Fractures of Neck of Femur & Subtrochantric - PDF

REHABILITATION FOR HIP FRACTURES & SURGERIES Femoral Neck Fractures Subtrochanteric Femur Fractures BY/ Dr. Mostafa Elshafey Lecturer of Orthopedic Physical Therapy Delta university for science and technology What is the difference between primary & second...

REHABILITATION FOR HIP FRACTURES & SURGERIES Femoral Neck Fractures Subtrochanteric Femur Fractures BY/ Dr. Mostafa Elshafey Lecturer of Orthopedic Physical Therapy Delta university for science and technology What is the difference between primary & secondary fracture healing mechanism?  A fracture with primary healing occurs without callus formation due to no evidence arising from a radiographic image, only when there is a reduction by internal fixation. In this healing process, new bone grows directly to unite the fracture. Usually, it occurs around two weeks after the injury, and the healing process depends on the osteoclastic resorption of bone, followed by osteoblastic new bone formation.  Secondary bone healing, the most common healing method, appears radiographically with callus formation. Increasing motion at the fracture site, the callus will become more prominent, adding stability by growing the bone fragments' width. It takes place in 4 phases; each phase's length depends on the severity of the fracture and the location: 1st Phase: Initiation of an inflammatory response. Amid this inflammatory response, increased vascularity allows for fracture hematoma formation, infiltrated by WBC, such as neutrophils and macrophages. These cells' function is to clear the necrotic tissue after the fracture with the appearance of hematoma and mesenchymal cell activation. 2nd phase: Mesenchymal cells will turn into chondrocytes which consequently will produce callus made of cartilage made of collagen and proteoglycans. In this phase, the periosteum's role is to provide early intramembranous ossification and neoangiogenesis. 3rd Phase: Proliferation and maturation of chondrocytes keep increasing the synthesis of collagen stored in the extracellular matrix. Then, chondrocytes undergo apoptosis. By recruiting other mesenchymal cells, they differentiate to osteoblasts, using the callus to place woven bone replacing the mineralized cartilage. 4th Phase: Regeneration of original bone by remodeling bony callus by osteoclastic resorption and osteoblastic processing will ensure new bone formation. An identical fracture in 2 different people will probably not have the same recovery because many factors affect the healing process. The most important ones are age and sex, nutritional status and other health problems combined with more specific reasons such as an infection or a loss of contact between facture segments.  Femoral Neck Fractures Definition A femoral neck fracture is a fracture occurring proximal to the intertrochanteric line in the intracapsular region of the hip.  Classification The following is Garden's classification: Type 1: an incomplete impacted femoral neck fracture in valgus position. Type 2: nondisplaced complete femoral neck fracture. Type 3: displaced femoral neck fracture in varus position. There is often disruption of the joint capsule. Type 4: completely displaced femoral neck fracture. It has the poorest prognosis. The femoral head may go on to avascular necrosis. In older patients, this fracture is usually treated with an endoprosthesis (hemi or total arthroplasty). Garden's type 1 Garden's type 2 Garden's type 3 Garden's type 4 Mechanism of Injury Most femoral neck fractures in the elderly are caused by low-energy trauma. This population is subject to senile osteoporosis. In younger patients, high-energy trauma is necessary to cause a femoral neck fracture, and therefore displacement of the fracture and damage to the blood supply is usually greater in those cases. Femoral neck has less periosteal layer. So, when it get injured, it must be treated surgically. These fractures have a high rate of nonunion and avascular necrosis because of the disruption of the blood supply to the femoral head. Methods of Treatment Open Reduction and Internal Fixation Fractures that are impacted, nondisplaced, or adequately reduced in patients younger than 65 years of age should be internally fixed with multiple parallel cannulated screws or a compression screw and side plate. These methods are primary mode of bone healing. Multiple parallel cannulated screws Compression screw and slide fixation. Prosthetic Replacement of the Femoral Head A fixed unipolar (Austin-Moore or Thompson type) or bipolar endoprosthesis may be used to treat an unstable displaced fracture when a satisfactory reduction cannot be achieved, and the patient is older than 65 years of age. Other indications include cases in which rheumatoid, degenerative, or malignant disease has caused preexisting articular damage. Bipolar endoprosthesis Treatment Goals Rehabilitation Objectives 1 Improve and restore range of motion of the knee and hip 2 Improve the strength of the following muscles: Gluteus medius, Gluteus Maximus, hip flexor, hip adductors, Quadriceps ( especially the lateralis, because it is exposed during surgery) and Hamstrings. 3-Normalize the patient's gait pattern. Achieve 90° hip flexion for proper sitting position. Expected Time of Bone Healing 12 to16 weeks. Expected Duration of Rehabilitation 15 to 30 weeks. Gait: Serial evaluation of leg length must be performed and shoe lift prescribed for the rare case of a significant leg-length discrepancy of greater than 3/4 inch. A progressive leg-length discrepancy after stabilization of the fracture may represent loss of correction of the fracture. A- Heel strike: G.Max & Vastus lateralis. B- Foot-Flat: Rectus femoris & Vatus lateralis. C- Mid-Stance: Iliopsoas & G.Med D- Swing Phase: This must be evaluated and strengthened as necessary once pain subsides.  Physical Therapy Treatment: Early to Immediate (Day of Injury to One Week) N.B. healing process that will be discussed is primary. BONE HEALING Stability at fracture site: None. Partial bony stability is present in impacted femoral neck fractures. Immediate mechanical stability is present once the fracture is treated with screws except in severe osteopenia. Hemiarthroplasty treatment has full mechanical stability. Stage of bone healing: Inflammatory phase. X-ray: No callus because healing is primary.  Prescription Precautions: Avoid extreme passive range of motion (to protect the sutures and inflamed tissues). So, be very gentle. Patients treated with endoprostheses (arthroplasty) avoid internal rotation and adduction past midline. Range of Motion: Active range of motion to ankle , Gentle active or passive movements of flexion and extension of the hip and knee (once the pain subsides) is permitted. Muscle Strength: Isometric gluteal and quadriceps exercises. Isotonic exercises to ankle. Functional Activities: Stand-pivot transfers and ambulation with assistive devices; raised toilet seat and chair (to avoid hip flexion past 90°). Weight bearing : Depending on procedure, either weight bearing as tolerated for stable impacted fractures or endoprostheses, or no weight bearing for elder people that have a delayed healing process.  Treatment: Two Weeks BONE HEALING Stability at fracture site: None to minimal Stage of bone healing: begin to reparative phase. X-ray: No callus because healing is primary. (Visible fracture line) Prescription Continue the same prescription of the last week Treatment: 4 to 6 weeks BONE HEALING Stability at fracture site: Moderate stability Stage of bone healing: Reparative phase. X-ray: No callus is visible because healing is primary. Prescription Precautions: continue the previous precaution. Range of Motion: Active, active-assistive range of motion to hip and knee. Muscle Strength: Isometric and isotonic exercises to hip and knee. Functional Activities: the same as previous weeks. Weight bearing: the same.  Treatment: 8 to 12 weeks BONE HEALING Stability at fracture site: Moderate stability from bone healing. Stage of bone healing: Late reparative phase. X-ray: No callus because healing is primary. (Visible fracture line). Treatment: 8 to 12 weeks Prescription Precautions: Avoid excessive adduction and internal rotation if an endoprosthesis (arthroplasty) is present. Range of Motion: Active, active-assistive, and passive range of motion to hip and knee. Muscle Strength: Isotonic and isokinetic exercises to hip and knee. Progressive resistive exercises instituted. Functional Activities: Weight-bearing transfers and ambulation with assistive devices. Weight bearing : Full weight bearing to weight bearing as tolerated. Treatment: 12 to 16 weeks BONE HEALING Stability at fracture site: Stable. Stage of bone healing: Remodeling phase. X-ray: No external callus is visible because healing is endosteal (primary). Fracture line is obliterated.  Prescription Precautions: Avoid excessive adduction if an endoprosthesis is present. Range of Motion: Full active and passive range of motion to hip and knee. Muscle Strength: Isokinetic and isotonic exercises and progressive resistive exercises. Functional Activities: Patient is independent in transfers and ambulation without assistive devices. Weight bearing: Full weight bearing.  Subtrochanteric Femur Fractures Definition Subtrochanteric fractures occur between the lesser trochanter and the adjacent proximal third of the femoral shaft. They may extend proximally to the intertrochanteric region. Methods of Treatment Intramedullary Rod Interlocking intramedullary devices are the treatment of choice for most subtrochanteric femur fractures. They must always be proximally interlocked to provide control of rotation, angulation, and length. This allows for early mobilization of the patient and minimizes the complications associated with prolonged bed rest. Secondary mode of bone healing. This allows for early mobilization of the patient and minimizes the complications associated with prolonged bed rest. Compression Screw and Side Plate Primary mode of bone healing in rigidly fixed fractures; secondary in extremely comminuted fractures and those with bone graft. This fixation is augmented with a bone graft along the medial side of the fracture, which provides for early healing of the medial side and prevents hardware failure when the comminution is severe. Special Considerations of the Fracture The subtrochanteric region of the femur is an area of high stress because of the combination of forces from gravity and muscle groups that insert on the proximal fragment. The compressive load on the medial cortex exceeds the tensile load laterally. This imbalance causes varus collapse. Unstable Hematoma The subtrochanteric region has a rich blood supply and therefore a fracture may cause significant hemorrhage. Embolism Pulmonary venous embolism may occur after 72 hours of bed rest. Mechanism of Injury These fractures may result from high-energy trauma in young patients or from distal extension of intertrochanteric fractures in elderly patients. Treatment Goals Improve and restore hip range of motion (sitting in a chair requires 90 degrees of flexion). Expected Time of Bone Healing 12 to16 weeks. Expected Duration of Rehabilitation 16 to 20 weeks. Gait: Improve the strength of the following muscles: Quadriceps (especially the vastus lateralis) Hamstrings Gluteus medius Gluteus maximus Tensor fascia lata Adductor magnus: hip adductor. Do not strengthen this muscle because it stresses the fracture site and the implants. A- Heel strike: G.Max & Vastus lateralis. B- Foot-Flat: G.Max & Vatus lateralis. (During mid-stance, there is significant stress on the fracture site when the pelvis rotates on the femur to advance the opposite extremity. Patients may experience pain secondary to weight bearing as the leg advances into single-limb support). C- Mid-Stance: Iliopsoas & G.Med D- Swing Phase: It is affected because of quadriceps & hamstrings.  Physical Therapy Treatment: Early to Immediate (Day of Injury to One Week) N.B. healing process that will be discussed is secondary one as the fracture is surgically fixed by the intramedullary nail. BONE HEALING Stability at fracture site: None. Stage of bone healing: Inflammatory phase. X-ray: No callus.  Prescription Precautions: No adduction and abduction to hip. No isometric exercises to quads and hamstrings. Range of Motion: Active range of motion to hip and knee in flexion and extension. Muscle Strength: Isometric exercises to glutei. Functional Activities: Three-point gait with assistive devices. Weight bearing : Weight bearing as tolerated on affected extremity in stable fractures treated with intramedullary nails. Toe-touch weight bearing in unstable fractures or those treated by open reduction and internal fixation.  Treatment: Two Weeks BONE HEALING Stability at fracture site: None to minimal. Stage of bone healing: Beginning of reparative phase. X-ray: No callus; fracture line is still visible.  Prescription Precautions: Avoid torsional forces on fracture. Avoid excessive abduction or adduction. Range of Motion: Active, active-assistive to gentle passive range of motion to hip in flexion and extension. Muscle Strength: Isometric exercises to glutei, quadriceps and hamstrings. Functional Activities: continue the previous prescription. Weight Bearing: continue the previous prescription.  Treatment: 4 to 8 weeks BONE HEALING Stability at fracture site: With bridging callus. Stage of bone healing: Reparative phase. X. ray: Bridging callus is beginning to be visible. Prescription Continue the same prescription of the previous weeks in addition to Active range of motion to hip in abduction and adduction.  Treatment: 8 to 12 weeks BONE HEALING Stability at fracture site: With bridging callus, the fracture is usually stable. Stage of bone healing: Reparative phase. X-ray: Abundant callus in fractures with intact periosteum. Fracture line begins to disappear.  Prescription Precautions: None. Range of Motion: Full range of motion in all planes to hip and knee. Muscle Strength: Gradual resistive exercises to hip and knee. Functional Activities: Weight bearing as tolerated or full weight bearing during transfers and ambulation with assistive devices. Weight Bearing: full weight bearing as tolerated. Limited weight bearing should be necessary only for fractures with no callus present that are being considered for bone grafting.  Treatment: 12 to 16 Weeks BONE HEALING Stability at fracture site: stable. Stage of bone healing: Remodeling phase. X. ray: Abundant callus is present; fracture line begins to disappear. Prescription Continue the same prescription of the previous weeks in addition to progressive resistive exercises to hip and knee with full weight bearing during transfer and ambulation.