Daniel Woodward

East Tennessee State University, Year II

Mount Pleasant Manor

1. Pelvis Anatomy:

Sacrum Coccyx Ilium Ischium Pubis

2. Pelvis Functions: Provides link between spine & lower extremities Provide stability for trunk & legs Transmits body weight downward Absorbs forces when standing & walking Serves as bony site for muscle attachment Protects internal organs in lower abdominal region

Introduction

[10] [14]

SPR

IPR

1. Classification:

High Impact Injury vs. Low Impact Injury

Stable vs. Unstable

2. Pelvic Fractures associated with:

Increased mortality rates in the elderly

Decreased mobility & independence

Increased hospital stay

Substantial health care cost

Pelvic Ring Fractures

[2,4,11]

High Impact

Low Impact

Right Superior and Inferior Pubic Rami Fracture

1. Date of Injury: 1/08/13

2. Mechanism of Injury: Patient fell at home when walking to bathroom; legs gave way as she

fell on her bottom

3. X-Rays confirmed stable pubic rami fractures

4. Received Acute PT/OT for pain management in hospital

5. Discharged 1/15/13 from hospital to sub-acute rehab facility (Mount Pleasant Manor)

Patient Injury

Medical Diagnosis

Right Superior & Inferior Pubic Rami Fractures [13]

Muscles Attaching around the Pubic Rami

[12]

1. Injury Classification:

Low Impact Stable

2. MOI: Trauma usually due to a simple fall (fall less than 3 feet)

3. Occurrence: Commonly occurs in the elderly (60+ years old)

4. Females > Males

5. Symptoms: Bruising, swelling, or crepitus in pubis region Pain in groin, lateral hip, or the buttock area when WB Decreased ROM/strength due to pain Decreased ability to perform SLR on affected side Antalgic gait for those who can ambulate

Epidemiology

[11]

1. Current Treatment Strategies:

Pain management, rest, maintain ROM & strength, & gait training with protected weight bearing.

2. Prognosis:

Varies depending on patient age, mental status, & overall health

Injury usually heals quickly due to large amount of soft tissue in this area.

Most healthy patients require protected weight bearing for about 6 weeks until the pain has diminished

Epidemiology

[6, 8, 11 ]

1. To examine deficits of a patient who has suffered a right superior & inferior pubic rami fracture

2. To create an effective treatment plan utilizing evidence based practice to address deficits associated with injury

Purpose Statements

1. Tinetti’s Gait & Balance Assessment Score

2. Level of Assistance Required for Functional Tasks

3. Ambulatory Distance

4. Pain Rating

Outcome Measures

1. Medical History:

75 year old female

Severe osteoporosis with multiple fractures

Right TSR, Left RCT repair

Right THA, Left THA with 2 revisions (15 years ago)

Apparent & True Leg length discrepancy

April 2012 – Fracture of Left femur/patella due to fall

Most Recent: (R) superior & inferior pubic rami fracture (stable) & 4th finger fracture due to fall

The Patient

2. Medial History Continued:

Depression

History of Hypertension

Multiple Bowel Resections; residual spastic colon

Peptic Ulcer Disease

Chronic diarrhea

Inguinal hernia repair

Bilateral Cataract Surgeries

FALL RISK!

The Patient

3. Family History: (+) for cancer in her brother

Sister has peripheral artery disease

Father had diabetes

Mother had congestive heart failure

4. Social History: Smoked ~ 1 pack per day for more than 50 years

Does not drink alcohol or abuse any drugs

Manages well on her own with her ADL’s

The Patient

5. Medications and POSSIBLE side effects

Imodium: Dizziness and drowsiness

Temazepam: Day time drowsiness, muscle weakness, lack of balance or coordination.

Vilazodone: Dizziness, fatigue, feeling jittery

Losartan: Dizziness, drowsiness, confusion

Omeprazole: Dizziness, confusion, feeling jittery, weakness

KCl: Confusion, anxiety, muscle weakness

OxyContin: Drowsiness, dizziness

Lortab: Anxiety, dizziness, drowsiness, blurred vision.

The Patient

6. Occupation:

Retired

7. Living Situation: Lives with sister; 9 steps to enter home

8. Prior level of function: Ambulated at home without assistive device

9. Precautions: WBAT on Right Lower Extremity Full Code

The Patient

Patient Information Measurement

Height 5'4''

Weight 88 lbs

Blood Pressure 135/78 mmHg

Heart Rate 60 bpm

Awareness Alert and oriented x 3

Neurological WNL

The Examination

1. UE ROM: Non-functional use of (R) shoulder; See OT Eval.

2. LE ROM:

The Examination

Joint Motion Left Extremity Right Extremity Normal Values

Hip Flexion 104° 95° 121°

Hip Extension NOT TESTED NOT TESTED 19°

Hip IR 29° 33° 32°

Hip ER 25° 23° 32°

Hip Abduction 35° 30° 42°

Hip Adduction 15° 17° 20°

Knee Flexion 126° 109° 132°

Knee Extension 0° 0° 10°-0°

Ankle Dorsiflexion 12° 14° 11°

Ankle Plantarflexion 48° 42° 64°

[9]

1. UE Strength: See O.T. evaluation

2. LE Strength:

The Examination

Muscle Group Left Extremity Right Extremity

Hamstrings 4 (GOOD) 4 (GOOD)

Quadriceps 4 (GOOD) 4 (GOOD)

Adductors 3 (FAIR) 4 (FAIR)

Abductors 4 (GOOD) 4 (GOOD)

Hip Flexors 2+ (POOR) 2+ (POOR)

Hip Extensors NOT TESTED NOT TESTED

Dorsiflexors 4 (GOOD) 4 (GOOD)

Plantarflexors 5(NORMAL) 5 (NORMAL)

1. Leg Length Discrepancy

Patient has custom 1 inch (2.54 cm) lift for Left shoe which she does NOT where.

The Examination

Leg Length Testing Left Lower

Extremity (cm)

Right Lower

Extremity (cm)

Difference

(cm)

True Leg Length 86.5 90 3.5

Apparent Leg Length 90 92.5 2.5

The Examination

Balance Tests Grade Description

Static Sitting GOOD Patient able to maintain balance without handhold support,

limited postural sway

Dynamic Sitting GOOD Patient accepts a moderate challenge; able to maintain balance

while picking object off floor

Static Standing GOOD Patient able to maintain balance without handhold support,

limited postural sway

Dynamic Standing FAIR Patient accepts minimal challenge; able to maintain balance while

turning head and trunk

Functional

Tests

Required

Assistance

Description

Bed Mobility Modified

Independence

*Unable to complete rolling to side-lying on either side secondary to pain.

*Required MI to initiate and complete roll half way towards both sides.

Transfers Stand By

Assistance

*Required verbal cueing for safety.

*Required SBA for supine<>sit and sit<>stand/SPT with RW.

Ambulation Contact Guard

Assistance

*Required verbal cueing for proper sequencing of gait to accommodate for

pain and WBAT status for Right LE.

*Ambulated 30 feet with RW.

The Examination

1. Tinetti’s Balance Assessment Tool:

Measures patient’s gait & balance Scoring: Ordinal scale ranging from 0 – 2

0 = most impairment 2 = independence of the patient Three measures: Gait assessment score, overall balance assessment

score, and gait & balance score Total Balance Score = 16 Total Gait Score = 12 Total Test Score = 28

2. Interpretation: 25 – 28 = Low Fall Risk 19 – 24 = Medium Fall Risk < 19 = High Fall Risk

The Examination

1. Tinetti’s Score = 14

Patient is a HIGH FALL RISK!

2. Pain = 7 / 10

Pain Description:

Pain in legs, lower back, pubic region. Pain increased with SLR, when turned onto side, or in WB; especially painful on (R) LE in hip & pubic region.

The Examination

1. Achieves ¾ side-lying to either side using bed rails & without

pain

2. Modified Independent Transfers Supine <> Sit Sit <> Stand/SPT with a RW

3. Modified Independent > SBA for ambulating with a RW up to 60’

4. GOOD dynamic standing balance

5. Tinetti’s score of 16

Short Term Goals

These goals changed from week to week as patient progressed

1. Independent Bed Mobility

2. Independent to modified independent Transfers Supine <> Sit <> Stand/SPT with RW

3. Modified Independent Ambulation up to 150’ with RW

4. Able to Ascend/Descend 9 steps

5. Final Tinetti’s minimal score of 19

Long Term Goals

1. Physical Therapy: 5x/week x 4 weeks

Safety & Moderate Independence with all of the following:

Demonstrate Functional LE ROM

Demonstrate Functional LE Strength

Demonstrate Functional Bed Mobility

Demonstrate Functional Transfers

Demonstrate Functional Gait

Be able to ascend and descend 9 steps

2. Discharge Plan Mount Pleasant Manor Home

Plan of Care

1. Cryotherapy5

Research confirms that cryotherapy results in: Decreased inflammation Decreased blood flow Reduced swelling Reduced pain

2. Nustep7

Research supporting this exercise suggests that it: Decreases blood pressure Increases strength Increases walking speed

Evidence Based Practice

3. Prophylactic Measures11

Range of Motion

Strength

Prevent Immobility

4. Standing Activities/Ambulation1

Research suggests that weight bearing activities are effective in preserving or even increasing bone mass.

Ambulation should be encouraged!

Evidence Based Practice

1. Warm Up

Nustep 15 minutes at Level 1

2. LE ROM Heel slides for hip flexion, hip abduction, & hip adduction; 3 sets of 10

3. LE Strengthening Knee extension (quads), bridging (gluts), knee raises (hip flexors); 3 sets of

10

4. Bed Mobility Worked on rolling from side to side using modified independence

5. Transfer Training Practiced sit<>stand/SPT & sit<>supine using modified independence

6. Cryotherapy Ice pack x 15 minutes to control pain

Initial Treatment Plan

1. Modified 3-point Gait Pattern while using

walker.

2. Importance of using assistive device during gait/transfers at all times

3. Importance of wearing proper shoes with custom lift for left shoe

4. Pain Rating Scale

Patient Education

Pain Scale Interpretation

1. Initial Rating = 7 (Very Intense):

Pain completely dominates your senses, causing you to think unclearly about half the time. At this point you are effectively disabled and frequently cannot live alone. Comparable to an average migraine headache

2. After Education = 4 (Distressing):

Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard. So strong you notice the pain all the time and cannot completely adapt.

1. Warm Up:

Nustep 20 minutes at Level 1

2. LE Strengthening and ROM Exercises: Heel slides for hip flexion, abduction, adduction Knee extension (quads), bridging (gluts); 3 sets of 10

3. Gait Training: CGA ambulation 30’ x 2 with a rolling walker, breaks, & a more continuous

and symmetrical gait Knee raises over small hurdles while ambulating in parallel bars (hip

flexors)

4. Step Exercise: CGA stepping exercise on to 2 ½ inch step while in parallel bars ; 3 sets of 10 Leading with both LE’s

Treatment Progression 1

Step Exercise

1. Warm Up:

Nustep 20 minutes at Level 1

2. LE Strengthening Exercises:

Knee extension (quads); 3 sets of 10

3. Gait Training

SBA Ambulation 75’ x 2

4. Dynamic Standing Balance Activities

Tic-Tac-Toe Toss in standing

Balloon Volleyball in standing

5. Step Exercise:

CGA stepping exercise on to 4 inch step while in parallel bars ; 3 sets of 10

Leading with both LE’s

Treatment Progression 2

Tic-Tac-Toe Toss Balloon Volleyball

1. After three weeks, patient demonstrated sufficient

safety, endurance, and strength with all transfers and ambulation

2. In order to continue the progression towards further independence, the W/C was discharged

3. Patient was educated on current status & was asked to use supervision when ambulating away from her hall

W/C Discharge

1. Warm Up:

Nustep 20 minutes at Level 1

2. Gait Training:

MI ambulation 150’ x 2 with a rolling walker

3. Standing Balance Activities

Balloon Volleyball in standing

Kicking ball activity with Right LE

4. Step Exercise:

CGA stepping exercise on to 6 inch step on therapy stair set ; 3 sets of 10

Leading with both LE’s

Treatment Progression 3

Single Leg Stance Activity

1. Warm Up:

Nustep 20 minutes at Level 1

2. Gait Training:

MI ambulation 150’ x 2 with a rolling walker

3. Standing Balance Activities

Balloon Volleyball in standing

Kicking ball activity with Right LE

4. Step Exercise:

CGA ascending with the Left LE and descending leading with the Right LE 4 steps 3x

Also worked on ascending/descending steps sideways to simulate home environment.

Final Treatment

Therapy Steps

Outcome Measures

Outcome Measure Initial Assessment Final Assessment

Tinetti’s Score 14 24

Required Assistance for

Functional Tasks

MI Bed Mobility

SBA Transfers

CGA Ambulation

Independent Bed Mobility

MI Transfers

MI Ambulation

Ambulatory Distance 30 feet 150 feet x 2

Pain Rating 7/10 3/10

1. Wii Therapy (Balance/Decreased Fall Risk)3

Research shows that six 1 hour sessions of Wii bowling simulation significantly improved Berg Balance, DGI, and TUG scores for an 89 year old female

Alternative Treatment

1. Aisenbrey, Jeannie A. "Exercise in the Prevention and Management of Osteoporosis." Journal of the American Physical

Therapy Association 67.7 (1987): 1100-104. PubMed. Web. 18 Mar. 2013. <http://www.physther.org/content/67/7/1100.full.pdf+html>.

2. Boufous, Soufiane, Caroline Finch, Stephen Lord, and Jacqueline Close. "The Increasing Burden of Pelvic Fractures in Older People, New South Wales, Australia." Injury 36.11 (2005): 1323-329. PubMed. Web. 12 Mar. 2013. <http://www.sciencedirect.com.ezproxy.etsu.edu:2048/science/article/pii/S0020138305000495>.

3. Clark, Robert, and Theresa Kraema. "Clinical Use of Nintendo Wii(TM) Bowling Simulation to Decrease Fall Risk in an Elderly Resident of a Nursing Home: A Case Report." Journal of Geriatric Physical Therapy 32.4 (2009): 174-80. Ebscohost. Web. 10 Apr. 2013. <http://search.proquest.com.ezproxy.etsu.edu:2048/docview/736484473?accountid=10771>.

4. Dodge, Greg, and Rob Brison. "Low-impact Pelvic Fractures in the Emergency Department." Canadian Journal of Emergency Medicine 12.6 (2010): 509-13. PubMed. Web. 12 Mar. 2013. <http://www.cjem-online.ca/v12/n6/p509>.

5. Greenstein, Gary. "Therapeutic Efficacy of Cold Therapy After Intraoral Surgical Procedures: A Literature Review." Journal of Periodontology 78.5 (2007): 790-800. PubMed. Web. 12 March 2013. <http://www.joponline.org/doi/pdf/10.1902/jop.2007.060319>.

6. Hill, R., C. M. Robinson, and J. F. Keating. "Fractures of the Pubic Rami: Epidemiology and Five-year Survival." The Journal of Bone and Joint Surgery 83-B.8 (2013): 1141-144. Google Scholar. Web. 12 Mar. 2013. <http://www.bjj.boneandjoint.org.uk/content/83-B/8/1141.full.pdf+html>.

7. Johnson, Timothy, Scott McPhee, and Mary Dietrich. "Effects of Recumbent Stepper Exercise on Blood Pressure, Strength and Mobility in Residents of Assisted Living Communities: A Pilot Study." Physical & Occupational Therapy In Geriatrics 21.2 (2002): 27-40. Google Scholar. Web. 12 Mar. 2013. <http://informahealthcare.com/doi/abs/10.1080/J148v21n02_03>.

References

8. Krappinger, Dietmar, Peter Struve, Rene Schmid, Jakob Kroesslhuber, and Michael Blauth. "Fractures of the Pubic

Rami: A Retrospective Review of 534 Cases." Archives of Orthopaedic and Trauma Surgery 129.12 (2009): 1685-690. PubMed. Web. 12 Mar. 2013. <http://link.springer.com/article/10.1007%2Fs00402-009-0942-5?LI=true>.

9. Norkin, Cynthia C., and D. Joyce. White. "Normative Range of Motion Values." Measurement of Joint Motion: A Guide to Goniometry. 4th ed. Philadelphia: F.A. Davis, 2009. 427-28. Print.

10. O'Connor, Shaun. "STUDYBLUE", n.d. Web. 13 Mar. 2013. <http://www.studyblue.com/notes/note/n/chapter-8-appendicular-skeleton-lecture/deck/4262031>

11. Sarwark, John F. "Fracture of the Pelvis." Essentials of Musculoskeletal Care. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2010. 558-61. Print.

12. Vivere, Amare, Ridere: Pubic Ramus Fracture in the Distance Runner." Vivere, Amare, Ridere: Pubic Ramus Fracture in the Distance Runner. N.p., n.d. Web. 13 Mar. 2013. <http://gazelle74.blogspot.com/2012/05/pubic-ramus-fracture-in-distance-runner.html>.

13. Where Is the Pubic Rami?" Where Is the Pubic Rami? InnovateUs Inc, n.d. Web. 13 Mar. 2013. <http://www.innovateus.net/innopedia/where-pubic-rami>.

14. "Why Pelvis In Men and Women Different Size and Shape?" Nanda Books. N.p., 2010. Web. 13 Apr. 2013. <http://nandabooks.blogspot.com/2012/11/why-pelvis-in-men-and-women-different.html>.

References