Fracture of neck of femur (intracapsular)

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-

  1. 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-
  1. Shortening of leg
  2. Tenderness in groin
  3. Painful hip movement with spasm
  4. 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-

  1. To restore Full or at least functional range of motion of hip joint.
  2. To restore adequate strength, power and endurance of muscles around the hip and knee.
  3. 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