Hip Orif Physical Therapy Protocol

Mobilisation After Fracture: Femoral Neck Fracture Physiotherapy

Note

• Required Healing time- 12 to 16 weeks
• Required Rehabilitation time- 15 to 30 weeks

Patients with cemented joint replacements can weight bear as tolerated unless the operative procedure involved a soft-tissue repair or internal fixation of bone.

Patients with cementless, or ingrowth , joint replacements are put on partial weight bearing or toe-touch weight bearing for 6 weeks to allow maximum bony ingrowth to take place.

I. Frequency

• A. Inpatients should be seen daily, twice if possible.
• B. Outpatients are followed as necessary.

II. Treatment techniques and goals

A. Two to three days postoperative

• 1. Instruct patient in deep breathing and cough. Goal: Prevent postoperative pneumonia and atelectasis.
• 2. Initiate isometrics and ankle pumps with involved extremity. Goal: Prepare patient for active exercise program.
• 3. Initiate bedside sitting once physician has cleared patient for this activity. Goal: Prepare patient to begin transfer and progressive gait training processes.

B. Three to five days postoperative

III. Equipments

IV. General considerations

Treatment For Hip Fractures

Open reduction and internal fixation is a procedure most commonly used to treat severe hip fractures.

The surgery is performed under sterile conditions in the operating room under general anesthesia.

• After sterilizing the affected area, your surgeon will make a cut through the skin and muscle of the thigh.
• Your surgeon will locate the fracture by carefully sliding in between the muscles of the thigh.
• Your surgeon will put the fragments of your femur back into position .
• Your surgeon will secure the fragments of the femur to each other by using metal plates, screws, wires, or pins.
• For a fracture in the middle of your femur, your surgeon may utilize a specially designed metal rod that passes through the middle of the bone and screws into both ends of the bone.
• Your surgeon may also carry out any other repairs if required.
• After securing the bone, your surgeon will close the incisions by suturing or staples and cover with sterile dressings.

Preparation For Orif Surgery

Since ORIF is often employed to treat severe fractures, it typically takes place as an emergency procedure. Prior to surgery, you may have:

• A physical exam to inspect blood circulation and nerves affected by the fracture
• X-ray, CT scan, or MRI scan to assess surrounding structures and broken bone
• Depending on the type of fracture you have sustained, you may be given a tetanus shot if you are not up-to-date with your immunization
• A discussion with an anesthesiologist to determine the type of anesthesia you may undergo
• A discussion with your doctor about the medications and supplements you are taking and the need to stop any
• A discussion about the need to avoid food and drink past midnight the night prior to your surgery

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Posterior Total Hip Replacement Rehab

Precautions for first 6 weeks

• NO hip flexion > 90°
• Weight bearing as tolerated with assistive device
• NO sitting for long periods of time
• Use toilet with raised seat for 3 months
• Use abduction wedge while sleeping or resting, up to 12 hrs
• Transfer to sound side Hip rotation should be limited:
• AVOID excessive IR and FLEX > 90°

1-4 weeks Immediate Post-op/ Maximum Protection Phase

• Hip FLEX to 90°
• Isometric exercises in pain-free range

• Hip abduction, lying on back
• Ankle dorsiflexion, ankle pumps
• Hamstring sets, digging heel in
• Straight leg raise
• Hip adduction with roll between legs, squeezing

4-5 weeks Moderate Protection Phase:

• Weight bearing restrictions as per M.D. Progress
• AROM gradually and in protected range
• NO hip FLEX > 90°

6+ Weeks Minimum Protection Phase

• Increase hip EXT and ABD strength for ambulation
• PRE with light weight and high repititions, no stress ER
• Bicycling to increase muscular endurance and general conditioning
• Transition to cane, if necessary
• Begin stretching and strengthening the glutes
• AVIOD high-impact exercises

Rom And Strength Traning

If internal hardware was removed due to the restriction of ROM, there may be further loss of ROM once the limb is immobilized. To minimize the loss, the physical therapist may employ passive physical therapy exercises in which there is no weight-bearing. Depending on the injury, these may include:

• Passive knee flexion
• Hip abduction or adduction

After the cast or immobilizer is no longer needed, resistance training and weight-bearing exercises may be added, increasing in intensity and duration week on week. In addition to in-office exercises, your physical therapist will provide you a list of exercises to do at home.

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Classification Of Hip Fractures

Hip fractures is classified into intracapsular and extracapsular fractures

Risk factors for hip fracture include:

• Gender: prevalent in women postmenopausal twice as likely as premenopausal to have hip fracture
• Reduced Bone density

Hip Orif Rehab Exercises

The hip is a ball and socket joint and is susceptible to fractures. These bone injuries typically affect older people and commonly result from a fall. Hip fractures also occur in the younger population due to trauma, such as a motor vehicle accident or a fall from a high surface. Hip fractures in older people tend to occur near the ball portion of the hip joint, often requiring surgery to repair the bone. Rehabilitation with a physical therapist begins soon after surgery to restore motion and function of the hip.

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Massive Rotator Cuff Repair

The emphasis for this massive rotator cuff repair protocol is to prevent the loss of fixation and return to activities as quickly as possible.

Rehabilitation Goals: Progress to work/sport-specific activities as quickly as possible, protect the shoulder, PROM for shoulder flexion, abduction, IR to abdomen, and ER to neutral, and limited removal of sling in safe environment at 10-14 days.

Rehabilitation After A Hip Fracture

, DO, New York University, Robert I. Grossman School of Medicine

Rehabilitation is begun as soon as possible after hip fracture surgery Treatment Hip fractures may occur in the round upper end of the thighbone, in the narrow part of the thighbone just below the head , or in the bumps in the broader area just below the neck… read more , often within a day. The initial goals are to help people retain the level of strength they had before the fracture and to prevent problems that result from bed rest Problems Due to Bed Rest Staying in bed for a long time without regular physical activity, as may occur in a hospital, can cause many problems. A leg injury, leg surgery,… read more . The ultimate goal is to restore their ability to walk as well as they were able to before the fracture.

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When Should I Call My Doctor

Discuss follow-up appointments while you are still in the hospital, but call your doctor right away or seek immediate medical care if you have:

• Increasing pain or the pain does not go away

• Increasing redness or swelling around the incision, oozing from the incision, high fever, or chills

• Loss of feeling or decreased feeling in the affected leg

What Happens During A Femur Fracture Open Reduction And Internal Fixation

Your healthcare provider can help explain the details of your particular surgery. These details will depend on the location and severity of your injury. An orthopedic surgeon and a team of specialized healthcare professionals will do the surgery. The whole operation may take a few hours. In general, you can expect the following:

• You will receive general anesthesia to make you sleep through the operation, so that you wont feel any pain or discomfort during the procedure.
• A healthcare provider will carefully monitor your vital signs, like your heart rate and blood pressure, during the operation. You may have a breathing tube inserted down your throat during the operation to help you breathe.
• After cleaning the affected area, your surgeon will make an incision through your skin and muscle of your thigh.
• Your surgeon will bring the pieces of your femur back into alignment .
• Next, your surgeon will secure the pieces of your femur to each other . To do this, he or she may use screws, metal plates, wires, or pins. For a fracture in the middle part of your femur, surgeons often use a specially designed long metal rod that passes through the middle of the bone. It screws into the bone at both ends.
• Your healthcare provider may make other repairs, if necessary.
• After the team has secured your bone, the layers of skin and muscle around your thigh will be surgically closed.

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Discharge Planning And Follow Up

3 appointments need to be made on discharge:

1. Orthopedics: Orthopedics Team schedules Orthopedic Surgery Follow up

a. ORIF: follow-up in Trauma Clinic with Advanced Health Provider for first visit

b. Hemiarthroplasty or total hip arthroplasty: follow-up with Arthroplasty Fellow for first visit

2. Bone Health: Primary Team schedules bone health appointment for 1-2 months after discharge

a. Place referral to UCSF Skeletal Health if patient is local to SF and can return for consult

b. If patient not local to San Francisco, contact local Primary Care Provider with recommendations for bone health optimization

3. Primary Care: Primary Team makes appointment with PCP within 2-4 weeks

a. Call the practice to arrange for the hospital f/u visit

b. Ortho-bundled payment program: If patient meets criteria for the OBP, a Care Support Program Nurse Practitioner will connect with patient before discharge to ensure continuity

c. Inpatient Case Manager & OBP Program Coordinator will be in communication to ensure collaboration with the UCSF complex care management team

Primary team ensures detailed instructions in the AVS:

Duration Of Physical Therapy

You can expect to start physical therapy a few weeks after your hardware removal surgery. ROM and strength gains can usually be made quickly, and within 4 to 6 weeks you should nearer to your preoperative level of function.

Every injury is different and everyone heals at different rates. Speak with your healthcare provider to find out what you should expect with your specific condition.

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The First 24 Hours After Surgery

Whether you’ve had your fractured hip surgically repaired or it was replaced with a hip implant, physical therapy and rehabilitation will, in most cases, begin the day after your surgical treatment. That’s because, although rest is an essential component of a healthy recovery, too much of it increases your risk of a number of complications after surgery, including blood clots, pressure sores and pneumonia. Avoiding those complications which can be a serious setback in term of recovery and may even be life threatening means getting mobile as quickly as possible.

Depending upon your particular circumstances, the first experience with rehabilitation therapy may be as simple as range of motion exercise, with the assistance of a physical therapist at your bedside. If you’re deemed able by your medical team, you might be helped to a sitting position at the edge of your hospital bed, and in many cases, you may be asked to stand with assistance or perhaps take a few steps. Just how strenuous therapy will be during that first 24 hours will depend on factors like the severity of your hip fracture, the details of your surgery, your overall health, and your level of pain, among many other factors. Of course, as you begin to recover from your surgery, therapy sessions will, as a rule, become progressively more demanding.

Reducing Your Risk Of Complications

You can reduce your risk of certain complications by:

• Getting up out of bed as soon as your healthcare team says you can, and moving about in your bed as much as possible, to protect your skin and strengthen your muscles. Tell your nurse and doctor if you are too uncomfortable to move about.

• Notifying your doctor immediately of any concerns, such as bleeding, fever, or increase in pain

• Taking your medications exactly as directed

• Telling all members of your care team if you have allergies or sensitivities

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Why Might I Need A Hip Pinning

You might need a hip pinning if you have had a broken hip. Hip fractures often must be fixed with surgery. Depending on the type and complexity of your break, as well as your health, you may need either a hip replacement or a hip pinning.

In general, if you have a break that involves the head and neck of the femur , you are likely a good candidate for hip replacement or pinning. Based on the nature of the break and how much the bone has moved out of place, the blood supply to the head of the femur may be damaged. This can lead to death of the bone in that area. The term for this is avascular necrosis. It is most common in older adults. A hip replacement can prevent problems such as arthritis that may happen because of avascular necrosis.

Hip pinning is a treatment choice in younger adults and children. Its also good for hip fractures that happen between the greater and lesser trochanter . Other types of implants are more typical for breaks that are farther down the leg .

Hip fractures often occur because of falls or some other form of blow to the hip. Health problems that raise the risk for falls include:

• Visual problems

Conditions such as osteoporosis, cancer, and repetitive stress injuries also can weaken bones. That can increase your risk for hip fracture.

Potential Complications Of Hip Fracture Orif

ORIF surgeries are quite common with the high number of hip fractures that occur every year. Despite this, complications are possible including:

• Failure of the bone to heal

• Nerve damage from the fracture itself or the procedure

• Fat embolism, which is when some fat tissue leaks from the bone marrow and like a blood clot, it can travel to other parts of your body and cause a pulmonary embolism, heart attack or stroke.

• Hardware failure, such as breakage of wires, screws, and other implants

• Irritation from the hardware if it rubs against the tissues

• Pressure sores from prolonged bedrest during recovery

• Urinary tract infections. Many patients who have hip fracture repair surgery also have a urinary catheter for a few days after surgery. The catheter could increase your risk of developing a urinary tract infection.

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How Can A Physical Therapist Help

The doctor in charge of your care will determine when the time is right for you to see a physical therapist to assist you with further recovery. Your physical therapist will design a specific treatment program to restore function and help you return to activities of daily living.

Physical therapists support your recovery by helping you:

• Improve the movement in your leg, hip, and back.
• Strengthen your muscles.
• Improve your standing balance and ability to walk.
• Return to the level of activity that you enjoyed before the break. This may include a return to sports like tennis, golf, or bike riding for people who were living a physically active lifestyle.

Your treatment program, based on your unique condition and goals, will be designed to help you return to your regular activities and may include:

Use of an assistive device. At first, your physical therapist may prescribe the use of an assistive device, such as a walker or crutches, and teach you how to use it. Many femur fractures require patients to avoid putting any weight on the broken leg to allow time for the bone to heal. Some people may be allowed to put a small amount of weight on the leg. Each personâs recovery is different. Older adults and people with other health conditions may need to first use a wheelchair.

Manual therapy. Your physical therapist will provide manual therapy to gently help you start to regain motion. They may perform gentle exercises that you canât perform yourself at first.

What Freud Can Teach Us About Hip Orif Physical Therapy Protocol

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