fracture-related pain may require specialist assessment. The clinical and public health burden of VCFs increases markedly with age, is significantly greater in women due to lower bone mineral density, and carries implications not only for pain and mobility but for respiratory function, gastrointestinal tolerance, and cardiovascular capacity in individuals with thoracic deformity.

Effect

The effect of a compression fracture on daily life is substantial and frequently underestimated by those who have not experienced one. Pain — which begins with movement and weight-bearing and gradually becomes harder to separate from rest — alters every activity of daily living. The loss of spinal height and the development of kyphotic posture change how individuals reach, lift, carry, sleep, and sit. In thoracic compression fractures, restricted chest expansion reduces respiratory capacity, with implications for exercise tolerance, infection risk, and general fatigue. Multiple vertebral fractures, which occur in a cascade pattern in susceptible spines, compound these effects significantly.

A 2024 review in the American Journal of Medicine confirmed that vertebral fractures produce significant back pain and patient-reported functional impairment, and that their management is frequently suboptimal due to underdiagnosis and insufficient rehabilitation. In trauma-related VCFs in younger adults, the psychological sequelae of the accident itself — acute stress, PTSD-type symptoms, fear of movement, loss of confidence — overlap with and amplify the physical pain in ways that generic physical rehabilitation does not address. The relationship between pain perception, fear of movement, and activity avoidance in vertebral compression fractures has been specifically examined: a randomised controlled trial demonstrated that rehabilitation combined with targeted pain management addressing pain perception and activity avoidance produced significantly better outcomes than standard rehabilitation alone.

Management

The evidence base for rehabilitation after vertebral compression fracture is clear that physical therapy significantly improves pain and patient-reported outcomes, and that resistance and aerobic training are associated with improvements in bone mineral density that reduce the risk of further fracture. Exercise programmes must be carefully designed and individually prescribed — not all exercises are appropriate in the context of spinal fragility or post-surgical instrumented spinal fixation — and the exercise approach must be developed in close communication with the treating surgical team.

Beyond the physical dimension, rehabilitation for compression fracture must address the patterns of fear-avoidance, kinesiophobia, and pain catastrophising that develop in response to a painful spinal injury and that consistently predict poorer functional recovery when left unaddressed. Pain neuroscience education — reframing the patient’s understanding of their pain from a purely structural to a central nervous system model — is specifically evidenced to reduce catastrophising and kinesiophobia in this group, and is integrated throughout the rehabilitation programme in my practice. Where the fracture arose in the context of trauma, trauma-informed approaches address the psychological responses to the incident itself.

References for Trauma-Related Compression Fractures: Description: (9, 10) Effect: (11, 12) Management: (11, 13, 14)

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High-Energy Fractures with Significant Bone and Soft Tissue Loss

Description

High-energy fractures are those arising from forces sufficient to cause extensive bone fragmentation, periosteal stripping, disruption of the surrounding soft tissue envelope, and — in many cases — damage to adjacent neurovascular structures. They are typically caused by road traffic accidents, industrial accidents, falls from significant height, or blast injuries. The classification of fractures by energy, most commonly using the AO/OTA classification system, reflects the reality that fracture configuration and energy level are among the most important predictors of complications including delayed union, non-union, infection, compartment syndrome, neurovascular injury, and functional deficit.

Significant bone loss — resulting either from the injury itself or from surgical debridement of devitalised tissue — creates a particular biological and mechanical challenge. Without sufficient bone stock to bridge the fracture gap, healing is compromised and reconstruction may require bone grafting, bone transport via external fixation (Ilizarov or similar techniques), or biological augmentation with bone substitutes and growth factors. Soft tissue loss — including muscle, fascia, skin, and subcutaneous tissue — compounds the surgical challenge and may require plastic surgical input with local or free flaps to achieve wound closure and provide the vascularised environment in which bone can heal.

These injuries are frequently managed across multiple specialties over a prolonged clinical course. The rehabilitation practitioner enters a complex, evolving picture in which surgical goals, fracture fixation status, tissue viability, neurovascular function, and pain management are all in dynamic relationship with one another — and in which the psychological state of the patient is an independent determinant of outcome.

Effect

The personal burden of a high-energy fracture with bone and soft tissue loss is profound. These injuries are typically sustained by working-age adults in the prime of their productive and family lives. The initial trauma — which frequently involves emergency surgery, intensive care, and a period of clinical uncertainty about limb salvage — is itself psychologically overwhelming. Research on central sensitisation after orthopaedic trauma has identified that early high-intensity pain and neurophysiological alterations following fracture may precede longer-term mixed pain phenotypes, and that psychological distress and PTSD, prevalent after major trauma, can exacerbate centrally mediated pain. Crucially, screening and targeted interventions for these psychological responses are rarely embedded in routine orthopaedic trauma practice.

The extended timeline of care — which may involve multiple surgical procedures over months or years — sustains an elevated physiological stress response, disrupts sleep, prevents return to work and domestic roles, and creates a cumulative burden on relationships, finances, identity, and psychological wellbeing. The individual is simultaneously managing physical pain, functional limitation, surgical recovery, and the psychological aftermath of a traumatic event — often without coordinated psychological support. In medico-legal contexts, high-energy fractures with bone and soft tissue loss represent some of the most complex presentations to assess, requiring specialist analysis of causation, surgical course, rehabilitation adequacy, and both physical and psychological prognosis.

Management

Integrated rehabilitation for high-energy fractures must coordinate closely with the surgical team across the continuum of care. In the acute phase, physiotherapy targets pain management, prevention of deconditioning, breathing support where relevant, and the earliest safe mobilisation consistent with fixation stability. As the surgical picture evolves, rehabilitation must adapt — progressing weight-bearing and active exercise in line with bone healing, supporting soft tissue recovery, and managing the neuromuscular consequences of tissue loss and surgical intervention.

Central sensitisation — increasingly recognised as an overlooked contributor to chronic pain and functional disability after orthopaedic trauma — must be actively assessed and addressed. A 2026 scoping review by UK NHS clinicians confirmed that trauma-induced neuroimmune activation, altered cortical and spinal excitability, and molecular pathways consistent with central sensitisation are documented after fractures and major injuries, and that early predictors of adverse trajectories include severe acute pain, neuropathic descriptors, and psychological distress. Pain neuroscience education, CBT, and trauma-informed somatic approaches address these mechanisms in ways that biomechanically-led rehabilitation alone cannot. Occupational therapy targeting functional roles, return to meaningful activity, and adaptive equipment supports independence during the protracted recovery course.

References for High-Energy Fractures with Significant Bone and Soft Tissue Loss: Description: (15, 16) Effect: (17, 18, 19) Management: (17, 19, 20, 21)

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Open Fractures with Repeated Surgery, Managed with External Fixation

Description

An open fracture — one in which the bone communicates with the external environment through a wound in the overlying skin and soft tissue — represents a clinical emergency. Contamination, infection risk, soft tissue devitalisation, and the disruption of the periosteal blood supply that is essential to bone healing all make open fractures substantially more complex than closed injuries. They are graded by severity (most commonly using the Gustilo-Anderson classification) from Grade I, involving a small clean wound, through to Grade IIIC, involving extensive soft tissue loss with arterial injury requiring repair — a presentation carrying high rates of limb loss and life-threatening complication.

External fixation — in which metal pins are passed through the bone above and below the fracture and connected by an external frame — is widely used in the management of open fractures, both as definitive fixation and as a temporary stabilisation method to allow wound management before conversion to internal fixation when soft tissue conditions permit. In complex presentations, circular frame (Ilizarov-type) external fixation may be maintained for months as the primary reconstruction device — allowing bone transport, segment correction, or gradual compression at the fracture site while the soft tissue envelope is progressively restored.

For the patient, external fixation is a visible, often bulky device attached to the limb that restricts clothing, requires daily pin-site care, limits bathing and certain movements, and serves as a constant physical reminder of the injury and its ongoing severity. The psychological dimensions of living with an external fixator have been insufficiently recognised in clinical practice, and a 2025 scoping review confirmed that while psychological challenges associated with these devices are well documented, follow-up with sufficient psychological support remains the exception rather than the rule.

Effect

The psychological impact of open fracture is immediate and often lasting. In the immediate aftermath, patients face the combined psychological effect of traumatic injury, sudden hospitalisation, physical impairment, and — for high-grade injuries — the possibility of limb loss. Evidence from Oxford Academic’s authoritative publication on open fracture management confirms that psychological distress following open fracture is common and can be lasting, with approximately a third of individuals with severe injuries experiencing clinically significant psychological difficulty. Post-traumatic stress symptoms are typical in the immediate period following open fracture, and for a minority they escalate over time into PTSD and depression — a trajectory that is predictive of worse functional outcome and that requires active clinical attention rather than expectant observation.

External fixation specifically produces psychological challenges related to device visibility, self-concept, social withdrawal, anxiety about pin-site complications, and the repeated surgical encounters that characterise this treatment course. Research comparing internal and external fixation found that patients undergoing external fixation experience significantly higher rates of anxiety, depression, low self-esteem, and insomnia than those managed with internal fixation, and that these psychological responses persist beyond the early postoperative period. The cumulative effect — sustained physical pain, device dependency, repeated hospital admissions, restricted activity, altered appearance, and unresolved psychological distress — creates a clinical picture that requires comprehensive biopsychosocial rehabilitation, not simply physiotherapy alongside orthopaedic follow-up.

Management

A 2024 systematic review of rehabilitation techniques for adults undergoing external fixation for lower limb reconstruction confirmed that despite widespread clinical use of these devices, there is currently no consensus on optimal rehabilitation techniques and that significant variation in practice exists. The review, conducted by clinicians at the Royal London Hospital and Bournemouth University, highlighted the need for structured, evidence-informed rehabilitation protocols. Within this landscape, specialist rehabilitation must be individually constructed and closely coordinated with the surgical team.

Psychological support: NICE guideline NG116 recommends trauma-focused CBT for adults with acute stress disorder or clinically important PTSD symptoms within the first month post-trauma — a recommendation directly relevant to the open fracture population, in whom unaddressed psychological responses independently predict worse outcome. 

Physiotherapy during external fixation management must navigate the constraints of the device while maximising strength, range of motion, neuromuscular function, and general conditioning. Alongside physical rehabilitation input addresses the very substantial practical limitations that external fixation imposes on daily activities, domestic tasks, and return to work and supports adaptive strategies during what may be a prolonged period of device-wearing. 

Psychological support — addressing the acute stress response, fear of further injury or complication, body image, and the sustained existential uncertainty of a protracted recovery — is integrated throughout rather than added as an afterthought.

References for Open Fractures with External Fixation: Description: (22, 23, 24) Effect: (24, 25, 26) Management: (24, 27, 28, 29)

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Delayed Union and Non-Union of Bone

Description

Fracture union — the biological process by which bone regenerates across a fracture gap to restore structural continuity — is a complex sequence of overlapping phases: haematoma formation, inflammatory response, soft callus formation, hard callus mineralisation, and remodelling to lamellar bone. This process typically completes within a timeframe that varies by bone type, patient age, and mechanical environment. Delayed union describes a failure to achieve union within the expected timeframe for that injury in that patient. Non-union represents the point at which healing has ceased — biologically and mechanically — without bone continuity being achieved, and at which further spontaneous healing is unlikely without intervention.

Research published in 2024 confirms that the prevalence of long bone non-union ranges from 10 to 15 percent of surgically managed fractures — a clinically significant complication rate reflecting the reality that delayed bone healing remains a genuine challenge despite advances in surgical technique, implant technology, and biological augmentation. Risk factors for delayed and non-union span four domains: injury-related factors (fracture gap, bone loss, soft tissue injury, infection), patient-dependent factors (age, nutrition, systemic disease, smoking, medications including NSAIDs), surgical factors (fixation stability, fracture reduction adequacy), and mechanical factors (loading environment). High-energy trauma, open fractures, the use of external fixation as a staged treatment, and postoperative infection are among the strongest predictors of non-union.

Effect

The effect of delayed union and non-union on the individual is profound and frequently extends far beyond what the clinical record captures. At the biological level, a fracture that has not united remains mechanically unstable — producing pain with loading, limiting weight-bearing and functional activity, and creating an environment of sustained inflammation and periosteal stress response. At the personal level, the experience of a fracture that has failed to heal — despite surgery, compliance with rehabilitation, and the passage of time — is one of the most psychologically distressing situations in orthopaedic care.

Research examining the physical and psychological outcomes of long bone fracture non-union found that patients with established non-union carry a significantly elevated burden of depression, anxiety, and PTSD-type symptoms compared with populations who achieve union, and that psychological burden does not resolve simply with surgical correction of the non-union — suggesting that the prolonged experience of failed healing creates its own psychological sequelae requiring direct treatment. The functional impact — continued inability to work, restricted daily activity, dependence on aids and assistance, and disruption to domestic and family roles — compounds across the months and sometimes years of the non-union course. In the medico-legal context, non-union following trauma represents one of the most complex prognostic assessments, requiring specialist evaluation of causative factors, surgical course, rehabilitation adequacy, psychological burden, and realistic functional prognosis.

Management

Rehabilitation for delayed union and non-union must be closely integrated with surgical management and calibrated to the current biological and mechanical status of the fracture. Where biological stimulation — through ultrasound, bone morphogenetic proteins, or autologous bone grafting — is being used to promote healing, rehabilitation must support the mechanical environment required for that biological response while maximising the patient’s overall physical condition and psychological coping. The value of evidence-based rehabilitation programmes in the non-union context is explicitly highlighted in the recent literature: patients managed with collaborative, individualized rehabilitation programmes that incorporate the patient’s perspective and experience alongside the clinical data are more likely to recover fully or to a greater extent than those managed in a predominantly surgical or biomedical framework.

Psychological support is not optional in this population. The prolonged course of non-union, characterised by repeated surgical encounters, sustained pain, functional limitation, and uncertain prognosis, creates conditions in which depression, anxiety, and catastrophising are common and clinically significant. These responses are not simply reactions to circumstances that will resolve when healing is achieved — they actively impair the rehabilitation engagement, pain experience, and functional trajectory of the individual. CBT, ACT, pain neuroscience education, and trauma-informed approaches — delivered by a clinician with deep experience in complex orthopaedic rehabilitation — address the psychological dimension of non-union in ways that optimise both the experience of the recovery period and its functional outcome.

References for Delayed Union and Non-Union: Description: (30, 31, 32) Effect: (33, 34) Management: (30, 35, 36)

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Trauma or Fracture-Related Limb Amputation

Description

Limb amputation following trauma or fracture — whether arising from the severity of the initial injury, vascular compromise, infection, or the failure of limb salvage procedures — represents one of the most life-altering outcomes in orthopaedic trauma surgery. In the context of high-energy fractures, open fractures with Grade IIIC vascular injury, or established infection that has rendered the limb non-viable, amputation may follow a period of sustained limb salvage attempts during which the individual has undergone multiple surgical procedures, prolonged hospitalisation, and the psychological uncertainty of not knowing whether their limb can be preserved. The decision to proceed to amputation — whether made acutely or after a protracted salvage course — carries its own profound psychological dimensions.

Traumatic limb amputation is anatomically, physiologically, and psychologically distinct from dysvascular amputation. The individual is typically younger and physically fit prior to the injury, the amputation follows a traumatic event rather than a chronic disease process, and the psychological context includes the acute trauma of the causative accident, the experience of limb salvage attempts, and the loss — sudden or anticipated — of a limb that was previously intact and functional. The British Society of Rehabilitation Medicine’s standards for amputee and prosthetic rehabilitation provide the framework within which post-amputation care should be structured.

Effect

The psychological and functional impact of traumatic limb amputation is extensive and well-documented. Depression is frequently experienced in the early stages following lower limb amputation and can persist for up to two years. Anxiety, body image disruption, grief, anger, and identity reorganisation are all normal aspects of the psychological response to limb loss, and each requires clinical acknowledgement and, for many individuals, therapeutic support. PTSD — arising from the traumatic incident itself, from the experience of repeated surgery, or from the surgical experience of amputation — is a recognised complication that independently amplifies pain, restricts rehabilitation engagement, and worsens quality of life when unaddressed.

Research on psychological adjustment and quality of life following lower limb amputation consistently identifies that the biopsychosocial factors shaping adjustment are at least as important as the physical and prosthetic factors in determining long-term outcomes. Return to work following amputation is a key rehabilitation goal and a key legal question in trauma cases, and a 2024 study examining biopsychosocial predictors of return to work after lower limb amputation identified that psychological, social, and functional factors — not simply prosthetic fit and physical recovery — determine vocational outcome. The evidence is equally clear that psychological support following amputation is effective: a qualitative study published in 2025 exploring the experiences of receiving formal psychological support following lower limb amputation found that such support was experienced as meaningful, important, and insufficiently available within standard NHS provision.

Management

Rehabilitation following traumatic limb amputation requires an interdisciplinary team approach coordinated over a sustained period. Physiotherapy addresses residual limb conditioning, prosthetic rehabilitation, gait training, strength and balance, and the prevention of the musculoskeletal secondary complications — including lower back pain — that are a significant long-term burden in lower limb amputees. Occupational therapy addresses functional independence across all daily living domains, home adaptation, return to driving, and vocational rehabilitation. Prosthetic rehabilitation requires specialist prosthetics input alongside physiotherapy to optimise fit, function, and the amputee’s confidence and competence with their prosthesis.

Psychological support — which may include CBT, trauma-focused therapy for PTSD, grief counselling, and body image work — is not a supplementary element of amputation rehabilitation but a core component of it. The community-based rehabilitation model, identified in a 2024 systematic review as a key framework for supporting individuals with lower limb amputation, recognises that reintegration into social, occupational, and family life requires a biopsychosocial approach that addresses not only physical function but the psychological and social dimensions of adjustment to life with limb loss. In my practice, somatic psychotherapeutic approaches address the nervous system dysregulation that persists in the aftermath of trauma, supporting the individual’s capacity to engage with physical rehabilitation and to rebuild a coherent and forward-looking sense of identity and possibility.

References for Trauma or Fracture-Related Limb Amputation: Description: (37, 38) Effect: (39, 40, 41) Management: (37, 41, 42, 43)