Surgical treatment of femoral shaft fractures with an IM nail is considered the standard of care with union rates between 95% and 99%,13 Despite this success, functional limitations and impairments often persist after the injury and surgical procedure, which may result in residual disability.2,3,13 This disconnect between fracture union and residual functional impairments suggests that factors other than fracture healing may contribute to the long-term outcome in femur fracture patients. 3 0 obj Preoperative x-ray of femoral shaft fracture. Isometric exercises for the hip and knee are prescribed. Specific time . They enrolled 32 patients with IM nailing after femoral shaft fracture, 14 patients with IM nailing after closed femoral shortening, and 40 controls. Disclosure: The authors did receive commercial/industry funding in support of their research and in preparation of this article. If there is an overt fracture line on the radiographs with no displacement, and provided that only the cortex is involved, an initial period of either bed rest or complete nonweightbearing is necessary. Bain et al2 studied femur fracture patients treated with an antegrade IM nail and compared hip abduction strength to a control group. It is estimated that up to 5% of all stress fractures involve the femoral neck, with another 5% involving the femoral head. Its application to comminuted fractures of the femur. Patients treated with hemiarthroplasty should avoid keeping the hip in adduction or internal rotation to prevent redislocation. Rehabilitation Protocol for Patellofemoral Pain Syndrome . Inpatient physical therapy consists of gentle ROM, initiation of a WB as tolerated (WBAT) ambulation program with an assistive device, and initiation of lower extremity isometrics. In a more recent prospective longitudinal study, Archdeacon et al23 evaluated hip abductor function during gait after femoral fracture and antegrade nailing. is not considered a "hip fracture.". The bone's architecture may have been so weakened that patients state they 'heard a crack' before they hit the ground. This static heel propping stretch allowed for a low load, long duration stretch of the posterior knee. Weight-bearing with the affected extremity with the help of crutches or walker using a four point gait can be initiated as the patient can bear more weight now. Inpatient physical therapy was ordered twice daily and consisted of gentle range-of-motion activities, initiation of a weight-bearing-as-tolerated ambulation program with either a walker or bilateral axillary crutches, and . The onset of pain occurs at the hip or groin area during activities of weight-bearing. Foster TE, Healy WL. o No significant difference in femur fracture patterns has been found when proven cases of child abuse are compared to a control group. B. The optimal surgical management of a femoral shaft fracture is well documented in the literature. Most femur fractures are fixed within 24 to 48 hours. 34. An athlete may need to progress through a return to sports program,35 whereas an industrial worker may need to complete a functional capacity evaluation. Danckwardt-Lilliestrom G, Sjogren S. Postoperative restoration of muscle strength after intramedullary nailing of fractures of the femoral shaft. A. Outpatient vs. home health therapy (Phase 1): o 1-2x/ week x 6 weeks o Gait training with assistive device. In the hospital you are given shots in the belly called Lovenox and have pneumatic compression devices on your legs. In addition due to exposure during surgery, quadriceps and . Care should be taken while developing this individualized transitional program to continue to focus on known strength and gait impairments that affect long-term outcomes. You will be seen at 2 weeks, 6 weeks and 3 months from surgery where the provider will examine you and x-rays will be taken to follow bone healing. Toren A, Goshen E, Katz M, et al. V. Coordinate care with other disciplines involved. Participation in a focused intervention to assist the patient is developing activity-specific strength and skills will likely improve the long-term functional capacity and ultimate outcome for the patient. Other adaptive equipment as necessary for independence. While compression side stress fractures with no displacement is an indication for non-operative treatment. Very young children are sometimes treated with a cast. Distal femur fractures most often occur either in older people whose bones . % 1 0 obj Current evidence suggests that a significant cohort of femur fracture patients managed with an intramedullary (IM) nail will ultimately possess residual impairments and disability up to 3 years after surgery.2,3,10 It has been reported that approximately one half of patients treated for a leg fracture at level I trauma centers have some residual disability 12 months after the injury, and up to 20% of individuals treated surgically for femoral shaft fractures are unable to return to work 3 years after the injury.9,11 In a multicenter study of severe lower extremity injuries, approximately 70% of patients were able to return to work 12 months post injury; however, the chances of returning to work markedly decline after that time.12 This evidence validates the need to aggressively manage these patients in an attempt to progress them back to their prior level of function quickly, to avoid the risk of permanent disability. 28. PMID: Clough TM: Femoral neck stress fracture: the importance of clinical suspicion and early review. Accepted for publication January 27, 2009. Examination is positive for an antalgic gait with normal knee and hip range of motion. Further investigation of functional outcomes and rehabilitation are required to minimize disability after surgical fixation of femoral shaft fractures. Finsen V, Svenningsen S, Harnes OB, et al. Maintenance of full knee extension and progression of knee flexion activities are indicated until full functional ROM is attained. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. Deep knee flexion is avoided with these activities to limit irritation to the PF joint; however, they can be used with restrictions placed on knee flexion. Kempf I, Grosse A, Beck G. Closed locked intramedullary nailing. Modalities are used at this time to attain 2 goals. Mira et al19 reported that only 17% of patients (5/29) demonstrated normal quadriceps function 16 months after fixation of femoral shaft fracture. Any combination of these impairments can potentially limit the ability of a patient to return to prior levels of function. Broken intramedullary nails. Evaluate gross muscle strength and range of motion of other extremities. Myer GD, Paterno MV, Ford KR, et al. You may be trying to access this site from a secured browser on the server. Move your hip, knee and ankle as much as possible to avoid getting stiff. Continue outpatient physical therapy program as indicated. Copyright physiotherapy-treatment.com since 2009, Common Physical Therapy Abbreviations used in documentation. Not all patients with femur fractures require physical therapy. Neuromuscular stimulation to facilitation quadriceps recruitment. J Am Acad Orthop Surg. Theodoropoulos, J, Dwyer, T, Whelan, D, Marks, P, Hurtig, M, Sharma, P (2012) Microfracture for Knee Chondral Defects: a Survey of Surgical Practice . You are in: Home Trauma Femoral Stress Fracture. Similarly, patients with bilateral injuries are progressed through the protocol as much as possible, recognizing that some patients may be limited by pain. o Sport-specific rehabilitation Gradual return to athletic activity as tolerated - including jumping/cutting/pivoting sports Maintenance program for strength and endurance Comments: Frequency: _____ times per week Duration: _____ weeks Ostrum RF, DiCicco J, Lakatos R, et al. b. Do not take more than 4 grams of Tylenol a day or it can hurt your internal organs. A 3-point gait using crutches or walker is advised. 1). Some consideration must be given to extenuating circumstances regarding injuries and the rehabilitation protocol. 18. Night pain may occur if the fracture progresses. A femoral stress fracture often starts with a deep, dull gnawing or aching in the groin (inside of the leg) or front of the hip. The patient was a 19-year-old woman who recently completed a military basic training program. %PDF-1.5 Femur Fracture Physical Therapy Exercises . 5. Handheld dynamometry is an adequate substitute to objectify strength. An overt fracture with radiographic evidence of opening or displacement is significant and requires surgical intervention, usually in the form of a hip screw and plate. The rehabilitation used and control data were not reported in this study. Physical Therapist at SMC, New York, USA. Use of neuromuscular reeducation with electrical stimulation may be continued to facilitate a volitional quadriceps contraction as indicated. Future randomized control trials need to be implemented to validate this intervention and to optimize this treatment protocol. Test range of motion of hip, knee, and ankle. Reprints: Mark V. Paterno, PT, MS, SCS, ATC, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 10001, Cincinnati, OH 45229 (e-mail: [emailprotected]). Your wound was closed with either sutures or staples. By continuing to use this website you are giving consent to cookies being used. Early rehabilitation following surgical fixation of a femoral shaft fracture. If you do not have one, please call the office to schedule at 775-786-3040 as soon as you can. This level of quadriceps contraction often results in an early resolution of an extensor lag at the knee with active hip flexion. A three-point bending force is then applied to the thigh with the edge of the table being used as afulcrum. If you need prolonged narcotics, we can refer you to a pain management specialist. However, in subsequent analysis 8 months after surgery, the patient demonstrated improvement in hip kinematics but continued deficits in knee kinematics. femoral intramedullary nailing; rehabilitation protocol; Keyword Highlighting 6. Gait training activities with assistive devices to promote knee flexion during swing phase of gait and normalization of a typical gait pattern are also initiated. Concurrently, the ability to progress rehabilitation beyond range of motion (ROM) and non-weight bearing (NWB) strengthening activities was somewhat limited resulting in exacerbation of postoperative impairments, ultimately leading to higher levels of functional deficits and disability, such as delayed return to work. Hennrikus et al3 examined quadriceps torque after conservative management of femoral fracture in 33 adolescent patients and found that 39% of these patients demonstrated persistent side-to-side quadriceps deficit of greater than 15% of the involved limb at an average of 33 months post injury. A rehabilitation program designed to target these impairments provides the best opportunity for a favorable outcome. <> The research for this article was not funded by NIH or a similar funding agency. You will be seen at 2 weeks, 6 weeks and 3 months from surgery where the provider will examine you and x-rays will be taken to follow bone healing. However, some components of the protocol may be useful, particularly the ROM and stretching exercises and the modalities for muscle reeducation. 15. Usually, patients do 1-2 visits with the therapists a week and must continue these exercises at home daily for a good result. BMJ, 344:e2511, 2012. Complete specific tests, including Functional Ambulation Profile and Get Up & Go Test. Derotation bar helps prevent external rotation of the affected limb. Knee flexion ROM exercise is also initiated immediately postoperatively. Kapp et al7 evaluated the long-term deficits (mean 44 months) after IM nailing of femoral shaft fractures in 17 patients. The first measure of treatment is knowing the signs of a femoral neck stress fracture. The patient can now flex the hip upto 90 degree, by the self-assisted "heel drag", (i.e. Some error has occurred while processing your request. Treatment depends on where the injury occurs. Symptom relief. <>>> Alteration in gait mechanics is a functional impairment often observed after IM nailing of femoral shaft fractures. Nonoperative treatment of femoral shaft stress fractures is usually successful. Therefore, an aggressive physical therapy program with early WB may facilitate long-term success with patients undergoing IM nailing to quickly decrease the level of impairment that often leads to functional limitations and disability in these patients. Femoral Stress Fracture Symptoms. In 1999, it was reported that 57,000 patients in the United States sustain a midshaft femoral fractures, annually.1 The majority of these injuries occur in young, otherwise healthy, individuals and are the result of significant, high-energy trauma, such as motor vehicle accidents, falls from a height, or industrial accidents.2 Due to the traumatic high-energy nature of this injury and the current surgical intervention, resultant soft tissue pathology is common. Observe gross muscle strength of involved extremity by strength of. Cochrane Database of Systematic Reviews 2007, Issue 1. d. Assess range of motion of involved hip within limits of. Find one of our conveniently located offices in Reno, Sparks, Carson City & Fallon, 555 North Arlington Avenue These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. a. This is achieved with posterior lower extremity stretching, including seated hamstring stretch and seated gastrocnemius stretching with the assistance of a towel. With the progression in WB status, there is also a progression in closed kinetic chain strengthening activities in phase 2. The resulting fracture is usually displaced with lateral rotation of the femoral shaft so that the leg will be laterally rotated in comparison with the other limb. Reducing Subtrochanteric Femur Fractures: Tips and Tricks, Do's and Don'ts, The "Swashbuckler": A Modified Anterior Approach for Fractures of the Distal Femur. 1. No more than minimal knee effusion and lower extremity edema must be present. 29. 13. It is unusual for femoral shaft fractures to be treated without surgery. Ostrum et al5 studied 14 patients with an antegrade femoral IM nail after an isolated femur fracture. Activities of daily living can be allowed normally with the help of assistive devices. Diagnosis can be be made with radiographs but findings often lag behind often resulting in negative radiographs early on. Protection - Crutches with non-weight-bearing ambulation until complete relief of pain at . to maintaining your privacy and will not share your personal information without . The commonest causative sports are marathon and long-distance running. These are based on the latest orthopedic science and literature in order to give patients the most up to date care. 2017 Oct 18;88(4S):96-106. doi: 10.23750/abm . Stress fractures of the femur can occur in the whole bone like the neck, shaft and the condyles.Femoral stress fractures mainly develop on the medial compression side of the femoral shaft, within the proximal and middle thirds of the bone. These criteria include FWB without assistive device, minimal effusion, fair to good quadriceps strength with a manual muscle test of 4+/5 and fair to good hip abduction strength with a manual muscle test of 4/5. B. Historically, initiation of postoperative weight bearing (WB) after surgical fixation of femoral shaft fractures has been delayed until radiographic evidence of bony callous formation was present.25-29 Typically, this could extend up to 6-10 weeks postoperative, resulting in ambulation status remaining partial weight bearing (PWB) with use of an assistive device up to 3-4 months postoperative. However, a dearth exists with respect to postoperative rehabilitation recommendations, targeting the impairments that often limit return to activity. With respect to muscle contraction and strength, the patient must demonstrate a fair quadriceps contraction and fair hip abduction strength. Impaired hip abduction strength can also be targeted in an attempt to address functionally limiting deficits typically seen after femur fracture that leads to altered gait. Educate patient and family on exercise program. Patients with pelvis and leg fractures are at risk to get blood clots in the legs that can dislodge and travel in the bloodstream to the lungs causing disability or death. This is the method of choice for displaced fractures because of the dangers of avascular necrosis, and because of the benefits of early mobilization , which is so important in the frail. The usual method is to excise the head and perform replacement arthroplasty using one of the metal prosthesis e.g. Initiate training in activities of daily living, including bed mobility and transfers to and from bed and toilet. Progression through the program is dependent on successful attainment of baseline goals. Bone. 3. There are several ways to decrease the risk of this complication. With respect to gait, a normal gait pattern with no signs of Trendelenburg gait should be present. Progress to walker or. The treatment regimen is more or less the same as discussed above. Ostrum RF, Agarwal A, Lakatos R, et al. From the *Sports Medicine Biodynamics Center and Human Performance Laboratory, Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and Department of Orthopaedic Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH. Although a consistent treatment protocol does not currently exist, athletic trainers should base their rehabilitation progression on the athlete's symptoms and underlying risk factors. This construct usually consists of one large diameter rod placed inside the bone where your bone marrow is and is held in place with 2-4 screws at the top and bottom of the bone. This must be prescribed in only a 5 day supply each time. A continued focus is placed on functional limiting impairments, particularly knee extension and hip abduction activities. Stress fractures are generally classified as fatigue or insufficiency fractures: Stress Fracture can also be classified based on symptoms and imaging appearance: the diagnosis of a femoral neck stress fracture is often delayed for 5 to 13 weeks. The authors reported that approximately 12% of the patients complained of anterior knee pain at an average of 29 weeks postoperative. A hip fracture is a break in the upper quarter of the femur (thigh) bone. The initial focus is on attaining early full knee extension to decrease the risk of knee flexion contracture. The following protocol is designed to help patients in their healing with a single resource for frequently asked questions. 4. Reproduced with permission from OrthoInfo. Winquist RA, Hansen ST Jr, Clawson DK. 3). Increase strength of involved extremity to within functional limits. Usually, this appointment is made when you schedule surgery. A limb symmetry index of 85%-90% in both hip abductor and knee extensor and knee flexor strength is necessary to progress to discharge. b. How common are femoral stress fractures? Evaluate patient's home situation to determine need for additional equipment, home health physical therapy services, or other support. 31. b. These initial WB activities can quickly progress to include closed kinetic chain strengthening of the lower extremity. Zdravkovic D, Damholt V. Quadriceps function following indirect nailing of femoral shaft fractures. Retrograde femoral nailing: a focus on the knee. manual therapist, Medical Neuroscience (USA). c. Weight-bearing: By the end of first week, weight bearing with the help of a crutch or walker using a 3-point gait may be permitted. https://orthoinfo.org/. Soft tissue injuries intrinsic to the fracture and iatrogenic muscle injury associated with the surgical intervention create additional impairments and ultimately may limit return to the previous level of function.3-9. The most frequent symptom is the onset of sudden hip pain, usually associated with a recent change in training (particularly an increase in distance or intensity) or a change in training surface.The earliest and most frequent symptom is pain in the deep thigh, inguinal, or . The treatment of Femoral Stress Fracture varies according to the bone scintigraphy findings: Tension-sided femoral neck stress fracture is an indication for surgical fixation with parallel screws or a sliding hip screw device. For patients with endoprosthesis, weight bearing as tolerated is permitted. Wolters Kluwer Health, Inc. and/or its subsidiaries. Abduction strength following intramedullary nailing of the femur. Hulth A. Hip abduction weakness is described as a common complication of femoral IM nailing.2,4,5,14,15 Several authors have demonstrated side-to-side deficits in hip abduction strength with resultant alterations in gait, specifically a Trendelenburg gait pattern at time points up to 47 months after surgery.2,4 In addition, hip abduction weakness in this population has been identified as a complication, which ultimately leads to additional functional limitations, including stiffness, antalgic gait, decreased endurance with stairs, and difficulty ambulating stairs.2,4,5,14,16 The mechanism suggested by these authors was attributed to soft tissue injury at the time of either injury or surgery, an irritation of the abductor musculature from the surgical hardware, or inadequate postoperative rehabilitation.2 Inadequate postoperative rehabilitation, although frequently identified as a potential cause of this impairment, has not been documented adequately in the literature, nor prospectively analyzed. If it is leaking, replace dressing with a clean gauze pad and tape. If a patient is extremely stiff at their first postoperative visit and has trouble bending their hip or knee therapy will be started. 2) and toe raises can be initiated at this time to encourage a progressive increase in functional WB with both exercise and gait. }/p&qViiU^2*AMgk)6^x_b iMd1D)%R<= The Online bill pay website called Doxo.com is NOT affiliated with Reno Orthopedic Center (ROC). Patellar stress fracture Patellofemoral arthritis Pes Anserine Bursitis . First the patient is advised prone lying. A. Inpatients should be seen daily, twice if possible. Evaluation. endobj Enhancement of fracture-healing. Improve range of motion to normal functional status. 17. These studies agreed with previous studies by Danckwardt-Lilliestrom,14 which reported quadriceps weakness up to 7 years post IM nailing. This program would include an avoidance of activities such as deep squatting, repetitive loading of the PF joint, and activities that could cyclically load this region. This includes single-leg toe raises, mini squatting, and simple perturbations on an unstable platform. a. Supine: hip abduction and adduction, gluteal sets, quadriceps sets, straight leg raise, hip and knee flexion, short arc quadriceps, internal and external rotation. These data suggested that improvement in hip function and resultant gait were possible, but residual deficits in knee kinematics and quadriceps activation remained 8 months after surgery. 12. The Sickness Impact Profile as a tool to evaluate functional outcome in trauma patients. Bilateral support assistive devices (crutches or walker). Enhance your health with free online physiotherapy exercise lessons and videos about various disease and health condition. REHABILITATION PROTOCOL FOLLOWING FEMORAL CONDYLE MICROFRACTURE . Impaired quadriceps strength has also been identified as a common outcome after femoral fracture with or without surgical management.3,6,7,19 Numerous authors have documented that after both conservative and operative6,7,19 management of femoral fractures, significant residual quadriceps weakness persists. Official Journal of the American College of Sports Medicine. Movements: A full range active movements of the ankle, gentle active movements of flexion and extension of the hip and knee (once the pain subsides) is permitted. A targeted home program of progressive lower extremity and core strengthening activities in addition to a targeted gait retraining program may ultimately lead to an improved long-term outcome. After 8 weeks:Femoral neck fracture Physiotherapy Management. Current literature suggests that residual impairments after IM rod fixation of a femoral shaft fracture include hip abduction weakness, knee extensor weakness, anterior knee pain, and gait abnormalities. 1989;10:105108. REHABILITATION PROTOCOL: An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. Their objective was to compare hip abduction function and strength after insertion of a femoral IM nail. The distal femur is the area of the leg just above the knee joint. 6,9-11. o Among young children who sustain femoral shaft fractures, the likelihood of child abuse is much higher in non-walking children (42%), than in walking toddlers up to four years of age (2.6%) 12 Garden type 1) fractures may be managed by cannulated screw fixation. 25. Conversely, Finsen et al20 studied a group of 14 isolated femoral shaft fracture patients who were treated with IM nailing. In terms of segmental bone loss or even morbid obesity, we have allowed FWB with a planned bone grafting procedure for segmental loss. 1996) found that the 1 year death rate was as high as 23.8 percent. The "hip" is a ball-and-socket. Clinical and scintigraphic findings were suggestive of spontaneous osteonecrosis of the medial femoral condyle. B. Assess cardiac status prior to initiation of evaluation. High blood sugar can put you at risk for infection, wound complications and the bone not healing (nonunion). Patient is asked to keep trunk upright during task to facilitate core stability and hip abductor activation. Education programmes and treatment protocols can reduce the rates of displaced FNSFs. during 4-8 weeks:Femoral neck fracture Physiotherapy Management. Gait patterns after fracture of the femoral shaft in children, managed by external fixation or early hip spica cast. Only 10% of patients will demonstrate positive findings on plain radiographs taken within the first week of symptoms, and fewer than 55% of patients with femoral neck stress fractures will ever have radiographic evidence of the condition. Knowing how the fracture presents can lead to early diagnosis and avoid further complications. Retrograde intramedullary nailing of femoral diaphyseal fractures. Wolinsky P, Tejwani N, Richmond JH. Type 3- some displacement and rotation of the femoral head. In addition, posterior knee stretching is attained by elevating the lower extremity with the heel propped up for 10 minutes 3-4 times per day (Fig. . When treating these fractures with internal fixation, many fixation constructs exist. Proprioception activities including balance board activities, mini tramp marching, and WB PREs on an unstable surface are initiated at the end stages of phase 2. This targeted phase should be individually developed based on the physical capacities needed for the patient's specific return to function goals. Ultimately, immediate WB has been postulated to result in less hospitalization with decreased need for prolonged in-patient rehabilitation and ultimately a decreased cost of care; however, this link has yet to be substantiated in the literature. Ensure patient achieves milestone prior to progression . Taking OTC ibuprofen (Advil, Motrin) or acetaminophen (Tylenol) can help the pain. This process does not remove your bone marrow but just compacts it. During the 1st week:Femoral neck fracture Physiotherapy Management. b. 32. The intramedullary nail usually stays in for life and are not routinely removed. 1. Sometimes it will be delayed until other life-threatening injuries or unstable medical conditions are stabilized. [12] The highest incidence is seen at the femoral neck. Just remember that your reaction time will be slow for first 6 weeks so do not tailgate or drive too fast. Younger patients heal slightly faster and older patients or those with diabetes take slightly longer to heal. x\nFo0@U4kPfM(m-IU\fHJ$9msuF9{\]fF&\vv^8;6WUyXxs=J_x"4Ey|2p@_IR%"b7-X,jxXD74p6Y+Sb:?u5S,f>?>>F. 11. Leggon RE, Feldmann DD. Bednar DA, Ali P. Intramedullary nailing of femoral shaft fractures: reoperation and return to work. The purpose of this article was to describe the impairments and functional deficits associated with femoral shaft fractures treated with an intramedullary (IM) nail and to illustrate an evaluation-based rehabilitation program designed to target these functional deficits. A. A. Patient can now carry out all the activities of daily living independently. Acta Paediatr. Again, the authors of these studies have alluded to inadequate rehabilitation as a variable correlated to quadriceps strength after this injury; however, none have reported on this variable.7,14,19,20, Anterior knee pain is also frequently reported after antegrade and retrograde nailing of the femur.4,6,21 Ostrum et al5 prospectively reported on 86 patients who sustained a femoral shaft fracture and were treated with an IM nail. 24. Rockwood and Greens Fractures in Adults 8th Edition book. Simple weight shifting exercises without assistive devices to encourage increased comfort and confidence with progression of WB are initiated. Then patient is advised to bear weight on the knees. 1. Some authors have argued that when a serious bone defect is present, the use of cortical strut allografts for the treatment of type B2 and B3 periprosthetic femoral . This website uses cookies. You should see your surgeon or his physician assistant 10-14 days after surgery. Boden BP, Osbahr DC. Physical Therapy Not all patients with femur fractures require physical therapy. Controversies in intramedullary nailing of femoral shaft fractures. All these interventions are supplemented with a home exercise program, focused on hip and quadriceps strengthening. The physiotherapy regimen is more or less the same for patients treated with hemiarthroplasty (the emphasis is on to prevent adduction and internal rotation to prevent redislocation), McMurray's osteotomy, Meyer's muscle pedicle graft, etc. patients with mental illness or other diseases who could not comply with the treatment protocol. Anterior knee pain has been identified as a potential limiting impairment in prior studies investigating outcomes after femur fractures.5 Therefore, care should be taken in the implementation and progression of exercises that could potentially place adverse stress on the PF joint. 2015; 1775-1780. Hip abduction strengthening is also progressed with more closed kinetic chain activities, such as resisted lateral walking. joint. American Academy of Orthopaedic Surgeons. In addition, a positive correlation was found between hip abduction weakness and several functional complaints, including pain, stiffness, antalgic gait, decreased endurance with stairs, and difficulty ambulating stairs. Avoiding weight bearing exercises and performing frequent ROM exercises are a crucial part of the early rehabilitation process. Your femoral shaft was fixed with a titanium rod called an intramedullary nail. Standing hip abduction with band resistance. An evaluation-based rehabilitation protocol for femur fractures treated with an IM nail can facilitate restoration of function in a predictable manner and should be considered as a standard for patients with these injuries. The orthopedic surgeon by law can only give you narcotic pain medicine for 2 weeks after surgery. Femoral neck stress fractures represent a relatively rare spectrum of injuries that most commonly affect military recruits and endurance athletes. III. Please respect these regulations. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. MRI is a high sensitive and specific for diagnosis, and detects early changes. Inadequate postoperative rehabilitation is a potential cause of delayed strength. Time to full recovery varies, but has been reported as 5 to 10 weeks from diagnosis with return to full athletic participation at 8 to 16 weeks. If a patient is extremely stiff at their first postoperative visit and has trouble bending their hip or knee therapy will be started. d. Activities of daily living: Certain modifications are brought about in the activities of daily living. High-Risk Stress Fracture Initial Treatment (if Stable and Nondisplaced) Femoral neck (compression side)a NWB 4 to 6 wk, . A focus is placed on normalizing temporal spatial parameters, such as stride length, previously linked to long-term outcomes.23 As the patient progresses away from an assistive device, an increased focus is placed on controlling frontal plane trunk movements and a reduction of a Trendelenburg gait pattern. Establish independent gait without assistive device. Initial strengthening exercises focus on active control of knee extensor and hip abductor musculature to address these typical impairments. (17) has described a two-phase protocol for rehabilitation of the runner with a lower limb stress frac-ture. II. Patients with cementless, or ingrowth , joint replacements are put on partial weight bearing (PWB) or toe-touch weight bearing (TTWB) for 6 weeks to allow maximum bony ingrowth to take place. However, the authors noted that there was a large range of quadriceps deficit, and a correlation was observed between loss of quadriceps torque and time from surgery. You will start with non-weight-bearing exercises and gradually progress as you can tolerate putting more weight on your leg. may email you for journal alerts and information, but is committed If evidence of PF joint pain or PF joint injury from the initial injury is present, a patella protection program should be instituted. Failure to meet these baseline criteria will result in additional time spent by the patient in the initial phase of rehabilitation. Follow the acute treatment principles of protection, rest, ice, compression, elevation, medication, and modalities (PRICEMM). And it becomes stronger or sharper with more strenuous movement . However, excessive adduction and internal rotation should be avoided in patients treated with endoprosthesis. 9. 4) are continued with an increase in weights as tolerated. Tidy's Physiotherapy15: Tidy's Physiotherapy By Stuart B. Porter, Essentials of Orthopaedics for Physiotherapist By Ebnezar. Your dressing from surgery is waterproof. Although several studies cite inadequate rehabilitation as a contributing factor to this impairment, few have described rehabilitations program or prospectively analyzed this variable. Is There a Standard Rehabilitation Protocol After Femoral Intramedullary Nailing? ;hK@UtUXcW&J~;+@B2 pG-@AMd nZU% lwzcIfw#T ^9i?r> YQTx|j|M\gx)S]IM,C{3P22NC[U^c?pv"V9I$'@h_~0_bJPTEy O1 'Y;K*v`N9X*ha%vdMAMj*zp[% RgD9(-Mn~ A focus on progression of ROM continues in phase 2. Movements: Active and active-assistive movements of the hip, knee and ankle can now be started. The ideal surgical treatment of femoral neck fractures remains controversial. Once released to resume preinjury activities, a home exercise program aimed at functional progression toward preinjury work and recreational activities is recommended. Less severe cases may only have pain following a long run. This evidence suggests attempts to address gait impairments early in rehabilitation may result in improved long-term outcomes of patients after femur fractures. Femoral plating. An alternative method of fixation is a compression screw plate called a ' dynamic hip screw'- so called because it permits dynamic movement at the fracture site, which stimulates healing. 33. c. Assess sensation of involved extremity. This can be accomplished in a NWB position with the use of resistive bands and can ultimately be progressed to standing activities as the progression of WB will allow. Both the intensity and duration of the final steps of the end stages of this rehabilitation program may be greatly influenced by the type of work and activity to which the patient wishes to return. Flexibility will be necessary with these situations; however, every effort should be made to continue with a goals-based progression of the rehabilitation protocol, particularly, advancing to WBAT as quickly as possible because this really drives the progression of rehabilitation. The authors postulated that the mechanism of knee pain was either damage to the patellofemoral (PF) cartilage at time of injury and/or quadriceps atrophy. . THC and CBD products can be helpful for postoperative pain and decrease the amount of narcotics you need. J Orthop Sports Phys Ther 36:8088, 2006. the diagnosis of a femoral neck stress fracture is often delayed for 5 to 13 weeks. Reducing the Syndesmosis Under Direct Vision: Where Should I Look? Weight can be added as displayed to apply a low load, long duration stretch into extension. Functional impairment including hip abduction weakness, quadriceps weakness, anterior knee pain, and resultant deficits in gait biomechanics have been observed after IM nailing of the femoral shaft fractures. If these rules are bent, the orthopedic surgeon can lose his medical license, insurance contracts and be unable to care for other patients like you. Compliance with a targeted home exercise program designed to address known impairments that limit functional outcome will facilitate a more favorable outcome. Illustration of femoral shaft bone. However, it must be recognized that as the indications for IM nailing have expanded, the rehabilitation protocol, particularly early WB, may need to be reassessed. After 2 days you can take off the dressing. 5. Rehabilitation Objectives: The key goals for rehabilitation of femoral neck fractures and physiotherapy intervention are to restore the range of motion at hip and knee and to improve strength in lower limb muscles.The primary muscles affected are: Gluetus medius, iliopsoas, gluteus maximus, adductor magnus, longus and brevis. They did not report strength measures; however, they did report that 2 patients had persistent Trendelenburg gait due to hip weakness despite radiographic evidence of bony healing. Fractures of the thighbone that occur just above the knee joint are called distal femur fractures. The earliest and most frequent symptom is pain in the deep thigh, inguinal, or anterior groin area. Modern implants are generally able to withstand FWB for 6-12 months even in the face of bone loss and/or excessive body weight. 27. Second, effusion and edema management may be addressed with the regular use of elevation and cryotherapy. This article aims to provide a current concepts review on the topic of FNSFs in sport, assess . Pes anserine bursitis (tendinitis) involves inflammation of the bursa at the insertion of the pes anserine tendons on the medial proximal tibia. Wong J, Boyd R, Keenan NW, et al. Phys Ther 77:5867, 1997. The Reno Orthopedic Center Fracture and Trauma Surgeons have createdpostoperativefracture protocols for our patients. This objective assessment of function may vary depending on the patient's goals. If you already get narcotics from your primary care doctor or pain management doctor the orthopedic surgeon cannot write you a separate prescription. Most femoral shaft fractures require surgery to heal. Differential diagnosis of Femoral Stress Fracture includes: Recommended views include AP pelvis, AP and lateral of hip. Paterno, Mark V PT, MS, SCS, ATC; Archdeacon, Michael T MD, MSE. Exercises for a femur fracture include moving your hip through its full range of motion and increasing the strength of your glute and quadricep muscles. Athletes often complain of increasing hip and groin pain during runs that begins to take longer to go away. Balance and proprioception activities are advanced to single-leg activities as FWB without assistive devices is achieved. Former PT ISIC Hospital. Pain elicited is indicative of a Femoral Shaft Stress Fractures. a. The following is the Garden classification of femoral neck fractures: In addition, femoral neck fracture is classified by its location: Femoral neck fractures are extremely common in the elderly, often following falls, and most orthopedic units will have a number of these fractures at any one time. Subtle limitation of flexion and internal rotation may also be present with or without a positive log roll test. Inconsistencies in care exist in the postoperative rehabilitation management, which may result in residual impairments known to lead to disability. Pulmonary embolism and hypovolaemia are a distinct possibility and a careful watch is kept to prevent bedsores from developing, the patient is frequently turned in the bed. She was evaluated by a physical therapist in a direct-access capacity for a chief complaint of anterior right hip pain that limited her ability to run. Once the location and severity of the athlete's stress fracture(s) is diagnosed, treatment can begin. Brumback RJ, Toal TR Jr, Murphy-Zane MS, et al. Paterno MV, Archdeacon MT, Ford KR, et al. Franklin JL, Winquist RA, Benirschke SK, et al. The program is a dynamic incorporation of interventions designed to target these known impairments. Due to the limited sensitivity of radiographs, magnetic resonance imaging of the right hip was obtained, which revealed a stress fracture of the right . This also can assist in return of isolated quadriceps activity. A prospective randomised trial. I. Rehabilitation after IM nailing of a femoral shaft fracture has been partitioned into 3 phases. To close this popup, click the x in the top right corner. 1. You will have pain in your leg while it heals but it is safe to walk on it. This is probably the most common and most significant fracture in terms of morbidity, mortality and socioeconomic impact in developed countries (Reginster et al. Fractures, Stress / diagnostic imaging* Fractures, Stress / rehabilitation Humans Injury Severity Score . Isometrics, isotonic and progressive resistive exercises are continued to the hip, knee and ankle joints. Femoral Stress Fracture Protocol: Gym/Physical Therapy Program Katherine J. Coyner, MD UCONN Musculoskeletal Institute Medical Arts & Research Building 263 Farmington Ave. Farmington, CT 06030 Office: (860) 679-6600 Fax: (860) 679-6649 www.DrCoyner.com Avon Office 2 Simsbury Rd. Reno, Nevada 89503-4724. usually consists of one large diameter rod placed inside the bone where your bone marrow is and is held in place with 2-4 screws at the top and bottom of the bone. Active range of motion and passive range of motion exercises of the lower extremity are initiated immediately after surgery. At a mean of 37 months, they noted loss of flexion torque but not extension torque. Kapp W, Lindsey RW, Noble PC, et al. Tornetta and Tiburzi21 cited a 59% rate of knee pain during rehabilitation but noted improvement with only 13% complaining once quadriceps strength had returned. Provide written home exercise program. Before progression to phase 3, the patient must meet several criteria. Postoperative x-ray of femoral shaft fracture repair with plate and screws. IV. The use of computerized gait analysis22-24 has been used to objectively evaluate dynamic function of the lower extremities after femoral shaft fracture. The fulcrum or hanging leg test involves having the patient seated on an examination table with the leg hanging freely. Adherence to an aggressive physical therapy program following surgery appears to enhance the success of the procedure. By 12-16 weeks:Femoral neck fracture Physiotherapy Management. Alternate using heat and ice packs for the pain and inflammation. You may search for similar articles that contain these same keywords or you may Avon, CT 06001 Office: (860) 679-6600 Fax: (860) 679-6649 Collectively, these authors attribute anterior knee pain to PF joint trauma at the time of injury,4 quadriceps weakness, or symptomatic hardware.4,6,21. Ho KY, Farrokhi S, Powers CM. Treadmill walking should focus on training a more normal gait pattern, in addition to challenging the cardiovascular system. Your message has been successfully sent to your colleague. Phase 3 focuses on a progression of strength, normalization of gait, and an ultimate transition to desired activities. Fracture displacement 2 mm identified on imaging. Foot is elevated to facilitated early full knee extension. BJlP+q$C P:qj#e 3'PbLV^:Ke,P#h1c+RSMC=EJK"JvqB}q?oPBA. Femur Rotation Increases Patella Cartilage Stress in Females with Patellofemoral Pain. 22. Journal of Orthopaedic Trauma23:S39-S46, May-June 2009. IOR!^EB%Rq6[nSZ8!vfwXtboO5e7LBU7r 7|#]zj,+SB ,vxZntW(IW,L8QV=3KT)J1S'ctXgLCtI{ cLh%@}e/jzG2cU.mu;#5&J#tbYYzQ\dL1DA0X)xXeW4k Initiation of phase 1 (Table 1) of the femur fracture rehabilitation protocol begins postoperative day 1 in the hospital. Pouilles JM, Bernard J, Tremollires F, et al. An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. <> Complete specific muscle tests on all groups. a. Paterno et al24 longitudinally reported gait kinematic and kinetic findings in a case report of a patient after IM fixation of a femoral shaft fracture. The most frequent symptom is the onset of sudden hip pain, usually associated with a recent change in training (particularly an increase in distance or intensity) or a change in training surface. The treatment regimen is more or less the same as discussed above. Although bone scans provide a high sensitivity in detecting stress fractures, their low specificity combined with a relatively high dose of radiation make magnetic resonance imaging (MRI) the modality of choice in detecting stress fractures. 35. If the wound is dry, you do not need to cover it with a new bandage. Sam Echols from Advance Rehab in Rome, GA gives rehabilitation tips for runners experiencing stress fractures. Search for Similar Articles B. Initiate home health physical therapy services when indicated. Stress fractures result from accelerated bone remodeling in response to repeated stress. Methods: The proposed algorithm is carried out in four phases, each lasting three weeks, and the move to the next . Tips for Maintaining Proper Spine Posture, Minimally Invasive Foot & Ankle Surgeries, Acetabular Fracture Postoperative Protocol, Decreasing the Stress of a Visit to the ER, Distal Femur Fracture Postoperative Protocol, Femoral Shaft Fracture Postoperative Protocol, Hip Nailing & Intertrochanteric Femur Fracture Postoperative Protocol, Hip Pinning and Femoral Neck Fracture Postoperative Protocol, Humeral Shaft Fracture Postoperative Protocol, Shoulder & Proximal Humerus Fracture Postoperative Protocol, Tibial Plateau Fracture Postoperative Protocol, Wrist & Distal Radius Fracture Postoperative Protocol, Innovations in Modern Day Joint Replacement. Feeling the Pinch: What Does a Pinched Nerve Feel Like? With respect to strengthening, the patient continues to increase the intensity of the exercises initiated in phase 2 through increased resistance with PREs. Bain GI, Zacest AC, Paterson DC, et al. As previously suggested, these residual functional limitations, impairments, and ultimate disabilities may be due to soft tissue injury and compromise as a result of trauma at the time of either injury and/or surgery.3 The most common soft tissue limitations and impairments identified in the literature include hip abduction weakness with a resultant Trendelenburg gait pattern, quadriceps weakness, anterior knee pain, and decreased function with respect to gait and walking endurance.2,4-8. Gait train patient, observing weight-bearing precautions. 26. Please try again soon. Wolinsky P, Tejwani N, Richmond JH, et al. An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. However, if the metal becomes infected or is painful 1 year after surgery it can be removed. IM nail fixation is the standard of care for skeletally mature patients with highly predictable union rates. Prospective comparison of retrograde and antegrade femoral intramedullary nailing. Activity modification with cross-training during this time period allows maintenance of aerobic fitness, skill, and strength. Am J Sports Med 16:365367, 1988. General lower extremity stretching including gastrocnemius/soleus and hamstring stretching are encouraged. Postoperative x-ray of femoral shaft fracture repair with an intramedullary nail. More recent evidence suggests that early and immediate WB after surgical correction of femoral shaft fractures with fixation hardware of adequate strength is not only safe but also may facilitate fracture healing and promote more rapid time to union.24,25,30-34 Concurrently, initiation of immediate WB allows earlier initiation of physical therapy, a quicker progression to a full weight bearing (FWB) status independent of assistive device, and earlier initiation of progressive resistive exercises (PREs) to target strength and endurance impairments. A. Weight-bearing status must be determined by physician. Although stress fractures are a relatively uncommon etiology of hip pain. Each phase is evaluation based and progression is dependent on successful attainment of baseline goals. Controversies in intramedullary nailing of femoral shaft fractures. You may shower immediately after surgery. If the patient is pain free with day-to-day activities at 2 weeks, a rehabilitation program with low-impact exercise may be initiated. The current literature describing management of diaphyseal femur fractures is replete with evidence regarding surgical management and optimal bone healing. Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. 19. You can take 1-2 pills every 4-6 hours. Usually, this appointment is made when you schedule surgery. I. Individual screws sometimes require removal to stimulate bone to heal in a process called dynamization. A Femoral Neck Stress Fracture (FNSF) is caused by repetitive loading of the femoral neck that leads to either compression side (inferior-medial neck) or tension side (superior-lateral neck) stress fractures. A prospective functional outcome and motion analysis evaluation of the hip abductors after femur fracture and antegrade nailing. The pain usually occurs with weightbearing or at the extremes of hip motion and can radiate into the knee. Post femoral neck fracture physiotherapy aims to improve strength and range of motion of the involved extremity. Isotonic exercises are prescribed for the ankle as it helps to strengthen the gastro-soleus muscle and reduces the chances of thrombophlebitis and deep vein thrombosis. Femoral neck stress fractures (FNSFs) account for 3% of all sport-related stress fractures. Usually, patients do 1-2 visits with the therapists a week and must continue these exercises at home daily for a good result. Patient who plan a return to competitive sports activities should be guided through an appropriate return to sports progression, whereas those who plan to return to physically demanding employment should consider some type of work integration program. Shin, AY, and Gillingham, BL: Fatigue fractures of the femoral neck in athletes. You should not drive a car if you are still taking narcotic pain medication. Femoral shaft fractures treated with surgery take about 3 months to heal completely. o Subtrochanteric or distal shaft fracture foot-flat weight bearing. The first phase focuses primarily on rest and pain con- . Occasionally the fragments are impacted in slight abduction and the patient may be able to get up and walk after the injury. Balance, proprioception, and gait training activities are now be progressed. Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. This is one of the initial attempts to recruit the quadriceps muscle and decrease the potential knee extensor lag often seen with femur fracture patients. Other authors4,5,17,18 have also identified hip abduction weakness as a complication after antegrade IM nailing, which may lead to functional limitations. They will be removed at your first postoperative follow up appointment 10-14 days after surgery. Butcher JL, MacKenzie EJ, Cushing B, et al. In addition, more NWB activities such as knee extension with ankle weights from 90 degrees of flexion to 30 degrees of flexion and hip abduction strengthening (Fig. Therefore, the development and implementation of a criterion-based rehabilitation practice guideline is necessary to help standardize care and improve patient outcomes. In addition, active knee extension in a seated position, in an open kinetic chain, can be initiated without weight.

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