Hip Fractures

Chapter 6 Hip Fractures

Sandy B. Ganz, PT, DSc, GCS

Hip fractures are associated with significant morbidity and mortality in the United States, resulting in 350,000 hospitalizations annually. This number is an increase of 23% from 1988. Census trends indicate that the fastest rate of growth occurs in those populations over age 85 and those most susceptible to sustain a hip fracture. It is estimated that by 2040, the annual number of hip fractures will surpass 500,000, and that one in four women and one in eight men will sustain a hip fracture by age 90.

Since the inception of the prospective payment system (PPS), the care of elderly patients who have sustained a hip fracture has changed dramatically. Hospital length of stay for Medicare recipients decreased from 21.9 days in 1981 to 12.4 days in 1986, and patients enrolled in managed care programs had a hospital length of stay of 7.3 days. Discharge to skilled nursing facilities for short-term rehabilitation rose from 38% to 60%.

For those individuals who have sustained a hip fracture, returning to their prefracture functional status is a primary goal. Rehabilitation following hip fracture occurs along a continuum. Patients improve along a line of increasing functional status and may transition from the acute care setting to a free-standing rehabilitation hospital or a subacute facility, such as a nursing home for short-term rehabilitation where physical therapy services are provided daily. Patients may be discharged directly home following surgery and receive physical therapy services at home, or they are discharged home and receive physical therapy services in an outpatient facility.

The rehabilitation program following hip fracture is begun immediately following surgery. The clinician must take into consideration the type of surgical repair—whether it is an open or closed reduction and internal fixation or type of total hip arthroplasty (THA) or hemiarthroplasty—and surgical approach used (i.e., anterior/posterior approach) to set realistic short- and long-term goals and deliver appropriate postoperative care. The choice of settings in which rehabilitation is provided following hip fracture is most often determined by the physician, insurance coverage, patient factors, and the health care delivery system. Patients improve along a continuum. It is not uncommon for patients to receive therapy up to 6 months following fracture, and it is crucial for physical therapists to know the expected rate of recovery throughout this continuum of care. The purpose of this chapter is to describe the postoperative rehabilitation following internal fixation after hip fracture along a trajectory.

Surgical Overview

• Rehabilitation following femoral neck, intertrochanteric, and subtrochanteric hip fractures that were surgically repaired using an open/closed reduction and internal fixation is discussed in this chapter.

• The femoral neck fracture is a fracture that occurs proximal to the intertrochanteric line in the intracapsular region of the hip and is classified as nondisplaced or minimally displaced.

1 Nondisplaced or minimally displaced femoral neck fractures are commonly repaired using cannulated screws.

2 Cannulated (hollow) screws are typically inserted through fluoroscopy-aided placement for nondisplaced or minimally displaced fractures through a limited or percutaneous lateral approach.

– The hollow screws are placed over thin wires, which are removed from the screws after bone alignment has been made.

– Using this approach, the subcutaneous fat, vastus lateralis, and deep fascia of the fascia lata are affected.

• An intertrochanteric fracture is a fracture that occurs between the greater and lesser trochanter along the intertrochanteric line outside the capsule and is classified as stable or unstable.

1 The intertrochanteric region connects the femoral shaft and femoral neck at an angle of about 130 degrees. This angular moment created by weight bearing is greatest at this angle.

2 The most common instrumentation used for a stable intertrochanteric fracture is a sliding compression screw and side plate.

3 The instrumentation holds the bone fragments in their proper position while fracture healing occurs.

– A lateral approach is used, violating skin, subcutaneous tissue, fascia lata, vastus lateralis fascia, and muscle belly.

– Using this type of instrumentation, the distance is shortened between the insertion of the hip abductors in the greater trochanter and the center of rotation of the hip, which creates a mechanical disadvantage for the abductors. This may lead to a Trendelenburg gait pattern.

• A subtrochanteric fracture is a fracture that occurs between the lesser trochanter and the adjacent proximal third of the femoral shaft and may extend proximally to the intertrochanteric region.

1 Subtrochanteric fractures have been extremely difficult to fix because of the extreme angular force in the subtrochanteric region.

2 The bone type in the subtrochanteric region is cortical. Cortical bone has poor blood supply and decreased osteogenic activity; therefore, the two preferred methods of fixation are an extended compression screw device and intermedullary nail.

3 Fixation using a Richards compression screw-plate device is to repair a subtrochanteric fracture.

• The type of surgical intervention is determined by the severity, type, and location of the hip fracture.

1 Four types of instrumentation are commonly used in surgical intervention following hip fracture.

2 Internal fixation may be either open (ORIF) or closed (CRIF), bipolar hemiarthroplasty, hemiarthroplasty, or THA.

• Rehabilitation following THA was discussed in Chapter 1. This chapter focuses on the rehabilitation management of a hip fracture following open reduction and internal fixation.

• It is important for physical therapists to have an understanding of the phases of bone healing, as well as an understanding of the types of instrumentation and the principles of the fixation devices used in the surgical management of patients who have sustained a hip fracture. These concepts are pivotal because rehabilitation is guided by the phases of bone healing, type of fracture, and surgical procedure performed.

• Fixation devices used in fracture repair are either stress-sharing or stress-shielding devices.

1 Stress sharing implies that the fixation device permits partial transmission of a load across the fracture site, and micromotion occurs at the fracture site, which induces secondary bone healing with callus formation.

2 Examples of stress-sharing devices are rods, pins, and screws.

– A dynamic hip screw was used in the repair of an intertrochanteric fracture.

– The dynamic hip screw slides, causing micromotion at the fracture site and inducing secondary fracture healing.

– Cannulated screws were used in the repair of a femoral neck fracture.

3 Stress-shielding devices, such as the Gamma nail or Richards intermedullary hip screw, shield the fracture site from stress and transfer the stress to the rod, and primary bone healing occurs without callus.

• Regardless of the type of hip fracture or internal fixation performed, the principles of both fracture healing and rehabilitation are the same.

Rehabilitation Overview

• The rehabilitation goals following hip fracture are to have a successful outcome. A successful outcome is often defined as the return to prefracture level of function. This is a daunting task, because less than 50% of patients who have sustained a hip fracture do not return to their prefracture level of function.

• Following hip fracture, the following impairments are commonly seen: functional strength deficits, functional activity intolerance, impaired balance and coordination, decreased walking speed, and decreased ability to perform activities of daily living (ADL).

• The goals of rehabilitation following hip fracture are to increase muscle strength, endurance, and balance coordination, in an effort to improve the ability to transfer, walk, stair climb, and perform ADL.

• According to the guide to physical therapist practice, for the practice pattern 4G: Impaired joint mobility, muscle performance, and range of motion (ROM) associated with fracture; and 4H: Impaired joint mobility, motor function, muscle performance, and ROM associated with joint arthroplasty relating to the International Classification of Disease 9 code 820 (fracture of the neck or femur), the expected numbers of therapy visits throughout the continuum of care range from 6 to 70 visits.

Tags: Handbook of Postsurgical Rehabilitation Guidelines

Jun 22, 2016 | Posted by admin in PHYSICAL MEDICINE & REHABILITATION | Comments Off

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