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	To appreciate the importance of taking vital signs with positional changes in a patient who is postoperative. To understand the underlying mechanism of injury, especially as it pertains to falls, to prevent further adverse events. To articulate efficient and effective communication between health care providers to optimize the patient’s plan of care. Relate the pathophysiology and progression of pathology of an orthopaedic injury to the clinical manifestations and activity/participation limitations seen in physical therapy practice. Select, implement, and interpret physical therapy interventions based on the medical examination findings and plan of care. 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

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

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?

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
Vital signs	Supine	Sitting	Standing	Post-treatment
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

Fig. 9.2 An example of a urinary catheter.

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.