lower limb fractures - upper femoral Flashcards
what does NWB mean?
non weight bearing
what does PWB mean?
partial weight bearing
what does WBAT mean?
weight bear as tolerated
what does ORIF mean?
open reduction internal fixation - surgery to fix a broken bone by moving it back into place & stabilising it with plates, rods and screws
what does AVN stand for & what is it?
- AVN- avascular necrosis
- it is the death of bone tissue due to temporary or loss of blood supply to the bones
what does THR vs PHR mean?
- THR= total hip relacement
- PHR- partial hip replacement
how could the acetabulum be fractured ie what would the MOI involve?
- MOI - force transmitted up the limb
- eg from RTA, fall on the side, fall from a height
what other conditions could be observed with an acetabulum fracture?
- there may be a hip dislocation
- there may be sciatic nerve injury
what is conservative treatment?
treatment that avoids invasive measures such as surgery, usually with the intent to preserve function
what would conservative management of a acetabulum fracture involve?
- bed rest and traction (straightening bones / relieving pressure on spine or MSK system) for 6 weeks
- non weight bearing on crutches
what would the surgical management of an unstable acetabular fracture involve?
- surgery would involve ORIF and the pateint being NWB on crutches
- there would be continuous passive motion to help cartilage healing and ROM
what is continous passive motion (CPM)?
- a therapy that uses a machine to move a joint without the patients effort
- moves the joint through a controlled ROM that can be adjusted by the physio
How could a posterior dislocation of the head of the femur happen / MOI?
- by a head on RTA
what are the complications of a posterior dislocation?
- damaged sciatic nerve
- avascular necrosis
- Osteoarthritis - OA
what are important facts to note about upper femoral fractures?
- common in the elderly
- risk is higher in females rather than males
- there may be an associated co-morbitity (presence of 1 or more additional conditions along with the primary one)
- mortality is 15-36% in the first year
what artery supplies the head of the femur?
- a branch of the obturator artery
in what 2 ways are upper femoral fractures classified?
- intracapsular- high fracture within the capsule, fracture interupts blood supply to the femoral head
- extracapsular - less difficult to treat as femoral head blood supply is not compromised
what is a type of intracapsular fracture?
a femoral neck fracture
How many types of neck femur fracture are there ?
4
* they follow the garden fracture grading system
Describe a garden I fracture
- incomplete fracture with valgus impaction (ie broken bone pointing laterally)
Describe a garden II fracture
- complete fracture without displacement
Describe garden III fracture
- complete fracture with partial displacement
Describe a garden IV fracture
- a complete fracture with total displacement
how would a garden type I or II fracture be managed?
- early protected weight bearing is allowed WITH CAUTION
- use pain as a guide for management
- if it is undetected - there is a risk of later displacement days or even weeks after initial injury
how would a garden III or IV fracture be managed?
- ORIF
- pins or dynamic compression screw and plate
- protect from WB - ie patient is NWB
- potentially prosthetic replacement
- if associated damage to acetabulum - then maybe full hip replacement
what are important post op precautions to follow in order to prevent dislocation after a hemi arthroplasty or full arthroplasty of hip?
- avoid hip flexion beyond 90 degrees
- no crossing operated legs - as that would be adducting - which can lead to dislocation
- no twitsing from your hips
- dont turn your operated leg inward
- for around 6 weeks post OP
what are possible complications that can occur with a femoral neck fracture?
- avascular necrosis
- non union
- loosening of prosthesis
- collapse of femoral head with dynamic hip screw
- post op symptoms eg confusion, UTIs, pressure sores etc - higher risk if elderly
what is the cumulative ambulation score? (CAS)
- a score used for daily assessment of developments in basic mobility until independent ambulation is reached (ie can be mobile without assistance)
- consists of 3 activities - getting in and out of bed, sit to stand from a chair and walking
- each activity is scored from 0-2
define the term** ambulation**
- the ability to walk **without the need of any kind of assistance **
CASE STUDY
a 74 year old female falls at home and sustains a right garden III fracture. She recieved a right hemi arthroplasty and her post op instructions say that she can PWB… what are the discharge goals for physiotherapy and outline generic post op plan to achieve these goals
- discharge goals - ideally discharge after 3 days, we would want her to be as** independent as poss with bed and chair transfers** and we would want her to be able to walk 10-15m with a walking frame
- generic post op instructions
* sit to stand practice
* walking practice with zimmer frame
* educate her on how to use walking aid, ie using her hands and pushing her off chair, teaching her how to turn etc
* practing transfers - lying in supine position to sitting up etc
what are 3 examples of extracapsular fractures or trochanteric fractures?
- inter-trochanteric - ie between the trochanters
- sub - tranchanteric - below the trochanters
- avulsion greater trochanter - ie a piece of bone gets pulled off
Describe an intertrochanteric fracture
ie MOI, elderly vs young, treatment - surgery?
- extracapsular fracture
- MOI - sharp twisting injury
- heals well and AVN is rare
- if elderly - there may or may not be osteoporisis
- if younger - more trauma
- unstable fracture so it requires ORIF
Describe a subtrochanteric fracture
where does it occur? what can it be assocated with? treatment?
- occurs between the lesser trochanter and the adjacent proximal 1/3 femoral shaft
- rare
- may be associated with disease or pathology
- treatment involves ORIF
what group of muscles attah onto the greater trochanter?
the ABDUCTORS - eg gluteus medius, minimus, obturator internis etc
Descrie a avulson of the greater trochanter
MOi?, what movements are sore? treatment?
remember avulsion - bones gets pulled off
- a violent adduction strain can cause this
- severe localised pain
- abduction is painful
- treatment involves bed rest and then progressive WB with crutches
what MOI can cause a fracture of the shaft of the femur?
- considerbly violent RTA
- fall from height
- direct blow to flexed knee
what types of fractures can a fracture of the shaft be?
- spiral
- transverse
- oblique
what signs or observations can be seen with a femoral shaft fracture?
- unable to WB
- considerable fluid and blood loss
- leg sits in external rotation and abducted position
- thight appears short and fat
what are potential complications of a femoral shaft fracture?
- haemorrhage
- infection if its an open fracture (ie protruding through skin)
- non union
- mal union
- arterial and nerve injury
- fat embolism
what does the immediate management of a femur shaft fracture involve?
- restore blood and fluid volume
- if the fractue is open, then clean wound and removing debris
- antibiotics
what does the immobilising treatment stage of a femoral shaft fracture involve?
- may involve internal fixation
- external dixation - ie if its open, unstable, in an emergency situation
- long leg cast
what is an ilizarov frame?
- special type of external fixator
- used for limb lengthening
- correction of bone deformity
what can a brace be used for?
- may be used after external fixation
- allows hip and knee ROM
what is a fat embolism?
occurs when a small bit of fat enters the blood stream and can block blood flow
what are the key clinical signs of fat embolism that can happen 2/3 days after a bone break?
- trouble breathing
- fast heartbeat
- mental state changes
- vision changes
- jaundice
- fever
- rash
what is a quadricep lag?
- the patient cannot fully actively extend the knee, but it can be passively extended by the clinician
