Physiotherapy and Fractured Neck of Femur

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Table of Contents

Introduction
Management and treatment
Radiography
MRI
CT
Nuclear medicine
Surgical Treatment
Conservative Treatment
Reference

Introduction

The neck of the femur and structure of the head helps in the transmission of body weight efficiently by appropriate distribution of the bony trabeculae in the neck. The system, for example, the tension trabeculae and compression trabeculae along with strong calcar femoral on the medial torsion during locomotion and weight-bearing stresses. The fractured neck of the femur occasionally occurs in young adults and children and is highly in old age this is due to osteoporosis of the region. Fractures that are intracapsular may interfere with sources of blood to the femoral head, the cervical vessels in the retinaculum of the joint capsule or even intramedullary vessels. The intracapsular nature of the fracture hinders recovery from injury. This will lead to blood remaining inside the joint capsule thus increasing intracapsular pressure and damage of the femoral head.

Most patients are elderly people with a history of a fall and unable to walk. The injured lies in a position of external rotation and there is a shortening of the leg. The attachment of the capsule to the distal fragment prevents excessive external rotation of the leg. Thus there is tenderness over the anterior and lateral aspects of the hip joint. All movement is extremely painful. (Sue, 1997)

Many patients with this fracture, may have other pre-existing ill-health problems, their assessment and implications for achieving the best-desired outcomes depends on satisfaction with the care, treatment and achieved the outcome. Patient with pre-existing co-morbidity desired outcomes depends on their level of dependency.

Achieved outcomes need to be assessed at discharge in the subsequent three months and for those with pre-existing or consequent co-morbidity, in the longer term. The measuring and recording of pre-fracture mobility for comparison with the situation at post-fracture are important in assessment. These can be assessed by using physical aspects of daily routine, for example, walking scale or short mobility scores, use of walking Aids in both prior and subsequent to an injury. The measure of impairment and disability predominate because they are easy to measure and valuable for assessing fracture repair.

There may be a useful role for multidimensional health profiles in broadening the focus of measurement to the consequences of the fracture for the individual user as this will be used for desired outcomes. Morbidity will depend on a number of factors, for example, walking ability, available formal health and social services support and informal care support. For those from a residential home to meet any additional needs of the patient. For patients with pre-existing co-morbidity, changes in dependency must be looked at. Pre-existing and subsequent levels of handicap and implications for care need to be re-assessed. This implies that patients with pre-existing co-morbidity. A fractured neck of the femur may accentuate the level of dependence, others the fracture may form a transition point towards greater dependency.. (Sue, 1997)

The consequences for informal care, that is, friends, relatives, neighbours must be looked at. Mostly any lack of mobility and its subsequent implications on mental health and social functioning or isolation may be the outcome.

A study has been done to establish patients with this complication if they improve functional ability through rehabilitation. These reflected some indicators:

Age: Most children heal faster compared to adults and elders.
Social support: The patient improves with positive support from the family, friends, relatives and neighbours.
Delay in going to the theatre or delay in getting a post-operative check-x-ray may hinder the healing process. (Sue, 1997)
Illness: Patients who are ill, there functional ability delays. Patients with low Hemoglobin levels have low functional ability improvement.
Postoperative confusion: Due to mental disturbance during operative or during injury, the healing process delays. Male patients who are housebound and those with co-morbidities have a relatively high mortality rate due to low exercise. (Tarling and Aitken, 2002)

Patients with similar ASA grades have a better prognosis when operated upon 24 hours of admission with less morbidity and mortality as well as early discharge.

Thus level of support at home, characteristics of the patient, for example, age, socioeconomic status, source of admission, illness affects greatly the power of mobility and mortality in the patient with a fractured neck of femur.

Management and treatment

The outcome of interventions for fractured neck of femur depends on prevention, access to the hospital setting initial diagnosis, actual treatment, subsequent hospital-based recovery, recovery in the community (longer-term recovery). These factors will depend on the patient, carers, clinicians, managers and purchasers. (Tarling and Aitken, 2002)

Radiography

It is the initial preferred imaging in evaluating femoral neck fractures. It’s available, ease of acquisition and used for many years. Though it has some limitations like spiral fractures are difficult to asses on a single view. Communication not easily demonstrated, some stress fractures are invisible on plain images at all.

MRI

If clinical suspicion is high with radiography the case can be evaluated with MRI. This shows bone marrow edema, is both sensitive and specific in detection of neck fractures due to its ability to show actual fracture line and the resulting bone marrow edema. It has power in intrinsic spatial resolution and ability to image in multiple planes. Its disadvantage is longer imaging time, high cost.

CT

Is useful for imaging abnormalities of the bone itself has superior resolution, cross-sectional capabilities, amenability to image reconstruction in cronal and sagittal planes. It is most useful test for evaluating bony fractures. Its limitations are that axial fractures in the plane of the images can sometimes not be viewed. (Gregory, 2005)

Nuclear medicine

Nuclear medicine can be used to diagnose suspected femoral neck fractures. Technetium – 99m methylene diphosphonate (99mTc – MDP) is also useful in predicting healing femoral neck fracture. Study show that scanning with this performed within 2 weeks after fixation. Surgery for femoral neck fracture has an excellent prognostic value for future redisplacement.

At this level fractures have poor capacity for union due to interference with blood supply, presence of synovial fluids, difficult in controlling the small proximal fragment.

Surgical Treatment

The recent method of internal fixation of fracture is use of multiple compression screws. Patient above 60 years, the head of femur is moved and replaced by mental prosthesis, for example, Austin Moore’s prothesis.

When there is complications of fracture neck of femur for example, non-union, avascular necrosis of head of femur, there is a lot of pain and one develops instability on walking. Non-union conditions is treated by intertrochanteric osteotomy in children, replacement orthoplasty is done in elders. In very old patient, the leg is kept between sand bags afterward physiotherapy is administered. (Swanson and Murdoch, 2001)

Conservative Treatment

This is continuous application of skeletal traction through the upper tibia is applied and the leg is immobilized in the Bohler Braun splint and the foot end of the bed is raised. The coxa Vera gets corrected and the fracture unites in about 10 weeks. No serious defect in this treatment.

Operative Treatment is manipulative reduction and internal fixation, Nail plates are used in internal fixation, Complication here is malunion with coxa Vera and shortening. The morality rate within one year is reported between 20% and 35%.

Reference

Alexandra, H. (2001). Physiotherapy in Respiratory Care, (London, Cambridge University Press).

Cederholm, M. (2005). Nutritional treatment of bone fracture, (New York, Prentice Hall).

Christopher, B. and Catherine, S. (2007). The Musculoskeletal System at a Glance, (London, Oxford University Press).

Deborah, L. and Jane, C. (2000). Trauma Care: A Team Approach, (New York, Vintage Books).

Gregory P. (2005). ABC of Sports and Exercise Medicine (New York, University of Illinois Press).

Hansen, P. (1998). Age with a Future, (New York, Macmillan).

Horan, J. and Clague, E. (2004). Injury in the aging: recovery and rehabilitation – British Medical Bulletin, 2004 – British Council.

Stuart, B. (2003). Tidy’s Physiotherapy, (Bloomington, Indiana University press).

Sue, J. (1997). Pathways of Care, (New York, McGraw-Hill).

Swanson, A. and Murdoch, G. (2001). Fractured Neck of Femur, (Newcastle, Bloodaxe Books).

Tarling, M. and Aitken, E. (2002). Developing a fractured neck of femur, (London, Oxford University Press).

Wootton, P. and Brereton, M. (1999). Fractured neck of femur in the elderly, (New York, Prentice Hall).

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