intertrochanteric fracture and its physiotherapy managment

1. INTERTROCHANTERIC FRACTURE

2. CONTENTS
 INTRODUCTION
 EPIDEMOLOGY
 MECHANISM OF INJURY
 CLINICAL FEATURES
 MANAGEMENT
i. CONSERVATIVE
ii.SURGICAL
 PT POST SURGERY
 COMPLICATIONS
 REFERENCES

3. INTRODUCTION
Trochanteric fractures are the fractures distal to the femoral
attachment of the hip joint capsule.
 Intertrochanteric fracture
 Subtrochanteric fracture

4. Intertrochanteric fracture:
The fractures in the region of the greater trochanter of femur to the
lesser trochanter along the intertrochanteric line outside the hip
joint capsule is called an intertrochanteric fracture.

6. Subtrochanteric fracture
The fractures distal to lesser tronchanter (within
2inches) is called a subtronchanteric fracture

8. EPIDEMOLOGY
 Increases after 50 years of age
 Female :Male ratio 2:1
 Seen together with fracture neck of femur

9. MECHANISM OF INJURY
 Intertrocanteric fracture is commonly seen in elderly with
degenerative or senile and post menopausal osteoporosis the
mechanism of injury would a trival trauma like stuble or a fall .
 It is rare in young adults causes would be major trauma

10. CLINICAL FEATURES
 Pain in the hip or groin region
 Localised tenderness
 Inability to bear weight
 Limb appears short and markedly externally rotated
 Stiffness ,burising,swelling in around hip area

11. MANAGEMENT
 Conservative
i. Skeletal traction
ii.Pop hip spica
iii. Pop derotation bar
 Surgical-Open reduction internal fixation
i. Dynamic hip screw
ii.Ender’s nail
iii. Proximal femoral nail or gamma nail

12. Skeletal traction:
● It works under the bio-mechanics of stress sharing
devices by secondary mode of bone healing.
 It is used in terminally ill patients who are incapable of
enduring open reduction and internal fixation with a
sliding hip screw .Ex:Buck’s traction ,Russells’s traction.
 It is maintained until fracture becomes stable and less
painful.
 Complications:Venous pooling,thrombosis,pressure
ulcers

13. PoP derotation bar :
 It is used in elderly patient when surgery is not
indicated.
 It maintains neutal rotation and prevent external
rotation deformity.
 Fracture reduction is not accurate and may have
complication like malunion,coxa vara

14. Dynamic hip screw :
 Stress sharing
 Secondary mode of bone healing

15. Ender’s nail :

16. Proximal femoral nail /gamma nails:

17. PHYSIOTHERAPY POST SURGERY
Recovery time : 15-20 weeks; Based on patient cooperation and
condition
Post op. Day 1-1 week :
 Gentle active ROM exercise to hip ,knee (flexion ,extention
,abdution adduction )- to maintain range of motion.
 Isometrics to gluteal muscles and quadraceps -strengthening
 Isotonic exercise of ankle- to maintain strength and hep
prevent thrombosis
 Ankle toe movements- to prevent edema and stiffness of the
joint.

18.  crutch muscles strengthening- for gait training
 Weight bearing can be started (cancellanous bone) ; If its
stable fracture then weight bearing as tolerated. And toe
touch weight bearing when fracture is unstable
● For ambulation ;2 point or 3 point gait training can be
done with assistive devices
 Avoid passive range of motion exercises
 Avoid strenthening of adductors ;this will create stress
on fracture site

19. 2nd
week :
 Gentle active ROM exercise to hip ,knee - to maintain range of
motion. 90 degree flexion of hip is achievable
 Isometerics to gluteals,hamstrings.quadraceps muscles -for
strenghting .
 crutch muscles strengthening- for gait training

20.  Weight bearing can be started (cancellanous bone) ; If its
stable fracture then weight bearing as tolerated. And toe
touch weight bearing when fracture is unstable.
 For ambulation ;2 point or 3 point gait training can be done
with assistive devices
 Avoid standing on affected leg without support
 Avoid passive range of motion exercises

21. 4-6 weeks :
 Active ROM exercise to hip ,knee - to maintain range of
motion.
 If muscle shortening is noted then active assisted range of
motion to strech muscles.
 Gentle passive strech can also be done
 Isometerics to gluteals,hamstrings.quadraceps muscles
-for strenghting .when hip joint complete motion is
achieved strengthing can be progressed to progressive
resistance exercise
( quadraceps,hamstrings,gluteals,illiopsoas,adductors,abd
uctors)
 If pain persists modalities like moist heat ad hydrotherpy
can be given

22.  Weight bearing as tolerated
 Encourage independent ADLS
 Static balancing
 Weight shifts
 Avoid postural swaying
 Avoid torsional stress of fracture site which occurs at
extreme rage of motion

23. 8-12 weeks :
 Hip ,knee,ankle,full range of motion exercises
 If range of motion is limitedthen passive range of motion
exercises and gentle streching can be given
 Progressive resistance exercise to hip & knee
 Wean from assistive devices.
 Stair climbing (step over step) if fracture is healed
 Gait traning with all phases
 Full weight bearing activity

24. Complications :
 Malunion
 Delayed
 Nonunion
 Limb shortening
 Angular deformity
 Rotational malunion