Pathoanatomy-
These are displaced with external rotation of distal fragments and proximal migration.
Mechanism-
Depending upon age of patient-
- Children- uncommon
- Adults- severe injury
- Elder- occur due to trivial fall, osteoporosis
Classification-
- Anatomical classification-
- Subcapital
- Trans cervical
- Basal
2. Pauwel’s classification-
It is based on angle of inclination
- Type 1- 30°
- Type 2- 30°-50°
- Type 3>50°
3. Garden’s classification-
It is based on degree of displacement and severity of fracture
- Stage 1- Trabecular bending only no displacement
- Stage 2- All segments aligned, trabecular broken between head and neck and undisplaced
- Stage 3- All segments are out of alignment, complete fracture and incomplete displaced.
- Stage 4- completely displaced
Diagnosis-
- Patient complaints of little complain in growing while walking
- Inability of weight-bearing following injury like deploying on floor missed step etc.
- Can be missed for several days or weeks as there is almost no swelling.
- Physical examination-
- Shortening of leg
- Tenderness in groin
- Painful hip movement with spasm
- Active SLR not possible
- X-ray of pelvis
Complication-
- Non-union
- Avascular necrosis
- Osteoarthritis
Management-
Conservative management-
- Skeletal or skin traction (for 4-6 weeks)
- Hip spica( for 6 weeks) -only in children
- Pop boots and derotational bars(for 4-6 week) -in elderly patients
Physiotherapy management-
Objective-
- To restore Full or at least functional range of motion of hip joint.
- To restore adequate strength, power and endurance of muscles around the hip and knee.
- To obtain self-sufficiency in performing all the ambulatory activities with walking aids or suitable orthosis whenever necessary.
During immobilization-
- Immobilisation can be given by traction, hip spica for pseudoarthrosis.
- Proper relaxation positioning by the help of pillows to avoid rotation of limb which can lead to contractures.
- Adequate chest PT to avoid respiratory complications
- Resistive movements to ankle and toes of affected limb and all joints of unaffected limb.
- Strong isometrics of quadriceps, hamstrings, hip extensors and hip abductors for 10-10 seconds to avoid post immobilisation atrophy.
- Early knee mobilisation.
- Initiate sitting on bed.
- Pre gait training exercises on the edge of the bed in supine lying.
- Perform quadricep drills in a high sitting.
Mobilization-
- Weight bearing and a brief period of full weight bearing on the affected leg alone are very important to balance the whole body weight on the affected leg during standing and walking.
- Strengthening of quadriceps and gluteal muscles by progressively resistive exercises
- Passive stretching to increase range of motion
- Wall supported squatting and cross leg sitting with back supported against wall.
- Functional independence is gained by 8 to 12 weeks.
Post operative management-
Week 1-
- Assistive side turning in bed by use of pillow between legs to prevent pressure sores
- Proper relaxation positioning
- Resistive isometrics to gluteus Maximus and quadriceps by pressing down whole leg on the bed
- Resistive ankle toe movement and full range of motion of opposite limb.
Week 2 and 3-
- Stitches are removed by this time
- Begin small range relaxed passive movements.
- Self assisted heel drag and range of motion by the help of CPM, knee ratchet, roller skates.
- Assisted abduction in sling support.
- Self assisted SLR.
- Resistive knee swinging at the edge of the bed.
Week 4 to 8-
- Achieve 90° hip flexion by this time
After 8 weeks-
- Increase exercise intensity and reach maximum contractions.
- Weight bearing and weight transfer done according to the condition of the patient.
- Gait training and limp correction once the pain subsides.
Reference-
- Mark Dutton ( Dutton’s orthopaedic )
- Mohit Bhandari ( Evidence based orthopaedics)
- David J. Magee and Robert C. Manske ( Orthopaedic physical assessment)
- Jayant Joshi and Prakash Kotwal ( Orthopaedics and applied physiotherapy)
- J. Maheshwari and Vikram A. Mhaskar ( Essential orthopaedics