Intertrochanteric Fracture






























General Information


Case no.


9.A Intertrochanteric Fracture


Authors


Julie M. Skrzat, PT, DPT, PhD, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical TherapySean Griech, PT, DPT, PhD, COMT, Board Certified Clinical Specialist in Orthopaedic Physical Therapy


Diagnosis


Intertrochanteric fracture


Setting


Acute care setting, postoperative floor


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. To appreciate the importance of taking vital signs with positional changes in a patient who is postoperative.



  2. To understand the underlying mechanism of injury, especially as it pertains to falls, to prevent further adverse events.



  3. To articulate efficient and effective communication between health care providers to optimize the patient’s plan of care.



  4. Relate the pathophysiology and progression of pathology of an orthopaedic injury to the clinical manifestations and activity/participation limitations seen in physical therapy practice.



  5. Select, implement, and interpret physical therapy interventions based on the medical examination findings and plan of care.



  6. Develop an understanding of the medical management of a patient with an orthopaedic injury.





























Medical


Chief complaint


Status post (s/p) fall


History of present illness


The patient is a 60-year-old woman who presents to the emergency department s/p fall. She reports tripping over cat while walking to the bathroom. She was able to crawl to the phone to dial 911, but was unable to stand and bear weight on the right lower extremity (RLE). She denies striking her head or loss of consciousness.


Past medical history


Hypertension, coronary artery disease, type 2 diabetes mellitus, obesity (body mass index [BMI] = 31.05), diabetic neuropathy


Past surgical history


Hysterectomy


Allergies


No known drug allergies


Medications


Lisinopril, Atorvastatin, Pregabalin, Metformin























Social history


Home setup




  • Resides in a multilevel home with her husband.



  • Three steps with no rail to enter.



  • Half bath is on the first floor.



  • Bedroom and bathroom are located on the second floor.



  • Flight of stairs + one handrail to the second floor.


Occupation




  • Employed as a fifth-grade elementary school teacher.


Prior level of function




  • Independent with functional mobility and activities of daily living (ADLs).



  • Denies any functional limitations.



  • (+) driver


Recreational activities




  • Enjoys playing with her grandchildren (2 and 3 years old) and reading for leisure.


































Vital signs


Hospital day 0: emergency department


Hospital day 1: postoperative, on the ward


Blood pressure (mmHg)


149/82


128/72


Heart rate (beats/min)


116


78


Respiratory rate (beats/min)


18


16


Pulse oximetry on room air (SpO2)


97%


98%


Temperature (°F)


98.6


98.8









































Hospital day 0: emergency department


General


Well-nourished woman, appears to have discomfort in right hip, cognitively intact, answering questions appropriately.


Constitutional


(-) fever, chills, or weight loss


Head, ears, eyes, nose, and throat (HEENT)


(-) congestion, sore throat or otalgia, denies head injury in fall


Cardiovascular and pulmonary


(-) chest pain, palpitations, dyspnea on exertion, edema, syncope, aspiration, shortness of breath, orthopnea


(-) cough, congestion, wheezing or sputum production


Gastrointestinal


(-) abdominal pain, hematemesis, melena, nausea, vomiting, diarrhea


Genitourinary


(-) dysuria, frequency, urgency, blood in urine


Musculoskeletal


(+) right thigh and hip pain secondary to fall


(-) involvement of any other joint via swelling or warmth


Integumentary


(-) rash, open sores, cuts, bruises


Neurological


(-) headache, dizziness, weakness, numbness in extremities


(+) generalized tingling in both feel, which at times, becomes painful


Hematology/lymph


(-) abnormal bleeding or bruising; bumps or lumps






















Imaging /diagnostic test


Hospital day 0: emergency department


Hospital day 1: postoperative, ward


X-ray (right hip and pelvis)


1. Displaced intertrochanteric fracture of right femur


2. Marked osteoarthritic changes in the pelvis, acetabulum, and right hip joint


————————————


Electrocardiogram (ECG)


1. Fig. 9.1


1. Normal sinus rate and rhythm



No Image Available!




Fig. 9.1 The patient’s electrocardiogram on hospital day 0.


























Medical management


Hospital day 0: emergency department


Hospital day 1: postoperative, ward


Medications


1. Morphine sulfate 2 prn pain


2. Acetaminophen prn pain


3. Ondansetron prn nausea, vomiting


4. 0.9% sodium chloride 500 mL intravenous (IV) bolus


1. Acetaminophen prn pain


2. Ibuprofen prn pain


3. Oxycodone prn pain


Orthopaedic team


1. Recommend open reduction internal fixation to repair intertrochanteric fracture


1. Post-op hemoglobin has dropped from 11.6 to 9.2 g/dL. Start ferrous sulfate, ascorbic acid; monitor hemoglobin and hematocrit with complete blood count (CBC) tomorrow morning.


2. Pain well controlled, continue current regimen


3. Incision clear/dry/intact


Precautions




  • Bed rest



  • Fall risk



  • Non–weight bearing (NWB) RLE



  • Telemetry




  • Activity as tolerated



  • Fall risk



  • Weight bearing as tolerated (WBAT) RLE



  • Telemetry












Pause points


Based on the above information, what are the priorities?




  • Diagnostic tests and measures?



  • Outcome measures?



  • Treatment interventions?


































































































































Hospital Day 2, Post-Op Day 1, Ward: Physical Therapy Examination


Subjective


“Am I allowed to get out of bed?”


Objective


Vital signs


Pre-treatment


Post-treatment


Supine


Sitting


Standing


Blood pressure (mmHg)


110/78


90/50


Not attempted due to safety concerns


108/80


Heart rate (beats/min)


84


86


89


Respiratory rate (breaths/min)


16


17


18


Pulse oximetry (SpO2)


94% on room air


94% on room air


93% on 2 L/min O2 via nasal cannula (NC)


Borg Scale


0/10


3/10


0/10


Pain


1/10,


incision site


5/10,


incision site


3/10, incision site


General




  • Well-nourished woman



  • Appears to have discomfort in right hip


Cardiovascular and pulmonary




  • Denies chest pain



  • Normal S1, S2



  • Normal rate and rhythm



  • Bilateral lung bases with decreased breath sounds



  • Strong, nonproductive cough


Gastrointestinal


(+) reports constipation


Genitourinary


(+) urinary catheter


Fig. 9.2


Integumentary


Fig. 9.3


Musculoskeletal


Range of motion (ROM)




  • Bilateral upper extremity (BUE): within functional limit (WFL)



  • Left lower extremity (LLE): WFL



  • RLE: hip with empty end feels in all directions due to pain, knee WFL, ankle WFL


Strength




  • BUE: grossly 5/5



  • LLE: grossly 5/5



  • Right hip: not formally test tested



  • Right knee flexion/extension: 4/5



  • Right anterior tibialis and evertors: 1/5


Aerobic




  • Unable to test


Flexibility




  • Good appropriate hamstring length as shown by long sit to get out of bed


Other




  • N/A


Neurological


Balance




  • Unsupported sitting edge of bed: maximal assistance


Cognition




  • Alert and oriented × 4, somewhat drowsy


Coordination




  • Finger to nose: intact BUE


Cranial nerves




  • II–XII: intact


Reflexes




  • Left patellar: 2 + 



  • Right patellar: not tested


Sensation




  • Impaired sensation to light touch and vibration stocking distribution



  • Decreased tactile sense in peroneal distribution right leg and foot


Tone




  • Normal throughout BUEs and BLEs


Other




  • N/A


Functional status


Bed mobility




  • Rolling to left: supervision with moderate assistance to support RLE



  • Rolling to right: attempted, but was unable to complete due to increased pain in the right hip



  • Scooting up in bed: maximal assistance × 2



  • Supine to/from sit via long sit: moderate assistance



  • When sitting edge of bed, patient reported mild dizziness and lightheadedness Interventions were provided, with no resolutions of symptoms.


Transfers




  • N/A


Ambulation




  • N/A


Stairs




  • N/A



No Image Available!




Fig. 9.2 An example of a urinary catheter.



No Image Available!




Fig. 9.3 An example of the patient’s incision.

























Assessment


☑ Physical therapist’s


Assessment left blank for learner to develop.


Goals


Patient’s


“I want to get back to work.”


Short-term


1.


Goals left blank for learner to develop.


2.


Long-term


1.


Goals left blank for learner to develop.


2.














Plan


☑ Physical therapist’s


Will continue to see patient twice a day × 2 to 3 days. Will progress functional mobility within confines of weight-bearing status in preparation for discharge.






























Bloom’s Taxonomy Level


Case 9.A Questions


Create


1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient.


2. Develop two short-term physical therapy goals, including an appropriate timeframe.


3. Develop two long-term physical therapy goals, including an appropriate timeframe.


4. Develop a home exercise program for this patient. It should consistent of four exercises.


Evaluate


5. What member of the health care team would the physical therapist immediately communicate with about the patient’s hemodynamic response to sitting on the edge of the bed? Why is this important?


6. Should the physical therapist consult an orthotist to fabricate a molded ankle–foot orthosis (MAFO) if by post-op day 5 she still had foot drop?


Analyze


7. What is the rate and rhythm of the ECG strip on the day of presentation?


8. What is the interpretation of the patient’s incision?


Apply


9. If the patient did not eat her breakfast but did take the prescribed Metformin, would the physical therapist expect her blood sugar to be higher, lower, or the same as her normal, and how would this change the physical therapist’s plan of care?


10. Why does the patient have decreased breath sounds in bilateral lung fields? Is there anything physical therapists can do to remedy this?


11. Provide two therapeutic treatment recommendations for orthostatic hypotension.


Understand


12. Are there any precautions for mobility related to the urinary catheter? If so, what are they?


13. Describe the Wells Criteria for deep vein thrombosis (DVT). What is its indication and why might this be indicated with this patient?


Remember


14. State the purpose for the patient’s home medications: Atorvastatin, Pregabalin, Metformin, Lisinopril.


15. Define orthostatic hypotension. Identify common signs and symptoms.

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Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Intertrochanteric Fracture
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