Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with intertrochanteric femoral
fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
RA, 56 year old woman with recent history of
left proximal femoral fracture

1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Personal data

Patient Complaints
Moderate pain and stiffness in left hip, moderate disability in gait
Post surgical (internal fixation of the left intertrochanteric femoral fracture) rehabilitation status

ANAMNESIS (history)
Our 56 year old woman suffered, nine weeks ago, a left intertrochanteric femoral fracture after falling from a height
in her house - falling to the floor, and has underwent surgical treatment.
She had no previous history of postmenopausal osteoporosis (dual-energy x-ray absorptiometry DXA, 3 months ago,
showed a T score of -1.1), lumbar spondylosis and bilateral secondary knee arthrosis (meniscus tears and artroscopy
exploration in both knees, 5 years ago).
Her history reveals pain and disfunctional episods of her knee osteoarthritis disorder. After injury, RA was unable to
stand up and bear weight on her own and needed to lie down for relief. She didn`t reclaim other trauma, vertigo or
loss of consciousness.
She was transported to emergency department immediately, with her left leg in external rotation. After orthopedic
examination, she was diagnosed with left intertrochanteric femoral fracture. The surgical treatment was performed in
the same day for fracture - open reduction and internal fixation with implanted device intramedullary nail / rods -
in femoral shaft and screws in femoral head. Sutures are removed at 15 days. Post operative period was uneventful.
The patient was allowed to bear weight with the help of crutches only after 2 months.
RA is coming in our department to perform and to learn the rehabilitation measures for regaining her gait and her
independence in daily living.
Personal data
Questions (for assessment detailed answers see next page)

1. What is the anatomic fracture type of the intertrochanteric femoral fracture in our patient and how can it
condition the rehabilitation plan?
a. Intracapsular
b. Extracapsular
c. It is no important
R=b

2. Can we identify the contributing factors that determine particular fall in our patient?
a. Yes
b. No
c. Probably
R=a

3. How can we explain the fall in our patient?

a. Due to the environmental conditions
b. Due to the host factors
c. Due to the antirheumatic drugs
R = a,b
 Personal data
Questions` answers

1. What is the anatomic fracture type of the intertrochanteric femoral fracture in our patient and how can it
condition the rehabilitation plan?
According to what part of the femoral bone is involved, fractures are categorized into three groups: 45% the femoral
neck fractures (intracapsular), 45% fractures around the intertrochanteric crest (extracapsular), a bone segment that
links the greater and lesser trochanters, two bony eminences situated essentially between the femoral neck and the
upper part of the main shaft of the femur, to which the major skeletal muscles are attached (significant consequence
on the rehabilitation program) and 10% subtrochanteric fractures (extracapsular) that involve the femoral shaft itself,
below the lesser trochanter.

2. Can we identify contributing factors that determine particular fall in our patient?
Yes. Our patient is fallen on her left side, landed on hip. Because she made some house activity in height, her
protective reflexes hade to be inadequate to limit the energy of fall. RA has a normal weight, she has not a sufficient
muscle and fat structures around a hip.

3. How can we explain the fall in our patient?

Falls are caused by various combinations of environmental and intrinsic (host) factors. As many as half of all falls
involve environmental conditions such as structural hazards, icy sidewalks, inadequate lighting, frayed rugs, and
electrical cords. In our patient, who lives with her family, the disturbed lighting and unstable surface are important to
take into consideration as risk fall factors. Also, our patient has an advanced knee osteoarthritis with abnormalities of
gait and balance, and lower limb muscle weakness.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

RA is 1.70 m height and a weight of 64 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb ROM of right hip, both knee and ankle joints in normal functional limits, muscle strength of right lower
limb with normal values in accordance with her age.
Left hip joint - minimal pain with any movement of the left leg and minimal groin tenderness on palpation. The skin is
normal, with scar after surgical intervention in the lateral side of the groin. RA had limited ROM to 0-80 degrees
of flexion, 15 degrees of abduction, internal rotation less than 10 degrees, and external rotation less than 15
degrees. Weakness of the hip muscles was noted (the dynamic stabilizers of the pelvis, including hip flexors,
extensors, and abductors had -4, +3 and -4 at MMT, respectively) and the ability to stand and balance on left lower
limb is diminished. A passive straight-leg raise was possible but with pain, like rectus femoris stretch test.
Gait is possible with one crutch, on the right side (partial weightbearing gait on the left lower extremity).
Neurovascular status of lower limbs are intact. Her peripheral pulses are palpable, and she has normal distal sensation
in the both lower extremities.
Vital Signs: temperature 36.5C, blood pressure 130/70 mmHg, rhythmic pulse 72 b/min, 14 respirations / min.
Her medications include oral calcium and vitamin D supplements, paracetamol with tramadolum combination for pain,
chondroprotective agents.
Clinical data
Questions (for assessment detailed answers see next page)

1. It is important to assess the posture in our patient?

a. Yes
b. No
c. It can be ignored
R=a

2. Manual muscle testing is necessary in physical examination in our patient?

a. No
b. It can be ignored in rehabilitation program
c. Yes
R=c

3. Why is it important to perform ROM in our patient?

a. To establish the extension and flexion mechanisms of lower limb
b. To complete the physical examination
c. To monitor the pain of lower limb
R=b

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
a. For gait are important both extension and flexion kinetic chains of lower limb
b. For control the hip pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. It is important to assess the posture in our patient?

Yes. It may check the patient overall posture, including the alignment of her back, pelvic bones, hips, knees, and
ankles. By watching her aiding walk, we can check to see that our patient is putting only a safe amount of weight
through her operated leg and that her walking aid (crutch) is adjusted for her. We take into consideration
especially for left hip that the greater trochanter, where the gluteus medius and the gluteus minimus (hip
extensors and abductors) attach, and the lesser trochanter, where the iliopsoas (hip flexor) attaches.

2. Manual muscle testing is necessary in physical examination in our patient?

Yes. The physical examination of lower limb muscles starts with palpation. Through this physical examination
we feel the soft tissues around the sore area and check skin temperature and swelling, pinpoints sore areas, and
looks for tender points or spasm in the muscles around the hip. Muscles that may be checked include the
quadriceps (thighs), buttocks, hamstrings, and calves. The results are compared to your other side. Weakness in
key muscles will be addressed with a strengthening program.

3. Why is important to perform ROM in our patient?

The checking of the range of motion (ROM) in operated hip is a measurement of how far our patient can move
her affected hip in different directions. Measurements might include all motions, in all three planes (flexion /
extension, internal rotation / external rotation, abduction / adduction). These aspects are essential for gait
rehabilitation. The ROM values during each visit are important to chart the functional progress for our patient.

4. What is important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patient with hip fracture take into consideration the global kinetic exercises,
after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for flexion are
very important for independence ambulation, so previous kinetic program must do the MMT.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Imagistic data

X-rays.
This type of scan is the most common and widely available diagnostic imaging technique.
The diagnosis of a hip fracture is generally made by an X-ray of the hip and femur.
Necessary radiographs of the hip include an anteroposterior (AP) view of the pelvis and the involved hip and either a
cross-table lateral view or a frog lateral view of the hip. The pelvis radiograph is useful for preoperative planning,
particularly to determine the neck shaft angles for placement of cephalomedullary nails. A traction AP radiograph is
helpful for further delineating the fracture pattern if significant displacement has occurred.

Magnetic resonance imaging (MRI) scan.

Magnetic resonance imaging (MRI) scans are the most sensitive for the evaluation of fractures, particularly occult or
nondisplaced fractures. MRI scans can be used immediately after injury and can reveal soft-tissue pathology, such as
muscle strains, greater trochanteric bursitis, and pelvic fractures. A patient with hip pain after a fall whose xrays are
(apparently) negative needs an MRI scan.

Computed tomography (CT) scan.

This type of scan or even a reconstituted CT scan of the hip may be necessary to define the fracture in sufficient detail
to allow accurate planning of the surgical procedure.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the type of internal fixation performed in our patient?

a. Intramedullary nail and a large screw in femoral neck-head
b. Partial hip replacement
c. Fixation of metal plate and external fixation
R=a

2. The imagistic findings of X-ray scan can suggest the type of fracture (stable / unstable) in our patient?
a. No
b. Yes
c. It is a MRI image of hip
R=b

3. What type of intramedullary hip nail is used in our patient?

a. Long
b. Short
c. Unknown
R=b
 Imagistic data
Questions` answers

1. What is the type of internal fixation performed in our patient?

Anteroposterior x-ray of the hip in our patient shows intramedullary nail and a large screw in the femoral head and
neck engage a plate fixed to the shaft, with sliding of the screw allowed if and when the fracture impacts. The role of
this screw is to press the bone together by ambulation after surgery into a stable position. Intra-medullary devices
(cephalomedulary nails) theoretically offer less soft tissue dissection and a shorter moment arm (the vertical device, ie
the nail, is closer to the hip center than the plate would be) Intra-medullary fixation may be preferable for reverse
obliquity fractures of those with sub-trochanteric extension. This procedure allows the patient to begin putting weight
on it right after surgery.

2. The imagistic findings of X-ray scan can suggest the type fracture (stable / unstable) in our patient?
Cephalomedullary fixation may help with reduction of unstable fractures and prevent excessive shortening from
collapse, in that the nail acts as a calcar rand lateral wall replacement to support the femoral neck. Probably, it was a
"reverse obliquity fracture". In this particulary fractures, the fracture line courses laterally as it extends from proximal
to distal, running perpendicular to the intertrochanteric line. Even if there is no comminution and even if the fracture
line does not reach the subtrochanteric region, this fracture is unstable and prone to displacement with conventional
sliding screws, as the fracture line is parallel to the course of the sliding screw and displaces as the screw slides.

3. What type of intramedullary hip nail is used in our patient?

In our patient is used a short intramedullary hip nail; the nail does not extend down the full shaft of the femur. Cross-
locking of the nail prevents rotation of the nail within the femur. Short intramedullary hip screws can create a stress
riser in the bone at the distal screw, as it is mentioned in literature data. Patients treated with such devices had less
blood loss and better function of lower limb.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Functional data

We assess, in accordance with ICF:

impairments of body functions - pain, stiffness, muscle weakness, diminish in maxim hip ROM (b28015 pain in lower
limb; b2804 radiating pain in a segment or region);
changes in body structures intertrochanteric femoral fracture (s7408 structure of pelvic region, s7508 structure of lower
extremity);
activity limitation - limited walking ability and problems with ADLs (d4153 maintaining a sitting position - Staying in a
seated position, on a seat or the floor, for some time as required, such as when sitting at a desk or table)
participation restrictions - reduced participation in leisure activities and in household chores.
The primary ICF activities and participation codes associated with ankle stability and movement coordination impairments
are d450 walking, d4552 running, d4558 moving around, specified as direction changes while walking or running.

We used:
easily reproducible physical performance measures for activity limitation and participation restriction
VAS = 7 before, 3 after rehabilitation program;
6 Minute Walk, with crutches = 160 meters before; 250 meters after rehabilitation program;
Timed Up and Go, with crutches = 35 seconds before; 20 seconds after rehabilitation program;
scales for condition-specific health status measures
The EQ-5D index - health status part (EQ-5D-3L) of the Euroqol - is based on five dimensions of health-related
quality of life; mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each item has three levels
of severity; no problems, some problems, or major problems. Changes in severity level in each of the five dimensions
of the EQ-5D were 30%, 25%, 12%, 15%, 20%, respectively.
SF-36 (the lower the score the more disability - a score of zero is equivalent to maximum disability; the higher the
score the less disability a score of 100 is equivalent to no disability) = 37 before rehabilitation; 50 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to assess the functional status in our patient ?

a. Yes
b. No
c. Is no important to mention
R=a

2. The changes in body structures that appeared from surgery may explain?
a. Back pain and lumbar stifness
b. A further disturbance in the neuromuscular status
c. Optimal balance and gait
R=b

3. The final score of the two scales used for our patient The EQ-5D index and SF-36 are in concordance for
disability status ?
a. No
b. It is no possibility to compare the two score scales
c. Yes
R=c

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
a. There are no explanations
b. The functional status is not improved after intervention
c. The rehabilitation program for muscular joint status takes a few weeks after intervention
R=c
 Functional data
Questions` answers

1. It is important to assess the functional status in our patient ?

Yes. In accordance with the International Classification of Functioning, Disability and Health (ICF), the degree of impairments,
disabilities, participation problems and health related quality of life should be described from the patients perspective. A broken hip is a
serious condition at any age. The dominance of the ICF category of activity and participation in scales reflects what is important to
physicians treating an intertrochanteric femoral fracture.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structures that appeared from surgery may explain the picture of a further disturbance
in the neuromuscular status. Muscle attachments must be kept in mind in this type of fracture. The abductors and short external rotators
attach to the greater trochanter; the iliopsoas to the lesser. The adductors attach to the shaft below the intertrochanteric region.

3. The final score of the two scales used for our patient The EQ-5D index and SF-36 are in concordance for disability status ?
Yes. The both scales contain the items for quality if life and various daily activities in which the lower limb, hip especially, is
responsible for balance and gait. The gait scheme is disturbed in intertrochanteric femoral fracture. A hip fracture has a dramatic impact
on the patients HRQoL, also for patients with no health-related problems preoperatively. Also, the fracture typically takes 36 months to
heal, the deterioration in HRQoL sustained also twelve months after the fracture.

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Complete recovering from intertrochanteric femoral fracture reclaim 2 3 months for plateau in strength and functional gains. The
outcome measures chosen for our patient study are common clinical measures and their associated impairments are theoretically
addressable by targeted rehabilitation techniques, like medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Left intertrochanteric femoral fracture (operated 2 months ago, open reduction and internal fixation
surgery).
2. Mechanical low back pain. Lumbosacral spondylosis.
3. Secondary knee osteoarthritis (bilateral meniscus tears, five years ago).
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the important anatomical aspects for the complete diagnosis and prognosis in our patient ?
a. The vessels around the base of the femoral neck
b. Nerve structure
c. Muscle attachements
R=c

2. The significant rate of complication after surgery in our patient is?

a. Nonunion rate
b. Infection rate
c. Device failure rate
R= c

3. Should we mention a complete diagnosis for all patients disorders (knee osteoarthritis for example)? Why?
a. No, it is not an important aspect
b. Yes, because the disorders have an important conditioning for rehabilitation program goals and methods
c. Yes, but not important for rehabilitation program
R=b
 Complete diagnosis
Questions` answers

1. What are the important anatomical aspects for the complete diagnosis and prognosis in our patient ?
Intertrochanteric femoral fracture occurs further down the bone and tends to have better blood supply to the fracture
pieces. Cephalomedullary fixation is a percutaneous technique that has the potential for less blood loss, earlier full
weight-bearing, and better reductions. However, it is technically demanding and after the appropriate fixation device
has been placed, the muscles, fascia, and skin are closed.

2. The significant rate of complication after surgery in our patient is?

Intertrochanteric hip fractures have significant complication rates (20-30% in the first year) - 5% infection rate,
5%nonunion rate, 11% device failure rate. Local orthopedic complications can occur if an adequate stable reduction
of the fracture is not obtained and maintained or if the correct position is lost before healing because of movement
associated with daily activities and personal hygiene. Loss of position before healing can also occur if the fixation
device fails because of improper insertion or if the fracture does not heal before the end of the mechanical life of the
device.

3. Should we mention a complete diagnosis for all patients disorders (knee osteoarthritis for example)? Why?
The practice of ambulating patients as soon as possible after surgery, in rehabilitation program, has significantly
lowered the incidence of thrombophlebitis and consequent pulmonary embolism. Early mobilization probably
remains the single most effective method for reducing the incidence of these complications. But in gait scheme is
important to be functional and without pain all joints of lower limb and all muscles have to be optimal. Loss of
motion of the lower-extremity joints and muscle hypoatrophy (as described in knee osteoarthritis) are two major
dysfunction parameters.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Rehabilitation program (RP)

1. Objectives of RP in our patient:

painful status control;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the hip in the economy of the limb biomechanics;
maintenance of normal daily activities and maximization of quality of life; to return our patient to the same level of
independence and activity that existed before her injury.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, vitamin D3 and calcium carbonate oral
non-pharmacological modalities:
- educational, dietary and hygienic,
- posture (activity modification), elastic compression stockings in the first 4 weeks after surgical procedure,
- physical (thermotherapy ice-pack to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased joint
pain will reduce chances of developing complications during the rehabilitation process;
- massage classic for trunk, special venous drainage massage for lower limbs and special massage (Cyriax) of knees,
- kinetic and occupational therapy for ADL rehabilitation
- early rehabilitation includes gait training with assistive devices, walker and crutches, cane after; ankle pumps,
range of motion exercises (passive and active, from foot to hip), isometric contraction of all muscles of lower
limbs;
- non-weight-bearing exercises, treadmill exercises, weight-bearing exercises, respiratory exercises
- intensive physical training active ROM, strength training, progressive resistive exercises - can improve
quality of life and reduce disability, balance and proprioception exercises, global exercise to improve functional
mobility and walking ability.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. The rehabilitation program (RP) in our patient is similar with other or depends on some factors?
a. Is similar with other rehabilitation program
b. It is not dependent on several factors
c. It is dependent on several factors
R=c

2. Why we should respect the kinetic algorithm program in our patient rehabilitation ?
a. Because ROM exercises must preceded the strength exercise
b. Because it is the patient option
c. Because it is performed open reduction and internal fixation (ORIF)
R=a

3. What are the goals of RP in our patient, when she become in our department ?
a. Initiate functional weightbearing exercises, open kinetic chain AROM and isotonic strengthening exercises
b. Initiate proprioception and gradual gait exercises
c. Restoration of strength, power, and endurance
R = a, b

4. Why is occupational therapy important in our patient rehabilitation program?

a. Because patient regains her independence of daily living
b. Because patient regains her proprioception
c. Because patient had not pain in hip and lower limb
R=a
Rehabilitation program
Questions` answers

1. The rehabilitation program (RP) in our patient is similar with other or depends on some factors?
Rehabilitation programs can vary significantly by the type of institution, comprehensiveness of services, intensity of
program, and rehabilitation goals adapted to patient. The optimal setting to provide these rehabilitation services for a
particular patient depends on the number of problems needed to be addressed to achieve full rehabilitation (risk of
fall, gait and lumbar pain); the severity of functional deficits (ICF evaluation); the severity of any comorbid
conditions (osteoporosis and COPD); and access to rehabilitation services (our patient lived in rural location).

2. Why we should respect the kinetic algorithm program in our patient rehabilitation ?
The range of motion, strengthening, and proprioceptive exercises of the involved joint should be initiated and
progressed as indicated and tolerated by the individual. The rehabilitation program is adapted to the surgical
intervention performed for our osteoporotic patient, who has a risk of developing painful non-union status.

3. What are the goals of RP in our patient, when she become in our department ?
The patient is coming in our department after 8 weeks after intervention. The goals of rehabilitation program are:
continuing healing of fracture site, normalizing AROM and impaired proprioception, initiate gradual return to
functional activities and light work activities. All rehabilitation has to respect the progression for optimal control of
patients impairments and functional limitation, to prevent the falls.

4. Why is occupational therapy important in our patient rehabilitation program?

Because, after occupational therapy, our patient can safely manage toileting with walker/crutches without physical
assistance, perform safe shower transfer with minimal to no caregiver assistance, able to dress self with minimal to
no caregiver assistance using tools as needed, and she can communicate an understanding of hip precautions, to
prevent further falls.