INITIAL EVALUATION

FRACTURE

GENERAL INFORMATION
Pt’s Name: X.Y.Z.
Age: 66 y/o (Sig: Intertrochanteric fractures are common particularly in
the elderly; Garg, 2011; Advanced age may influence fracture
healing)
Sex/Gender: Female (Sig: Women are affected two to three times as often as
men; Burkhart et. al., 2013)
Address: San Lorenzo, Makati City (Sig: Pt’s compliance to treatment.)
Civil Status: Married (Sig: Pt’s support system.)
Occupation: Retired teacher
Birthday: January 1, 1952
Handedness: Left
Referring Unit: Makati Medical Center – Emergency Department
Referring MD: Dr. C.S.
Rehab MD: Dr. L.M.
Date of Admission: January 3, 2018
Date of Referral: January 11, 2018
Date of IE: January 11, 2018
Diagnosis: (L) Closed Comminuted Intraarticular Intertrochanteric Fracture
(Sig: Intertrochanteric fractures comprise 45% of acute hip
fractures; Bateman et. al., 2012).
Informant/Reliability: Patient/Good reliability
Height: 152 cm
Weight: 42.5 kg
BMI: 18.4 kg/m2 (Sig: Body weight or BMI has been found to be
inversely related to the risk of osteoporotic fracture; Salamat,
2013).

SUBJECTIVE INFORMATION
C/C
Verbatim: “Sobrang sakit ng kaliwang balakang ko (VAS 7/10) lalo na kapag nagagalaw at
hinahawakan siya.”

Translated: Pt. complains of sharp, severe, intolerable pain on (L) hip (VAS 7/10) especially
during movement and palpation.

Pt’s Goal: To be able to return to doing ADLs and recreational activities such as gardening, and
painting without pain and within functional range of movement

HPI
 Present condition started 3 weeks ago when the pt, a 66 year old retired teacher with
osteoporosis who has no history of falls, injured herself at home after slipping in the bathroom.
Pt. just finished dressing up after taking a bath and was about to fix her hair when she suddenly
slipped on a wet puddle just two steps away from the shower area and fell on the ground with the
(L) hip directly hitting the ground first. Pt. immediately felt sharp, severe, and intolerable pain
with a pain intensity of 8/10 localized on her (L) hip. Her son heard the fall and proceeded to run
to the bathroom where he saw his mother lying on the ground, wincing in pain. Without knowing
what happened, he tried to help his mother get up from the ground by placing his hands on her
dorsal trunk and (L) hip; however, she immediately shrieked upon contact. His son then
inspected his mother’s body for injuries and noticed the (L) leg with the foot and knee turned
outward (externally rotated) and is accompanied by swelling and ecchymosis forming near the
(L) upper thigh (Sig: Clinical features of intertrochanteric fracture include pain in the region of
the groin, swelling, tenderness over greater trochanter, inability to weight bear on the affected
limb, ecchymosis at the upper thigh, and the leg rotated externally; Garg, 2011). His son also
observed that there were no evident skin lacerations, protruding bone nor presence of
hemorrhage. He decided to call for an ambulance at the nearest hospital after suspecting fracture.
While waiting for help to arrive, he tried to calm the pt. by stabilizing her body in a fixed
position while lying on her back and by covering her legs in thick layers of towels to hold them
in place alongside with his hands to prevent her from making unnecessary positional changes to
avoid further damage. Once EMS had arrived after 5 minutes, emergency personnel immediately
checked her VS and found them to be WNL and R/O shock. EMS raised the victim carefully for
placement on the stretcher while the fracture is supported from the underside on both sides of the
break. Both of the pt’s lower limbs were tied together with each of the last four cravat bandages
of the stretcher to allow for temporary immobilization. Upon arrival to the hospital after 5
minutes, intravenous opiates (morphine 2–4 mg intravenously) were provided to the pt. Dr. C.S.
performed the clinical examinations and saw local swelling, ecchymosis, marked local
tenderness over the (L) hip, crepitus, and abnormal mobility on the (L) LE. The state of the skin,
circulation, sensory, motor, autonomic, and visceral tests were also checked and it was found that
they were all normal. To confirm the clinical evidences of fracture, the pt. underwent
radiographic x-ray examination in AP and lateral views where it was found that she has closed
comminuted intraarticular intertrochanteric fracture of the (L) hip and that no additional injuries
were sustained by the pt. The pt. remained awake and conscious throughout the entire clinical
and radiographical examinations. After a series of tests such as CBC, ECG, the pt. was cleared
for any contraindication and was indicated for surgery for (L) hip fracture repair. 30 hrs after the
accident, the pt. undergo surgery by open reduction and internal fixation using an intramedullary
rod and a gamma nail. Pt woke up from anesthesia after 10 hrs after the surgery. During the
postoperative period, the pt. was prescribed with taking routine scheduled administration of
acetaminophen (paracetamol) and "as needed" dosing of oral opiates (oxycodone 2.5–5 mg every
3 hours as needed) for analgesia. After 2 days of rest from the surgery, the pt. went through 4
days of physical therapy in the acute care setting which focused on bed and toilet transfers and
gait training with a rolling walker. The pt. is then referred to inpatient rehabilitation for further
evaluation and management.

PMHx
- (+) Type II osteoporosis
- (-) Osteopenia
 - (-) Prior fracture
- (-) DM
- (-) MVA
- (-) CVA
- (-) RA
- (-) Hyperparathyroidism
- (-) Hyperthyroidism
- (-) Cancer
- (-) Paget’s disease
- (-) Gastrectomy
- (-) Anorexia nervosa
- (-) Pernicious anemia
Sig: Osteoporosis is a major risk factor of fractures. Osteoporosis does not affect the healing
process but other certain medical comorbidities can negatively influence fracture healing.

FMHx
Mother Father
Osteoporosis (-) (-)
Osteopenia (-) (-)
Cancer (-) (-)
DM (-) (-)
CVA (-) (-)
Heart disease (-) (-)
Pernicious anemia (-) (-)
Sig: Pt’s fracture is not of genetic predisposition.

Personal/Social Hx
- Pt. is cooperative, optimistic, and engaging during the interview
- Non-smoker
- Non-alcoholic and non-caffeinated drinker
- Pt doesn’t consume anti-epileptic medications, steroids, diuretics, thyroid hormone, anti-
depressants, anti-hypertensives, and anti-arrhythmics
- Pt’s diet is composed mostly of vegetables, fruits, fish, and chicken and rarely eats pork
and beef
- Pt paints and gardens daily, cooks every meal, and walks for at least one hour every
morning
- Sig: Intake of medications like steroids, thyroid hormone, anticonvulsants, diuretics, anti-
depressants, anti-hypertensives, and anti-arrhythmics are known risk factors of fracture
and influence the risk of falling (Hamblen & Simpson, 2007).

Home Situation
- Pt lives with husband, son, daughter-in-law, and two grandchildren
- Pt lives in a two-storey house with one flight of stairs
- Pt’s room is located at the 2nd floor
- Stair composed of 12 steps
- Stair has railings with a height of 83 cm
 - Stair is composed of 12 steps with each step having a height of approx. 15 cm and a
width of approx 105 cm
- Flight of stairs has handrails consistently measuring 34 inches (865 mm)
- House has solid hardwood flooring in all rooms except bathroom and kitchen
- Bathroom and kitchen floors are made of porcelain tiles
- Doorframe width is 90 cm
- Height of toilet is 40 cm
- Approx. 6 steps from main door to living area
- Approx. 12 steps from main door to dining area
- Approx. 15 steps from main door to kitchen
- Approx. 5 steps from bedroom to bathroom
- Approx. 7 steps from bedroom to staircase

Ancillary Procedures
Date Procedure Findings
January 19, 2017 DXA T score = -2.6
Z score = -1.1
(+) Type II osteoporosis
January 3, 2018 X-ray (AP, lateral views) (L) Closed Comminuted
Intraarticular Intertrochanteric
Fracture
January 3, 2018 CBC Blood count is normal
January 3, 2018 Electrolytes evaluation Electrolytes are normal
January 3, 2018 ECG ECG is normal
January 3, 2018 Urinalysis (UA) Urinalysis is normal
January 3, 2018 ABG analysis ABG is normal
Sig: Laboratory studies should be ordered based on the patient and the potential for surgery.

Present Medications:
Medication Dosage Frequency Indication
Alendronate 5 mg Daily Treatment of
(Fosamax) osteoporosis
Calcium Ca 600 mg Daily Vitamin D and
Supplement/vitamin Vit D3 400 IU minerals supplement,
D - Oral Mg 40 mg treatment of
(Calciumade) Zn 7.5 mg osteoporosis
Mn 1.8 mg
Acetaminophen 500 mg Every 6 hours Pain control
(Paracetamol)
Oxycodone 2.5 mg Every 3 hours as Pain control
needed
Cephalosporins 2g Every 8 hours Anti-bacterial
(Cefoperazone)
Sig: Pt. consumes medications for pain control. R/O medications consumption which can alter
pt’s balance and increase risk of falling.
OBJECTIVE INFORMATION
A. Vital Signs
Before During After
T 36.2 C 36.3 C 36.2 C
PR 87 bpm 90 bpm 88 bpm
RR 19 cpm 22 cpm 20 cpm
BP 120/90 mmHg 130/90 mmHg 120/90 mmHg
Findings: The vital signs of the pt. are WNL but on the higher limit in accordance to age-specific
norms.
Sig: A normal response to pain is an increase in heart rate, breathing rate and blood pressure.
`

B. Ocular Inspection
- Ambulatory c rolling walker
- Patient is alert, coherent and cooperative
- Ectomorph
- (+) postural deviation (see postural analysis)
- (+) gait deviation (see gait analysis)
- (+) surgical wound on (L) hip (see wound assessment)
- (+) swelling on (L) hip and upper thigh
- (+) rigid dressing on (L) upper thigh
- (+) trophic skin changes on (L) hip
- (-) ecchymosis on (L) hip
- (-) discoloration on all exposed body parts
- (-) gangrene on all exposed body parts
- (-) deformity on all exposed body parts
- (-) atrophy on all exposed body parts
- (-) contractures on all exposed body parts
- (-) attachments on all exposed body parts

C. Palpation
- Normothermic on all exposed body parts
- (+) Grade III tenderness on (L) hip
- (+) Nonpitting edema on (L) hip and upper thigh
- (+) Muscle spasm/guarding on (L) hip and upper thigh
- (-) Ecchymosis on (L) hip
- (-) Crepitus on (L) hip elicited during active and passive movement
Sig: Patients usually present with tenderness over the greater trochanter and possibly
significant bruising and swelling (Bateman et. al., 2012). Muscles that surround the
injured area may go into spasm when they try to hold the broken bone fragments in
place, and these spasms may cause further pain (Garg, 2011).

D. Wound Assessment
- Surgical wound is localized on the (L) hip
 - Shape is longitudinal and has a length of 10 cm and a width of 2 cm
- Periwound skin condition is normothermic, has normal color and vascularity
- Wound is moderately rough and has evident sutures, and has clearly denned edges
- Skin surface has hair loss
- Wound is hydrated, and is tender to palpation
- Wound is granulated throughout its length, has no exudate, and no odor

E. Neurologic Evaluation
1. Sensory Testing
- 100% in (B) LE as to light touch, pressure, and pain
Findings: Intact (B) LE sensory integrity
Sig: R/O sensory deficits. The pt. has normal neurologic exam.

2. Reflex Testing
a. Muscle Stretch/DTR

Grading: ++ ++
0 - Absent 0 Arreflexia ++ ++
1 - Diminished + Hyporeflexia ++ ++
2 - Average ++ Normoreflexia
3 - Exaggerated +++ Hyperreflexia
4 - Clonus, very brisk ++++ Clonus ++ ++
++ ++
Findings: Pt has normoreflexia on all reflex sites. ++
++
Sig: R/O neurologic impairment

b. Pathologic Reflex
Findings: (-) Babinski reflex
Sig: R/O neurologic deficits 2° UMNL lesion

3. Cranial Nerve Testing

Findings: All cranial nerves are intact.
Sig: R/O balance deficiencies and risk of falls 2° neurological impairment of vision,
hearing, and balance

4. Motor Control: Balance

a. Static Balance
Test Response
Romberg’s Test Good – able to maintain balance s
handhold support, limited postural sway

b. Dynamic Balance
Test Result
Five Times Sit To Stand Test Pt took 14 seconds to finish the test
Findings: Pt’s result warrants further fall risk assessment
Sig: Greater than or equal to 14 seconds indicates need of further assessment for fall risk
 c. Outcome Measures for Balance
Test Result
Pt took 25 seconds to complete the test.
TUG test Varying levels in independence;
functional balance
Findings: Pt’s took 25 seconds to complete the test
Sig: If pt. takes more than 20 seconds to complete the task, the test is considered positive
as a predictor of falls

6 Minute Walk Test

Mobility Aid: Rolling walker
Pre-test Post-test
120/90 mmHg BP 130/90 mmHg
87 bpm HR 90 bpm
98% SPO2 99%
8 RPE 11
Findings: Pt completed a distance of 185 m c crutches s rest for a span of 6 min.
Sig: Pt has limited endurance

F. Range of Motion
All joints of (B) UE & LE are WNL, pain free, actively and passively done except for:
RIGHT LEFT
ROM and (N)
End AP Diff Passive Active A-P End
values Active Passive
Feel Diff Feel
5 Hip Flexion 20
Soft 0-100° 0-95° 0-55° 0-75° Empty
0-120°
5 Hip Extension 10
Firm 20° 15° 5° 15° Empty
0-20°
5 Hip Abduction 10
Firm 0-30° 0-25° 0-25° 0-35° Empty
0-45°
5 Hip Adduction 10
Firm 0-30° 0-25° 0-15° 0-25° Empty
0-30°
5 Hip IR 10
Firm 0-35° 0-30° 0-15° 0-25° Empty
0-45°
5 Hip ER 10
Firm 0-35° 0-30° 0-15° 0-25° Empty
0-45°
5 Knee Flexion 10
Soft 0-110° 0-120° 0-120° 0-130° Soft
0-135°
Findings: Pt has LOM on all (L) hip ROM and knee flexion ROM. Pt has empty end feel 2° pain
preventing further motion.
Sig: The patient may encounter limitation and difficulties in gross motor and ambulation skills
involving (B) LE
G. Manual Muscle Testing
All major muscles of (B) UE & LE are graded 5/5 except:
(L) Muscle Group (R)
4/5 Hip flexors 4/5
4/5 Hip extensors 4/5
4/5 Hip abductors 4/5
4/5 Hip adductors 4/5
4/5 Hip internal rotators 4/5
4/5 Hip external rotators 4/5
4/5 Knee flexors 4/5
4/5 Knee extensors 4/5
Findings: The pt. has weakness of (B) hip and knee flexors and knee extensors.
Significance: The pt. may have difficulties in performing gross motor activities involving (B) LE.

H. Functional Mobility
Pt scored 35/80 points on the Lower Extremity Functional Scale
Findings: Pt is a household ambulator.
Sig: The maximum score obtainable is 80 points which signifies complete function and the
lowest score is 0 which indicates very low function.

I. Special Test
Special Test Procedure Response Significance
Homan’s Sign Test In the supine position, (-) Pain in the calf in (-) DVT
the knee of the (B) calves
suspected leg of the
patient should be
flexed. The examiner
should then forcibly
and abruptly DF the
patient's ankle.
Findings: Pt has no DVT
Sig: DVT is a common complication after surgical procedure

J. Anthropometric Measurement
Muscle Bulk Measurement
Reference Point (R) (L) Difference
Greater trochanter to bulkiest 15 cm 14 cm 1 cm
portion of the muscle
Findings: Pt has no muscle wasting 2° disuse

Limb Girth Measurement

Reference Point (R) (L) Difference
 1” from the greater trochanter 38 cm 40 cm 2 cm
2” from the greater trochanter 36.5 cm 39 cm 2.5 cm
3” from the greater trochanter 34 cm 37 cm 3 cm
4” from the greater trochanter 32 cm 35 cm 3 cm
Findings: Pt has edema on (L) LE

Apparent LLM
Reference Point (R) (L) Difference
Umbilicus to Medial Malleolus 77 cm 76 cm 1 cm
Findings: The patient has (N) LLM
Sig: To R/O contractures 2° to mm imbalance and functional shortening

True LLM
Reference Point (R) (L) Difference
ASIS to Medial Malleolus 80 cm 79 cm 1 cm
Findings: The patient has (N) LLM.
Sig: (L) LE is already aligned with (R) LE, indicating fracture realignment. R/O structural
abnormality in LE.

K. Postural Analysis
On standing position, all landmarks are leveled and symmetrical on all planes (anterior,
posterior, and lateral), except:
Anterior Posterior Lateral
- Head is not in midline and is - Head is not in midline and is - Head tilted forward and
titled to the (R) titled to the (R) downward
- (L) shoulder is higher - (L) shoulder is higher - Cervical spine is
compared to the (R) shoulder compared to the (R) shoulder hyperextended
- Trunk is not in midline and - Trunk is not in midline and - Increased curvature of upper
is more directed to laterally to is more directed to laterally to spine
the right the right - Pelvis is titled forwards,
causing buttocks to protrude
- Hyperextended knees
- Protruding abdomen
Findings: Pt. presents c mild kyphotic posture 2° to osteoporosis.
Sig: Pt’s posture may impair static and dynamic balance. Bony misalignments force the arches
to lower, shifting the centre of gravity inward and forward, generating imbalances throughout
the entire musculoskeletal structure.

L. Gait Analysis
Pt is able to do household ambulation c rolling walker
Anterior Posterior Lateral
- Asymmetrical hip rotation, - Asymmetrical hip rotation, - Shorter stride length
movements on the ® side are movements on the ® side are - Decreased stride frequency
more exaggerated more exaggerated - Decreased knee flexion at
- Uneven stride length - Uneven stride length impact
- Left hamstring not being - Left hamstring not being - Less rearfoot eversion
activated as much hence the activated as much hence the - Trunk leans over to the (L)
left heel fails to recover the left heel fails to recover the side during weight bearing
same way as the right same way as the right
- Foot strike is on the (L) - Foot strike is on the (L)
forefoot forefoot
Findings: Pt. presents c antalgic (pain-relieving) hip gait in order to reduce the load on the hip,
and takes a short stride to minimize the time that the painful limb bears weight
Sig: Pt has difficulty maintaining balance and walking further distances

M. Activities of Daily Living

Pt scored 5/6 points on the Katz Index of Independence of ADLs
Findings: Pt is dependent on transferring but is independent on bathing, dressing, toileting,
continence, and feeding.
Sig: A score of 6 indicates that the client is independent and a score of 0 indicates that the
client is very dependent

ASSESSMENT
PT Diagnosis
- Pattern 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion
Associated With Fracture
- Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling
- Pattern 7A: Primary Prevention/Risk Reduction for Integumentary Disorders

PT Impression
- Pt’s condition is defined by impaired joint mobility, muscle performance, and ROM, and
is further defined by balance, postural, and gait deviations,

Prognosis and Rehab. Potentials

- Pt. has good prognosis for recovery of joint mobility, muscle performance, and range of
motion due to the type of fracture acquired by the patient (Sig: Intertrochanteric fracture
is a benign type of injury because it unites easily and with less complications; Garg,
2011). Pt. is cooperative, participative, and has maximal concentration during tasks. Pt’s
support system is compliant, willing to support and has the financial means to continue
with treatment.

Problem List
1. Pain c functional movements and activities
2. LOM on all (L) hip ROM and knee flexion
3. Muscle weakness of (B) hip muscles, knee extensors and flexors
4. Kyphotic posture
5. Dynamic balance problems
6. Antalgic gait
Preventive Goals
1. Pt will be able to prevent further increase of LOM.
2. Pt will be able to prevent integumentary disorders such as pressure ulcers due to
decreased mobility.
3. Pt will be able to demonstrate proper balance, postural and gait mechanics and control to
prevent fall-related injuries.
4. Pt will be able to prevent muscle atrophy due to inability to use the lower extremities
within functional range of motion

Long Term Goals

1. Pt will be able to decrease pain from 7/10 to 3/10 in the (L) LE in order for the pt to do
ADLs independently and without restrictions in 5 months
2. Pt will achieve an increase of 10-20° increments in all (L) hip ROM and knee flexion to
engage in ambulation activities within 5 months
3. Pt will achieve an increase in (B) hip muscles, and knee flexors and extensors’ muscle
strength from 4/5 to 5/5 manifested by ability to ambulate symmetrically and
independently w/in 4 months
4. Pt will be able to do community ambulation independently until fatigue within 7 months

Short Term Goals

1. Pt will be able to decrease pain from 7/10 to 5/10 in the (L) LE in order for the pt to
withstand longer periods of ambulation within 1 month
2. Pt will achieve an increase of 5° increments in hip and knee flexors as to assist with
ambulation within 2 weeks
3. Pt will achieve an increase in (B) hip muscles and knee flexors and extensors’ muscle
tone as manifested by ability to weight bear symmetrically w/in 2 weeks
4. Pt will be able to employ proper heel strike, loading response, midstance, terminal stance,
and during the swing phase on the (L) LE within 1 month

Participation Goals
1. Pt will be able to do gardening and participate in church activities within 7 months.

PLAN
Prescribed PT Mx
1. HMP x 20 mins on (L) hip to decrease pain
2. Conventional TENS x 20 mins, set at continuous mode, 100 ms pulse duration, 100 Hz
frequency x 20 mins on (L) hip as adjunct therapy to decrease pain
3. Active ROM exercises x 10 reps x 3 sets x 30 seconds hold on all hip and knee motions
to decrease pain and maintain joint mobility
4. Heel-raises when standing in the parallel bars x 10 reps x 3 sets to maintain strength of
gastrocnemius and soleus muscles
5. Isometric contraction x 10 reps x 3 sets x 15 seconds hold of (B) hip muscles and knee
flexors to maintain muscle tone
 6. Sitting balance on a therapy ball x 10 min to improve balance

Suggested PT Mx
1. Refer to occupational therapist to promote move safely during recovery and by providing
ingenious equipment for activities such as bathing, cooking, and dressing.

Home Instructions
1. Modify the pt’s home environment and remove barriers appropriate to the pt’s needs to
avoid risks of injury and falling
2. Partake in exercise programmes such as Tai Chi to improve muscle strength and balance
for fall prevention
3. Utilize proper positioning and suitable care for pressure areas of all extremities during
prolonged sitting and supine lying to avoid contractures and pressure ulcers
4. Employ proper hygiene in both dressing and postsurgical wound
5. Perform self-stretching exercises and PRE exercises

Kaye-Anne Cyrille Pizarro, SPT

Beatrice Salgado, SPT