Project 2015-1-RO01-KA202-015230

CASE REPORT
Rehabilitation program in a patient
with femoral neck fracture

Rodica Traistaru, Diana Kamal, Constantin Kamal

Filantropia Hospital - Craiova
SA, 64 year old woman with recent history of
left femoral neck fracture and
postmenopausal osteoporosis

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 femoral neck fracture) rehabilitation status

ANAMNESIS (history)
Our 64 year old woman suffered, eight weeks ago, a left femoral neck fracture after slipping in the bathroom and
falling on the floor, and has underwent surgical treatment.
She had previous history of postmenopausal osteoporosis (dual-energy x-ray absorptiometry DXA, 6 months ago,
showed a T score of -2.6, which is consistent with osteoporosis), scoliosis of the thoracic spine, lumbar spondylosis
and chronic obstructive pulmonary disease (COPD) (our patient has never been a smoker).
Her history reveals multiple right rib fractures that resulted from vigorous coughing 1 year ago. After the injury, SA
was unable to stand up and bear weight on her own and needed to lie down for relief. She didn`t reclaimed other
trauma, vertigo or loss of consciousness.
She was transported to emergency department after one hour, with her left leg in external rotation and appeared
shorter than the right leg. After orthopedic examination, she was diagnosed with left femoral neck fracture. The
surgical treatment was performed in the same day for the fracture - open reduction and internal fixation with two
screws. Sutures are removed after 15 days. Post operative period was uneventful.
The patient was allowed to bear weight with the help of crutches only after 2 months.
SA is coming in our department to perform and to teach the rehabilitation measures for regain her gait and her
independence daily life.
Personal data
Questions (for assessment detailed answers see next page)

1. Can we consider the fracture in our patient as a complication of the fall in her postmenopausal osteoporosis ?
a. Yes
b. No
c. Probably
R=a

2. The intervention in our patient is important for regaining the functional status of the lower limb?
a. No
b. Yes
c. It is indifferent
R=b

3. How can we explain the posture of left lower limb in our patient immediately after fall?
a. Due to the fall direction
b. Due to the age of our patient
c. Due to the anatomy and function of hip joint and hip muscles
R=c
 Personal data
Questions` answers

1. Can we consider the fracture in our patient as a complication of the fall in her postmenopausal osteoporosis?
Yes. A broken hip is a serious condition at any age. 90% of fractures involving the hip joint occur in patients after the
age of 50. Osteoporosis is a condition that causes loss of bone mass; the composition of the bone is normal, but it
is thinner than in normal people. The strength and density of bones decrease in osteoporosis and weak bones can
break easily. So, patients with osteoporosis are at much greater risk for developing a hip fracture from accidents such
as falls. The main complications of falling in females over age 50 are fractures affecting the hip joint, other
musculoskeletal trauma, subdural hematoma, dehydration, immobility, disability.

2. The intervention in our patient is important for regaining the functional status of the lower limb?
Yes. For femoral neck fracture a true intracapsular hip fractures, the surgeon may decide either to fix the fracture with
individual screws (percutaneous pinning) or a single larger screw that slides within the barrel of a plate. This
compression hip screw will allow the fracture to become more stable by having the broken area impact on itself.
Occasionally, a secondary screw may be added for stability.

3. How can we explain the posture of left lower limb in our patient immediately after fall?
The hip is a ball-and-socket joint that allows more range of movement than any other type of joint. The total load on
the femoral head is the sum of the forces producing these 2 torque forces; these forces are transmitted through the
femoral neck to the shaft, which create a significant amount of stress on the femoral neck as a result of compression
and bending. In a fracture of the femoral neck, the limb is typically laterally or externally rotated due to the pull of
the lateral rotators (short muscles within the gluteal region) and the weight of the leg and foot itself. The lateral
rotators are much more powerful than the medial (internal) rotators, which explains the position of the limb. The
powerful gluteal muscles, the hamstrings, the adductors, the flexors of the thigh arise from the pelvis or lumbar spinal
column above the fracture line and insert into the distal fracture fragment. Their pull results in the upward
displacement of the shaft and the shortening of the limb.
1. Personal data
2. Clinical data
3. Imagistic data
4. Functional data
5. Complete diagnosis
6. Rehabilitation program
 Clinical data

SA is 1.64 m height and a weight of 59 kg.

Pulmonary, cardiac, digestive and urogenital systems are normal in clinical exam. Mental status is clear.
Vertebral spine scoliosis of the thoracic spine, lumbar hyperlordosis, back pain.
Upper limb joints ROM and muscle strength with normal values in accordance with her age.
Lower limb ROM of right hip, both knee and ankle joints in normal limits, muscle strength of right lower limb with
normal values in accordance with her 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. SA had limited ROM to 0-85 degrees
of flexion, 20 degrees of abduction, internal rotation less than five degrees, and external rotation less than 10
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. Her peripheral pulses are palpable, and she has normal distal sensation
in both of the lower extremities.
Vital Signs: temperature 36.7C, blood pressure 140/80 mmHg, rhythmic pulse 74 b/min, 16 respirations / min.
Her medications include oral calcium and vitamin D supplements, and weekly alendronate, budesonide and terbutaline
inhalers.
Clinical data
Questions (for assessment detailed answers see next page)

1. Is it 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 physical examination in our patient?

a. No
b. It can be ignored in rehabilitation program
c. Yes
R=c

3. Why is 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 the hip pain
c. For chose the AINS medication
R=a
 Clinical data
Questions` answers

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

Yes. It may check the patient overall posture, including the alignment of her back, pelvic bones, hips, knees, and
ankles. By comparing each side, we can determine if there is swelling, bruising, or any loss in muscle size. By
watching her aiding walk, we can check to see that our patient is putting only a safe amount of weight through
her operated leg and that her walking aid (crutch) is adjusted for her.

2. Manual muscle testing is necessary in 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 important to perform ROM in our patient?

Checking the range of motion (ROM) in the operated hip is a measurement of how far our patient can move her
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 program for gait in patients with hip fracture take into consideration the global kinetic
exercises, after analytic kinetic program. The kinetic muscle chains of the lower limb for extension and for
flexion are very important for independence ambulation, so previous kinetic program 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.
The femoral neck fracture is an intracapsular fracture, like the head of the femur fracture, and is generally within the
capsule. The capsule is the soft-tissue envelope that contains the lubricating and nourishing fluid of the hip joint itself.
This fracture occurred at the level of the "neck" of the femur may have loss of blood supply to the bone
The anteroposterior (AP) pelvis view allows the affected and contralateral hips to be compared. The view of the
unaffected hip can be used for preoperative planning. An AP radiograph should be obtained of the affected hip with the
leg in internal rotation. In this view, will position the entire neck to best visualize fracture lines.

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. Sometimes, if the patient falls and complains of hip
pain, an incomplete fracture may not be seen on a regular X-ray, but the MRI scan shows a hidden hip fracture.

Computed tomography (CT) scan.

This type of scan can be useful in assessing more complex fractures. However, it is not as sensitive as MRI for seeing
hidden hip fractures. CT scans are useful for detecting fracture nonunion.
Imagistic data
Questions (for assessment detailed answers see next page)

1. What is the type of internal fixation performed in our patient?

a. Femoral neck pinning
b. Partial hip replacement
c. Fixation of metal plate and external fixation
R=a

2. The imagistic findings of X-ray scan can suggest the Garden type fracture our patient?
a. No
b. Yes
c. It is a MRI image of hip
R=b

3. Why screws should be placed within the central two thirds of the femoral head?
a. It is no important this aspect in surgical procedure
b. To preserve the strength of fixation
c. To minimize complications
R=c
 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 with a healed femoral neck fracture shows screws that are more widely
placed and therefore better able to resist the applied loads. If the screws were placed too close together, in our patient
with osteoporosis, this type of screw placement will increase the risk of failure. Placement of multiple screws across
the fractured femoral neck is the treatment of choice for femoral neck fractures, and may be performed following
either closed or open reduction using a standard lateral approach or a more limited percutaneous technique.

2. The imagistic findings of X-ray scan can suggeted the Garden type fracture our patient?
The Garden classification of femoral neck fractures is based on the amount of fracture displacement evident on the
anteroposterior x-ray of the hip, although the surgeon must be aware that significant displacement may be apparent on
the lateral x-ray and not on the anteroposterior film. Good results are to be expected following screw fixation of
nondisplaced femoral neck fractures, like in our patient. So, the type of fracture is certainly grade I (incomplete or
valgus impacted) or II (complete undisplaced).

3. Why screws should be placed within the central two thirds of the femoral head?
To minimize complications, screws should be placed within the central two thirds of the femoral head. The medical
data mentioned that the central screw is placed no closer than 5 mm to subchondral bone, recommending that 1
inferior screw should be placed along the medial femoral neck, with 2 more proximal screws placed in a triangular
configuration both anteriorly and posteriorly in the femoral neck. The screws should be placed as far apart as possible,
with the inferior and posterior screws adjacent to the cortex of the femoral neck.
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 femoral neck 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, 3 after rehabilitation program;
6 Minute Walk, with crutches = 150 meters before; 240 meters after rehabilitation program;
Timed Up and Go, with crutches = 40 seconds before; 22 seconds after rehabilitation program;
scales for condition-specific health status measures
The Harris Hip Score (HHS) - is a clinician-based outcome tool used for the assessment of femoral neck fractures.
HHS includes four subscales - there are 10 items. Score ranges from 0-100 with higher score representing less
dysfunction and better outcomes (a maximum of 100 points - best possible outcome) covering pain (1 item, 044
points), function (7 items, 047 points), absence of deformity (1 item, 4 points), and range of motion (2 items, 5 points)
= 31 before rehabilitation; 46 after rehabilitation program.
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) = 35 before rehabilitation; 48 after
rehabilitation program.
Functional data
Questions (for assessment detailed answers see next page)

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

a. Yes
b. No
c. Is no 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 HHS and SF-36 are in concordance with the
disability status ?
a. No
b. It 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. It is 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. Femoral neck fractures occur in the presence of multiple abnormal biomechanics conditions: a
high ratio of axial load to bending load, altered muscle, a direct blow to the greater trochanter may generate an axial
force along the neck, a combination of axial and rotational forces.

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 imbalance leads to changes in the application of stress across the femoral neck
that may exceed the bone's capability to respond appropriately to stress, in female with postmenopausal osteoporosis.

3. The final score of the two scales used for our patient The HHS and SF-36 are in concordance with the
disability status ?
Yes. The both scales contain the items for quality if life and various daily activities in which the lower limb, hip
especially, is responsible for balance and gait. The gait scheme is disturbed in femoral neck fracture. Femoral neck
fracture in the elderly poses a problem of poor bone quality and co-morbid medical conditions and dysfunctions.

4. How can we explain the values of the two tests used in functional assessment - 6 MWD and Timed Up and Go?
Complete recovering from femoral neck fracture 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, in accordance with 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 femoral neck Garden II fracture (operated 8 weeks ago, open reduction and internal fixation surgery),
2. Postmenopausal osteoporosis (medication controlled)
3. Mechanical low back pain. Lumbosacral spondylosis.
4. COPD
 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. Articular cartilage
c. Nerve structure
R = a, b

2. Long-term risks that may happen after the surgery in our patient are?
a. Bleeding and delayed wound healing
b. Fracture around the screws
c. Osteonecrosis - late avascular necrosis
R = b, c

3. Should we mention a complete diagnosis for all patients disorders (COPD 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 ?
It is usually most helpful to identify the femoral fracture anatomically and describe it accurately. Fractures may be
classified anatomically as intracapsular (45% of proximal femur fractures occur at the femoral neck) or extracapsular.
A femoral neck fracture may cut off the blood circulation to the ball of patient hip by tearing the blood vessels. The
synovial membrane incorporates the entire femoral head and the anterior neck, but only the proximal half of the
posterior neck. Widely displaced intracapsular hip fractures tear the synovium and the surrounding vessels. The
progressive disruption of the blood supply can lead to serious clinical conditions and complications, including
osteonecrosis and nonunion.

2. Long-term risks that may happen after the surgery in our patient are?
Long-term risks that may happen months to years after the surgical intervention. They include: nonunion (the pieces
of bone do not heal back together), fracture around the screws used to repair the bone, late avascular necrosis
(problems with the blood flow inside the bone, which can cause part of the bone to die), difference in leg length
(when the fractured leg is healed, it is a little shorter than the other leg).

3. Should we mention a complete diagnosis for all patients disorders (COPD 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. Various other
prophylactic measures are also employed, including the use of antiembolism stockings, continuous passive motion of
the hip, and antiblood-clotting medications such as coumarin and heparin, prevention the pulmonary infection.
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 her injury.

2. Methods of RP used in our patient:

pharmacological modalities - analgesics, biphosphonate drugs, vitamin D3 and calcium carbonate oral
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 masage for lower limbs and special massage (Cyriax) of groin,
- 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 other 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 we should respect the kinetic algorithm program in our patient 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. What are the goals of RP in our patient, when she become in our department ?
a. Initiate functional weightbearing exercises, open kinetic chain AROM and isotonic strengthening exercises
b. Initiate proprioception and gradual gait exercises
c. Restoration of strength, power, and endurance
R = a, b

4. Why is occupational therapy important in our patient rehabilitation program?

a. Because patient regains her independence of daily living
b. Because patient regains her 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 other 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 (osteoporosis and COPD); and access to rehabilitation services (our patient lived in rural location).

2. Why we should 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 painful non-union status.

3. What are the goals of RP in our patient, when she become in our department ?
The patient is coming in our department after 8 weeks after intervention. The goals of rehabilitation program are:
continuing healing of fracture site, normalizing AROM and impaired proprioception, initiate gradual return to
functional activities and light work activities. All rehabilitation has to respect the progression for optimal control of
patients impairments and functional limitation, to prevent the falls.

4. Why is occupational therapy important in our patient rehabilitation program?

Because, after occupational therapy, our patient can safely manage toileting with walker/crutches without physical
assistance, perform safe shower transfer with minimal to no caregiver assistance, able to dress self with minimal to
no caregiver assistance using tools as needed, and she can communicate an understanding of hip precautions, to
prevent further falls.