CHARLES UNIVERSITY IN PRAGUE
FACULTY OF PHYSICAL EDUCATION AND SPORTS
Department of Physiotherapy
Case study of physiotherapy treatment of a patient with the diagnosis of pertrochanteric fracture of the left hip
Bachelor’s thesis
Supervisor: Mgr. Michaela Stupková Author : Persia Ioannou
Prague, 2018
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Abstract
Title: Case study of physiotherapy treatment of a patient with the diagnosis of pertrochanteric fracture of the left hip joint.
Thesis aim: The aim of this thesis is to initially review the anatomy, kinesiology and biomechanics underlying the patient’s condition, as well as demonstrate, analyze and evaluate the therapeutic units that were provided.
Clinical findings: This study was evaluating the state of a 40- year-old patient with the main diagnosis of pertrochanteric fracture of the left hip joint. The assessment showed reduced range of motion and mobility, with differentiation in the condition of the muscles.
Also, there was atrophy of the left thigh muscles and the restricted movements.
Methods: All the used procedures were based on the literature given thought by the Charles University in Prague, Faculty of Physical Education and Sports.
Result: The patient made remarkable progress after only 6 sessions of therapy. The patient underwent great progress in terms of pain, range of motion and muscle imbalance in the area of hip. Furthermore, the therapies have shown to be very effective concerning the patient’s diagnosis.
Conclusion: The therapies that were performed were effective in this patient’s concrete diagnosis.
Keywords: Hip joint, fracture, pertrochanteric, PFN, DHS, treatment, rehabilitation, exercises.
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Abstrakt
Název: Případová studie fyzioterapeutické léčby pacienta s diagnózou pertrochanterické zlomeniny levého kyčelního kloubu.
Cílem práce: Cílem této práce je zpočátku přezkoumat anatomii, kineziologii a biomechaniky, které jsou základem stavu pacienta, a zároveň demonstrovat, analyzovat a vyhodnocovat poskytované terapeutické jednotky.
Klinické nálezy: Tato studie hodnotila stav 40letého pacienta s hlavní diagnózou pertrochanterické zlomeniny levého kyčelního kloubu. Posouzení ukázalo snížený rozsah pohybu a pohyblivosti s diferenciací stavu svalů. Také došlo k atrofii levých stehenních svalů a omezených pohybů.
Metodika: Všechny použité postupy byly založeny na literatuře, kterou uvažovala Fakulta tělesné výchovy a sportu Univerzity Karlovy v Praze.
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Výsledek: Pacient dosáhl pozoruhodného pokroku po pouhých 6 ošetřeních. Pacient udělal velký pokrok z hlediska bolesti, rozsahu pohybu a svalové nerovnováhy v oblasti kyčle.
Kromě toho se terapie ukázaly jako velmi účinné v diagnostice pacienta.
Závěr: Terapie, které byly provedeny, byly účinné v konkrétní diagnóze tohoto pacienta.
Klíčová slova: Kyčelní kloub, zlomenina, pertrochanteric, PFN, DHS, léčba, rehabilitace, cvičení.
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Declaration
I hereby declare that this work is entirely individually myself and on my own practice that took place at Ustředni Vojenská Nemocnice in Prague from 8th of January 2018 until 19th of January 2018. My practice was under supervision of my supervisors Mgr.
Kozderkova Romana and by Mgr. Michaela Stupkova in Department of Physiotherapy in Faculty of Physical Education and Sport of Charles University in Prague.
I also state that all the information, examination and therapeutic procedures, which are presented in this dissertation, were based on my knowledge gained from books, journals, reports and by attending lectures and seminars that I received from the professors of the Charles University in Prague at FTVS.
I declare that no invasive methods were used during the practical approach and that the patient was fully aware of the procedures at any given time.
Prague, April 2018 Persia Ioannou
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Acknowledgement
Firstly, I would like to express my gratitude towards my family for supporting and encouraging me through my whole studies in Czech Republic. Additionally, I want to express my thankfulness to my boyfriend who was next to me and offered me his help and support too. In addition I would like to show my great appreciation to my professors for educating and helping me during my studies in the Faculty of Physical Education and Sport in Prague.
Also, I would like to express my deepest thanks to my supervisor Mgr. Michaela Stupkova, who has helped me by giving me instructions and advice for the development of my Bachelor Thesis. Moreover, I would also like to express my thanks to my supervisor Mgr. Kozderkova Romana at the Ustředni Vojenská Nemocnice military hospital in Prague, where my clinical practice took place, for the special knowledge I was able to gain from her.
Finally, I would like to give my special thanks to my best friend Sophia Tzioni, that stood by me in every case, by helping and guiding me in every possible way.
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Dedication
I dedicate this thesis to my wonderful family, especially to my mother, Donia who has always been supportive of me throughout my whole life and most importantly now that I am away. They have always been there for me and without them I wouldn’t have been able to pursue my goals and dreams.
This thesis is especially dedicated to my grandmother, Persa, who even though she passed away, she is still in my heart and mind, as she will always be my greatest inspiration.
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Table of Contents
Abstract ... i
Abstrakt ... ii
Declaration ... iv
Acknowledgement ...v
Dedication ... vi
Table of Contants ... vii
1 Introduction ...1
2 General Part ...2
2.1 Hip Joint ...2
2.1.1 Anatomy of the hip joint...2
2.1.2 Anatomy of acetabulum ...2
2.1.3 Anatomy of femoral bone ...2
2.1.4 Ligaments of the hip joint...4
2.1.5 Muscles Anatomy, Innervation, and Function ...5
2.2 Kinesiology of hip joint...7
2.2.1 Introduction of kinesiology of the hip joint ...7
2.2.2 Movements of flexion of the hip ... 10
2.2.3 Movements of extension of the hip ... 11
2.2.4 Movements of abduction of the hip ... 12
2.2.5 Movements of adduction of the hip ... 12
2.2.6 Internal rotation of hip ... 13
2.2.7 External rotation of hip... 14
2.3 Biomechanics of hip joint ... 15
2.3.1 Mechanical loads of hip joint ... 15
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2.3.2 Weight – bearing and non – weight bearing functions of hip muscles ... 17
2.3.3 Angle of inclination... 17
2.3.4 Coxa – vara and coxa – valga of hip joint ... 18
2.4 Fracture of hip joint... 20
2.4.1 Epidemiology of hip fracture ... 20
2.4.2 Introduction of fracture of the hip joint ... 21
2.4.3 Intertrochanteric fracture: ... 22
2.4.4 Pertrochanteric fracture: ... 22
2.4.4.1 Etiology: ... 23
2.4.4.2 Clinical picture of post- surgery: ... 24
2.4.4.3 Diagnosis procedures: ... 24
2.4.4.4 Treatment: ... 25
2.4.5 Pre- operative physiotherapy: ... 26
2.4.6 Post- operative physiotherapy:... 27
3. Special Part - Case Study ... 29
3.1Methology: ... 29
3.2 Anamnesis: ... 30
3.2.1 Status presents: ... 30
3.2.1.1 Objective: ... 30
3.2.1.2 Subjective: ... 30
3.2.2 History Anamnesis: ... 30
3.2.3 Injury Anamnesis: ... 30
3.2.4 Surgery Anamnesis: ... 30
3.2.5 Medical Anamnesis: ... 30
3.2.6 FamilyAnamnesis: ... 31
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3.2.7 Social Anamnesis: ... 31
3.2.8 Occupational Anamnesis: ... 31
3.2.9 Allergy Anamnesis: ... 31
3.2.10 Hobbies: ... 31
3.2.11 Abuse: ... 31
3.2.12 Prior rehabilitation: ... 31
3.2.13 Except from patient’s health care file: ... 31
3.2.14 RHB indications: ... 32
3.2.15 Differeential balance: ... 32
3.3 Initial Kinesiology examination: ... 33
3.3.1 Observation: ... 33
3.3.2 Postural examination (static): ... 33
3.3.2.1 Anterior view: ... 33
3.3.2.2 Posterior view: ... 34
3.3.2.3 Side view: ... 34
3.3.3 Palpation of pelvis: ... 35
3.3.4 Assessment of stereotype (pattern) of breathing: ... 35
3.3.5 Gait analysis: ... 36
3.3.6 Special examination: ... 36
3.3.7 Anthropometric Measurements: ... 36
3.3.8 ROM examination by Janda (SFTR form): ... 37
3.3.9 Movement patterns: ... 38
3.3.10 Fascia examination: ... 38
3.3.11 Muscle palpation: ... 39
3.3.12 Length test: ... 39
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3.3.13 Strength test: ... 40
3.3.14 Joint play examination: ... 40
3.3.15 Neurological examination: ... 41
3.3.15.1 Superficial sensation ... 41
3.3.15.2 Deep tendon reflexes: ... 41
3.4 Examination conclusion: ... 42
3.5 Rehabilitation plan: ... 43
3.5.1 Short – term rehabilitation plan: ... 43
3.5.2 Long – term rehabilitation plan: ... 43
3.6 Therapy summary: ... 44
3.6.1 Day1 08/01/2018 ... 44
3.6.2 Day2 10/01/2018: ... 46
3.6.3 Day3 12/01/2018: ... 48
3.6.4 Day4 15/01/2018: ... 51
3.6.5 Day5 17/01/2018 ... 54
3.6.6 Day6 19/01/2018 ... 57
3.7 Final kinesiologic examination: ... 62
3.7.1 Observation: ... 62
3.7.2 Postural examination (static): ... 62
3.7.2.1 Anterior view: ... 62
3.7.2.2 Posterior view: ... 63
3.7.2.3 Side view: ... 63
3.7.3 Palpation of pelvis: ... 64
3.7.4 Assessment of stereotype (pattern) of breathing: ... 64
3.7.5 Gait analysis: ... 64
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3.7.6 Special examination: ... 65
3.7.7 Anthropometric Measurements: ... 65
3.7.8 ROM examination by Janda (SFTR form): ... 66
3.7.9 Movement patterns: ... 67
3.7.10 Fascia examination: ... 67
3.7.11 Muscle palpation: ... 68
3.7.12 Length test: ... 68
3.7.13 Strength test: ... 69
3.7.14 Joint play examination: ... 69
3.7.15 Neurological examination: ... 70
3.7.15.1 Superficial sensation ... 70
3.7.15.2 Deep tendon reflexes: ... 70
3.8 Examination conclusion: ... 71
3.9 Evaluation of the Effect of the therapy: ... 72
4. Conclusion: ... 73
5. Bibliography: ... 74
6. Supplements: ... 77
6.1 Ethical Board ... 77
6.2 INFORMOVANÝ SOUHLAS ... 78
6.3 Table of Figures: ... 79
6.4 Table of Tables: ... 80
6.5 List of Abbreviations: ... 81
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1. Introduction
My bachelor practice took place in Ustředni Vojenská Nemocnice military hospital in Prague. This practice started on Monday 8rd of January 2018 and ended on Friday 19th of January 2018.
The case study of physiotherapy treatment that I chose was for a patient with the main diagnosis of pertrochanteric fracture. The patient had with me 6 sessions of physiotherapy to improve his overall condition. On the first day 08/01/2018, we took the anamnesis, did the examination of the patient and did some therapies. As well as the first day, on the last day 19/01/2018, we did therapy and we took our final kinesiologic examination.
The thesis is divided into two parts. Theoretical parts describe the anatomy, kinesiology, and biomechanics of the hip areas as well as special chapter that includes the clinical presentation, pathogenesis, and intervention of the impaired joint. In the practical part, I analysed every procedure I have done with my patient, all the examinations, conclusions, therapies, results, goals, and evaluation of the effect of the therapy are mentioned.
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2. General Part 2.1 Hip Joint
2.1.1 Anatomy of the hip joint
Firstly, the hip joint is a large, ball and socket synovial type between the head of the femur and acetabulum of the pelvis which connects the leg with the trunk, joining the lower limb to the pelvic girdle.
Also, the ilium is found at the rear of the hip joint while the location of ischium is at the lower front of the joint. The pubis is found above the joint.
In general, the hip joint serves a major function of connecting the lower limb to the girdle of the pelvic and it is an articulation designed for stability and weight bearing activities. It consists from layers such as, the bone (deepest) the ligaments of the capsules and the muscles on the top. (1,3)
Figure 1: Hip joint in posterior view [2]
2.1.2 Anatomy of acetabulum bone
Importantly, the acetabulum is the large cup-shaped cavity and it is located on the lateral surface of the pelvic bone in the region where the ilium, pubis and ischium fuse has a half of a sphere shape that almost entirely encompasses the hemispherical head of the femur and contributes substantially to joint stability while its margin is marked inferiorly by acetabular notch. What is more, the wall of the acetabulum consists of non-articular and articular parts. The non-articular part is rough and forms a shallow circular depression, the acetabulum fossa, in central and inferior parts of the acetabular floor. In contrast, the articular surface is broad and surrounds the anterior, superior and posterior margins of the acetabular fossa. Lastly, the lunate surface is a crescent shape surface surrounding the acetabular fossa. (1,5,)
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2.1.3 Anatomy of femoral bone
The femur as a bone is the longest, heaviest and strongest in the skeleton, it has a just about entirely cylindrical shape in its greater part and it is located in the thigh of each lower limb.
The proximal part of the femur consists of a spherical shaped head, a short and cylindrical neck, which is in the middle between head and body (shaft) of the femur, and two trochanters; shaft of the femur is almost cylindrical, the greater trochanter, is an easily palpable bony landmark for clinicians is at the lateral side of the hip joint while the lesser trochanter provides with no palpation.
The head of the femur consists of an articular and non-articular surface as well.
Continuing anatomically, directly in the center of the head a small depression can be found which is called Fovea, and is the non-articular part of the bone. The rest of the head surface together with the lunate structure of the acetabulum forms the articulation of the hip joint.
However, the distal part of the femur is larger in comparison to the rest of the bone and the proximal part consists of two condyles, the lateral and medial femoral, which both serve as attachment points for muscles and bony structures in the knee joint articulation. [1,8,9]
Figure 2: Anterior view of femur (4)
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2.1.4 Ligaments of the hip joint
Ligaments are considered to be in the most important components of the hip joint due to their key function in the joint. Mainly, the ligaments ensure that the joint is stable even in cases where it is subjected to weight pressure. The fibers of all three ligaments (iliofemoral ligaments, pubofemoral ligaments and ischiofemoral ligaments) are oriented in a spiral fashion around the hip joint so that they become taut when the joint is extended. There are three types of ligaments noted below∶
Iliofemoral ligament: It is located in the anterior of the hip joint and it is a very strong triangular ligament. Its apex is attached to the ilium between the anterior inferior iliac spine and the margin of the acetabulum. Moreover, its base is attached along the intertrochanteric line of femur. It should be mentioned that, the outer bands of the ligament attaching to the upper and lower parts of the intertrochanteric line are the strongest parts, with the central area being thinner and weaker. This results in the ligament appearing a Y shape.
Ischio-femoral Ligament: It is considered to be the second type of ligament that is found in the hip joint. Also, it is the only type of ligament that is found on the posterior end of the hip. Ischio-femoral ligament mostly serves an important purpose of attaching the posterior side of the acetabulum rim and labrum. It basically wraps itself around the joint and then attaches into the anterior part of the femur bone. The position and orientation of Ischio-femoral Ligament has two functions; first it strengthens the joint capsule at the posterior end and secondly it prevents the hip joint from extending too much.
Pubofemoral ligament: This ligament has got a triangular-shape and it is anteroinferior to the hip joint. It principally, runs from the iliopubic eminence and superior pubic ramus to the lower part of the intertrochanteric line, blending with the inferior band of the iliofemoral ligament. [1]
Figure 3: Ligaments of hip joint in anterior view. [6]
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2.1.5 Muscles, Anatomy, Innervation and Function
Muscle Origin Insertion Innervation Action
Gluteal Maximus
External surface of ilium behind posterior gluteal line, fascia of erector spinae
Posterior aspect of iliotibial tract of fascia lata
and gluteal tuberosity of proximal femur
Inferior gluteal nerve
Powerful extensor of flexed femur at
hip joint
Gluteal Medius
External surface of ilium between anterior
and posterior gluteal line
Elongate facet on the lateral surface of the
greater trochanter
Superior gluteal nerve
Abducts femur at hip joint;
holds pelvis secure over stance leg and pelvic drop on the opposite
swing side during walking
Gluteal minimus
External surface of ilium between inferior
and anterior gluteal lines
Linear facet on the anterolateral
aspect of the greater trochanteric
Superior gluteal nerve
Abducts femur at hip joint;
holds pelvis secure over stance leg and pelvic drop on the opposite
swing side during walking Rectus Femoris Anterior inferior
iliac spine
Tibial tuberosity
Femoral nerve
Hip flexion, knee extension Vastus Medialis Medial lip of
linea aspera
Tibial tuberosity
Femoral
nerve Knee extension
6 Vastus Lateralis Lateral lip of
linea aspera
Tibial tuberosity
Femoral
nerve Knee extension Vastus
Intermedius
Upper anterior femoral shaft
Tibial tuberosity
Femoral
nerve Knee extension Psoas Major Posterior
abdominal wall
Lesser trochanteric of
femur
Anterior rami nerve
Flexes the thigh at the hip joint
Iliacus Posterior abdominal wall
(iliac fossa)
Lesser trochanteric of
femur
Femoral nerve
Flexes the thigh at the hip joint
Tensor fasciae latae
Lateral aspect of crest of ilium between anterior
superior iliac spine
Iliotibial tract fascia lata
Superior gluteal nerve
Stabilizes the knee in extension
Sartorius Anterior superior iliac
spine
Medial surface of tibia just inferomedial tibial tuberosity
Femoral nerve
Flexes the thigh at the hip joint
and flexes the leg at the knee
joint Gracilis A line on the
external surfaces of the body of
the pubis
Medial surface of proximal shaft of tibial
Obturator nerve
Adducts thigh at hip joint and flexed leg at knee joint Pectineus Pectineal line
and adjacent bone of pelvis
Oblique line extending from
base of lesser trochanteric to linea aspera on
posterior
Femoral nerve
Adducts and flexes thigh at
hip joint
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surface of proximal femur
Adductor longus External surface of body of pubis
Linea aspera on middle one- third of shaft of
femur
Obturator nerve
Adducts and medially rotated
thigh at hip joint Adductor brevis External surface
of body of pubis and inferior pubis ramus
Posterior surface of proximal femur
and upper one- third of linea
aspera
Obturator nerve
Adducts thigh at hip joint
Adductor magnus Adductor part- ischiopubic
ramus Hamstring part-
ischial tuberosity
Linea aspera, supracondylar line, adductor
tubercle
Obturator and sciatic nerve
Adducts and medially rotates
thigh at hip joint
Obturator externus
External surface of obturator membrane and
adjacent bone
Trochanteric fossa
Obturator nerve
Laterally rotates thigh at hip
joint
Biceps Femoris Ischia tuberosity Head of the fibula
Tibial portion of sciatic n.
Hip extension, knee flexion, Semitendinosus Ischia tuberosity Pes anserinus Tibial portion
of sciatic n.
Hip extension, knee flexion,
8 Semimembranosu
s Ischia tuberosity Tibial medial condyle
Tibial portion of sciatic n.
Hip extension, knee flexion, Gastrocnemius Medial/Lateral
femoral condyle
Calcaneal
tuberosity Tibial nerve Knee flexion, plantar flexion
Table 1: Muscle anatomy, innervation and function [1].
Figure 4: Muscle anatomy of superficial and deep dissection of femur (posterior view) [7].
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2.2 Kinesiology of the Hip Joint
2.2.1 Introduction of Kinesiology of the Hip Joint
To begin with, hip kinesiology is the study of the mechanics of hip movements.
In this section, the muscles that are involved in hip extension, hip flexion, hip internal rotation, hip external rotation, hip abduction and hip adduction are identified. (3)
Specifically, the hip joint serves as a central pivot point for the body as a whole, which is very important in weight bearing and walking activities since it provides the movement with stability. Basically, this large ball and socket joint allows simultaneous, triplanar movements of the femur relative to the pelvis, as well as the trunk and pelvis relative to the femur. The convex shaped femoral head fits into and articulates with the concave shaped acetabulum and slides in the direction opposite the movement of the thigh. (3, 12)
Generally, the hip is a very stable joint and the most difficult joint to dislocate but lacks some range of motion. Therefore, it is a lose some ROM. Being a triaxial joint, the motions of the hip joint are flexion and extension in the sagittal plane, with approximately 120 degrees of flexion and 15 degrees of extension. Also, abduction and adduction occur in the frontal plane, with about 45 degrees of ABD. Whereas, ADD is usually thought of as the return to anatomical position, although there is approximately an additional 25 degrees of motion possible beyond the anatomical position. In the transverse plane, medial and lateral rotations are sometimes referred to as internal and external rotation. There are approximately 45 degrees of rotation possible in each direction from the anatomical position. (3)
As a result, lifting the foot off the ground, reaching towards the floor or rapidly rotating the trunk and pelvis while supporting the body over one limb typically needs strong and specific activation of the hip’s surrounding musculature. An abnormal performance of the muscles of the hip, may modify the distribution of forces across the joint’s articular surfaces, potentially causing degenerative changes in the articular cartilage, bone and surrounding connective tissues. What is more, when a particular muscle or muscle group is weak, painful, dominant or tight, can well affect the alignment across the lumbar spine, pelvis and femur, ultimately affecting the alignment throughout the entire lower limb. (11) Moreover, the amount of gliding differs
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depending on the inclination of the neck during the movement of the hip. When the hip is flexed or extended, the head of the femur rotates within the acetabulum producing a slight amount of gliding to and fro. The upward inclination of the neck of femur in the acetabulum in the conversely rotation of the hip is accompanied by a certain amount of gliding. (11)
To sum up, the three kinds of hip joint movement are taking place in different combinations of axis and planes. Extension and flexion are realized in the coronal axis in a sagittal plane. ABD and ADD in the sagittal axis in a coronal place while external and internal rotation on the longitudinal axis in transverse plane. (3)
2.2.2 Movements of flexion of the hip
Hip flexor is the movement of the anterior femur from anypoint towards the anterior pelvis in the sagittal plane. In other words, the flexion of the hip is the movement in which the whole lower extremity moves in anterior and cranial direction.
(12)
Firstly, the main prime mover of hip flexion is psoas muscle. The antagonist muscles in this case include biceps femoris, semimembranosus, semitendinosus and gluteus maximus, whereas the synergistic muscles of hip flexion include rectus femoris, sartorius and pectineus. Also, the stabilizers in hip flexion are deep rotators of the hip while fixators comprise of rectus abdominis, erector spinae and obliques. (12)
Particularly, when the knee is extended, flexion of the hip is arrested by the action of the hamstring muscles. However when the knee is flexed, flexion of the hip- joint is arrested by the soft parts of the thigh and abdomen being brought into contact.
The ROM of this movement is about 90⁰ with extended knee, and about 125⁰ with flexed knee. What is more, the muscles which provide the flexion are the Iliopsoas, Rectus femoris, Sartorius, Pectineus, Adductores longus and brevis, Gracilis and the Tensor fascia latae. (10, 12)
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It must be noted that, considerable variations in hip joint motion may occur. In fact, they can deviate from the average values, depending on the age. For example, having in mind the movement of a new born and that of an adult, it is noted that new born babies begin performing flexion but limited extension of their hip. Throughout their physical development in childhood they pass from a point where they gradually increase the amount of hip extension while flexibility tends to gradually decrease throughout childhood and into adulthood. Finally, between the ages 70 and 92 it decreases in all hip motions and abduction motion is especially seen. (10)
2.2.3 Movements of extension of the hip
In general, hip extension is the movement of the posterior femur from any point towards the posterior pelvis in the sagittal plane. In other words, the extension of the hip includes the movement in which the whole lower extremity moves in posterior and cranial direction. Also, the ROM of this movement is about 10⁰ and extension is controlled by the tension of the iliofemoral ligament.
The muscles mainly involved in the movement are the Gluteus maximus, assisted by the hamstring muscles except the short head of biceps femoris. (12)What is more, gluteus maximus acts as the prime mover during hip extension while biceps femoris, semimembranosus and semitendinosus muscles act as major synergists. Psoas, tensor fascia latae, Sartorius, rectus femoris, pectineus and iliacus act as antagonists.
The major stabilizers of hip extension include deep rotators of the hip while gluteus medius muscles act by neutralizing the external rotation of gluteus maximus muscle.
The fixators of hip extension include abdominis muscles, erector spinae muscles and obliques. (12)
Lastly, if the ROM is to be compared to flexion, it can be seen that the extension is much more limited and this is because of the iliofemoral ligament. Similarly, like in flexion, the active extension range is less than the passive. Also, when the knee is flexed, hamstring loses some of their efficiency and thus the range is less than 10. (10)
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2.2.4 Movements of abduction of the hip
Abduction of the hip is the movement the femur in the frontal plane laterally to the side away from the midline. At 45◦ of abduction lateral tilting of pelvis is noticed when we compare the positions of the two posterior superior iliac spines. When abduction reaches the maximum the angle between the two limbs is at 90. Hence, in this position, pelvis is tilted laterally a 45◦ to the supporting limb. (12)Additionally, the abduction of the hip joint is the movement in which the whole lower extremity shifts laterocranially. Abduction is controlled by the medial band of the iliofemoral ligament and the pubocapsular ligament. The ROM of this movement, as mentioned above, is 45⁰ and is usually accompanied by some degree of lateral tilt (elevation) of the pelvis;
this pelvic movement is also called hip hiking.. The muscles providing hip abduction are Gluteus medius and minimus, as well as Tensor fascia latae. (10)
What is important is that, the prime mover of hip abduction is gluteus medius.
Additionally, the synergistic muscles of hip abduction include gluteus minimus and maximus, sartorius and tensor fascia latae. The antagonist muscles include pectineus, adductor longus, gluteus maximus and adductor magnus muscles. A carefully managed equilibrium of strength and elasticity between internal rotators and external rotators guarantees that there is optimum muscular synergies. Also, assisting flexion is prevented by different muscles such as rectus femoris, biceps femoris, semimembranosus, psoas and semitendinosus. The deep rotators of hip act as stabilizers while obliques, erector spinae and rectus abdominis act as fixators of hip abduction.
(12)
2.2.5 Movements of adduction of the hip
On the other hand, adduction is the movement of the femur in the frontal plane medially towards the midline. Clinically it can be described as the contact of the two thighs at the body’s midline (0°). However, the lower extremities may cross over the midline into additional adducted positions of 10°. Since the hip must be in slight flexion to allow clearance for full adduction, adduction is not a pure planar movement.
However, it is a significant movement in many daily activities such as in running, kicking, pivoting, and crossing the thighs during relaxed sitting. (12)
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To continue with, the prime movers of hip adduction are the adductors while synergists include semitendinosus, inferior fibers of gluteus maximus, semimembranosus and quadratus femoris. The antagonistic muscles of hip adduction include gluteus minimus and medius, Sartorius, fascial slips and tensor fascia latae.
Neutralizers of hip adduction include the thigh adductors that facilitate rotation.
Finally, a well-integrated balance of strength and tractability between internal rotators and external rotators facilitates muscular synergies. (12)
Thus, the adduction of the hip joint involves the movement in which the whole lower extremity shifts mediocranially and it is controlled by the thighs coming into contact. The ROM of the movement is about 10⁰ . In adduction muscles such as adductores magnus, longus, and brevis, the Pectineus, and the Gracilis are involved.
(10)
2.2.6 Internal Rotation of Hip
Basically, internal rotation of the hip joint, is the medial rotary movement of the femur in the transverse plane around its longitudinal axis toward the midline. This rotation is controlled by the ischiocapsular ligament and the posterior part of the capsule with the ROM of this movement being 45⁰ . (11, 12)
The inward rotation of the the thigh is mostly the work of the gluteus minimus and the tensor fascia latae. The synergistic muscles of hip internal rotation include biceps femoris, frontal fiber of gluteus medius muscle, semitendinosus, anterior adductors and semimembranosus muscles. Moreover, hip internal rotation is neutralized by gluteus maximus and medius. Although, excessive flexion and adduction is prevented by gluteus minimus. Stabilizers in this case include deep rotators of the hip while fixator muscles comprise of erector spinae, obliques and rectus abdominis.
(10,12)
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2.2.7 External Rotation of Hip
Nevertheless, external rotation of the hip joint, is the movement in which the femur rotates in lateral direction, in the transverse plane around its longitudinal axis away from the midline and it is controlled by the lateral band of the iliofemoral ligament. The ROM of this movement is 45⁰ . (11, 12)
The prime mover of hip external rotation is piriformis and other muscles that are employed in the movement are obturatorius externus and internus, gemellus superior and inferior, and quadratus femoris. Still, muscles that mutually function in the movement are the deep rotators of hip such as biceps femoris, gluteus maximus, sartorius and adductor magnus as well as the posterior strands of gluteus medius.
Whereas, the opposite movement is produced by muscles such as the anterior fiber of gluteus minimus and medius, anterior adductor muscles, semitendinosus and semimembranosus muscles. The hip extension rotation is neutralized by various muscles that include hip flexors and anterior adductors that act by reducing the tendency of exterior rotators to over extend and thus abduct the hip. Stabilizers, in this case, include gluteus medius and minimus or deep rotators of the hip. Lastly, the major fixators of hip external rotation include erector spinae, rectus abdominis and obliques.
(10,12)
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2.3 Biomechanics of Hip Joint 2.3.1 Mechanical Loads of hip joint
Primarily, each hip is burden with weight which is conveyed from the vertebral column through the pelvis girdle. The hip is one of the joints that can bear a large amount of weight and is never fully at rest during the activities of everyday life. In an upright standing position both legs burden with the body weight and each hip can support almost 1/3 of the total weight of the body. Nonetheless, the overall charge on each hip, in this case, is bigger than the weight bolstered, because tension in the large, strong hip muscles additionally appends to the pressure at the joint. Due to muscle tension, the pressure on the hip is more or less the same as the weight of the body during the swing phase of walking.
To continue with, information from femoral implants demonstrates that hip joint loading ranges around 238% of body weight (BW) during the support phase of walking, with values of approximately 251% BW and 260% BW during climbing and descending stairs, correspondingly. Also, when carrying a burden such as a suitcase of 25% body weight on one side raises the burden per 167% on the contralateral hip, when contrasted to the hip on the loaded side. In faster walking, the burden on the hip rises during both swing and support phases. On the other hand, the level of hip loads during jogging can decrease with a smooth gait pattern and soft heel strike.
Concluding, body weight is the power that affects upward through the skeleton from the foot, and muscle tension adds pressure to this large load on the hip.
Fortuitously, the hip joint is well designed to hold up under the large burden it usually supports. Due to the diameter of the humeral head being bigger than the articulating surface of the acetabulum, contact between the two bones during the start of the weight bearing begins around the periphery. As loading increases, the contact area at the joint also increases, such that the pressure levels remain almost stable.
16
Resulting to using a crutch or cane on the side opposite an injured or painful hip being considered salutary because it serves to spread the load more evenly between the legs throughout the gait cycle. During stance, a support opposite the painful hip decreases the amount of tension required from the powerful abductor muscles, reducing, in that way, the burden of the painful hip but at the same time increases the pressure on the opposite hip. (31)
Figure 5: Different forces of hip joint. Wt indicates gravitational force while Fm indicates the muscle force. R indicates joint reaction force. (30).
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2.3.2 Weight-bearing and Non-weight-bearing Functions of Hip Muscles
It is important to bear in mind that, lower extremity muscles must be considered and examined in cases of weight-bearing and in cases of non-weight-bearing as well.
During weight-bearing and body movement lower extremities seem to significantly contribute to function. The control and support of the weight of the head, arms, and trunk (HAT) has to do with controlling and supporting almost two-thirds of one’s body weight (e.g., 100 lb in a 150-lb individual). Conversely, the mass moved when moving a single lower extremity is equal to just one-sixth of one’s body weight (e.g., 25 lb in a 150-lb individual). (10)
Evidently, supporting the trunk and the upper body requires a much larger force and greater control than those of a single extremity. Non weight bearing (NWB) lower extremity movements are those that render speed to movements like swinging the leg during kicking, running, or walking. Nonetheless, in weight bearing (WB) movements, the muscles of the lower extremity need to perform forceful contractions upon the extremity’s fixed distal segment. A movement like that depends on hip and pelvic muscles to grant pelvic stability on the moving extremity. In functional terms, even slight to moderate muscle attenuation significantly affects the ability to perform proper closed chain functions even though open chain motions without resistance might seem intact. (10)
2.3.3 Angle of Inclination
Primarily, the angle of inclination of the proximal femur refers to the angle within the frontal plane between the femoral neck and the medial side of the femoral shaft. At birth this angle measures around 140 to 150 degrees. This is mainly due to the loading across the femoral neck during walking, this angle generally decreases to its typical adulthood value of about 125 degrees and optimizes the alignment of the joint surfaces. Also, a changed angle of inclination is referred to as either coxa vara or coxa valga. Thus, coxa vara (Latin coxa, hip, + vara, to bend inward) refers to an angle of inclination markedly less than 125 degrees, whereas coxa valga (Latin valga, to bend outward) refers to an angle of inclination markedly greater than 125 degrees. These irregular angles can critically change the articulation between the femoral head and the
18
acetabulum, thereby affecting hip biomechanics. Lastly, serious malalignment can result in dislocation or stress-induced degeneration of the joint. (11)
Figure 6: Angle of inclination in the proximal femur (11)
2.3.4 Coxa – Vara and Coxa – Valga of hip joint
Broadly, the surgical operation known as coxa vara (or valga) osteotomy intentionally alters a pre-existing angle of inclination. Mainly, this operation involves cutting a wedge of bone from the proximal femur, thereby changing the orientation of the femoral head to the acetabulum. The basic goal of this operation is too often improve the congruency of the weight-bearing surfaces of the hip. Notably, no matter what the kind or the reason of the hip surgery is, less muscle force needs to be generated on the hip during the stance phase of walking because by reducing the magnitude of muscular based joint forces may assist an arthritic or unstable prosthetic hip from excessive wear during walking.
Furthermore, some patients, after undergoing a varus osteotomy, ameliorate the stability of the joint by aligning the femoral head more directly into the acetabulum.
Also, a probable side effect of coxa vara is an augmented bending moment (or torque) located across the femoral neck. Consequently, the functional length of the hip abductor muscles may be decreased by Coxa vara, reducing, in that way, the ability of these muscles to generate force and raising the probability of a “gluteus medius limp.” The increased abduction torque potential gained by the increased hip abductor moment arm can be triggered by the loss in muscle force.
19
Nevertheless, coxa valga can derive from a surgical operation or from a pathological reason such as hip dysplasia. Fortunately, a probable positive outcome of the valgus position is a reduction in bending moment arm which changes the angle of inclination of the proximal femur and changes the biomechanics of the joint. These changes may have positive or negative biomechanical impact. The varus position augments the moment arm of the hip abductor force and the better leverage increases the abduction torque generated per unit of hip abductor muscle force. This condition may benefit people with weak hip abductor. Moreover, by augmenting the leverage of the abductor muscles permit a given level of abduction torque across the femoral neck.
This condition also decreases the vertical shear across the femoral neck. The valgus position may, however, raise the functional length of the hip abductor muscles, thus improving their ability to generate force.
In addition, some patients, after undergoing a varus osteotomy, ameliorate the stability of the joint by aligning the femoral head more directly into the acetabulum.
Importantly, a probable side effect of coxa vara is an augmented bending moment (or torque) located across the femoral neck. On the contrary, a possible negative effect of coxa valga is the reduced moment arm available to the hip abductor force. In extreme coxa valga, the femoral head can be locateded more lateral to the acetabulum, much likely favouring dislocation. The consequences coxa valga shows in function may be hip instability with a predisposition to dislocation or subluxation. Also, the limb might appear longer.
Notably, a probable positive outcome of the valgus position is a reduction in bending moment arm which changes the angle of inclination of the proximal femur and changes the biomechanics of the joint. As a result, these changes may have positive or negative biomechanical impact. The varus position augments the moment arm of the hip abductor force. The better leverage increases the abduction torque generated per unit of hip abductor muscle force. Finally, this condition may benefit people with weak hip abductor. Moreover, by augmenting the leverage of the abductor muscles permit a given level of abduction torque across the femoral neck. This condition also decreases the vertical shear across the femoral neck. The valgus position may, nevertheless, raise the functional length of the hip abductor muscles, thus improving their ability to generate force. (10, 11)
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2.4 Fracture of hip joint
2.4.1 Epidemiology in hip fracture
To begin with, based on the above chart it can be clearly shown that Austria, Norway and Sweden hold the higher number of women suffering from hip fracture, with numbers exceeding 700 000 women. Importantly, the highest number of men suffering from hip fracture are also held by the same countries along with the Netherlands, with a rate of over 300 000 men. Although, in Austria men suffering from these disease transcend the number of 500 000 women, which is a substantial higher rate from even the second and third country, accordingly. It is crucial to note that the difference of men and women rates is significantly great, as in all the above countries fewer men than women suffered from hip fracture. This can be indicated in a greater degree in Norway and Sweden where women experiencing hip fracture are double or more the numbers of men experiencing the disease. Lastly, Hungary, Greece, England and Switzerland have significantly lower rates in both men and women, compared to the previously mentioned countries, suffering from hip fractures. (13)
Table: Age- standardized hip fracture rates (per 100 000 population) across different country (13)
0 200 400 600 800 1000
Switzerland England Greece Sweden
Norway Austria Hungary The Netherlands
Women Men
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2.4.2 Introduction of Fracture of the Hip joint
It is well known that hip fracture as an incidence increases with the age and also constitutes as the second leading cause of hospitalization in the elderly people. The most important factors that often have to do with the increased incidence of hip fracture in the elder people are the higher occurrence of falling and age-related osteoporosis. It is considered a severe health issue for older people which is increasing in the first three months after the fracture. Furthermore, medical condition which exists prior to the fracture itself is in most cases the problem. Importantly, women sustain the 80% of people over 65 years old who maintain hip fracture. On the other hand, the mortality percentage in men is twice as high. According to research, only 40% of people can perform basic functional activitiesafter 6 to 12 months of their hip fracture. Hip fracture can result in significant loss of function. (11)
It is important to note that, the fracture line of an intertrochanteric fracture goes along the base of the femoral neck amongst the trochanters, as in pertrochanteric fracture in line includes both trochanters or one of the two. As an effect, the pertrochanteric fracture is often less stable than an intertrochanteric fracture. (11,16)
On the other hand, the cortical bone in the proximal femur aids to protect against hip fractures. In cases where the hip bones are in good health and mineralization, they are able to maintain tremendous loads, as shown in many weight-lifting events.
In general, extracapsular fracture consist of intertrochanteric and pertrochanteric fractures. These can be further classified as stable or unstable fractures. Unstable fractures have loss of bone continuity posteromedially along the proximal femur, which is where most weight bearing occurs. Usually, the pertrochanteric fractures is less stable than the intertrochanteric fracture due to the fact the latter goes through the vase of the femoral neck between the trochanters. Generally, these reguire anatomic reduction and fixation.
22
2.4.3 Intertrochanteric Fracture
The intertrochanteric proximal femoral fractures are considered to be a real a challenge for the healthcare system around the world, and as a result it takes up an important amount of today's orthopaedic surgeons workload. The most important factor for the reduction of mortality which follows the fracture is the timely surgical management. (17)
Specifically, the fractures take place in the area between the greater and lesser trochanter and can involve two structures. Inter trochanteric (I/T) fractures which include 45% of all hip fractures. In this region there are weight bearing trabeculaes and there is also a good amount of cancellous bone and vascularity, hence decreasing the risk of avascular necrosis and non-union. According to Evan’s classifications and others the intertrochanteric fracture can be divided into stable and unstable fractures. (17,18)
2.4.4 Pertrochanteric fracture
Equally important, pertrochanteric of the proximal femur shapes a huge number of fractures in the elderly patients. Stimson defines it in regards to cases where the line of fracture starts at or near the lower part of the junction of the neck and shaft and passes through or close below the great trochanter, dividing the bone into two parts, of which the upper is formed by the head, neck and upper part of trochanter. The line of fracture may be awry from within, outward and upward, or from behind upwards and forwards. (14) As a result, the main goal to stabilize these fractures rapidly and adequately through internal fastening so as to mobilize the patients as soon as possible.
(15)
23
2.4.4.1 Etiology
First and foremost, as mentioned before, pertrochanteric fractures are a very usual incident between elderly patients. These specific groups of patients occupy around the 30% of hospital beds. Thus, pertrochanteric fractures of the femur are mainly an injury occurring in a later age. These fractures account for constitute the 50% of all hip fractures. (15,24)
To begin with, femur fractures are a usual incident with elderly people who might have sight problems, loss of muscle strength and balance and consequently loss of bone density and strength. Also, it is common in elderly patients who are more prone to falls. (26)
Pertrochanteric fracture is a serious and frequent injury which results to high morbidity and mortality. Degenerative bone disease such as, osteoporosis, can cause loss of bone strength and density which may increase the risk of femur fractures.
Additionally, osteoporosis, increased incidence of trivial trauma which then subsequently complicates the treatment of these fractures. Other causes of femur fractures might be difficult falls, in car crashes, skiing accidents, heavy objects falling on the leg, and many more everyday life incidents. (15)
A specific study has shown that the male gender was predominant, with a male to female ratio of 1.4:1, with the male gender obtaining the 58.3%. The particular study is agreeable with local studies but this is not the case when it comes to western studies, where women have double the risk due to postmenopausal osteoporosis and longer lifetime. (15,24)
Figure 7: Age distribution of patients with pertrochanteric hip fractures. (24)
0%
5%
10%
15%
20%
25%
30%
35%
21-30 31-40 41-50 51-60 61-70 71-80
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2.4.4.2 Clinical picture of post- surgical
In most cases, they might face severe hip pain, and might be unable to walk.
Through examination, an abducted and externally rotated hip with leg-length difference might be revealed. This might result for the patient to have tenderness over the hip and restricted range of motion, when rotating and flexing the limb. Finally, the symptoms that supervene are intense pain, inability to move the leg and stand up or walk.
Additionally, the opereted leg may look shorter, damage to the surrounding muscle and tendon tissue so as to nearby blood vessels. (22,26)
There are also cases where patients may have normal movement and complain only of undetermined pain in their buttocks, knees, thighs, groin, or back. These cases often report no prior trauma, specifically in situations with cognitive injury. As a result their physical examination may be normal. (26)
2.4.4.3 Diagnosis procedures
For the diagnosis of such incidents many advanced imaging studies, such as computed tomography (CT) and magnetic resonance imaging (MRI), have been and are considered useful. Thus, for cases with negative radiographs but a strong suspicion of fracture, MRI, have been proven to be much more specific than a CT scan. On the other hand, such imaging studies are cost effective and might also include a delay in treatment, so they should be used only when necessary. (26,27)
Consequently, for the decrease of the fracture as well as the position of the implant, plain anteroposterior (AP) and lateral radiographs can be obtained on the first postoperative day. For the reduction to be considered sufficient, the cortical congruence at the calcar region must be settled, and the displacement amongst the fragments must not exceed 2 mm. In addition to this, the position for the screw in the femoral neck for both the DHS and the PFN ideally, must be defined as central on the lateral radiograph and central or inferior on the AP radiograph. Continually, follow-up reviews can be attempted at six weeks and four months post-operatively. The comparison of the changes in the position of the fracture and implant, with the post-operative radiographs, were recorded. Situations where the patient lived and they being able to walk were recorded as in the preoperative phase. Finally, a return to the pre-operative level is considered as an initial standard of outcome. (20)
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2.4.4.4 Treatment
The most crucial function for the treatment of pertrochanteric fracture is the production of a controlled fracture impaction, by sliding the neck screw with torsional stability. (19) It is important to note that, in young people anatomic reduction and fracture fixation, in a combination with a longer period of non-weight-bearing, is preferred in most cases as it significantly limits the risk of a posttraumatic coxarthrosis.
(18)
Thus, the most common used implants for the fracture fixation are the sliding hip screw and cephalomedullary devices. Only by using stable and simple patterns, the rate of the fracture union can be considered rather high. On the other hand, patients with poor bone quality, who have a more challenging treatment and a big risk of collapse, usually do not have stable fracture formations.(24) To continue with, the crucial goal of the treatment is to manage stable fixation. This subsequently allows early mobilisation of the patient, but to achieve this target the development of many intramedullary nails must be achieved, as well. The specific nails may challenge the prior role of the compression screw which was the main method of fixation. The results have shown that using the proximal femoral nail may give a faster postoperative restoration of walking, in comparison to the dynamic hip screw. (22)
Although, the ideal treatment of these kinds of fractures requires an implant which involves the minimal invasive operation technique as well as a full body weight- bearing and of course a low complication rate. Despite the fact that the DHS has shown frequent complications, especially in unstable pertrochanteric fractures, it has indicated rather good results in overall. (20,28)
In addition to this, the proximal femoral nail (PFN) appears to have more positive outcomes compared to other devices in the treatment of trochanteric fractures, as it constitutes an intramedullary implant. According to published data the PFN is a trustable implant, with similar results to DHS results regarding unstable trochanteric fractures. (20)
Importantly, the clinical trial of pertrochanteric fracture treatment with a proximal femur locking compression plate (PFLCP) must be notes. It was found that PFLCP is proven to provide three- dimensional fixation mechanical advantages in
26
comparison to other common treatments, even in cases of unstable fractures in the osteoporotic bone, through the written and analysed results from patients treated with PFLCP. (23)
Figure 8 : Post- operative hip functional score following treatment with dynamic hip screw. (24)
2.4.5 Pre – operative physiotherapy
Basically, pre-operative physiotherapy involves exercises which the patient should do before the surgery is performed. Particularly, these activities have an important role in preparing the patient for the surgery. Also, the patient should be also shown to breathing exercises and proprioceptive training. Through the performance of these activities, it is ensured that the patient is appropriately prepared to use a wheelchair or crutches, assistance which is most possibly used after surgery. (25)
67%
3%
20%
10%
Excellent 67%
Very Good 3%
Good 20%
Fair
27
2.4.6 Post - operative physiotherapy
On the other hand, post-operative physiotherapy are the exercises that patients who have already undergone surgery should be involved in. Engaging with these exercises healing is promoted, whilst gaining the patient's walking ability is also ensured. On the first day, breathing exercises, isometric exercises of the lower ends and exercises which prevent thromboembolic, can be applied. The post-surgery patient is mostly encouraged to start walking on the second or third day after the surgery.
Although, walking long distances should be prevented by the patient in order for dislocation of the healing hip joint to be avoided because of fatigue, which is something caused by walking long distances. What is more, patient must walk with decrease weight bearing on the already operated leg. Over weight bearing creates stress which is transferred to the joint and as a result it predisposes the hip joint to dislocation. Over the course of the following days, the patient should be engaged in another form of exercises in a prone position and side-lying position using a pillow between the knees. In the course of the third week, walking up and down the stairs should be the next exercise.
Overall, post-operative physiotherapy aids towards the recovery of trauma from the surgery and gain back his stability and ability to walk. ROM exercises for the hip, knee and ankle. The patient can also begin strengthening exercises based on the surgeon’s orders to improve walking safety and efficiency. Also, we can use PIR to relax hypertonic muscles, soft tissue technique for the scar, manual therapy for restricted joints, stabilisation exercises with support with different balance pad, bosu.
balneotherapy. In addition, the swimming we can use in the beginning starts with some AM in the water and walking and then intensity the difficult of exercises with special swimming tools, stationary bicycle and condition training, starts with PM and AM and after we can use resistand band. In the end of the station we can use some exercises in one leg to increase the loss of endurance during the immobilisation period. Also, the exercises aren’t only on the area of fracture but also for the knee, ankle, abdomen for better walking pattern and equal strength on both lower extremities. (25)
28
Another key component of rehabilitation following hip fracture is education on its prevention. Home safety prevent falls, regular moderate exercise can slow bone loss and maintain muscle strength also improve balance and coordination. Post- operative physiotherapy helps the patients to recover from trauma of surgery and regain his stability and capacity to walk.
More specifically, there has been cases were rehabilitation was began 48 hours post - surgery whilst the patient lied in bed. The patient was encouraged to perform isometric exercises to the amount where the pain was tolerated and graduate mobilization has started within the first week after surgery. Also, in such cases the patients complications were documented in a time frame of 6 weeks to 12 months. (20)
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3. Case Study
3.1 Methodology
My bachelor practice took place in Ustředni Vojenská Nemocnice in Prague.
This practice started on Monday 8th of January 2018 and ended on Friday 19th of January 2018 (10 days of practice). Each day had duration of 8 hours. The total amount of hours of practice was 80 hours.
My clinical work placement was supervised by Mgr. Romana Kozderkova. The number of the sessions with my patient was sixteen.
The therapeutic procedures were applied in an individual therapy and exercise room. In the therapies, we used soft tissue techniques, fascia techniques, joint play mobilization, muscle relaxation, stretching, and strengthening techniques, sensomotoric exercises, and general exercises. For the examinations, I also used instruments such as a goniometer, measurement tape, neurological hammer and plumb line.
30
3.2 Anamnesis (medical history) 3.2.1 Status presents:
3.2.1.1 Objective:
Examined person: D.J Medical Code: S7200 Year of birth: 1978 Height: 1.90cm Weight: 85Kg BMI: 23.5kg/m²
Crutches: Forearm crutches 3.2.1.2 Subjective:
He is feeling a little bit painful the area around hip and he mentioned that when he is walking with crutches he has pain around the left knee and it’s a bit swollen.
3.2.2 History Anamnesis:
On 30th November in the afternoon my patient was doing skiing in Austria when he fell down from height 30cm. That day he did a surgery on the left femur and after 5 days they told him that he is in a good condition and left him to leave. He came back to Prague and the next day he went to UNV and started rehabilitation.
3.2.3 Injury Anamnesis:
In 1996 he injured his right shoulder with result of dislocation that resolved by surgery
3.2.4 Surgery Anamnesis:
He did a surgery (dynamic hip screw- DHS) on the left femur 3.2.5 Medical Anamnesis:
Now he is taking Clexane 1 per day from 1/12/2017 until 12/01/2018
31 3.2.6 Family Anamnesis:
All his relatives are healthy with no serious medical condition.
3.2.7 Social Anamnesis:
He lives in a flat, on the 2nd floor without elevator.
3.2.8 Occupational Anamnesis:
The patient is working in bank but now he is sick leave. He is return back to his work on Monday 15/01/2018
3.2.9 Allergy Anamnesis:
Cats, pollen 3.2.10 Hobbies:
He is likes to play tennis, to walk, to run and to do ski 3.2.11 Abuse:
None
3.2.12 Prior rehabilitation:
None
3.2.13 Excerpt from patient’s health care file:
Patient has X-ray on the hip joint after 2 weeks of his surgery on 12.12.2017 of the left hip on anterior – posterior side.
Figure 9 : Post -operative X-ray in interpretation of the left hip Anterior- Posterior.
32 3.2.14 RHB indications:
Doctor indicated physiotherapeutic courses that will be able to correction of the walking stereotype without fear and also breathing exercises that would help the patient to have an upright position when walking. Moreover, sensomotoric exercises, soft tissue techniques for the scar, stretching and strengthening exercises for the muscles surrounding hip and increase ROM.
3.2.15 Differential balance:
My hypothesis for the patient who had peritrochanteric fracture of hip is that his left thigh will have swelling and restricted fascia and superficial layers of skin.
Also, I except some muscle imbalance Gluteus muscles (gluteus maximus, minimus and medius), and quadriceps femoris mucle (vastus lateralis, vastus intermedius, vastus medialis) will be hypotonic muscles. Hypertonic muscles will be rectus femoris, tensor fasciae latae and adductors of the hip (adductor magnus, adductor longus, adductor brevis, gracilis and pectineus). Moreover, weakness on the muscles around the leg (quadriceps, gluteus muscles, adductors, abductors of the hip and hamstrings). There must be a limited range of motion in hip and knee joint and shortened muscles might be present (gastrocnemius, soleus, adductors and flexors of the hip). It is possible that restricted joints will be found (Lisfranc’s joint, Chopart’s joint, Talocrural joint, Metatarsophalangeal joints, Interphalangeal joints) and wrong stereotype of hip abduction and hip extension. During standing most probably patient will have the operated leg forward of the body (forward left leg) and also during walking, instability may be present. Patient might be able to be self-sufficient and walk independently (there might be overuse of upper extremity) and might use the 2- point alternate gait with crutches during walking (both crutches and operated leg together then non-operated. Breathing might be wrong (e.g. inactivation of abdominal muscles)
33
3.3 Initial Kinesiology examination:
3.3.1 Observation:
- Slight swelling on the anterior and lateral part of the left thigh and area around the knee.
- The scar is on the lateral part of the left thigh and it is 13 cm long without stitches.
- The surgical scar of the right tibia has normal temperature and sensation.
- The scar it’s restricted in all direction and unmovable
- There is slight redness around the scar and there isn’t a hematoma on the posterior left thigh on the gluteus muscle.
3.3.2 Postural examination (static):
3.3.2.1 Anterior view:
- Base of support – Normal base of support but the left foot is forward than the right.
- Position of the feet- Eversion on the left foot.
- Position and shape of the toes – Normal toes.
- Weight distribution - Looks more weight on the right leg.
- Muscles tibialis anterior – Symmetrical.
- Contour of the calf muscles – Symmetrical.
- Position of knees – Neutral
- Position of patella’s – Lateral shifted on left knee.
- Position of thighs – Small amount of atrophy is also visible in left thigh muscles.
- Pelvis – Lateral tilt, left side is higher than the left.
- Symmetrical tension of abdomen.
- Left thoracobrachial triangle bigger than the right.
- Position of the collarbones - Left slight higher than the right.
- Left shoulder higher than the right.
34 - Symmetrical upper trapezius.
- Position of the head – slight protracted.
3.3.2.2 Posterior view:
- Base of support - Normal base of support but the left foot is forward than the right.
- Shape of ankles - Symmetrical
- Achilles tendon – Symmetrical in both sides.
- Contour of the calf muscles – Symmetrical - Position of knees –Neutral
- Position of thighs – Atrophy is visible on the left thigh.
- Subgluteal line - Almost same height in both sides.
- Pelvis- Lateral tilt, left side is higher than the left
- Gluteal muscles - decreased contour of gluteus muscles on the right side and may hypotrophicity.
- Paravertebral muscles – symmetrical - Cervical vertebras - ideal shape
- Thoracic vertebras - in a small degree of C shape scoliosis to the right with the top on the curve around the Th5-8
- Lumbar vertebras - ideal shape
- Left thoracobrachial triangle bigger than the right - Upper extremities – right shoulder is higher than the left.
- Right scapula is protracted.
- Symmetrical upper trapezius.
- Head – protracted.
-
3.3.2.3 Side view:
- Weight distribution - more to the right.
- Shape and position of the ankle – Symmetrical in both sides.
- Shape and contour of the shin - Normal, no deformities.
- Position of the knee joints- Symmetrical.
- Torsion of pelvis on the left side and anterior tilt.
- Cervical spines – ideal.
