Physical Therapy Interventions for Traumatic Left Proximal Humerus and Left Femoral

Neck Fractures in the Acute Care and Inpatient Rehab Settings: A Case Report

Author: Brandon Svorinic

Research Advisor: Rochelle Kopka, PT, DPT, DHSc

Doctoral Program in Physical Therapy

Central Michigan
Mount Pleasant, Michigan

April 18, 2024

Submitted in the Faculty of the

Doctoral Program in Physical Therapy at
Central Michigan University
In parallel fulfillment of the requirements of the
Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Rochelle M. Kopka
Rochelle Kopka, PT, DPT, DHSc
Date of Approval: April 18, 2024
 ABSTRACT

Background and Purpose

Total hip arthroplasties are a common surgical procedure. Surgeons have several approaches

they may prefer including posterior, direct anterior, and anterolateral. These surgical

approaches are often preferred following hip fractures in the elderly population. The direct

anterior approach is an approach that has gained popularity in the last 15 years as it is a less

invasive approach and involves minimal post-op precautions. There is no set research outlining

the rehab process for traumatic involvement for more areas than just the hip. Since traumatic

events resulting in hip fracture and subsequent hip arthroplasty are common, the need for

further research involving concurrent fractures and/or other musculoskeletal abnormalities is

necessary.

Case Description

The patient was a 76-year-old male that had a fall when looking out his window and

losing balance early in the morning, resulting in a left femoral neck fracture and left proximal

humerus fracture. He underwent a direct anterior left total hip arthroplasty and conservative

treatment for his left upper extremity (LUE). The patient had a history of right lower extremity

(RLE) foot drop. The patient was weightbearing as tolerated on the left lower extremity (LLE),

and non-weightbearing (NWB) on the LUE, maintaining the LUE in a sling. The patient was

initially evaluated in the acute care setting. After a single acute care evaluation, the patient

transferred to the inpatient rehab setting.

Outcomes

The patient had improvements in functional outcomes as outlined by the QRP including gait,

bed mobility, transfers, and wheelchair propulsion.

Discussion

The purpose of this study was to add to the body of research in hip and other concurrent

musculoskeletal trauma following a traumatic event and examine the rehab process in the acute

care and inpatient rehab setting. The patient had a prior history of foot drop on the

contralateral RLE, severe nerve pain, and a concurrent left humerus fracture which were

barriers during the rehab process. Additionally, the patient was unable to extend his stay

beyond 18 days in the inpatient rehab setting, preventing further improvements in functional

status. Further research should examine other therapy approaches such as aerobic focused

interventions. Additional research should also look at outcomes in the outpatient, home health,

and subacute rehab settings.

Background and Purpose

The direct anterior total hip arthroplasty is a treatment approach that has gained

popularity over the past 15 years. It is often the preferred method of treatment for femoral

neck fractures in the elderly. This may be because it is a less invasive approach that allows

increased tissue sparing compared to other total hip procedures. Additionally, it has less post-

operative precautions compared to more traditional hip replacement surgeries. The direct

anterior hip replacement approach procedure includes making a surgical incision over the

proximal lateral femur over the tensor fascia lata muscle, osteotomy of the femoral neck and

removal of the femoral head, and a labrectomy. The patient is typically weightbearing as

tolerated (WBAT) on the operative extremity. Hip precautions include no extremes of motion on

the operative extremity. 1

It is important to examine the rehabilitation process following direct anterior total hip

arthroplasties. Additionally, it is important to understand how trauma based direct anterior hip

arthroplasty rehabs compared to a planned direct anterior hip arthroplasty. The individual in

this case had a trauma based direct anterior hip arthroplasty and will add to the body of

research in this specific category. Several studies have been conducted regarding direct anterior

total hip arthroplasties.

One study looked at direct anterior hip replacements compared to posterior approach

hip replacements. This study looked at the outcome measures included time to discontinue

walker, crutches, and cane, car transfers, activities of daily living, the timed-up-and-go test

(TUG), time to drive, return to work, and the ability to walk 150 ft, ambulate stairs, and walk
half a mile. Each patient was seen by a physical therapist the morning after surgery and

received two sessions prior to discharge from the hospital. Physical therapy after surgery

included transfers from bed to chair. If the patients could ambulate 150 feet and navigate four

stairs, they were sent home. If unable to do so, they were sent to skilled nursing facilities. After

discharge, the patients received physical therapy intervention based on general rehab protocols

provided to physical therapists through either home health or outpatient-based care. Results

suggested that the direct anterior approach allowed earlier post-op recovery based on TUG

times. However, this measured difference appeared to decrease between weeks 2-6, where

there were slim to no differences detected between groups. Overall, the study found that

anterior and posterior procedures had similar measures throughout all the outcomes

measured.2

Another study looked at the impact a direct anterior total hip arthroplasty had on 1 year

mortality and surgical complications after a femoral neck fracture. The study looked at patients

who had trauma mechanisms and were not ambulating prior to the injury and compared direct

anterior hip replacements to posterior hip replacements. Specific physical therapy interventions

are not outlined, though it is plausible to assume general rehab protocols were followed.

Results showed that the direct anterior patients had a decreased risk of a revision surgery and

decreased mortality after 1 year compared to posterior group. 3

Another study looked functional outcomes of the direct anterior approach compared to

direct lateral approach following acute femoral neck fractures. Post-operatively, patients were

discharged home if they were able to transfer in and out of bed and chair by themselves,

independently ambulate 50 meters with or without an assistive device, and navigate 4 stairs.
Outcomes measured were the TUG, and other clinician-based hip outcome measures. Patients’

were followed up with 2 years after surgery. The results showed that the direct anterior

approach allowed for earlier mobility and improved and earlier functional outcome scores

compared to the direct lateral approach. 4

Another study looked specifically at the outcomes of a direct anterior total hip

arthroplasty following femoral neck fractures in the elderly. Outcomes assessed were total

hospital stay time, mortality rate, and functional and cognitive outcomes. The study did not

showcase specific physical therapy rehab interventions, though it is plausible to assume general

post-op hip protocols. The results showed that direct anterior hip replacements are a safe

option for femoral neck fracture patients in the elderly. 5

While research has been conducted regarding the rehab process following direct

anterior hip replacements, there are several variables that are not touched upon including the

impact of trauma and coexistence of other injuries and specific interventions performed during

the rehab process. It is important to understand the specific physical therapy interventions

utilized following direct anterior hip replacement. This case report will better outline specific

interventions utilized following direct anterior approach hip replacements.

Prior to preparing this case report, consent was obtained from the patient to proceed.

All information contained in this case report meets the Health Insurance Portability

Accountability Act (HIPAA) requirements of the clinical agency for disclosure of protected health

information. This case report was completed under the direction of the Department of Physical
Therapy and with the oversight of the College of Graduate Studies at Central Michigan

University.

Case Description

Patient History and Review of symptoms

The patient was a 76-year-old male that had a fall on his left side due to loss of balance

early in the morning after waking up. Imaging showed he had a left femoral neck fracture and

left proximal humerus fracture. He underwent a left total hip arthroplasty with a direct anterior

approach and conservative treatment for his left upper extremity (LUE). After surgery, the

patient was given instructions to refrain from extreme hip ranges of motion and was weight

bearing as tolerated (WBAT) on the left leg. The patient was instructed to wear a sling for most

of the day in the LUE for the first two weeks and maintain a non-weight bearing (NWB) status.

The patient was initially evaluated in the acute care setting and deemed appropriate for the

inpatient rehab setting after a single acute care evaluation and treatment.

Upon subjective questioning at initial evaluation, the patient reported that he was an

active individual prior to hospitalization but had progressive weakness and sciatica in his right

lower extremity (RLE). He believed that this contributed to 2 falls in the past 4 months. He

stated that he lived with his wife in a single-story home with a basement. He stated his house

had 3 steps to enter with no handrails, though he could also enter with a single platform step

into his garage with no handrails. He stated that his office was downstairs which had greater

than 10 steps w/ a single handrail but would be able to work from a laptop on the main floor.

His prior level of function was independent with intermittent use of a single point cane (SPC)
with RLE weakness. He reported a pain level of about 4/10 in both the LUE and LLE. Medications

include Gabapentin and muscle relaxants. The patient was a retired pilot and enjoyed flying

prior to his injury. No other significant medical history was provided. His goals for therapy

included returning home and decreased pain.

Clinical Impression #1.

With subjective information recorded, it was inferred that the patient would have

decreased functional strength and mobility, decreased dynamic balance, and decreased overall

confidence with daily activities. These impairments could be observed with performance of

functional movements, general manual muscle strength testing, and qualitative observation.

Due to the patient’s prior level of function, it is inferred that he will make improvements to be

able to return home and return to baseline. This patient is a good candidate for case report due

to his extensive deficits and his quick transition from acute care to inpatient rehab. This case

adds to the body of research of how intensive therapy can impact a patient with extensive UE

and LE deficits.

Examination

Strength and range of motion testing. Range of motion (ROM) was not formally assessed with

goniometric measurements but appeared to be within functional limits (WFL) or RUE, LLE, and

RLE. LUE strength was not formally assessed due to doctor protocol. The patient demonstrated

adequate strength of the RUE muscles against gravity. Manual muscle tests were performed in

sitting for ankle dorsiflexion and plantarflexion, knee extension and flexion, and hip abduction,

adduction, and flexion. The patient demonstrated significant weakness in hip abduction
strength for both left and right lower extremities (LEs). Overall, the patient has general LE

weakness. Manual muscle testing was graded on a 5-point scale. Upon examination, the

strength deficits included left hip abduction (2), right hip abduction (2+), right hip adduction (3).

The rest of the LE MMT were WFL. These results may indicate reasoning for significant bilateral

dynamic knee valgus. The weak hip abductors are unable to sufficiently stabilize the knee,

resulting in a valgus position. Reliability for manual muscle testing ranges from 0.65-0.93.6,7

Functional Measure: The quality reporting program (QRP) is a functional outcome measure that

examines a variety of functional tasks. It is useful for the inpatient rehab setting to determine

functional capacity and readiness for discharge. The QRP itself is not well researched, but

includes functional activities including bed mobility, transfers in chairs and cars, ambulation on

even and uneven surfaces, stair navigation, and wheelchair propulsion. Initial results indicate

that the patient required significant improvements before a safe return to home.The full list of

scores and tasks performed during the QRP can be located in the table.

Balance. Patient balance was measured qualitatively in sitting and standing. Pt static sitting and

standing balance appeared WFL. Dynamic sitting balance was poor, and pt was unable to

maintain trunk control without manual assistance when transitioning from supine to sit and vice

versa. The patient’s poor balance may be due to lack of functional ability in general.

Bed mobility. The patient performed bed mobility with moderate assistance. The head of the

bed was raised, and the patient required manual assistance of his trunk to move to upright

position without loss of balance. He was able to move his LEs off the bed independently. The
patient lacked the ability to independently perform bed mobility, an essential functional activity

at home, and required improvement in this area.

Transfers. The patient was able to perform sit-to-stand transfers with an elevated bed with max

assistance with a Sara Stedy™ (SS), a piece of equipment used for safe patient handling. Once

secure in the SS and sitting on its elevated surface, the patient was able to complete about 10

sit-to-stands. Although there is limited research regarding the use of the SS, the equipment

manual claims it is an effective device to elevate and transport patients who have the ability to

maintain a standing position. The piece of equipment has a bar for the patient to hold on to pull

themselves up. Once standing, two paddles can be placed behind the patient that allow them to

sit from an elevated surface which can be useful for training sit-to-stands from an elevated

position. Once in this position, the SS has wheels that can be locked or unlocked to transport

patients safely. A figure of the SS is included in Figure 1.8

Gait Training. Pt was unable to ambulate on initial examination due to LE weakness. The patient

was unable to navigate stairs on initial examination due to LE weakness.

Evaluation/Clinical Impression #2

The patient presented with bilateral LE strength deficits and decreased sitting balance

(Table). He was unable to perform general bed mobility, transfers, ambulation, and stair

navigation independently. The examination matched expectations following surgical

intervention due to past subjective history and the patient being in the acute stage of recovery.

The plan to reduce deficits and return the patient to baseline included LE strengthening,

functional strengthening including sit-to-stands, bed mobility, ambulation, and stair training,
and dynamic balance training. It was initially planned that the patient would stay in the acute

care setting for the time being with an inpatient rehab consult. The patient was approved for

inpatient rehab and began to attend inpatient rehab within 48 hours of the evaluation. The plan

for inpatient rehab therapy was 180 minutes of therapy a day spread between Occupational

Therapy and Physical Therapy for 5-7 times a week. Therapy continued for approximately 18

days before the patient was discharged. The patient had several positive factors for recovery.

These factors include that he was active prior to his fall, had a positive support system with his

wife and friends, had a positive outlook on his recovery process, and daily attention on his

deficits in the inpatient rehab setting. Potential barriers for recovery include the patient’s RLE

progressive weakness and foot drop which seemed to be causing falls prior to the current event.

Despite this, the patient’s potential for recovery was excellent due to the patient’s motivation to

recover. Long term goals for the patient were to improve functional strength and mobility for

bed mobility, ambulation, and stairs to be able to return home.

Interventions

The patient was examined in the acute care setting and transitioned to inpatient rehab. The

patient attended inpatient rehab that consisted of occupational therapy and physical therapy 5-

6 times a week, each Physical Therapy session lasting 90 minutes. He attended 10 physical

therapy rehab sessions before discharge home. Interventions included therapeutic exercise,

therapeutic activity, gait training, and neuromuscular reeducation.

Gait Training. The patient immediately began gait training in parallel bars with RUE support with

moderate assist of 2. Initially, patient demonstrated LLE knee buckling which required knee
blocking and trunk support. As the patient continued to practice, knee buckling decreased and

the patient progressed to CGA support in the parallel bars. The patient progressed to

ambulating with CGA with the use of a large based quad cane (LBQC) in the RUE. At discharge,

the patient still demonstrated a narrow base of support during ambulation and slightly

decreased step length of the RLE. These deficits were able to be corrected for short periods of

time with verbal cueing. The patient was unable to initially perform stair navigation due to LE

weakness. Initial exercises included toe tapping to a 3-inch step. This progressed to stair

navigation up and down 6-inch steps without an assistive device and one handrail with CGA. The

patient was able to manually propel in a wheelchair 150 ft x 2. Functional training and using the

principle of specificity were utilized for all functional interventions. The principle of specificity

states that gains can be better made when training in the same way that you will perform a task.

In this case, the patient performed modified ambulation to get better at independent

ambulation. This method of rehab has proven to improve overall functional ability.9

Neuromuscular reeducation. The patient performed general dynamic balance activities in

standing and during ambulation. This included transitions during bed mobility, in sitting,

standing, and walking. This method again focused on the use of functional training and the

principle of specificity. 9

Therapeutic exercise. Therapeutic exercise focused on LE weakness. Strengthening exercises

were focused mainly on hip abduction as that was the patient’s main weakness area and patient

demonstrated knee valgus, flexion, and internal rotation in standing. However, other

musculature was also included with LE strengthening. It has been shown that moderate loads

and approximately 8-12 reps with 60-80 percent 1 rep max optimize hypertrophic gains.10
Therapeutic Activity. Therapeutic activity focused on improving the independence of functional

tasks the patient would be required to do at home. This included general sit-to-stand transfers

and bed mobility. The patient initially had difficulty with sit-to-stands from lower surfaces. Initial

exercises focused on deep squatting and fatigue around 8-12 reps to allow for muscle

hypertrophy. 5 At discharge, pt required CGA to Min A depending on fatigue level for sit-to-

stands from about a 22-inch surface. The patient rapidly improved bed mobility from initial

evaluation. The patient was able to perform 5-7 repetitions of supine-EOB and vice versa with

standby assist (SBA) and no instances of loss of balance. These activities focused on the

principle of specificity 9

Outcomes

The patient made significant progress and was able to return home with assistance from his

sister. The patient met all desired goals to return home. The patient’s sister received general

training for all functional activities that the patient still required supervision to minimal assist

with.

Range of Motion and Strength

ROM was initially WFL. Strength of bilateral hip abduction was initially the main deficit and

evidenced by the patient’s tendency to fall into dynamic knee valgus of both LEs. By discharge,

individual manual muscle tests were not performed, but muscle function was assessed through

functional activities with the Function Quality Reporting Program (QRP).

QRP
The patient made significant progress with the QRP. He made improvements in every category

apart from picking up an object which was deemed unsafe. While there are no specific statistics

regarding significant difference, the patient’s functional status went from partial assistance to

independent for general bed mobility. Went from dependent to partial assistance for sit-to-

stands. Went from unable to attempt to supervision assistance for ambulation up to 150 ft and

stair navigation up to 12 stairs. Went from supervision assist to independent for wheelchair

propulsion. Based on these improvements, it is evident that the patient had an increase in

overall functional status.

Balance.

The patient had no significant balance deficits and continued to demonstrate appropriate

balance strategies throughout treatment.

Bed mobility.

The patient demonstrated significant improvement in bed mobility, able to perform all bed

mobility with complete independence in a regular bed. This includes from supine to edge of bed

and vice versa and rolling left and right in bed.

Transfers.

Pt required CGA to Min A when performing sit-to-stands with a LBQC from about a 22-inch

surface. The patient’s sister was trained to assist with this specific transfer. While he did not

meet his initial goal of supervision level assist, the patient was able to achieve a level that was
adequate to return home with assistance. The patient performed car transfers with supervision

level assist with a LBQC.

Gait Training

The patient continued to demonstrate decreased step length of the RLE and narrow BOS. Verbal

cueing improved step length of the RLE. It was speculated that the patient’s ambulation at

baseline was with a narrow base of support. The patient’s sister demonstrated competency with

CGA during ambulation. At discharge, the patient was able to navigate 12 6-inch stairs with a

single hand rail and no AD with CGA. The patient’s sister was trained for CGA and demonstrated

competency with this task.

Discussion

The purpose of this study was to examine the transition of care between acute care and

inpatient rehab and add to the total body of research on the functional progression of patients

that undergo a traumatic based hip arthroplasty with other concurrent musculoskeletal trauma.

The initially referenced studies showed improvements in general functional tasks including the

TUG, ambulation of household distances, and general functional capacity. Similarly, this study

showcased improvements in the overall function of the THA patient. Conversely, the patient in

this study had other ongoing deficits including a traumatic incident that subsequently resulted

in an unplanned THA and a fractured humerus. Additionally, the patient had a prior history of

drop foot on the contralateral LE which complicated the rehab process. The results in this study

were different in the way that they represented a wider range of functional results that

showcased additional improvements. One main barrier in this case study was the patient’s
nerve pain, left humerus fracture, and a history RLE foot drop. The nerve pain consistently

interfered with the patient’s confidence and overall ability to perform sit-to-stands, as forward

trunk flexion aggravated the pain. The humerus fracture and foot drop interfered with the

intensity of interventions, as the patient was unable to tolerate more complex treatment

options such as ambulation without an AD. A limitation of the study is that a variety of

therapists worked with the patient, leading to inconsistency in treatment sessions. Additionally,

the patient was unable to extend his inpatient rehab stay, where further benefits may have

occurred. In conclusion, the specific functional therapy in the acute care setting and the

intensive inpatient rehab setting contributed to positive outcomes in overall function and return

to home. Additional research may look at an aerobic based training approach, focused more on

raising heart rate rather than functional strength. Another option would be to look at a similar

case a subacute rehab setting, home health, or outpatient setting.

References

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surgical technique. World Journal of Orthopedics. 2016;7(1):38.

doi:https://doi.org/10.5312/wjo.v7.i1.38

2. Rodriguez JA, Deshmukh AJ, Rathod PA, et al. Does the Direct Anterior Approach in THA

Offer Faster Rehabilitation and Comparable Safety to the Posterior Approach? Clinical

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doi:https://doi.org/10.1007/s11999-013-3231-0

3. Cichos KH, McGwin G Jr, Boyd B, Ghanem ES. Direct Anterior Approach Total Hip

Arthroplasty Is Associated With Reduced 1-Year Mortality and Surgical Complications

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doi:https://doi.org/10.1016/j.arth.2023.05.045

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Continuum. Sports. 2021;9(2):32. doi:https://doi.org/10.3390/sports9020032

Table.
Quality Reporting Program (QRP) Scores
Task Initial Evaluation Final Evaluation

Roll left and right 6 6

Sit to lying 4 6

Lying to sitting edge of bed 3 6

Sit to stand 1 3

Chair/bed-to-chair transfer 1 3

Car transfer 88 4

Walk 10 ft 88 4

Walk 50 ft 88 4

Walk 150 ft 88 4

Walk 10 ft on uneven surface 88 4

1 step (curb) 88 4

4 steps 88 4

12 steps 88 4

Picking up object 88 88

Manually propel wheelchair 50 ft 4 6

Manually propel wheelchair 150 ft 4 6

6 = Independent, 5 = setup or clean-up assistance, 4 = supervision or touching assistance, 3 =

partial/moderate assistance, 2 = substantial/maximal assistance, 1 = Dependent, 88 = not

attempted
Figure.

Picture diagram of the Sara Stedy.