Musculo-Skeletal Physiotherapy II

1. CASE DISCUSSION

2.  45 year old lady slips and falls on the ground.
She is unable to get up and walk. The X Ray
reveals a fracture of the femur at the lesser
trochanter.

4. FRACTURE OF THE FEMUR
 Two types
 Extracapsular
 Intracapsular
 Extra capsular
 Trochanteric
 Subtrochanteric

5.  Trochanteric (Evan’s classification)
 Stable # configuration – Type A & B
 Unstable # configuration – Type C & D
 Type C – lateral cortex is intact
 Type D – lateral cortex is violated
 Type E – Reverse obliquity
Fractures parallel to neck axis &traverse lat. cortex

7.  Subtrochanteric
 Three types- Simple, Wedge , Complex
All unstable due to relatively small contact area

8.  Intra capsular
 Classification (Low energy)
 Fracture site- subcapitus, transcervical, basicervical
 Inclination of the # -
 Pauwel’s classification
 Type I – 30 degree
 Type II – 50
 Type III – 70

9.  Relation of # fragment
 Garden classification
 Type I – incomplete & impacted
 Type II – Complete & undisplaced
 Type III – Complete & partially displaced
(intact post.retinacular ligament)
 Type IV – completely displaced
(disruption of reti.vessels)

10.  Classification (High Enegy)
 Type I - undisplaced neck #
 Type II – simple displaced neck #
 Type III – Comminuted displaced neck #
 Type IV – FON + # of acetabulum or shaft of the femur
 Type V – Neck # that occur or recognized during
antegrade nailing of shaft

11. FIRST AID
 Safe place
 Reassure the person
 Have the victim lie flat and rest.
 Ask for help
 CPR
 If there is a wound remove the clothes
 If there is bleeding apply direct pressure to the
wound to stop the bleeding.
 Cover the wounded area with a clean cloth or
dressing.
 Continue to apply pressure as long as the
wound bleeds. Add new dressings over existing
ones.

12.  Immobilize the injured area. A splint is a
good way to immobilize the affected area,
reduce pain and prevent shock.
 Effective splints can be made. The general
rule is to splint a joint above and below the
fracture.
 Or, lightly tape or tie an injured leg to the
uninjured one, putting padding between
the legs, if possible.

17.  Check the pulse in the limb with the splint. If you
cannot find it, the splint is too tight and must be
loosened at once. Check for swelling,
numbness, tingling or a blue tinge to the skin.
Any of these signs indicate the splint is too tight
and must be loosened right away to prevent
permanent injury
 Keep her fasting
 Inform relatives
 Move to hospital

18. PRIMARY SURVEY AND
RESUSCITATION

19. CARE OF INJURY – 4 STAGES
 Prevention
 Pre-hospital care
 Hospital care
 Rehabilitation
“Manage the patient, Not the fracture”

20. INITIAL ASSESSMENT AND RESUSCITATION
 A = Airway
 B = Breathing
 C = Circulation
 D = Disability of CNS
 E = Exposure of the patient
 F = Foley catheter

21. AIRWAY AND BREATHING
 At risk in all unconscious patients.

22. CIRCULATION
 Blood loss is greater than the NOF
fracture and trochanteric fracture. Large
volume of blood can accumulate in the
thigh.
 Skin: cold , pale ,sweating
 Pulse: rate, volume, rhythm
 Blood Pressure
 JVP
Adequate fluid resuscitation.

23. DISABILITY OF CNS- AVPU
 Head injury
 Examination: Level of consciousness
External wounds
Pupils- dilated, unequal
 CT scan of the brain

24.  Damage to cervical spine
 Suspected in all unconscious and
head injured patients.
 In line bimanual immobilization
 Semi rigid collar
 X-ray cervical spine

25. Exposure :
Foley catheter :
Analgesics:
Antibiotics

26. DIFFERENTIAL DIAGNOSIS-
•Generalized bone diseases
1.Paget’sdiseaseofbone
2.Primaryhyperparathyroidism
3.Osteomalacia
4.Osteoporosis

27. DIFFERENTIAL DIAGNOSIS-
 Localized bone diseases
1. Metastases from carcinoma breast, lung, kidney,
and thyroid.
2. Multiple myeloma
3. Primary bone tumors
Malignant-
Osteosarcoma
Chondrosarcoma
Benign
Osteoclastoma
Bone cyst

28. HISTORY
 1.Name- (for identification purposes)
 2.Age-important to identify the disease
since most of the diseases have an age
distribution
eg:- osteoporosis -over 50 yrs
osteosarcoma-10-25 yrs
osteoma 40-50yrs
Parosteal osteosarcoma-30- 60yrs
-imporatant to take decisions on surgical
fitness

29. 3.Sex- Osteoporosis is more common in females
4.Occupation-exposure to radioactive radium and
thorium dioxide increases the risk of
development of osteosarcoma
5.P/C-
What has happen-(circumstance)
?accident/?deliberate harm
At what time?
After math-LOC/Numbness/Bleeding/
Inability to walk
Time of the last meal?
Intoxication?(alcohol/drugs)

30. Early fractures or any prolong immobilisation?
Suffering from any illness?
Wt loss (CA/TB)
Change in Ht?
Hx of renal stones?
6.PMHx-DM,HT,Asthma
Cushing’s,Hyperthyroidism,Acromegaly
CVA,fainting attack,epilepsy,hypoglysemia
7.PDHx- Corticosteroids
8.PSHx-Any previous trauma,any Sx and
complications

31. 9.Menstual Hx-
10.Allergies-
11.Immunisation-eg tetanus
12.Family Hx-eg-osteogenesis imperfecta
osteopetrosis
13.Personal Hx-smoking,alcohol,lifestyle
family life (?assault)
14.Dietary Hx-?protein and Vit deficiency?
Inadequate Ca intake

32. EXAMINATION
1. General Examination
2.Examination of the Hip Joint
3. Special Examination of systems
4. Radiographical Examination

33. GENERAL EXAMINATION
•Patient is in pain
•Unable to stand
•Limb is shortened and lies in external
rotation
•Skin wounds or obvious deformity

34. MENTAL AND EMOTIONAL STATE
PHYSICAL ATTITUDE
GAIT
PHYSIQUE
FACE
SKIN
HANDS
FEET
NECK – LYMPH NODES, THYROID GLAND
BREAST
AXILLAE
T
PULSE
RESPIRATION
ODOURS

35. Ecchymosis of the proximal thigh- occasional

36. EXAMINATION OF THE HIP JOINT
Inspection
Skin changes- Redness, swelling
Shape
Position
Scars
Wasting of gluteal and thigh muscles
Palpation
Temperature, tenderness over the joint
Skin, soft tissue, muscles, bone
Movements
Voluntary, involuntary , crepitus
Flexion- measured with knee bent. Opposite thigh must remain in neutral position. Flex
the knee as the hip flexes.
Abduction- measured from a line that forms an angle of 90 degrees with a line joining
the ASISs .
Adduction
Rotation in flexion
Rotation in extension
Extension- attempt to extend the hip with the patient lying in the lateral or prone position

37. HAEMATOMA OR BRUIT OVER THE AREA SUGGEST
ARTERIAL DAMAGE .
Look for,
•Shortening in External rotation of the
involved extremity
•Palpation below the ingunum elicits pain
•Inability to move

38. ADDITIONAL EXAMINATIONS OF HIP
JOINT :
MEASUREMENT OF TRUE AND
APPARENT SHORTENING

39. SPECIAL EXAMINATION
1. Circulatory system
2. Neurological Examination
3. Musculoskeletal System

40. 1. CIRCULATORY SYSTEM
WHY? 1) CARDIOVASCULAR SYNCOPY OR
INITIAL STROKE COULD HAVE CAUSED THE
FALL
2) DETECT OTHER CARDIOVASCULAR
PROBLEMS
Inspection
Palpation
Percussion
Auscultation

41. PALLOR, CYANOSIS, EDEMA
PULSE, BP, JVP

42. PERIPHERAL PULSES- ABSENT MEANS
MAJOR VESSEL INJURY

43. 3. MUSCULOSKELETAL SYSTEM
•Examination of Associated Injuries
Wrist #
Head injury
Most frequently associated injuries are due to
patient’s osteoporosis in other areas of the
body.
They are sustained at the same time as the
trochanteric fracture

44. RADIOGRAPHIC EXAMINATION
• AP Radiograph of the distal Pelvis
•AP and Lateral Radiographs of the hip joint
•Femur
•Knee joint
^

45. INVESTIGATIONS
 To Diagnose Fracture
 To Find Aetiology
 Preoperative Assessment
 Postoperative evaluation

46. DIAGNOSE FRACTURE
 X-Ray Hip
Rule of 2s
2views
2joints
2limbs
2times
Rule of As
Anatomy
Articularv
Alignment
Angulation
Apex
Apposition
 CT Scan-Not indicated in routine evaluation

47. FIND AETIOLOGY
 X-ray- Osteoporosis
Paget’s Disease
Chondrosarcoma
Lytic lesion Involves the inferior aspect
of the neck and the medial
intertrochanteric area.

48.  Ewing sarcoma.
Entire proximal part of the femur is
filled with mottled sclerotic
densities indicative of a diffuse
pathological process.

49.  CXR , X-ray pelvis, Bone scan -
Metastasis
 Serum Ca –Hyperparathyroidism
Osteomalacia
T3,T4- Hyperthyroidism
 Bone marrow biopsy- Multiple myeloma

50. PREOPERATIVE ASSESSMENT
 CXR
 FBC
 Hb
 ECG
 FBS

51. POSTOPERATIVE EVALUATION
 X-ray Hip
To evaluate the reduction

52. TREATMENT

53. DEFINITIVE MANAGEMENT OF THE FRACTURE
 Management of fracture can be considered as,
 Operative treatment
 Non operative treatment
 Indications for Non operative Treatment
 An elderly person whose medical condition carries
an excessively high risk of mortality from
anaesthesia and surgery
 Non ambulatory patient who has minimal
discomfort following fracture

54. NON OPERATIVE MANAGEMENT
 Skeletal traction is the most common method used to control and reduce
pain
 In subtrochanteric fracture most common method to reduce the fracture
is by skeletal traction with a transcondylar Steinmann pin
 90 degree flexion is used to relax the iliopsoas: correct the flexion and
external rotational deformities
 period of traction ranges from 12 to 16 weeks
 should be monitored with regular radiological imaging
 Early removal of skeletal traction may be followed by bracing with a hip
spica cast when early callus is seen in x-ray films.
 Maintenance exercise must be administered regularly to maintain the
mobility of joints and muscle strength

55. POSITION OF PATIENT IN TREATING SUBTROCHANTERIC FRACTURES WITH SKELETAL TRACTION

56. COMPLICATIONS
 In elderly patients, this approach was associated with high complication
rates
 typical problems included decubiti, urinary tract infection, joint
contractures,
pneumonia, and thromboembolic complications, resulting in a high
mortality rate.
 In addition, fracture healing was generally accompanied by varus
deformity and shortening because of the inability of traction to effectively
counteract the deforming muscular forces

57. SURGICAL TREATMENT
 Surgical stabilization is the standard of care
 Internal fixation of fractured end is widely performed.
 Intramedullary nail fixation is the preferred treatment
 Two methods
 Open Method
 Closed Method

58. OPEN METHOD
 possible in fractures with minimal comminution but it demands an
extensive dissection
 weight-bearing may not be possible until the fracture heals
 disadvantage of the open technique is extensive soft tissue
dissection
 temporarily fixed with reduction forceps or Kirschner wire (K-wire)
fixation; then fixed with lag screws
 plate is fixed proximally to the femoral head and neck for maximal
stability

60. CLOSED METHOD
 closed reduction and internal fixation
 Closed reduction is usually performed with the use of a fracture
traction table with a transcondylar Steinmann pin
 fixation can be carried out with percutaneous implant insertion
 most common implant used is the intramedullary locked nail
 does not disturb the fracture hematoma
 minimum soft tissue dissection
 need to use fluoroscopy and the difficulty in performing distal
locking are potential disadvantages

61. SLIDING HIP SCREW
 This device is indicated only for very proximal fractures.
 The sliding of the screw allows medialization of the distal
fragment, which reduces bending moment on fracture and implant

62. OTHER TREATMENT
 Hence this was pathological fracture we have to find the cause and treat
for that.
 metastatic tumours are the most common types of tumour deposits in
this region
 So other metastatic sites should also be investigated before definitive
fixation of the fracture is performed.
 In the case of primary, investigate for secondaries and follow
chemotherapy / Radiation therapy

63. 1.)Surgical
2.)Non surgical
Cast bracing
Hip sica cast + traction

64. Pre operative measures
a) Assessment of the patient
 Cormobid factors
 Surgical fitness
 Risk for anesthesia
b) Pre operative templating - for proximal
comminution the use of a fixed angle
device with the proper blade and
compression screw length

65. When an intramedullary device is chosen,
templating for length, canal diameter is
necessary for proper planning.
c)Measurements
Normal side femur length

66. Surgery
main techniques:
 external fixation
 open reduction and internal fixation
a) Extra medullary implants
b) Intra medullary implants

67. Extra medullary devices
1.)Sliding compression screw plate
2.)Dynamic hip screw(DHS) e.g:-DCS
Indications:-
Fractures with stable configurations
Unstable fractures with an intact lateral cortex

68. Intra medulary devices
1)Intra medullary hip screw(IMHS)
Cephalomedullary nails
Reconstruction nails(centromedullary)
Indications:-
Shorter nail-If fracture line doesn’t extend more
than 1 to 2cm distal to lesser trochanter
Longer nail-unstable fractures

69. IMHS

70. External fixation-
Rarely used but is indicated in severe
open fractures.
For most patients, external fixation is temporary,
and conversion to internal fixation can be made if
and when the soft tissues have healed
sufficiently.

71. Post operative period.
1.)Following intramedullary nailing if the bone quality
and cortical contact is adequate, 50% partial weight
bearing can be allowed immediately.
With less stability, patients can perform touchdown
weight bearing.
Following OR and plate fixation, minimal protected
weight bearing can begin immediately but is advanced
slowly beginning approximately 4 weeks after surgery,
with full weight bearing anticipated at 8-12 weeks.
Elderly patients may have difficulty with compliance with
weight bearing restrictions.

72. 2.) Check for proper union
3.) Prevent infections
4.) Wound care
5.) Nutrition- high protein diet

73. COMPLICATIONS
Acute complications
1. Damage to nerves and blood vessels
2. Haemorrhage
3. Other soft tissue damage
Long term complications
1. Failure of fixation
-screws may cut out of the bone if reduction is poor or
if the fixation device is incorrectly positioned. Reduction
and fixation may have to be re-done.

74. 2. Malunion
-only complication that is frequent
-may occur through bending or breakage of a nail plate or
simply through compression of the soft cancellous bone
with metal.
-causes union with a slightly reduced neck-shaft angle-
coxa vara

75. -If neglected,
I. May unite with marked lateral rotation of the shaft.
II. May develop severe coxa vera associated with shortenig.
 Treatment
1. In most cases, can be accepted without treatment.
2. In severe deformities,
-the bone is divided in the trochanteric region and the
fragments are secured in the correct position by a compressive
screw plate or other appropriate device(as in a fresh fracture.

76. complications due to treatments
1. casts
-pressure ulcers
-thermal burns
-thrombophlebitis
2. Internal fixation
-infections
-neurological and vascular injury
-thromboembolic events
-avascular necrosis
-posttraumatic arthritis

77.  Complications of immobilization
1. Bed sores
2. Hypostatic pneumonia
3. Osteoporosis
4. Hypercalcaemia
5. Hypercaliuria
6. Urolithiasis
7. UTIs
8. Muscle wasting
9. Joint stiffness
10. DVT
11. Pulmonary embolism
12. Psychological depression

78. FOLLOW UP AND
REHABILITATION
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79. FOLLOW-UP
 Close follow-up is required following
fixation
 50% PWB can be allowed immediately
 Wound is checked for proper healing 7-14
days post operatively
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80.  Patient should have monthly clinical
evaluations and radiographs to monitor
healing.
 Quadriceps rehab to be started within 02
weeks post operatively
 Most patients will have significant
disability for 4-6 months
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81.  Impact activities may be possible after 06
months (Should wait 01 year before
returning to full contact sports)
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82. REHABILITATION
Rehabilitation involves:
* Ankle pumps (to prevent DVT)
* Chest Physiotherapy (Airway clearance)
* Exercises :
Quadriceps, Hamstrings and Glutei
(Isometrics)
Heel Slides (in supine lying)
Strengthening Ex to Upper Limbs (Before
prescription of walking aids)
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83. Static Quadriceps Ex.

84. Static Hamstring Ex.

85. DKA 08-09-10
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Heel Slides

86. Mobility and weight bearing
* Increase bed mobility (Supine to Sitting)
* Increase ambulation with appropriate weight
bearing (TDWB with walker -> PWB with walker)
* Perform SLR (up to 6” from the bed level in
supine lying)
* Mini Squats
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87. Straight Leg Raise (SLR)

88. DKA 08-09-10
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Mini Squat/Half Squat

89.  Within 1-2 Weeks
* Reinforce good posture
* Add standing hip abduction, adduction,
extension and flexion with hip and knee flexion
exercises
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90. DISCHARGE CRITERIA
 Gets out of bed independently.
 Able to ambulate 50 feet independently in a
hall with assistive device.
 In and out of bathroom independently.
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91. AFTER DISCHARGE
 Advice to the patient on:
 Changes to the home environment
 Lifestyle changes
 Prevention
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92. THANK YOU
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