FRACTURES OF THE HIP - Amazon S3 & Murthy, 2000 Normal Functional Flexion 125-128 90-110 Extension...

Hip Fracture: What We Do Well and What We Can Do Better – An Interdisciplinary Clinical Perspective

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©Copyright 2015 Great Seminars Online. All rights reserved. 1

FRACTURES OF THE HIP

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General Information

•  >350,000 hip fractures per yr in USA

•  Incidence of hip fracture increasing among young patients secondary to high energy trauma

•  Risk of hip fracture for women 5�8� or taller twice that for under 5�2�

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Analysis of Past Secular Trends of Hip Fractures & Predicted Number in the Future 2010-2050

•  Based upon Ntl Hospital Discharge Survey data, future estimates for hip fractures in the US by the year 2050 range from 458,000 to 1,037,000 with largest number occurring in females older than 65 years of age

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Brown. J Orthop Trauma Feb 2012

•  1/3 of seniors over age 75 that fall die from complications within 18 mos, 25% die w/in 12 months

•  20-40% of adults over 65 will fall

•  White men have the highest fall- related death rates

•  Women sustain ~ 80% of all hip fxs

•  Among both sexes, hip fracture rates ! with age

•  Ages 85 & older are 10-15 X more likely to fx than 60-65 yrs

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Hip Fracture Descriptions

•  Subcapital Fracture – just below head of the femur

•  Femoral Neck – anywhere along the neck of the femur

•  Intertrochanteric – femoral fracture between greater and lesser trochanter

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•  Subtrochanteric – fracture of the proximal femur, at or below the level of the lesser trochanter

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Complications of Hip Fx •  Wound healing post-operatively •  Infection •  DVT •  Pressure Sore-skin ulcers develop in 20% of

hip fx pts •  Buttocks, sacrum, heel most common

•  Mortality

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Morbidity & Mortality Following Hip Fractures in the Over 90s… Byrne et al. J Bone Joint Surg Br 2012

•  81 patients aged from 90 – 98 years; •  19% complication rate in hospital with 8 inpatient

deaths •  Mean survival was 475 days •  Within 40 days of surgery, 25% of patients died •  50% of patients were alive 126 days post-operative

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Predictors of 5 Year Survival Following Hip Fracture

•  2640 pts placed in high or low risk group •  High-risk group had only 17% survival rate at 5 yrs •  Overall survival rate of 25% •  Increased survival factors were age < 80 yrs,

independent with mobility pre-injury, living at home prior to their fracture

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Stewart et al. Injury 2011

Evidence-Based Exercise Prescription for Balance and Falls Prevention: A Current Review of the Literature

•  Meta-analysis by Sherrington of 44 studies determined the minimum dose of exercise to effectively " the risk & rate of falls to be 50 hours

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Shubert. J Geriatric PT July-Sept 2011

•  Mode of exercise most effective in preventing falls •  Moderate to high challenge balance training

•  Effective interventions •  Directional reaching in a static position, tandem

stand, single-leg stand, dynamic activities including reaching, turning, stair-stepping, dance steps, circling, figure eights, obstacle courses, dual-task training

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•  Multifactoral intervention •  Interventions should focus primarily on balance &

balance challenging activities

•  Exercises should be performed while standing if possible/safe

•  No minimal dose yet determined

•  Program should include consistency, structure, individualization to client

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Exercise Prescription for Frail Adults


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FEMORAL NECK FRACTURES

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GARDEN CLASSIFICATION SYSTEM Garden I – impacted fracture (may or may not have a complete fracture line)

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GARDEN II FRACTURE Complete fracture without displacement or angulation

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GARDEN III FRACTURE Complete fracture with partial displacement May see shortening and ER of the distal fracture fragment

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GARDEN IV Complete fracture with total displacement of the fracture fragments Continuity between proximal and distal fragments are disrupted

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Garden I & II Fractures •  Minor discomfort with A /PROM of the injured hip

•  Groin pain

•  Muscle spasm with extreme hip range of motion

•  TTP over greater trochanter

•  Type I fracture treated with CRPP fixation

•  Type II treated with PP or sliding hip compression screw

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Garden III & IV Fractures •  Pain over the entire hip region •  Positioned in hip ER/ABD with slight shortening

of the limb

•  Non-operative treatment is rare •  Initially managed with Buck’s tx

•  ORIF – PP, Sliding Hip Screw, TFN (Trochanteric Femoral Nail), Bipolar Hemiarthroplasty, THA

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Evidence Summary: Systematic Review of Surgical Treatments for Geriatric Hip Fractures

•  81 articles of 76 RCT •  Age, sex, pre-fx function & cognitive impairment are

related to mortality & functional outcomes •  Fracture type did not relate to functional outcome •  Mortality, pain, function & QOL did not differ by

surgical implant

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Butler et al. JBJS June 2011

Treatment of Displaced Neck Fractures of the Femur with THA

•  86 fxs with retrospective review over 12 years •  7 dislocations – 1 required reoperation •  4.6% incidence of a 2nd procedure, as well as low

mortality rate make THA a viable treatment

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Rudelli et al. J Arthroplasty Feb 2012 BIPOLAR HEMIARTHROPLASTY

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Rehab Considerations with Hemiarthroplasty

•  Cemented Device – WBAT

•  Uncemented – WBAT per literature

•  Dislocation Precautions •  Avoid combined movements of the operative hip for

6-12 weeks (surgeon specific)

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Hemiarthroplasty vs Primary THA for Displaced Fractures of the Femoral Neck in the Elderly

•  Meta-analysis of literature •  Mortality & post-op infection had no statistical

differences •  Reoperation rate higher in HA •  Lower dislocation rate in HA •  Pain rate higher in hemiarthroplasty

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Zi-Sheng et al. J Arthroplasty 2012 Apr

REHABILITATION FOLLOWING ORIF HIP FRACTURES

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Systematic Review of Hip Fracture Rehabilitation Practices in the Elderly

•  Meta-analysis/literature review from Medline, PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials

•  55 studies

•  Most frequently reported + outcomes were associated with ambulatory ability

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Chudyk et al. APMR February 2009

Acute Setting •  + outcomes associated

with use of clinical pathways

•  intensive OT (daily) & PT (BID) initiated on POD 1

•  multidisciplinary team including geriatrician

Post-Discharge •  + outcomes in RH / SNF/

HH - frequency of OT (>5 sessions/week

•  PT of 1.5 hrs/day & OT of 1 hr/day, both 5 days/wk

•  PT & OT 45-60 min each weekday for 4 wks

•  varied duration

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Rehab/SNF/HH setting interventions

•  treadmill gait training •  PT plus quadriceps

training

•  e-stim to the quads

•  weight bearing exercises

•  balance training

•  falls prevention

Outpatient setting interventions

•  combined aerobic & progressive resistance training

•  quad & hip abductor strengthening

•  functional training, balance training

•  home exercise program

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Weight Bearing Orders after Hip Fracture Surgery: A Quality Assurance Project

•  Excellent systematic literature review of multiple studies regarding weight bearing after operative fixation of proximal hip fractures

•  Most all articles cited support WBAT for stable fixated fractures

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Mammel. J Orthop Nurs Nov 2008

AO Principles of Fracture Management Ruedi. AO Publishing 2007 (2nd edition)

• Stable Femoral Neck fx/DHS – WBAT

• Unstable Femoral Neck–PWB x 3 mos

•  IT fx/ DHS or femoral nail – WBAT

• ST fx / femoral nail or DHS – PWB for initial 10 weeks with FWB when comfortable

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Mehta. J Rehabil Med April 2011

•  Meta-analysis of RCT – 5 studies

•  Home & OPPT similar outcomes with trend of better results with increasing intensity of PT treatments •  but not significant

•  No strong consensus for recommending one rehab setting over the other

Systematic Review of Home Physio- therapy after Hip Fracture Surgery

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Predictors for ambulatory ability and the change in ADL after hip fracture in patients with different levels of mobility before injury: a 1-year prospective cohort study.

•  Ambulatory ability recovered to the prefracture level in ~ half of pts 6 mos after surgery •  little change in the next 6 mos

•  In community ambulators, pre-injury independence in bathing ability pre-fx was a strong indicator of ambulatory ability after surgery

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Fukui et al. J Orthop Trauma 2012 Mar

Characteristics & Outcomes in Patients Sustaining a Second Contralateral Fracture of the Hip

•  In this series, pts presenting with 2nd fx were more likely to be female, older, institutionalized

•  lower mobility & mental test scores

•  higher 1 year mortality level in 2nd fx grp

•  In 2/3 of pts, the 2nd fx was in same anatomical location;

•  ~ 70% occurred within 3 yrs

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Sawalha & Parker. JBJS January 2012

Hip Range of Motion Hoppenfeld & Murthy, 2000

Motion Normal Functional

Flexion 125-128° 90-110°

Extension 0-20° 0-5°

Abduction 45-48° 0-20°

Adduction 40-45° 0-20°

Internal Rotation 40-45° 0-20°

External Rotation 45° 0-15°

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INTERTROCHANTERIC HIP FRACTURES

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Intertrochanteric Hip Fractures

•  Occur along a line between greater & lesser trochanter

•  Totally extracapsular

•  Hip internal rotators remain attached to the distal fx fragment

•  some of the short hip ER still

•  attached to the proximal head and neck fragment

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Intertrochanteric Hip Fractures •  ~ ½ of all proximal femur fractures •  Extracapsular fxs 4 X as common as femoral neck

fractures •  Occur primarily in the elderly

•  10 – 12 yrs older than persons with intracapsular femoral neck fx

•  Females > males •  Mechanism of injury – falls

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Intertrochanteric Hip Fracture

Expected Bone Healing Time: 12 to 15 Weeks

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Clinical Signs / Treatments:

•  LE markedly shortened with as much as 90 degrees hip ER deformity

•  Swelling of the hip girdle with ecchymosis over greater trochanter

•  Pain with any hip motion

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Clinical Signs / Treatments:

•  Immediate post–injury treatment with Buck’s Traction to fx limb

•  Non–operative treatment is uncommon •  Operative treatment

•  ORIF with sliding hip screw (DHS), TFN (trochanteric femoral nail), IMN, THA

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Provider Factors Associated with IMN Use for IT Hip Fractures

•  Factors associated with greater IMN use than DHS in elderly pts

•  orthopaedic faculty at teaching hospitals

•  younger surgeons (< 45 yrs old), hospitals with a high volume of IT fxs

•  IMN higher cost than DHS

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Forte et al. J Bone Joint Surg Am. 2010 May

Rehabilitation s/p ORIF Intertrochanteric Fx •  OT & PT interventions/treatments are the

same as for ORIF Femoral Neck Fractures •  Balance training •  If questionable fx stability, WB may be limited

or delayed for 8-12 weeks

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SUBTROCHANTERIC FEMUR FRACTURES

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• Mechanism of injury - direct trauma • Younger pt’s from high energy trauma

• Older pt’s from falls

• Slower rate of union and higher rate of malunion • secondary to presence of comminuted cortical bone

•  large biomechanical stresses in the subtroch area may result in fixation failure before bony union occurs

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Clinical Signs / Treatment: •  Primarily are closed fractures with positional

femur deformity

•  TTP over fracture site

•  Bruising may be present

•  Open fxs uncommon but do occur with severe soft tissue & bone injury / associated with mult tx

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Treatment Options for ST Fractures:

•  Non-operative treatment – Uncommon •  Operative treatment ORIF: IMN, TFN, Blade

Plate •  Sliding Hip Compression Screw supplemented

with •  bone graft if necessary •  cast brace if fracture stability questionable

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Less invasive stabilization system (LISS) versus proximal femoral nail anti-rotation (PFNA) in treating proximal femoral fractures: a prospective randomized study.

•  59 patients with mean f/u of 26.8 mos avg OR time longer in LISS group by 33 minutes

•  No differences in outcomes or complications

•  Early WB not recommended with LISS in pts with osteoporotic bone or unstable fxs

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Zhou et al. J Orthop Trauma March 2012

Is There a Standard Rehabilitation Protocol after Femoral IMN?

•  Evaluation-based rehab protocol to target known impairments frequently seen after femoral fracture • hip abduction weakness, quad function, anterior knee pain, gait abnormality

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Paterno & Archdeacon. J Orthop Trauma 2009 June

Phase 1 •  Begin POD 1 with f/u OPPT 2-3 days per week

•  WBAT with assistive device

•  A/PROM LE with focus on full knee extension

•  Modalities as indicated for ms reeducation (e-stim to quads), edema control, pain management

•  Stretching: focus on HS, gastroc/soleus

•  Strengthening: QS, distal LE, SLR in 4 planes, hip ABDuctors

•  Balance/Proprioception/Gait: WBAT with assistive device

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Phase 2 •  Initiated when full knee extension, minimal knee

effusion, fair quadriceps & hip abductor contractions, 50% WB tolerated

•  Progress strengthening exercises to knee extension (90-30 degrees with weight), heel/toe raises, mini squats, resisted standing hip exercises (ankle weights or theraband), standing knee flexion PRE

•  Gait activities – side-stepping, retro walking •  Add stationary bike & pool therapy

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Phase 3 •  Initiated when FWB with or without assistive device,

minimal knee effusion, good quadriceps contraction, fair to good hip abductor contraction

•  Strengthening: ! weight with PREs, FWB activities (step-ups, single-leg mini squats), closed-chain single-limb strengthening

•  Balance: single-leg stance activities, dynamic surfaces •  Treadmill walking, jogging, activity-specific conditioning

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Musculoskeletal function and quality of life in elderly patients after a subtrochanteric femoral fracture treated with a cephalomedullary nail.

•  53 pts •  mean age 83 yrs treated with a Gamma nail •  very low reoperation rate •  overall function & QOL scores " than pre-injury scores at 4 mos &

only slight improvement at 12 mos •  still below pre-injury data

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Miedel. J Ortho Trauma 2011 April

FRACTURES OF THE HIP - Amazon S3 & Murthy, 2000 Normal Functional Flexion 125-128 90-110 Extension...

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