Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with fracture of the distal femur

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
TE, 72 year old woman with recent history of
sagittal, lateral femoral condyle 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 right knee, moderate disability in gait
Post surgical (fixation method of sagittal, lateral femoral condyle fracture) rehabilitation status

ANAMNESIS (history)
Our 72 year old woman suffered, six weeks ago, a right lower limb injury distal right femoral fracture - and has
undergone the surgical treatment.
She has previous history of osteoporosis, well controlled with medication.
She performed daily activities in standing and walking postures in her previous professional life.
Her history reveals a combination of the direct blow to the knee and a fall, during a bathroom cleaning activity.
When she fell, less rotation forces associated to the low energy trauma lead to distal femoral fractures. After injury,
TE could not walk, unable to perform a straight leg raise and accused severe pain and swelling in her right thigh and
knee. The surgical treatment was performed after 2 days for displaced sagittal lateral femoral condyle fracture - open
reduction and internal fixation, plate and screw fixation which may reduce the frequency of hardware symptoms.
Sutures are removed at 14 days.
TE is coming in our department after she removed the knee cast, after 6 weeks after intervention, and to perform and
to teach the rehabilitation measures for regain her gait and her independence in daily life.
 Personal data
Questions (for assessment detailed answers see next page)

1. What is the important mechanism of injury to the distal femoral in our patient?
a. Less frequently rotation forces
b. Fall from heights
c. Traffic accident
R=a

2. Is it important to regain the function of lower limb in our patient?

a. No
b. Yes
c. It is indifferent
R=b

3. How can we explain this type of fracture in our patient?

a. The muscles of lower limbs are hypotonic
b. Our patient has other diseases of lower limb
c. Distal femoral fractures must respect and adapt to the deformity forces
R=c

4. What significant aspect in our patient (female) anamnesis is missing?

a. The age of her menopausal status
b. The number of her children
c. Her marital status
R=a
 Personal data
Questions` answers

1. What is the important mechanism of injury to the distal femoral in our patient?
Distal femur fractures most often occur either in older people whose bones are weak, or in younger people who
have high energy injuries, such as from a car crash. Mechanism of injury for our patient was a low-energy fall
with less frequently rotation forces that occurred while making some house activity.

2. Is it important to regain the function of lower limb in our patient?

Yes. Restoration of the functional integrity and strength of the extensor mechanism in our patient is essential for
gait and performing the daily activities.

3. How can we explain the type of fracture in our patient?

Distal femoral fractures engage the condyles and the femoral metaphysis. The anatomical axis of the femur runs
about 10 degrees laterally from the loading axis, which is connecting the centre of the femoral head with the
middle of the talar joint line. Therefore, axial load of the leg results in bending stress of the femur that is mainly
compensated by the iliotibial tract. The characteristic deformity after injury is shortening of the fracture (caused
by the quadriceps and hamstring muscles) with varus and extension of the distal joint segment as a result of
unopposed pulling of the hip adductors and gastrocnemius muscles respectively. All efforts reducing and
retaining distal femoral fractures must respect and adapt to this deformity forces.

4. What significant aspect in our patient (female) anamnesis is missing?

The menopausal status is important for bone resistance. If our patient would have a younger age of menopausal
status she is expose to higher risk for osteoporosis. Posttraumatic arthritis and osteoporosis are two disorders that
sum their disabiliry on the lower limbs.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

TE is 1.65 m height and a weight of 67 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine dorsal kyphosis, lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb with knee minimal valgus, passively correctable to neutral. Skin in right distal thigh region with post
intervention scars, without any pathologic aspects. The patient mentions pain in the right knee that is aggravated
by palpation and kneeling. Pain along the supero-lateral knee sides. Four cm. right thigh atrophy were noted.
Right AROM is from -5 to 70 degrees and left AROM is from 0 to 130 degrees. Without knee crepitus palpable with
ROM (active and passive). MMT values are +4 for great gluteus, +4 for hip stable muscles, +4 for left quadriceps
and -4 for right quadriceps, 4 for and 5 for left right hamstrings strength.
Gait is possible with crutch in left hand (partial weightbearing gait on the right lower extremity). The patient
complained of right knee pain when she got up from a chair and walked.
Neurovascular status of lower limbs are intact.
Vital Signs: temperature 36.8C, blood pressure 145/70 mmHg, rhythmic pulse 76 b/min, 18 respirations / min.
Clinical data
Questions (for assessment detailed answers see next page)

1. How can we explain the knee stiffness in our patient?

a. Because the cartilage is destroyed
b. Because our patient is female in menopausal status
c. Immobilization after surgical program
R=c

2. Knee range of motion is important for gait rehabilitation ?

a. Yes
b. No
c. It is a biomechanical parameter that can be ignored in gait rehabilitation program
R=a

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

a. To establish the extension mechanism of knee
b. To complete the physical examination
c. To monitor the knee pain
R=a

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 knee pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

1. How can we explain the knee stiffness in our patient?

Type B fractures are partial articular, which means that parts of the articular surface remains in contact with the
diaphysis. After open reduction of the affected femoral condyle to achieve anatomic reduction, recovery
treatment require keeping the leg immobilized in a cast for a long period of time, so the knee becomes stiff and
the thigh muscles may become weak.

2. Knee range of motion is important for gait rehabilitation ?

For a normal gait any patient with any time of distal femoral fracture, with knee dysfunction, must have minimal
90 degrees in flexion and complete extension. These values are necessary for optimal ambulating in any type of
surfaces.

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

AROM of knee permits to establish the extensor mechanism. The distal femoral fractures involve the extensor
retinaculum. Dysfunction of the extensor mechanism renders the patient unable to extend the knee against
gravity and usually implies that a tear is present in the medial and lateral quadriceps expansion.

4. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patient with patellar 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.
The most common way to evaluate a fracture is with x-rays, which provide clear images of bone. X-rays can show
whether a bone is intact or broken. They can also show the type of fracture and where it is located within the femur.
Radiographs obtain standard antero-posterior, lateral and oblique traction views can help characterize injury but are
painful for patient in elderly patients, evaluate for any pre-existing knee disorders.
Standard (AP) x-ray in our patient after surgical intervention
-femoral distal fracture was aligned and fixed with plate and four screws

Computed tomography (CT) scan.

This type of scan shows a cross-sectional image of injured limb and
provides cross-sectional and 3-D images with valuable information about
the severity of the fracture. This scan can show whether the fracture enters the joint surface and, if so, how many pieces
of bone there are.

CT obtain with frontal and sagittal reconstructions useful for establishing intra-articular involvement identifying separate
osteochondral fragments in the area of the intercondylar notch identifying coronal plane fracture.
Imagistic data
Questions (for assessment detailed answers see next page)

1. The imagistic findings of X-ray can suggest the type of surgical procedure ?
a. Yes
b. No
c. It is an incorrect knees X ray
R=a

2. What is the importance of osteosyntesis performed in out patient?

a. To regain the muscle function
b. To reconstruction anatomical features
c. To control acute pain
R=b

3. Is CT examination essential for our patient?

a. Yes
b. No
c. It is possible to perform if the patient inssurance is complete and extended
R = b, c
Imagistic data
Questions` answers

1. The imagistic findings of X-ray knee can suggest the type of surgical procedure ?
Yes. In antero-posterior X ray we can observe longitudinal lateral plate combined with four screws. This plate
osteosynthesis technique has lowered the rates of non-union, deep infection and implant failure. During this
operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together
with special screws and metal plates attached to the outer surface of the bone.

2. What is the importance of osteosyntesis performed in out patient?

The importance of surgical treatment are anatomical reconstitution of the articular surface; reduction of the
metaphyseal component of the fracture to the diaphysis and restoration of normal axial alignment, length and
rotation; so, due to stable internal fixation patient can performe early motion and functional rehabilitation of the limb.

3. Is CT examination essential for our patient?

Standard x-rays with special views of the femur are usually sufficient to diagnose a distal femoral fracture caused by
a low-energy trauma. However in more difficult cases where x-rays are not decisive, CT scan may be necessary.
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 (b28015 pain in lower limb; b2804 radiating pain in a segment or region),
stiffness, muscle weakness;
changes in body structures distal femoral fracture (s7508 structure of lower extremity), muscles tendon re-attachments;
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 knee 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 = 8 before, 3 after rehabilitation program;
6 Minute Walk, with crutch = 220 meters before; 300 meters after rehabilitation program;
Timed Up and Go, with cane = 30 seconds before; 24 seconds after rehabilitation program;
scales for condition-specific health status measures
Modified scale of Bostman et al. (excellent = 29 - 32 points, without disability; good = 23 - 28 points, minimal
disability; poor = below 23 points, more disability) = 17 before rehabilitation; 23 after rehabilitation program;
Knee Society Clinical Rating Scale (KSCRS) (80-100 = Excellent Score, without disability; 70-79 = Good Score;
60-69 = Fair Score; below 60 = Poor score, more disability) = 60 before rehabilitation; 71 after rehabilitation;
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) = 26 before rehabilitation; 38 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. It is important to repair the anatomical features in distal femur in our patient for her lower limb function?
a. Yes
b. No
c. Its not important to mention
R=a

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

3. The final score of the two scales used for our patient Modified scale of Bostman et al. and Knee Society Clinical
Rating Scale (KSCRS) are in concordance with the disability status ?
a. Yes
b. No
c. It is no possibility to compare the two score scales
R=a

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 (six ten weeks) after intervention
R=c
Functional data
Questions` answers

1. It is important to repair the anatomical features in distal femur in our patient for her lower limb function?
Yes. Fractures of the distal femur are severe and medical management and treatment are difficult. The knee must
remain free and mobile as much as possible after intervention. Stabilization on the frontal plane is usually not
difficult, while saggital plane stability with rotation of the condyles is much more difficult. The metaphyseal portion,
in particular of the anterior cortex can serve as a reference point.

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.

3. The final score of the two scales used for our patient Modified scale of Bostman et al. and Knee Society Clinical
Rating Scale (KSCRS) are in concordance for disability status ?
Yes. The both scales contain the items for ROM and various daily activities in which the lower limb, knee especially,
is responsible for balance and gait. The principal function of the extensor mechanism of the knee in humans is to
maintain erect posture. Activities such as ambulation, rising from chair and descending or ascending stairs are typical
examples.

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Patients recovering from distal 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, in accordance with medical literature data.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Complete diagnosis

1. Sagittal, lateral right femoral condyle fracture operated 6 weeks ago.

2. Mechanical low back pain. Lumbosacral spondylosis.
3. Primary osteoporosis (medication controlled).
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. What are the clinical arguments established in physical examination for our patient complete diagnosis?
a. Femoro-tibial alignment
b. Knee range of motion and ligament stability
c. Digestive examination
R = a, b

2. What are the most frequent possible complication in our patient?

a. Infection
b. Knee arthritis
c. Bone healing problem
R=b

3. We must mentioned complete diagnosis for all patients disorders? 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 clinical arguments established in physical examination for our patient complete diagnosis?
A physical examination was performed to determine femoro-tibial alignment, knee range of motion and ligament
stability 6 weeks after surgery. Femoro-tibial alignment was determined clinically by examination of the knee and by
evaluation from AP and lateral knee radiographs of the anatomical axes of the femur and tibia, and measurement of
the angle of intersection at the knee to determine the varus or valgus angle. Knee range of motion was determined by
visual inspection during knee assessment and confirmed with goniometric passive range of motion measurement.

2. What are the most frequent possible complication in our patient?

Newer techniques in treating these difficult fractures have cut the infection rate by more than a half: Currently less
than 5% of patients have infections. Open fractures and high energy fractures (such as car accidents) are at higher
risk for infection and slowing bone healing (infection can cause bone healing problems).
Distal femur fractures that enter the the knee joint may heal with a defect in the normally smooth surface of the joint.
Because the knee is the largest weightbearing joint in the body, any defect can damage the protective articular
cartilage and, over time, result in arthritis. In some cases, the joint surface may wear down to bare bone.

3. We must mentioned in complete diagnosis all patients disorders? Why?

Recovery programs typically reclaim kinetic exercises. In cardiac patients all kinetic program must respect the
intensity, duration and frequency in accordance with cardiac status. Also, the back pain (lumbosacral spondylosis) is
a real stone in rehabiliation program goals and sessions.
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;
controlling the residual inflammatory process;
to restore function of the involved limb
correcting abnormal walking scheme, with recovery of normal walking;
keeping the knee in the economy of the limb biomechanics;
maintenance of normal daily activities;
maximization of quality of life.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, chondroprotective drugs, calcium, D vitamin and biphosphonate durgs
non-pharmacological modalities:
- educational, dietary and hygienic,
- posture (activity modification),
- physical (thermotherapy cold/paraffin to control pain and edema; electrotherapy - TENS, laser, NMES) - decreased
joint swelling and pain will reduce chances of developing complications during the rehabilitation process;
- massage classic and special massage (Cyriax) of knee,
- kinetic
- early rehabilitation includes gait training with assistive devices, crutche and cane; isometric quadriceps
exercises and straight-leg raises: exercises to prevent loss of motion and strength in adjacent joints (ankle
exercises promote circulation);
- range of motion, strengthening, and proprioceptive exercises of the knee joint is initiated and progressed as
indicated and tolerated by the individual; exercises are continued until flexibility and strength are restored in the
knee joint, a normal gait pattern is observed, and full function returns.
Rehabilitation program
Questions (for assessment detailed answers see next page)

1. Why it is important to perform a rehabilitation program (RP) in our patient?

a. Because the RP improves only the knee ROM
b. Because the RP improves the upper limb function
c. Because the RP improves the lower limb function
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 the kneecap is replaced
R=a

3. What are the goals of RP in our patient, when she become in our department ?
a. Initiate functional weight bearing exercises , open kinetic chain AROM and isotonic strengthening exercises
b. Initiate balance/proprioception exercises and advance intensity of PROM
c. Gradual restoration of strength, power, and endurance
R = a, b

4. What are the precautions of the RP in our patient during her hospitalization?
a. Limit knee flexion with strengthening to 45 degrees
b. Limit knee flexion with strengthening to 90 degrees
c. Avoid post-activity swelling
R = a, c
 Rehabilitation program
Questions` answers

1. Why it is important to perform a rehabilitation program in our patient?

The main aim of the operation is to achieve freedom from pain and mobility including restoration of the distal
femoral segment. Rehabilitation program is essential to preserve the joint mobility, to counterbalance flexion
deformity of the knee, and above all, to maintain the strength of peri-articular muscles, which assist to improve the
joint stability.

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.

3. What are the goals of RP in our patient, when she become in our department ?
The patient is coming in our department after she removed the knee cast, after 6 weeks after intervention. In the
phase II (6 12 weeks after intervention), the goals of rehabilitation program are: no effusion, full knee extension,
single leg stand control, normalize gait, regain full motion, regain full muscle strength, good control and no pain with
functional movements, including step up/down, squat, partial lunge (staying less than 60 of knee flexion)

4. What are the precautions of the RP in our patient during her hospitalization?
During the RP performed in the patient hospitalization we must take into consideration the following precautions: no
impact activities until 12 weeks post-op; limit knee flexion with strengthening to 45 degrees; avoid loading knee at
deep flexion angles, post-activity swelling stair stepper, deep knee bends and squats. If these precautions are not
present, we can apply the next RP phases, for complete recovery.