Femoral Trochantric and Proximal Humerus Fracture, from Diagnosis to Rehabilitation

A prospective, hospital-based, case study of an in-patient, a doctor, who received physiotherapy and reported functional improvement

S. Hemakumar

Department of Physiotherapy, Kauvery Hospital, Chennai, India

Background

The incidence of femoral fracture is generally higher in those older than 65 years; the rate of femoral fractures in the general population is 3 fractures per 10,000, annually [1].

The incidence is steadily increasing probably due to the demographic changes and the steady rise in the average life expectancy of the population and therefore the presence of a larger number of elderly patients. The reduction of Bone Mass Density (BMD) related to age is the main factor which predisposes the elderly to a greater risk of hip fracture.

Older persons (over 70) have a higher incidence of femoral fracture. A fracture of the proximal femoral is common in the elderly, with special emphasis on intracapsular (of the femoral neck) and extracapsular (trantrochanteric and subtrochanteric). Persons with osteoporosis are also more likely to break their femur.

Thus, hip fractures are strongly associated with BMD in the proximal femur, but there are also many clinical predictors of hip fracture risk that are independent of bone density. Hip fracture incidence was 17 times greater among 15% of the women who had five or more of the risk factors, exclusive of bone density, compared with 47% of the women who had two risk factors or less [2]. However, the women with five or more risk factors had an even greater risk of hip fracture if their bone density Z score was in the lowest tertile [3].

Morbidity and mortality rates have been reduced in femoral shaft fractures, mainly as the result of changes in methods of fracture immobilization. Current therapies allow for early mobilization, thus reducing the risk of complications associated with prolonged bed rest.

Case Presentation

An 85-years aged female doctor presented to the ER on 30th November 2021 with history of slip, and fall on the outstretched right hand, at her residence the same morning.

Following this, she was unable to use her right arm and unable to bear weight on her right leg. So, she immediately shifted to Kauvery Hospital, Chennai. She underwent an X-ray, which showed the fracture of the right proximal humerus and right femur intertrochanteric fracture.

She had a past history of diabetes, hypertension, hypothyroidism, bronchial asthma, cholecystectomy, left partial mastectomy and kyphoplasty compression fracture T12, 10 years back.

Course at hospital

Patient was admitted with the above-mentioned complaints, necessary investigations were done, was diagnosed with a fracture of the right femur, and planned for surgery. After cardiac fitness and anesthetic clearance, and with informed consent, she underwent surgery on 01st December 2021

Present surgical notes, 01 Dec 21

Right proximal femur nailing (PFN), (Long) – Hardinge approach

Right proximal humerus fracture – conservative management (shoulder arm sling).

Physiotherapy

Post OP vitals were stable, so she was referred for physiotherapy (acute care physiotherapy).

Plan was graded ambulation, to be gradually increased.

On physio evaluation

Thin built
Kyphotic posture
Arm sling (Rt side)
Swelling present on Rt Leg (below knee, upto the toes)
On catheter
Drain present
Clawing of toes bilaterally

General examination:

Conscious and Oriented (fear of movement present)
Vitals: HR, 86b/m; SPO2, 98%; BP, 118/89 mm. hg
Pattern of Breathing: Shallow breathing present
Incentive Spirometry (flow-oriented): <600 cc/sec
Cough effort: Good (protective)
AROM: left upper limb and lower limb – ROM is full and free
Motor examination: Reflex and tone – Normal

Neurological examination

Not able to stand, otherwise within normal limits

Gait

Not able to assess.

Functional Independent Measures

Bed mobility – Maximum Dependent

Barthel Index

	18/12/2021	29/01/2022	18/02/2022
Bowels	2	2	2
Bladder	2	2	2
Grooming	0	1	1
Toilet use	0	1	2
Feeding	1	2	2
Transfer	1	3	3
Mobility	2	3 (using aid)	3
Dressing	0	1	2
Stairs	0	0	0
Bathing	0	1	1
Total	8×5=40/100	16×5=80/100	18×5=90/100

Elderly mobility score

TASK	18-12-21	29-01-22	18-02-22
Lying to sitting	1	2	2
Sitting to lying	1	2	2
Sitting to standing	0	2	2
STtanding	1	2	3
Gait	0	2	3
Timed walk (6Met)	0	1	3
Functional reach	2	4	4
Total	5	15	19

Physiotherapy: 01/12/2021 – 17/12/2021

Relaxed diaphragmatic breathing exercises
Incentive spirometry
Coughing techniques encouraged.
Active ROM exercises for left upper and lower limbs; right fingers, wrist, forearm and elbows Active ROM exercises to right toes, ankle, hip abduction exercises.
High sitting – weight shifting right side encouraged (suture site).
Sitting to standing encouraged.
Transfer bed to chair encouraged with two-person support to single-person support.
High sitting knee extension exercises 20 repetitions each side.
Ambulation encouraged with two-person support 10-20 steps (initially starts with 5 steps, 10 steps, 15 steps; guided by patients’ confidence and orthopedic opinion) along with shoulder arm sling on the right side.
Educated regarding the importance of exercises, and prescribed as basis of FIT principle. Home care advices given.

Physiotherapy till 29/01/2022

As basics/old exercises (1-10) as follows in-home physiotherapy program after discharge

Strengthening exercises: 0.5 kg weight cuffs normal side (left side lower and upper limb).
Shoulder pendular exercises for right shoulder, as per surgeon’s order.
Balance exercises are encouraged in sitting both static and dynamic balance exercises.
Balance exercises are encouraged in standing only static. Dynamic balance activities are encouraged within the limits.
Gait pattern encouraged. Ambulation is encouraged (40-50 steps).
Educate about her present condition and the importance of exercises/movements. Home exercises encouraged, and advice to perform minimum 3 times a day.

And Physiotherapy till 17/02/2022 as basics/old exercises follows (1-16)

Right shoulder active-assisted ROM exercises encouraged (in lying).
Functional activities encouraged in sitting for her right arm (gradually from inner range – mid range – outer range).
Grip strength encouraged (short and long muscles strengthening exercises encouraged).
Dynamic balance training in standing encouraged.
Gait training encouraged (considering step lengths, stride lengths and cadance). Walking Independently without any aids (with an orthopedician review).

Discussion

Post-operative physiotherapy (physical exercises)

Improving muscle strength is necessary to enhance postoperative walking capacity for rehabilitation and to diminish the risks of falls. Physical activity will help:

Preventing other fractures
Increasing gait speed & balance
Increasing ADL performance
Regaining walking capacity as early as possible after immobilization to avoid respiratory complications.
Better brain function and more social contact

Aerobic fitness is useful to include in a physical therapy plan for an improved cardiorespiratory capacity will lead to a better walking capacity.

Physical exercises are not only crucial for rehabilitation after fracture but for ongoing reinforcing of the mineral bone density, especially in vulnerable populations like elder fragile patients, osteoporotic post-menopausal women or people suffering from osteoporosis or osteopenia. Long-term odd-impact exercise-loading, is associated, similar to high-impact exercise-loading, with a 20% thicker cortex around the femoral neck. In aerobic fitness, these type of movements are most frequently used.

Moderate magnitude impacts from odd-exercise loading is mechanically less demanding and makes the body work in all directions, retraining the biomechanical qualities and properties of the bone structure and impacting positively the bone mineral density. Fitness aerobics, dance fitness, dance, ball games, and gymnastics involving rapid turns and movements are good examples of odd-impact exercises.

Futhermore, duration, frequency and intensity are important and should be customized to the different age-groups.

Strengthening exercises seem to be key for functional improvement. These strength exercises may as well produce advantages in the psychosocial area which tends to be altered in elder patients that suffered a fracture. Weight-bearing exercises will reinforce dynamic balance and functional performance, especially exercises in standing positions since they are more challenging for the postural control.

Home physiotherapy training

Home Rehabilitation Training leads to better rehabilitation and better performance in daily activities. Home physiotherapy training is suitable for all elder patients, including those suffering from cognitive or psychological impairment. The literature stresses the importance of home physiotherapy, in combination with day-to-day activities like going to the shop, for gaining confidence, balance, and functionality and reducing the number of falls. Therefore, it can also be seen as a way to prevent falls. Fall prevention programmes are important for the elder population that has already suffers a femoral fracture. The literature indicates that elder people often fall again following a previous hip or femoral fracture and that this constitutes a major health problem. Prevention and treatment of fall-risk factors are key. These programs should include gait training with advice on assistive devices and medication, exercise programmes for balance training, treatments for cardiovascular problems, environmental modifications and hypotension.

References

Wu JQ, Mao LB, Wu J. Efficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2019;14(1):83.
Archer KR, Davidson CA, Alkhoury D, et al. Cognitive-behavioral-based physical therapy for improving recovery after traumatic orthopaedic lower extremity injury (CBPT-Trauma). J Orthop Trauma. 2022;36:S1-S7.
Kronborg L, Bandholm T, Palm H, et al. Effectiveness of acute in-hospital physiotherapy with knee-extension strength training in reducing strength deficits in patients with a hip fracture: A randomised controlled trial. PLoS ONE 2017;12(6): e0179867.
Stí¥hl A, Westerdahl E. Postoperative physical therapy to prevent hospital-acquired pneumonia in patients over 80 years undergoing hip fracture surgery-a quasi-experimental study. 2020.

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Femoral Trochantric and Proximal Humerus Fracture, from Diagnosis to Rehabilitation