Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with left intertrochanteric femoral
fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
GT, 72 year old man 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 72 year old man suffered, ten weeks ago, a left intertrochanteric femoral fracture after a fall in his house garden
slipping and falling from his own height, and has undergone surgical treatment.
He has previous history of cervical and lumbar spondylosis, bilateral primary knee arthrosis, primary hypertension
with optimal medication control.
His history reveals multiple pain and disfunctional episodes of his knee osteoarthritis disorder. After injury, GT was
unable to stand up and bear weight on his own and needed to lie down for relief. He didn`t reclaim other trauma,
vertigo or loss of consciousness.
He was transported to the emergency department immediately, with his left leg in external rotation. After orthopedic
examination, he was diagnosed with left intertrochanteric femoral fracture. The surgical treatment was performed in
the same day of the fracture - open reduction and internal fixation with implanted device intramedullary nail / rods
- in femoral shaft and screws in femoral col and diaphysis. 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.
GT is coming in our department to perform and learn the rehabilitation measures for regaining his gait and his
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 this
condition the rehabilitation plan?
a. Extracapsular
b. Intracapsular
c. It is not important
R=a

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

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

a. Due to the patient age
b. Due to the environmental 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 this
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 can determine particularity of the fall in our patient?
Yes. In old people, the hip fracture was the "beginning of the end," a signal of compromised ambulation"end of the
beginning," a clinical manifestation of aging and frailty that was previously subclinical or the cumulative effect of
small declines reaching a threshold that precipitates the hip fracture.

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

Falling is a common event for elderly people. 90% of falls in the elderly are the result of a simple fall. Falls are the
leading cause of death from injury worldwide for people age 65 and older. Between 30 and 50 percent of the elderly
suffer at least one fall per year, and a subset of this group is at risk for more frequent falls. Those in the latter group
have the highest risk of fracture. A major determinant of whether a fall results in a fracture is thought to be bone
strength, although other factors such as the type of fall (e.g., direction and site of impact), muscle mass, and
protective.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

GT is 1.74 m height and a weight of 78 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear for his age.
Vertebral spine cervical and lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with his 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 his 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. GT had limited ROM to 0-75 degrees
of flexion, 20 degrees of abduction, internal rotation less than 15 degrees, and external rotation less than 20
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. His peripheral pulses are palpable (our patient is nonsmoker), and he
has normal distal sensation in both lower extremities.
Vital Signs: temperature 36.5C, blood pressure 140/75 mmHg, rhythmic pulse 76 b/min, 16 respirations / min.
His medications includes paracetamol with tramadolum combination for pain, chondroprotective agents and specific
antihypertensive drugs.
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 the 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 of the hip pain
c. For AINS medication selection
R=a
 Clinical data
Questions` answers

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

Yes. We may check the patients overall posture, including the alignment of his back, pelvic bones, hips, knees,
and ankles. By watching his aiding walk, we can check to see that our patient is putting only a safe amount of
weight through his operated leg and that his walking aid (crutch) is adjusted for him. We take into consideration
especially for the 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 the 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 it 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
his 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 programs for gait in patients with hip fracture take into consideration the global kinetic
exercises, after analytic kinetic programs. The kinetic muscle chains of the lower limb for extension and for
flexion are very important for independent 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.
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. Partial hip replacement
b. Intertrochanteric nail with integrated interlocking screws
c. Fixation of metal plate and external fixation
R=b

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

3. Can we explain the osteosintesis choice in our patient?

a. No
b. Yes
c. Probably
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 (intertrochanteric) nail fixed to the shaft with two
cortical screws and a large screw in the femoral head. The role of this screw is to press the bone together by
ambulation after surgery into a stable position. Intra-medullary device (cephalomedulary nail) theoretically offer less
soft tissue dissection and a shorter moment arm (the vertical device, if the rod, 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 on X-rays can suggest the type of fracture (stable / unstable) in our patient?
Approximately 5% of fractures are extremely unstable, and the direction of the fracture is parallel to the femoral neck.
This fracture type is called the reverse oblique pattern. For unstable intertrochanteric fractures, including those of the
reverse oblique pattern and those with subtrochanteric extension, an intramedullary hip screw is indicated. This device
combines a sliding hip screw with an intramedullary nail.

3. Can we explain the osteosintesis choice in our patient?

Yes. Most intertrochanteric fractures are managed with either a compression hip screw or an intramedullary nail,
which also allows for impaction at the fracture site. The compression hip screw is fixed to the outer side of the bone
with bone screws and has a large secondary screw (lag screw) that is placed through the plate into the neck and head
of the hip (see compression hip screw figure above). The design of the device allows for impaction and compression at
the fracture site. This may increase the stability of the area and promote healing. This intramedullary nail contributes
to the repair of the intertrochanteric fracture. The nail is in the hollow cavity of the femur (thighbone) rather than on
the side of it (as with a plate).
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 = 8 before, 4 after rehabilitation program;
6 Minute Walk, with crutches = 175 meters before; 240 meters after rehabilitation program;
Timed Up and Go, with crutches = 36 seconds before; 22 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 25%, 20%, 10%, 15%, 15%, 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) = 39 before rehabilitation; 52 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

1. Is it important to assess the functional status in our patient ?

a.Yes
b.No
c.It is not 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 with the
disability status ?
a.No
b.There 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. Is it 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 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 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 recovery 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 Garden III femoral fracture (operated 2 months ago, open reduction and internal
fixation surgery).
2. Mechanical low back pain. Lumbosacral spondylosis. Cervical spondylisis
3. Primary knee osteoarthritis.
4. Arterial hypertension well drug controlled
 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 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 the gait scheme is
important to be functional and without pain in all joints of the lower limb and all muscles have to be optimal. Loss of
motion of the lower-extremity joints and muscle hypotrophy (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 his injury.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics
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 others 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 should we respect the kinetic algorithm program in our patients 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. The electrical stimulation (NMES) can be prescribed in our patient?

a. No
b. Yes
c. Probably
R= b

4. Why is it important to involve a multi-disciplinary team for the rehabilitation program?

a. Because this team can apply optimal rehabilitation
b. Because patient regains his 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 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 (osteoarthritis, arterial hypertension); access to rehabilitation services (our patient lived in rural location).

2. Why should we 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 a painful non-union status.

3. The electrical stimulation (NMES) can be prescribed in our patient?

Gentle electrical currents through the skin can help ease the pain and decrease swelling. Electrical stimulation eases
pain by replacing pain impulses with the impulses of the electrical current. Electrode pads are placed over the sore
area, and the stimulation is generally applied for about 15 minutes. Once the pain lets up, the muscles begin to relax.
Some patients say electrical stimulation feels like a gentle massage. By relaxing the muscles, the physical therapist
may be able to exercise and do activities easier.

4. Why is it important to involve a multi-disciplinary team for the rehabilitation program?

A multi-disciplinary team includes different healthcare professionals working together: physiotherapists healthcare
professionals trained in using physical methods, such as massage and manipulation, to promote healing and
wellbeing, occupational therapists healthcare professionals who identify problem areas in everyday life, physicians
(geriatrician a doctor who specializes in the healthcare of the elderly) .