Vol. 14 Issue 5
PTs Should Be Hip to Orthopedic Rehab
Frequently, therapists can feel somewhat clueless in conversations with orthopedic surgeons about their stance on what is good and bad for hip fractures. So let's review the literature on this topic and become hip to the orthopedic view of hips.
There are more than 250,000 hip fractures per year in the United States. This number is projected to double by 2050. The average age to fracture a hip is 79.3, at a cost of $13,470 for total care. This article will discuss the controversial topics of weight bearing status, fixations devices, exercises and protocols.
Weight Bearing Status
According to the general guidelines set at Vanderbilt University Medical Center, femoral neck and intertrochanteric (IT) fractures are weight bearing as tolerated (WBAT). Weight bearing status for subtrochanteric fractures varies anywhere from toe-touch weight bearing (TTWB) to weight bearing as tolerated (WBAT), depending on the fracture pattern, fixation choice and surgeon preference. If the surgeon questions the fixation with any hip fracture, he may choose weight bearing restrictions. Choices for weight bearing must be made on an individual basis with reference to the above criteria. Unrestricted weight bearing is preferred if possible and safe, because it enhances functional recovery. This is particularly important for older patients.
Fracture fixation depends entirely upon the fracture location and fracture pattern. Femoral neck fractures are fixed based on the Garden Classification (see table 1).
Garden I fractures are treated with percutaneous pinning (PP). Garden II fractures are fixed with PP or sliding hip compression screw.
Garden III and IV are initially managed with Buck's traction followed by open reduction internal fixation (ORIF), by PP, hip screw, endoprosthesis, hemiarthroplasty and possibly total hip arthroplasty (THA).
Intertrochanteric fractures are also placed in Buck's traction and then followed by ORIF with dynamic sliding screws (DHS) or gamma nail. Subtrochanteric fractures are more commonly treated nonoperatively and may be managed with casting or a fracture brace.
If they are managed operatively, the fixation devices used are intramedullary nail (IMN), gamma nail, blade plates and sliding hip compression screw, supplemented with bone graft if necessary. These patients may also wear fracture braces if there is questionable fracture stability following an ORIF.
Protocols for Hip Fracture Management
Many facilities do not have a specific protocol for patients sustaining a hip fracture because there are so many types and degrees of hip fractures. Table 2 shows a very general sample hip fracture protocol.
Best and Worst Exercises
The favorite and most beneficial exercise are ones that work on motion in the operative extremity (see pictures 1 and 2). In addition, the rehabilitation sessions must focus on function. It is imperative to work intensely on sit-to-stand activities (see picture 3), transfers, turns during ambulation and on any activity that may have caused the fall.
The worst exercises are working on passive motion or stretches until there is evidence of fracture healing. Twelve weeks is the general time for this in a hip fracture; however, it is best to ask the orthopedic surgeon about the bone healing. In addition, stressing ambulation distance instead of working on safe transfers can be detrimental.
In April 2002, the results of the National Consensus Conference on Improving Care for Hip Fracture Patients were published. They found that 50 percent of patients with hip fracture do not regain their prefracture level of mobility and that the annual cost for treating hip fractures in this country is between $10 billion and $15 billion.
They recommended better reimbursement, continuum of care, more education, prevention, research and communication.
So we have an important and costly course charted for us, but with better understanding between doctor and therapist, we have a bright future ahead.
Dr. Lewis is a physical therapist in private practice and president of Physical Therapy Services of Washington, DC. She lectures exclusively for GREAT Seminars and Books, Inc. Dr. Lewis is also the author of numerous textbooks. Her Website address is www.greatseminarsandbooks.com. Sandy Shelton is senior therapist for Vanderbilt's Medical Center Orthopedic Unit, Nashville, TN.
Table 1: Garden Classifications
Garden I–Impacted Fracture;
Garden II–Complete Fracture without displacement;
Garden III–Complete Fracture with partial displacement; frequently is shortening and ER of the distal fragment;
Garden IV–Complete Fracture with total displacement of the fracture fragmentscontinuity between proximal and distal fragments is disrupted.
Table 2: Rehabilitation Following ORIF Hip Fractures
Acute Phase: DOS-Week 1
• Active assisted range of motion (AAROM) to operative lower extremity (LE); avoid passive range of motion;
• Active LE isometrics;
• Contralateral and bilateral upper extremity (BUE) strengthening exercises;
• Bed mobility, transfer and gait training using assistive device WB status per MD/WBAT;
• Functional training in ADL activities using assistive devices, per OT recommendations;
• Proprioception training.
Subacute Phase: Weeks 4-6
• AAROM; patients should achieve hip flexion to 90 degrees;
• Continue to avoid passive motion to the hip until ^ fracture site stability;
• Isometric and isotonic LE exercises;
• Gait training with assistive device, weight bearing (per surgeon).
Advanced Rehab: 8-12 weeks
• A, AA, PROM operative LE as necessary to obtain full range;
• Stretching exercises to hip and knee as needed to ^ active range;
• Resistive exercises;
• Gait with WBAT to full weight bearing depending on fracture stability; assistive device as needed.
Rehab Findings: 12-16 weeks
• AROM of hip and knee should be within normal range;
• Muscle strength in the hip girdle should be normalizing;
• Fracture, whether treated nonoperative or operative, should all be advanced to WBAT; assistive devices used prn.