https://orthoinfo.org/. Fractures, Stress / diagnostic imaging* Fractures, Stress / rehabilitation Humans Injury Severity Score . 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. 5. c. Weight-bearing: This has to be done on the following lines: d. Activities of daily living: Modifications in activities of daily living are the same as mentioned earlier. You broke your thigh bone which is called the femoral shaft. Progress to walker or. Displaced fractures will need operative fixation. Bone fatigue found on imaging No fracture line. You are in: Home Trauma Femoral Stress Fracture. BJlP+q$C P:qj#e 3'PbLV^:Ke,P#h1c+RSMC=EJK"JvqB}q?oPBA. Duttons Orthopaedic Examination, Evaluation, And Intervention 3rd Edition. The Online bill pay website called Doxo.com is NOT affiliated with Reno Orthopedic Center (ROC). A femoral neck stress fracture is a stress fracture of the proximal femur at the hip that most commonly occurs in runners or other athletes who perform repetitive impact to the lower extremities. One or more of the authors have received funds in excess of $10,000 for consulting fees not related to the subject of this article. 1 0 obj You may shower immediately after surgery. Conversely, Finsen et al20 studied a group of 14 isolated femoral shaft fracture patients who were treated with IM nailing. 2) and toe raises can be initiated at this time to encourage a progressive increase in functional WB with both exercise and gait. And it becomes stronger or sharper with more strenuous movement . The usual method is to excise the head and perform replacement arthroplasty using one of the metal prosthesis e.g. Symptom relief. Sam Echols from Advance Rehab in Rome, GA gives rehabilitation tips for runners experiencing stress fractures. 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. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. 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. Progression through the program is dependent on successful attainment of baseline goals. This treatment regimen is most appropriate for compression (as opposed to tension) fractures. 10. REHABILITATION PROTOCOL FOLLOWING FEMORAL CONDYLE MICROFRACTURE . Paterno MV, Archdeacon MT, Ford KR, et al. Establish independent gait without assistive device and minimize complications. 14. Distal femur fractures most often occur either in older people whose bones . Dartmouth Atlas examines lack of prevention in US health care. 1. Archdeacon M, Ford KR, Wyrick J, et al. Immediate weight-bearing after treatment of a comminuted fracture of the femoral shaft with a statically locked intramedullary nail. Simple weight shifting exercises without assistive devices to encourage increased comfort and confidence with progression of WB are initiated. With respect to muscle contraction and strength, the patient must demonstrate a fair quadriceps contraction and fair hip abduction strength. A WBAT status is continued with the use of an assistive device, as needed for safe ambulation. The program is a dynamic incorporation of interventions designed to target these known impairments. High blood sugar can put you at risk for infection, wound complications and the bone not healing (nonunion). Individualize exercise program according to each patient's needs, but generally include the following. THC and CBD products can be helpful for postoperative pain and decrease the amount of narcotics you need. Adherence to an aggressive physical therapy program following surgery appears to enhance the success of the procedure. Make final assessment of patient's functional level, gait, range of motion, and strength. 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 The long-term requirement of treatment for femoral stress fractures seems cumbersome to many athletes and clinicians alike. In a more recent prospective longitudinal study, Archdeacon et al23 evaluated hip abductor function during gait after femoral fracture and antegrade nailing. 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. For patients with endoprosthesis, weight bearing as tolerated is permitted. Tidy's Physiotherapy15: Tidy's Physiotherapy By Stuart B. Porter, Essentials of Orthopaedics for Physiotherapist By Ebnezar. Intramedullary nail (IMN) fixation is the gold standard for the treatment of fresh femoral shaft fractures. 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 . Most patients need about 3-4 months of therapy to regain their preinjury range of motion and strength. 1999). Postoperative x-ray of femoral shaft fracture repair with plate and screws. 7. Current concepts of fracture healing. . 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. Osteoporosis is often referred to as the silent epidemic as it may not present any clinical signs until fracture. In terms of segmental bone loss or even morbid obesity, we have allowed FWB with a planned bone grafting procedure for segmental loss. If healing does not occur, internal fixation with some form of hip pin is indicated. Data is temporarily unavailable. A hip fracture is a break in the upper quarter of the femur (thigh) bone. Inadequate postoperative rehabilitation is a potential cause of delayed strength. Therefore, the development and implementation of a criterion-based rehabilitation practice guideline is necessary to help standardize care and improve patient outcomes. You may be trying to access this site from a secured browser on the server. 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. Paterno, Mark V PT, MS, SCS, ATC; Archdeacon, Michael T MD, MSE. ;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~ 2015; 1775-1780. The patient was a 19-year-old woman who recently completed a military basic training program. 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. The patient can now be encouraged to sit with the legs hanging over the edge of the bed and supporting and lifting the affected limb with the unaffected leg. Educate patient and family on exercise program. Bilateral femoral stress fractures in a child due to in-line (roller) skating. The first phase focuses primarily on rest and pain con- . 25. b. 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. If unrecognized and if proper treatment is not initiated, this condition carries potentially devastating consequences. Search for Similar Articles o Isometric quadricep and abductor exercise. Interestingly, deficits in stride length and hip abductor function correlated significantly with the patient reported functional outcomes at 2 years after injury. Management of fractures to the socket is a completely different. I. The current literature describing management of diaphyseal femur fractures is replete with evidence regarding surgical management and optimal bone healing. In Nevada, marijuana is legal, and you do not need a doctors prescription to get it. With respect to strengthening, the patient continues to increase the intensity of the exercises initiated in phase 2 through increased resistance with PREs. Progression through the program is dependent on successful attainment of baseline goals. 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. This level of quadriceps contraction often results in an early resolution of an extensor lag at the knee with active hip flexion. A. Pouilles JM, Bernard J, Tremollires F, et al. 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. Hulth A. The ideal surgical treatment of femoral neck fractures remains controversial. A 3-point gait using crutches or walker is advised. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. Evaluate functional ability with regard to transfers and bed mobility. All devices discussed in this article are Food and Drug Administration approved. These initial WB activities can quickly progress to include closed kinetic chain strengthening of the lower extremity. High-risk stress fractures: evaluation and treatment. After 8 weeks:Femoral neck fracture Physiotherapy Management. This is typically attributed to hip abductor and quadriceps weakness. Significant deficits were found in isometric quadriceps torque (18%) of the involved limb versus the uninvolved as measured on a dynamometer. Butcher JL, MacKenzie EJ, Cushing B, et al. Patients with significant soft tissue wounds, whether open fractures, crush injuries, or even significant thigh contusions, may present a patient scenario that requires adaptation of the rehabilitation protocol. 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. Subtle limitation of flexion and internal rotation may also be present with or without a positive log roll test. Cochrane Database of Systematic Reviews 2007, Issue 1. At the conclusion of phase 3 and before discharge from formal rehabilitation, the patient should pass several baseline tests. Mini squatting with handheld assist at table to allow early quad activation. Acta Paediatr. It may even travel down into the knee. Seen most frequently in runners, dancers, and military recruits. An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. Although stress fractures are a relatively uncommon etiology of hip pain. Type 2- cortex is broken but there is no angulation. Closed intramedullary shortening of the femur. A fair quadriceps muscle contraction is defined as the ability to generate a superior patellar glide. Roentgenograms every 23 days during the first week are necessary to detect any widening of the fracture line. This must be prescribed in only a 5 day supply each time. Your femoral shaft was fixed with a titanium rod called an intramedullary nail. Zdravkovic D, Damholt V. Quadriceps function following indirect nailing of femoral shaft fractures. Then patient is advised to bear weight on the knees. 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. Modern implants are generally able to withstand FWB for 6-12 months even in the face of bone loss and/or excessive body weight. The patient may progress to 1 crutch for assistance with balance during gait and may progress to no assistive devices when indicated. This can be initiated in a NWB position with open kinetic chain activities such as simple hip flexion, extension, and abduction exercises. BMJ, 344:e2511, 2012. Neuromuscular stimulation to facilitation quadriceps recruitment. B. Outpatients are followed as necessary. Femoral shaft fractures treated with surgery take about 3 months to heal completely. II. endobj during 4-8 weeks: Femoral neck fracture Physiotherapy Management. Mira AJ, Markley K, Greer RB III. Patient is asked to keep trunk upright during task to facilitate core stability and hip abductor activation. You may search for similar articles that contain these same keywords or you may When knee and hip are placed in a flexion position to stress the quadriceps femoris, the surgical window automatically shifts 2-3 . Incidental stress reaction found on imaging No fracture line. First, neuromuscular reeducation with electrical stimulation is initiated postoperatively for the quadriceps muscle to help regain volitional control of the quadriceps (Fig. 1. If you need prolonged narcotics, we can refer you to a pain management specialist. Foot is elevated to facilitated early full knee extension. Your wound was closed with either sutures or staples. The authors reported that approximately 12% of the patients complained of anterior knee pain at an average of 29 weeks postoperative. Post femoral neck fracture physiotherapy aims to improve strength and range of motion of the involved extremity. Very young children are sometimes treated with a cast. 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. If you are diabetic keep your blood sugar well controlled. These studies agreed with previous studies by Danckwardt-Lilliestrom,14 which reported quadriceps weakness up to 7 years post IM nailing. The onset of pain occurs at the hip or groin area during activities of weight-bearing. It is unusual for femoral shaft fractures to be treated without surgery. Before progression to phase 3, the patient must meet several criteria. 22. Patients will hear similar information in eachpostoperative visit but it is easy to forget what is said. 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. Rehabilitation after IM nailing of a femoral shaft fracture has been partitioned into 3 phases. 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. Stress fractures result from accelerated bone remodeling in response to repeated stress. Sometimes, the pain is felt in the thigh. Hip abduction is also a focus in early strengthening to address this impairment (Fig. In addition, active knee extension in a seated position, in an open kinetic chain, can be initiated without weight. Ostrum et al5 studied 14 patients with an antegrade femoral IM nail after an isolated femur fracture. This process does not remove your bone marrow but just compacts it. IOR!^EB%Rq6[nSZ8!vfwXtboO5e7LBU7r 7|#]zj,+SB ,vxZntW(IW,L8QV=3KT)J1S'ctXgLCtI{ cLh%@}e/jzG2cU.mu;#5&J#tbYYzQ\dL1DA0X)xXeW4k 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. Initiate training in activities of daily living, including bed mobility and transfers to and from bed and toilet. Continue outpatient physical therapy program as indicated. A fracture is a broken bone. 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. 1996) found that the 1 year death rate was as high as 23.8 percent. First-line interventions include protected weight bearing with crutches for 1 to 4 weeks depending on symptom severity and radiologic grade of the injury. Initiation of phase 1 (Table 1) of the femur fracture rehabilitation protocol begins postoperative day 1 in the hospital. Any combination of these impairments can potentially limit the ability of a patient to return to prior levels of function. Full weight-bearing is allowed. Standing hip abduction with band resistance. x\nFo0@U4kPfM(m-IU\fHJ$9msuF9{\]fF&\vv^8;6WUyXxs=J_x"4Ey|2p@_IR%"b7-X,jxXD74p6Y+Sb:?u5S,f>?>>F. In addition, with the progression of WB to 100% without the use of an assistive device, the patient may begin single-leg strengthening activities, such as step-ups, half lunges, and single-leg mini squats. These goals addressed WB status, knee effusion, leg edema, quadriceps control, hip abduction strength, and a normalization of gait. A prospective randomised trial. 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. J Am Acad Orthop Surg. 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 . 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. 33. This is achieved with posterior lower extremity stretching, including seated hamstring stretch and seated gastrocnemius stretching with the assistance of a towel. Leggon and Feldmann6 reported on 19 patients with retrograde femoral nailing after isolated femoral fracture. I. <> Their objective was to compare hip abduction function and strength after insertion of a femoral IM nail. Progression of static balance activities on stable platforms is progressed to more dynamic single-leg activities on stable and unstable platforms, and conditioning is progressed by incorporating treadmill walking. Magnetic resonance imaging showed a stress fracture of the medial femoral condyle. Use of raised toilet seat and chair, wearing the trousers from the affected limb first and removing it from the unaffected limb, rolling on to the unaffected side before getting up from the bed are some of the recommended modifications in daily living. Leggon RE, Feldmann DD. Management and treatment of femoral neck stress fractures in recreational runners: a report of four cases and review of the literature Acta Biomed. dragging the heel upto the buttocks with the help of the normal leg). Tornetta and Tiburzi21 cited a 59% rate of knee pain during rehabilitation but noted improvement with only 13% complaining once quadriceps strength had returned. Femoral neck stress fractures represent a relatively rare spectrum of injuries that most commonly affect military recruits and endurance athletes. Similarly, patients with bilateral injuries are progressed through the protocol as much as possible, recognizing that some patients may be limited by pain. stream Move your hip, knee and ankle as much as possible to avoid getting stiff. c. Continue to evaluate gross strength of involved extremity. Brumback RJ, Toal TR Jr, Murphy-Zane MS, et al. Tornetta P III, Tiburzi D. Antegrade or retrograde reamed femoral nailing. Avoiding weight bearing exercises and performing frequent ROM exercises are a crucial part of the early rehabilitation process. Orthofixar does not endorse any treatments, procedures, products, or physicians referenced herein. IM nail fixation is the standard of care for skeletally mature patients with highly predictable union rates. To close this popup, click the x in the top right corner. 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. a. However, excessive adduction and internal rotation should be avoided in patients treated with endoprosthesis. Phase 3 focuses on a progression of strength, normalization of gait, and an ultimate transition to desired activities. Provide written home exercise program. Next as a preclude to weight bearing, four point kneeling is advised. %PDF-1.5 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. Complete specific tests, including Functional Ambulation Profile and Get Up & Go Test. Progression through the program is dependent on successful attainment of baseline goals. 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. There are several ways to decrease the risk of this complication. Gait patterns after fracture of the femoral shaft in children, managed by external fixation or early hip spica cast. The research for this article was not funded by NIH or a similar funding agency. All rights reserved. Inconsistencies in care exist in the postoperative rehabilitation management, which may result in residual impairments known to lead to disability. Kapp W, Lindsey RW, Noble PC, et al. d. Assess range of motion of involved hip within limits of. Fractures of the thighbone that occur just above the knee joint are called distal femur fractures. a. The patient is progressed to partial and then full weight-bearing on crutches as symptoms permit. Occasionally the fragments are impacted in slight abduction and the patient may be able to get up and walk after the injury. IV. If it gets wet, remove the bandage, and place a new one. Balance and proprioception activities are advanced to single-leg activities as FWB without assistive devices is achieved. Specific time . All these interventions are supplemented with a home exercise program, focused on hip and quadriceps strengthening. Assisted and self-resistive exercises for the hip and knee muscles can be carried out. Physical Therapy Not all patients with femur fractures require physical therapy. Education programmes and treatment protocols can reduce the rates of displaced FNSFs. Pain with palpation may be present at the anterior thigh with hopping on the affected leg reproducing the pain. Evaluation. By continuing to use this website you are giving consent to cookies being used. Usually, this appointment is made when you schedule surgery. d. Activities of daily living: Certain modifications are brought about in the activities of daily living. The treatment regimen is more or less the same as discussed above. In addition due to exposure during surgery, quadriceps and . 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. Most femoral shaft fractures require surgery to heal. The commonest causative sports are marathon and long-distance running. Pain elicited is indicative of a Femoral Shaft Stress Fractures. The program is a dynamic incorporation of WB progression, gait training, ROM activities, physical therapy modalities, stretching, PREs, balance, proprioception activities, and conditioning.24. Fracture subjected to high shearing forces. The first measure of treatment is knowing the signs of a femoral neck stress fracture. Evaluate gross muscle strength and range of motion of other extremities. during 4-8 weeks:Femoral neck fracture Physiotherapy Management. 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. Long-term outcomes after lower extremity trauma. 3. . This information is provided as an educational service and is not intended to serve as medical advice. Pain can also radiate to the anterior thigh, gluteal region and even down to . Type 1- inferior cortex is not completely broken. 34. 30. However, it is deferred in unstable fractures. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. Observe gross muscle strength of involved extremity by strength of. Mira et al19 reported that only 17% of patients (5/29) demonstrated normal quadriceps function 16 months after fixation of femoral shaft fracture. In other words, the fracture caused the fall, not the fall the fracture. Femur Fracture Physical Therapy Exercises . The rehabilitation used and control data were not reported in this study. A. Inpatients should be seen daily, twice if possible. Sitting: Long arc quadriceps, hip flexion, ankle pumps. III. The authors attributed this finding to muscle damage sustained at the time of injury as quadriceps weakness correlated to the measured fracture displacement. Illustration of femoral shaft bone. As with most stress injuries plain x-rays are typically negative early in the course of the injury. B. This article aims to provide a current concepts review on the topic of FNSFs in sport, assess . Femoral Stress Fracture typically occurs on the superior side (tension-side fractures) or the inferior side (compression side fractures) of the femoral neck. You may drive the day after surgery. During 2-4 weeks:Femoral neck fracture Physiotherapy Management. It's important to give the fracture time to heal by keeping weight off your leg and using crutches. Active range of motion and passive range of motion exercises of the lower extremity are initiated immediately after surgery. Activities of daily living can be allowed normally with the help of assistive devices. However, a dearth exists with respect to postoperative rehabilitation recommendations, targeting the impairments that often limit return to activity. Wolinsky P, Tejwani N, Richmond JH, et al. may email you for journal alerts and information, but is committed Williams flexion exercises focus on placing the lumbar spine in a flexed position to reduce excessive lumbar lordotic stresses. REHABILITATION PROTOCOL: An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. Femoral plating. Femur Rotation Increases Patella Cartilage Stress in Females with Patellofemoral Pain. Jones DL, Erhard RE: Diagnosis of trochanteric bursitis versus femoral neck stress fracture. Patient compliance is important. 2 0 obj Physical Therapy Protocols Guidelines for Rehabilitation- Edited by Janet Bezner, M.S., PT., and Helen Rogers, M.A., P.T. Furthermore, if not treated correctly, these fractures are well known for complications and difficulties. 2017 Oct 18;88(4S):96-106. doi: 10.23750/abm . manual therapist, Medical Neuroscience (USA). General lower extremity stretching including gastrocnemius/soleus and hamstring stretching are encouraged. Knee flexion ROM exercise is also initiated immediately postoperatively. Therefore, targeting rehabilitation intervention to address recognized impairments may lead to more predictable outcomes after femoral shaft fracture. Stress fractures of the femoral shaft are diagnosed most commonly in runners, in particular female runners, with the most common location being the junction of the proximal and middle thirds of femoral shaft. A. 2. 16. These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. 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. The treatment regimen is more or less the same as discussed above. o Subtrochanteric or distal shaft fracture foot-flat weight bearing. However, some components of the protocol may be useful, particularly the ROM and stretching exercises and the modalities for muscle reeducation. 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. o No significant difference in femur fracture patterns has been found when proven cases of child abuse are compared to a control group. Early rehabilitation following surgical fixation of a femoral shaft fracture. An injury to the socket, or acetabulum, itself. The intramedullary nail usually stays in for life and are not routinely removed. 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. Nonoperative treatment of femoral shaft stress fractures is usually successful. As an example, an intra-articular supracondylar femur fracture managed with an IM nail is not the same injury as a midshaft femur fracture managed with the same device, and the rehabilitation protocol must be individualized based on the injury and bony stability. Gurney B, Boissonnault WG, Andrews R: Differential diagnosis of a femoral neck/head stress fracture. Copyright physiotherapy-treatment.com since 2009, Common Physical Therapy Abbreviations used in documentation. Some consideration must be given to extenuating circumstances regarding injuries and the rehabilitation protocol. Your dressing from surgery is waterproof. 8. Arazi M, Ogun TC, Oktar MN, et al. Physical Therapist at SMC, New York, USA. Objective: To develop a well structured and reproducible treatment algorithm for athletes with femoral shaft stress fractures. Femoral Stress Fracture Symptoms. Walking and moving as much as you can is also preventative. <> Exercises: Ankle isotonic exercises are continued. A critical analysis of quadriceps function after femoral shaft fracture in adults. 3). Usually, patients do 1-2 visits with the therapists a week and must continue these exercises at home daily for a good result. 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. Patients with cemented joint replacements can weight bear as tolerated (WBAT) unless the operative procedure involved a soft-tissue repair or internal fixation of bone. See home treatments. Find one of our conveniently located offices in Reno, Sparks, Carson City & Fallon, 555 North Arlington Avenue Riemer BL, Foglesong ME, Miranda MA. Gait train patient, observing weight-bearing precautions. In addition to the focus on the proximal lower extremity musculature, distal lower extremity strength is also addressed, which includes a focus on gastrocnemius and soleus activation. B. 12. Some error has occurred while processing your request. While compression side stress fractures with no displacement is an indication for non-operative treatment. Fracture displacement 2 mm identified on imaging. . Femoral bone density in young male adults with stress fractures. Toren A, Goshen E, Katz M, et al. Methods: The proposed algorithm is carried out in four phases, each lasting three weeks, and the move to the next . Osteopenia after plated and nailed femoral shaft fractures. Caution: No passive range of motion at this stage. Movements: Active and active-assistive movements of the hip, knee and ankle can now be started. American Academy of Orthopaedic Surgeons. The use of computerized gait analysis22-24 has been used to objectively evaluate dynamic function of the lower extremities after femoral shaft fracture. Enhance your health with free online physiotherapy exercise lessons and videos about various disease and health condition. Future randomized control trials need to be implemented to validate this intervention and to optimize this treatment protocol. Most femur fractures are fixed within 24 to 48 hours. joint. B. Full active and passive range of motion exercises are permitted to the hip and knee joints. 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. Garden type 1) fractures may be managed by cannulated screw fixation. Licensed Physical Therapist in NY and Texas, USA. 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. V. Coordinate care with other disciplines involved. your express consent. Ostrum RF, DiCicco J, Lakatos R, et al. Boden BP, Osbahr DC. o Midshaft fracture, nail >8mmweight bearing as tolerated. It allows the upper leg to bend and rotate at the pelvis. However, no passive movements are still recommended. % Winquist RA, Hansen ST Jr, Clawson DK. 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. Edible use avoids the other risks associated with smoke inhalation and has more controllable dosing. Fatigue fracture of the interlocking nail in the treatment of fractures of the distal part of the femoral shaft. 1. Am J Sports Med 16:365367, 1988. 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. 4 0 obj A limb symmetry index of 85%-90% in both hip abductor and knee extensor and knee flexor strength is necessary to progress to discharge. This static heel propping stretch allowed for a low load, long duration stretch of the posterior knee. 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. 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. 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. Ostrum RF, Agarwal A, Lakatos R, et al. Alteration in gait mechanics is a functional impairment often observed after IM nailing of femoral shaft fractures. 1. A prospective functional outcome and motion analysis evaluation of the hip abductors after femur fracture and antegrade nailing. 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. Theodoropoulos, J, Dwyer, T, Whelan, D, Marks, P, Hurtig, M, Sharma, P (2012) Microfracture for Knee Chondral Defects: a Survey of Surgical Practice . The patient can now flex the hip upto 90 degree, by the self-assisted "heel drag", (i.e. Abduction strength following intramedullary nailing of the femur. Copyright physiotherapy-treatment.com since 18 April 2009, Return fromFemoral neck fracture Physiotherapy to Home Page. They will be removed at your first postoperative follow up appointment 10-14 days after surgery. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 816.96] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. Pes anserine bursitis (tendinitis) involves inflammation of the bursa at the insertion of the pes anserine tendons on the medial proximal tibia. 2. Compliance with a targeted home exercise program designed to address known impairments that limit functional outcome will facilitate a more favorable outcome. 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. Depth of squat and progression away from handheld assist is added over time as strength improves. 19. At 19 months after surgery, 55% of the patients reported some knee pain with diffuse knee pain reported in 15% of the patients. 1989;10:105108. Pain with running then progresses to pain with activities of daily living and functional limitation. 1997;86:332333. Do not take more than 4 grams of Tylenol a day or it can hurt your internal organs. Passive range of movements by the physiotherapist or by continuous passive motion apparatus is begun to the hip and knee. In the hospital you are given shots in the belly called Lovenox and have pneumatic compression devices on your legs. Einhorn TA. 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. Just remember that your reaction time will be slow for first 6 weeks so do not tailgate or drive too fast. Nichols P. Rehabilitation after fractures of the shaft of the femur. Upon discharge from the hospital, the patient is enrolled in an outpatient physical therapy program 2-3 d/wk. Lacking periosteum & union is endosteal, 4. Reducing the Syndesmosis Under Direct Vision: Where Should I Look? 35. Postoperative x-ray of femoral shaft fracture repair with an intramedullary nail. Retrograde femoral nailing: a focus on the knee. Wong J, Boyd R, Keenan NW, et al. 23. b. Fredericson et al. b. Once the location and severity of the athlete's stress fracture(s) is diagnosed, treatment can begin. 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. Isometric exercises for the hip and knee are prescribed. As with most stress injuries of bone, the history often reveals a recent increase in frequency, intensity, or duration of a repetitive activity. 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. An evaluation-based rehabilitation protocol designed to target known impairments after a femoral shaft fracture is presented. 3 0 obj Mini squatting (Fig. 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. (17) has described a two-phase protocol for rehabilitation of the runner with a lower limb stress frac-ture. Less severe cases may only have pain following a long run. If the wound is dry, you do not need to cover it with a new bandage. to maintaining your privacy and will not share your personal information without 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. 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. Early weight-bearing after statically locked reamed intramedullary nailing of comminuted femoral fractures: is it a safe procedure? 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. 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. Patients treated with hemiarthroplasty should avoid keeping the hip in adduction or internal rotation to prevent redislocation. 4. 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. Residual weakness 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. If it is leaking, replace dressing with a clean gauze pad and tape. c. Assess sensation of involved extremity. At a mean follow-up of 47 13 (minimum = 24) months, the patients demonstrated 14% deficit in mean hip abduction strength. Finsen V, Svenningsen S, Harnes OB, et al. Controversies in intramedullary nailing of femoral shaft fractures. High-Risk Stress Fracture Initial Treatment (if Stable and Nondisplaced) Femoral neck (compression side)a NWB 4 to 6 wk, . the diagnosis of a femoral neck stress fracture is often delayed for 5 to 13 weeks. Bone scan or MRI may be necessary for an early diagnosis. Type 3- some displacement and rotation of the femoral head. Protocol for 8-Week Return to Running after a Femoral Stress Reaction PM R. 2019 Aug;11(8) :904-907. . 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. endobj Outpatient vs. home health therapy (Phase 1): o 1-2x/ week x 6 weeks o Gait training with assistive device. Increase strength of involved extremity to within functional limits. Do not immerse your wound in a bath or hot tub until your stiches or staples are removed. Once released to resume preinjury activities, a home exercise program aimed at functional progression toward preinjury work and recreational activities is recommended. Bednar DA, Ali P. Intramedullary nailing of femoral shaft fractures: reoperation and return to work. Required Rehabilitation time- 15 to 30 weeks. After 2 days you can take off the dressing. 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. 21. Effect of weight-bearing on healing of cortical defects in the canine tibia. 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. A report of five hundred and twenty cases. Bain et al2 studied femur fracture patients treated with an antegrade IM nail and compared hip abduction strength to a control group. Disclosure: The authors did receive commercial/industry funding in support of their research and in preparation of this article. patients with mental illness or other diseases who could not comply with the treatment protocol. Pain can also occur in the lateral aspect or anteromedial aspect of the thigh. Patients can usually return to a desk job or light duty after a few days. This evidence suggests attempts to address gait impairments early in rehabilitation may result in improved long-term outcomes of patients after femur fractures. It is estimated that up to 5% of all stress fractures involve the femoral neck, with another 5% involving the femoral head. J Orthop Sports Phys Ther 36:8088, 2006. Bain GI, Zacest AC, Paterson DC, et al. 6. You will have pain in your leg while it heals but it is safe to walk on it. Get new journal Tables of Contents sent right to your email inbox, May 2009 - Volume 23 - Issue - p S39-S46. By 12-16 weeks:Femoral neck fracture Physiotherapy Management. First, the patient must bear at least 50% of his weight with an assistive device during community ambulation. Follow the acute treatment principles of protection, rest, ice, compression, elevation, medication, and modalities (PRICEMM). Evaluate patient's home situation to determine need for additional equipment, home health physical therapy services, or other support. Please respect these regulations. Bone. 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 . A. modify the keyword list to augment your search. Phys Ther 77:5867, 1997. The optimal surgical management of a femoral shaft fracture is well documented in the literature. Your wound has been closed with sutures or staples depending on your surgeons preference. If a patient is extremely stiff at their first postoperative visit and has trouble bending their hip or knee therapy will be started. A fair hip abduction strength is defined as the ability to elevate the lower extremity against gravity from the resting side-lying position. Derotation bar helps prevent external rotation of the affected limb. You can take 1-2 pills every 4-6 hours. 2. 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. If you do not have one, please call the office to schedule at 775-786-3040 as soon as you can. dragging the heel upto the buttocks with the help of the normal leg). The distal femur is where the bone flares out like an upside-down funnel. Balance, proprioception, and gait training activities are now be progressed. 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. Your message has been successfully sent to your colleague. Although several studies cite inadequate rehabilitation as a contributing factor to this impairment, few have described rehabilitations program or prospectively analyzed this variable. Reproduced with permission from OrthoInfo. 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. You should see your surgeon or his physician assistant 10-14 days after surgery. Fracture callus and a radiolucent fracture line usually appear 2 to 6 weeks after symptom onset. 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. A. Hennrikus WL, Kasser JR, Rand F, et al. Maintenance of full knee extension and progression of knee flexion activities are indicated until full functional ROM is attained. o AROM/ PROM of knee while sitting at side of bed. Several interventions of phase 1 are progressed as appropriate into phase 2. Individual screws sometimes require removal to stimulate bone to heal in a process called dynamization. The authors noted a substantial reduction in functional hip and knee motion 2 months after surgery. 29. No more than minimal knee effusion and lower extremity edema must be present. 1). 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. You have been given a prescription for narcotic pain medication. Wolters Kluwer Health 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. 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. Isometrics, isotonic and progressive resistive exercises are continued to the hip, knee and ankle joints. 20. Official Journal of the American College of Sports Medicine. This is probably the most common and most significant fracture in terms of morbidity, mortality and socioeconomic impact in developed countries (Reginster et al. Ensure patient achieves milestone prior to progression . This also can assist in return of isolated quadriceps activity. The earliest and most frequent symptom is pain in the deep thigh, inguinal, or anterior groin area. Modalities are used at this time to attain 2 goals. The patient can now flex the hip upto 90 degree, by the self-assisted "heel drag", (i.e. Thompson's hemiarthroplasty. The wound is inspected for evidence of infection and the drains are removed after 24 hours. 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. Prior an ultimate progression back to all functional activities, the patient should progress through a return to activity phase. With the progression in WB status, there is also a progression in closed kinetic chain strengthening activities in phase 2. Protection - Crutches with non-weight-bearing ambulation until complete relief of pain at . 24. Jurkovich G, Mock C, MacKenzie E, et al. Operative management of distal femoral fractures. Initial strengthening exercises focus on active control of knee extensor and hip abductor musculature to address these typical impairments. 18. Foster TE, Healy WL. Please try after some time. . Use of neuromuscular reeducation with electrical stimulation may be continued to facilitate a volitional quadriceps contraction as indicated. You should not drive a car if you are still taking narcotic pain medication. Former PT Winner Regional Health, South Dakota, Former HOD Physiotherapy & Fitness center @ NIMT Hospital, Greater Noida. Clinical and scintigraphic findings were suggestive of spontaneous osteonecrosis of the medial femoral condyle. Exercises: After the pain subsides, isometric gluteal and quadriceps exercises are begun. This process does not remove your bone marrow but just compacts it. Controversies in intramedullary nailing of femoral shaft fractures. Pegrum, J, Crisp, T, and Padhiar, N: Diagnosis and management of bone stress injuries of the lower limb in athletes. It is ok to take anti-inflammatory medicine like Motrin (ibuprofen) or Tylenol (acetaminophen) as well. Usually, this appointment is made when you schedule surgery. 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. 9. Please enable scripts and reload this page. With respect to gait, a normal gait pattern with no signs of Trendelenburg gait should be present. 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. This objective assessment of function may vary depending on the patient's goals. Successful attainment of these goals signifies an initial progression toward resolving known impairment that limits functional outcomes and results in progression to phase 2. This practice guideline was designed specifically to target impairments recognized after IM nail stabilization of femoral shaft fractures. If you already get narcotics from your primary care doctor or pain management doctor the orthopedic surgeon cannot write you a separate prescription. Journal of Orthopaedic Trauma23:S39-S46, May-June 2009. This includes single-leg toe raises, mini squatting, and simple perturbations on an unstable platform. Not all patients with femur fractures require physical therapy. femoral intramedullary nailing; rehabilitation protocol; Keyword Highlighting The Reno Orthopedic Center Fracture and Trauma Surgeons have createdpostoperativefracture protocols for our patients. Each phase is evaluation based and progression is dependent on successful attainment of baseline goals. Night pain may occur if the fracture progresses. Long-term residual musculoskeletal deficits after femoral shaft fractures treated with intramedullary nailing. Patellar stress fracture Patellofemoral arthritis Pes Anserine Bursitis . However, if the metal becomes infected or is painful 1 year after surgery it can be removed. Cardiovascular conditioning is also initiated at 6 weeks postoperative with the addition of stationary biking as adequate knee flexion is achieved. 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. However, in subsequent analysis 8 months after surgery, the patient demonstrated improvement in hip kinematics but continued deficits in knee kinematics. A continued focus is placed on functional limiting impairments, particularly knee extension and hip abduction activities. 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. These goals address weight bearing (WB) status, knee effusion, quadriceps control, and hip abduction strength. Progression of this exercise includes removal of the cane support. z>; (ojTTf1'8Ih oWi7T7,@ViFtIE|J]H8V Intra-articular fracture (synovial fluid a deterrent to union), 3. b. Enhancement of fracture-healing. Bucholz RW, Ross SE, Lawrence KL. . b. Due to the limited sensitivity of radiographs, magnetic resonance imaging of the right hip was obtained, which revealed a stress fracture of the right . The initial focus is on attaining early full knee extension to decrease the risk of knee flexion contracture. Establish independent gait without assistive device. Usually, patients do 1-2 visits with the therapists a week and must continue these exercises at home daily for a good result. Diagnosis can be be made with radiographs but findings often lag behind often resulting in negative radiographs early on. Br J Sports Med 36:308309, 2002. <>>> Preoperative x-ray of femoral shaft fracture. Hip abduction strengthening is also progressed with more closed kinetic chain activities, such as resisted lateral walking. is not considered a "hip fracture.". Handheld dynamometry is an adequate substitute to objectify strength. Treatment depends on where the injury occurs. The distal femur is the area of the leg just above the knee joint. Initiation of balance and proprioception activities begins as WB is initiated. Rehabilitation Protocol for Patellofemoral Pain Syndrome . Prospective comparison of retrograde and antegrade femoral intramedullary nailing. The pain usually occurs with weightbearing or at the extremes of hip motion and can radiate into the knee. These are based on the latest orthopedic science and literature in order to give patients the most up to date care. 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. 2000 Nov-Dec;8(6):344-53. doi: 10.5435/00124635-200011000-00002. Closed intramedullary nailing of femoral fractures. When treating these fractures with internal fixation, many fixation constructs exist. Request physician consult for necessary equipment or other needs. Kapp et al7 evaluated the long-term deficits (mean 44 months) after IM nailing of femoral shaft fractures in 17 patients. Return without restriction to jobs that require heavy lifting or manual labor usually takes about 6 weeks. 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. 26. Treadmill walking should focus on training a more normal gait pattern, in addition to challenging the cardiovascular system. Wolters Kluwer Health, Inc. and/or its subsidiaries. Improve range of motion to normal functional status. Alternate using heat and ice packs for the pain and inflammation. In addition, the auscultatory patellar-pubic percussion test may be positive. First the patient is advised prone lying. 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. 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