Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with a displaced femoral neck fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
KT, 69 year old woman with recent history of left femoral
neck fracture and postmenopausal osteoporosis

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 (left hip arthroplasty with partial denture) rehabilitation status

ANAMNESIS (history)
Our 69 year old woman is from an urban environment and suffered, 7 weeks ago, a left femoral neck fracture after falling
on the stairs, and has underwent surgical treatment.
She had previous history of postmenopausal osteoporosis (dual-energy x-ray absorptiometry DXA, 3 months ago,
showed a T score of -3.1, which is consistent with osteoporosis), she is also diagnosed with stage 2 Hypertension.
After the injury, KT was unable to stand up and bear weight on her own and needed to lie down for relief. She didn`t
reclaimed other trauma, vertigo or loss of consciousness.
She was transported to emergency department after a few hours, with her left leg in external rotation and appeared
shorter than the right leg. After orthopedic examination, she was diagnosed with left femoral neck fracture. The surgical
treatment was performed the next day for the fracture - left hip arthroplasty with implantation of partial denture. Sutures
are removed after 15 days. Post operative period was uneventful.
The patient was allowed to bear weight with the help of crutches only after 2 months.
KT is coming in our department in order to perform and to learn the rehabilitation measures needed to recover her gait
and her independence in daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. Can we consider the fracture in our patient as a complication of the fall in her postmenopausal osteoporosis ?
a. Yes
b. No
c. Probably
R=a

2. The intervention in our patient is important for regaining the functional status of the lower limb?
a. It is indifferent
b. Yes
c. No
R=b

3. How can we explain the posture of left lower limb in our patient immediately after fall?
a. Due to the anatomy and function of hip joint and hip muscles
b. Due to the fall direction
c. Due to the age of our patient
R=a
 Personal data
Questions` answers

1. Can we consider the fracture in our patient as a complication of the fall in her postmenopausal osteoporosis?
Yes. A broken hip is a serious condition at any age. 90% of fractures involving the hip joint occur in patients after the
age of 50. Osteoporosis is a condition that causes loss of bone mass; the composition of the bone is normal, but it
is thinner than in normal people. The strength and density of bones decreases in osteoporosis and weak bones can
break easily. So, patients with osteoporosis are at much greater risk for developing a hip fracture from accidents such
as falls. The main complications of falling in females over age 50 are fractures affecting the hip joint, other
musculoskeletal trauma, subdural hematoma, dehydration, immobility, disability.

2. The intervention in our patient is important for regaining the functional status of the lower limb?
Yes. For femoral neck fracture with displacement, the surgeon may decide an arthroplasty with either partial denture
or uncemented / cemented total denture. The intervention is crucial for regaining our patients functional status

3. How can we explain the posture of left lower limb in our patient immediately after fall?
The hip is a ball-and-socket joint that allows more range of movement than any other type of joint. The total load on
the femoral head is the sum of the forces producing these 2 torque forces; these forces are transmitted through the
femoral neck to the shaft, which create a significant amount of stress on the femoral neck as a result of compression
and bending. In a fracture of the femoral neck, the limb is typically laterally or externally rotated due to the pull of
the lateral rotators (short muscles within the gluteal region) and the weight of the leg and foot itself. The lateral
rotators are much more powerful than the medial (internal) rotators, which explains the position of the limb. The
powerful gluteal muscles, the hamstrings, the adductors, the flexors of the thigh arise from the pelvis or lumbar spinal
column above the fracture line and insert into the distal fracture fragment. Their pull results in the upward
displacement of the shaft and the shortening of the limb.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

KT is 1.60 m height and a weight of 61 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine scoliotic attitude.
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 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 postero-lateral side of the groin. KT had limited ROM to 0-75
degrees of flexion, 15 degrees of abduction, internal rotation less than five degrees, and external rotation less than
10 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 both of the lower extremities.
Vital Signs: temperature 36.8C, blood pressure 140/70 mmHg, rhythmic pulse 72 b/min, 18 respirations / min.
Her medications include oral calcium and vitamin D supplements, and weekly alendronate, antihypertensive drugs.
Clinical data
Questions (for assessment detailed answers see next page)

1. Is it 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. It can be ignored during the rehabilitation program
b. Yes
c. No
R=b

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

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

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

1. Is it 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 comparing each side, we can determine if there is swelling, bruising, or any loss in muscle size. 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.

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
look 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 it important to perform ROM in our patient?

Checking the range of motion (ROM) in the 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. Why is it important to perform MMT (manual muscle testing) for all muscles of lower limb?
All rehabilitation program for gait in patients 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 programs 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.

The anteroposterior (AP) pelvis view allows the affected and contralateral hips to be compared. The view of the
unaffected hip can be used for preoperative planning.

Surgical lateral view X-ray- This incidence has the advantage of seeing not only the femur (and the tail), but also the
acetabular cup, which can reveal decubitus or acetabular osteolysis that can escape from the AP X-ray
 Imagistic data
Questions (for assessment detailed answers see next page)

1. What type of surgical intervention was performed in our patient?

a. Femoral neck pinning
b. Partial hip replacement
c. Fixation of metal plate and external fixation
R=b

2. Can the X-ray findings suggest the Garden classification stage of fracture in our patient?
a. Yes
b. No
c. It is a MRI image of hip
R=a

3. Is MRI examination essential for our patient?

a. Yes
b. No
c. It is possible
R=b
 Imagistic data
Questions` answers

1. What type of surgical intervention was performed in our patient?

In patients aged between 60 and 80 years, the decision between internal fixation and arthroplasty remains
controversial. In this age group, the optimal treatment should be individualized depending on the fracture pattern and
displacement, and preoperative ambulation, level of independence, disability and general health status of the patients.
Anteroposterior x-ray of the left hip in our patient shows implantation of a left hip partial denture.

2. Can the X-ray findings suggest the Garden classification stage of fracture in our patient?
The Garden classification of femoral neck fractures is based on the amount of fracture displacement evident on the
anteroposterior x-ray of the hip, although the surgeon must be aware that significant displacement may be apparent on
the lateral x-ray and not on the anteroposterior film. A stage IV Garden fracture is a complete and fully displaced
fracture. The femur is externally rotated and superiorly displaced relative to the femoral head. The head, completely
detached from the neck, remains in anatomic position relative to the acetabulum. On the AP x-ray of our patient it can
be clearly seen the fracture and displacement of the left femoral neck.

3. Is MRI examination essential for our patient?

Due to the metallic denture used for the hip replacement, the MRI exam cannot be performed.
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 femoral neck 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 activities limitation and participations restriction
VAS = 9 before, 5 after rehabilitation program;
6 Minute Walk, with crutches = 135 meters before; 205 meters after rehabilitation program;
Timed Up and Go, with crutches = 46 seconds before; 27 seconds after rehabilitation program;
scales for condition-specific health status measures
The Harris Hip Score (HHS) - is a clinician-based outcome tool used for the assessment of femoral neck fractures.
HHS includes four subscales - there are 10 items. Score ranges from 0-100 with higher score representing less
dysfunction and better outcomes (a maximum of 100 points - best possible outcome) covering pain (1 item, 044
points), function (7 items, 047 points), absence of deformity (1 item, 4 points), and range of motion (2 items, 5 points)
= 29 before rehabilitation; 41 after rehabilitation program.
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) = 32 before rehabilitation; 43 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 HHS and SF-36 are in concordance with the
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. Femoral neck fractures occur in the presence of multiple abnormal biomechanics conditions: a
high ratio of axial load to bending load, altered muscle, a direct blow to the greater trochanter may generate an axial
force along the neck, a combination of axial and rotational forces.

2. The changes in body structures that appeared from surgery may explain?
Additionally, the changes in body structure that appeared from surgery may explain the picture of a further
disturbance in the neuromuscular status. Muscle imbalance leads to changes in the application of stress across the
femoral neck that may exceed the bone's capability to respond appropriately to stress, in female with postmenopausal
osteoporosis.

3. The final score of the two scales used for our patient The HHS and SF-36 are in concordance with the
disability status ?
Yes. The both scales contain the items for quality of life and various daily activities in which the lower limb, hip
especially, is responsible for balance and gait. The gait scheme is disturbed in femoral neck fracture. Femoral neck
fracture in the elderly poses a problem of poor bone quality and co-morbid medical conditions and dysfunctions.

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 femoral neck fracture fracture reclaim 2 3 months for plateau in strength and functional
gains. The outcome measurements chosen for our patient study are common clinical measurements 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. Left femoral neck Garden IV fracture (operated 7 weeks ago, arthroplasty with partial denture)
2. Postmenopausal osteoporosis (medication controlled)
3. Hypertension
 Complete diagnosis
Questions (for assessment detailed answers see next page)

1. Do the clinical aspects bring enough data for our patients complete diagnosis?
a. Yes
b. No
c. It is indifferent
R= b

2. Long-term complications after the surgery, in our patient are?

a. Bleeding and delayed wound healing
b. Dislocation
c. Osteonecrosis - late avascular necrosis
R = b, c

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

1. Do the clinical aspects bring enough data for our patients complete diagnosis?
Symptoms for displaced fractures can be pain in the entire hip region or slight pain in the groin and pain referred
along the medial side of the thigh and knee. Physical examination in displaced fractures can show the affected leg in
external rotation and abduction, with shortening. However the complete diagnosis is based on imaging techniques (X-ray,
IRM, CT scan).

2. Long-term complications after the surgery, in our patient are?

Long-term risks that may happen months to years after the surgical intervention. They include: nonunion (the pieces
of bone do not heal back together),dislocation of the partial denture, late avascular necrosis (problems with the blood
flow inside the bone, which can cause part of the bone to die), difference in leg length (when the fractured leg is
healed, it is a little shorter than the other leg).

3. Should we mention a complete diagnosis for all the patients disorders (Hypertension for example)? Why?
Rehabilitation program for total hip replacement typically reclaim kinetic exercises. In cardiac patients all kinetic
programs must respect the intensity, duration and frequency in accordance with cardiac status.
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, biphosphonate drugs, 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 masage for lower limbs and special massage (Cyriax) of groin,
- 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 others or depends on some factors?
a. Is similar with other rehabilitation program
b. It is dependent on several factors
c. It is not dependent on several factors
R=b

2. Why should we 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 was performed a partial arthroplasty
R=a

3. What are the goals of RP in our patient, when she presented in our department ?
a. Initiate functional weight bearing 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 proprioception
b. Because patient had not pain in hip and lower limb
c. Because patient regains her independence of daily living
R=c
Rehabilitation program
Questions` answers

1. The rehabilitation program (RP) in our patient is similar with others 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 hypertension); access to rehabilitation services (our patient lived in an urban 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 presented in our department ?
The patient is coming in our department 7 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.