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Clinical Education | Continuing Education | Grand Rounds Case Studies
Case Study:† Acute Care Rehabilitation after Bilateral Pelvic
by
Dale Healy, MS, PT

††††††††††† This is a case study of a young female with bilateral pelvic fractures and her immediate treatment and recovery with physical therapy in an acute care setting.† Rehabilitation efforts in a hospital are focused on gaining functional mobility skills in order for the patient to be discharged to home.†† When these goals cannot be attained prior to the patient reaching medical stability, alternative settings must be considered, namely acute and subacute rehabilitation facilities.

††††††††††† A 24-year-old female was attending a horse show.† During a practice session, her 1800-pound horse reared, throwing her to the ground, and then landing on top of her.† She sustained a crush injury to her pelvis and was initially taken to a hospital.† Upon admission, it was determined she had sustained bilateral superior pubic rami fractures, a right anterior pubic ramus fracture, significant diastasis of the left sacroiliac (SI) joint, an L5 transverse process fracture, and a pelvic hematoma.† An abdominal CT eliminated other intraabdominal pathology.† The following day, a left distal femur traction pin was placed.† Per protocol, the patientís hematologic status was closely followed due to the pelvic hematoma.† On hospital day three (HD#3), the patient was noted to have a UTI and a left lower extremity (LLE) angiogram was performed where an IVC filter was placed as prophylaxis treatment for immobility.†† During this time, the patientís hematocrit and hemoglobin continually trended downward.† However, the usual treatment of blood transfusion was not an option due to the patientís religious choice.† When IV iron was administered as an alternative treatment, an allergic reaction was noted and the medication discontinued.† On HD#13, an ultrasound revealed a left popliteal vein occlusive thrombus.† Due to the complex nature of her pelvic fractures, the anemia complicated by her choice to decline blood products, and the blood clot, the patient was transferred to Duke via ambulance.

The patient was admitted to Duke Hospital in fair condition to the orthopedic service.† Her hematocrit was 0.21 and her hemoglobin was in the low seven range.† X-rays of the pelvis and a bilateral lower extremity (BLE) ultrasound were repeated on arrival.†

A CT
of the pelvis exposed an extension of the right pubic ramus fracture into the parasymphyseal bone as well as a nondisplaced fracture of the left parasymphyseal bone into the pubic symphysis.† The decision was made to take the patient to the OR the following day for stabilization.

††††††††††† Under general anesthesia, a closed reduction was performed with percutaneous pinning of the left SI joint.† Also, a uniplanar anterior external fixator was placed through the anterior columns.† During surgery, several areas of skin breakdown were noted.† A wound care consult was made and the wounds treated secondarily without complication.†

On post-operative day 2 (POD#2) and overall HD#16, a physical therapy consult was received.† The patient was restricted to non-weight bearing (NWB) on her LLE but was allowed weight bearing as tolerated on the right leg (RLE).† The physical assessment revealed a LLE strength of 1+/5 throughout, a RLE strength of 2-/5 throughout and bilateral upper extremity strength of 5/5 throughout.† Of note was the fact that the patient had been bedbound for over two weeks.† The patient was assisted into a sitting position at the edge of the bed, requiring maximum assistance (max A) of two people and use of a trapeze bar.† She was able to sit with bilateral upper extremity support & contact guard for an unspecified amount of time.† Contrary to what was expected, the patient tolerated sitting without complaints of dizziness or an increase in pain.† Once back in supine, exercise protocol for pelvic fractures was introduced.† The pt was instructed in ankle pumps, quad & glut sets, heel slides & short arc quads.† From this initial evaluation, the following goals were established:

Goal 1: The patient will perform BLE exercises with minimal assistance (min A).†

Goal 2: The patient will transfer supine (sup)<>sit with moderate assistance (mod A) of 1.†

Goal 3: The patient will transfer sit<>stand and pivot bed<>wheelchair or bedside commode (BSC) with a standard walker (SW) & LLE NWB with min A.†

Goal 4: The patient will propel a wheelchair 100í independently.†

Goal 5: The patient will perform pressure relief while in wheelchair every 15 minutes independently.

These goals were expected to be accomplished within one week and a recommendation for discharge to home with 24-hour assistance and home health PT was made.

††††††††††† The patient was seen the following day (POD#3/HD#17).† Her father was present throughout the session for training purposes.† She was noted to have improved BLE strength: hip flexion 2/5, knee extension 3/5 & ankle dorsiflexion & plantar flexion 4-/5.† The lower extremity exercises were completed with min A at ten repetitions each with instruction provided to the patientís father on how to provide similar assistance.† The patient was able to transfer sup>sit with mod A and tolerated sitting edge of bed for ten minutes.† For the first time, she attempted and was able to stand for approximately 30 seconds with a SW and contact guard assist while maintaining her left leg in a non-weight bearing position, requiring only min A for the sit>stand transfer.† Her exceptional upper body strength was demonstrated by her ability to boost her lower body up and back onto the bed when returning to a supine position.

††††††††††† On POD#4/HD#18, the patient began to express her concern over being in the hospital for such a long period of time, mostly from a financial standpoint.† During this PT session, she required mod A to transfer sup>sit to stand with a SW and to transfer to a wheelchair.† She was then instructed in maneuvering techniques and was able to propel herself 125í with min A.† Ninety minutes later, PT returned to assist her back to bed.† She was able to take three small steps with the SW and min A to maintain her LLE NWB.† Exercises were not performed on this visit as patient stated she had been doing so independently.

††††††††††† The next day (POD#5/HD#19), the patient began to express her concern about being able to manage at home.† During the previous three PT visits, she had not rated her pain over a 4/10, which she was managing with Tylenol.† However, she admitted that she fatigued quickly during her PT sessions.† On this visit, her mother was present to observe and receive instruction.† The patient required only min A for all transfers except when standing from the wheelchair, which had a seat height of 20 inches (required mod A).† She tolerated being up in a wheelchair for an hour.† A rolling walker (RW) was tried during the transfer back to bed in order to minimize the exertion of her upper extremities, which the patient found to be helpful.† The exercise protocol was again completed with one modification.† The patient was shown how to use a towel under her left thigh to assist with hip flexion until strong enough to do so independently.† At the end of the session, she and her mother stated their preference for flying back to their home state rather than enduring a seven-hour car ride, which would be elongated by the process of multiple transfers for purposes of voiding.

††††††††††† On the next visit (POD#6/HD#20), the patient again commented on her level of fatigue with activity.† Her transfers were more difficult on this date, requiring mod A.† She was able to propel herself 700í in the wheelchair with supervision only & performed pressure relief every 15 minutes independently.† Her mother commented on her need to return to work and to care for the horses the patient normally cared for.† At this point, the patient could not be alone for any period of time due to her inability to transfer independently.† The recommendation was made for a short acute rehab stay, which the patient and her mother agreed to eagerly.† The patient resource manager (PRM) assigned was able to secure a bed offer from in her home state for admission in two days.

On POD#7/HD#21, the patient was able to ambulate some distance for the first time.† A shoe was donned on her right foot to give her added height so that she could more easily keep the LLE NWB.† Additionally, she propelled her wheelchair 300í independently.† However, she required min A of 2 people to transfer from sit>stand.

††††††††††† POD#8/HD#22 was the patientís last day in acute care.† Her father had arrived for training with his daughter in car transfers and for use of the wheelchair.† She continued to require up to mod A for transfers, sit>stand remaining the most difficult for her.† The patient and her father were instructed in car transfers and performed with the use of a mock car in the PT gym with only minimal verbal cues.† Her father was instructed in how to break down and set up the wheelchair for transport in a car.

††††††††††† At the time of any initial PT evaluation, information is gathered regarding the patientís home environment and level of available assistance.† At the very least, a patient must be able to get into their home once they arrive.† If they have assistance 24 hours a day, a patient can be discharged home if their helper is able to demonstrate competency in performing basic transfers, i.e. supine<>sit<>stand and pivoting to a BSC or wheelchair.† In this case, the patient and her family indicated in the beginning that someone would be with the patient at all times once at home.† As a result, goals were written to reflect this expected outcome.† Over the course of time, the patient began to realize several things: her recovery would take longer than expected, the effort she needed to put into her physical rehabilitation would be draining and that financial plans needed to be made for the future (her mother, the primary caretaker, needed to work and now had to become responsible for taking care of the horses that were ordinarily the patientís responsibility).†† The combination of being unable to perform transfers (e.g. to go to the bathroom) and no longer having 24 hour assistance at home led to the recommendation for a short acute rehab stay.† This necessitated a shift in the focus of the therapy.† To qualify for acute rehab, a patient has to require assistance for transfers and goals for gait training.† Additionally, the patient had to be able to get to her new destination.† This patient had obvious difficulty with transfers but had not attempted ambulation when the referral to acute rehab was made.† Emphasis was then placed on beginning to ambulate.† The final step was getting the patient to the rehab facility.† The determination had been made for her to fly home and she had demonstrated that she could go by plane in a wheelchair since she had tolerated sitting upright in a wheelchair for a period of time.† The final obstacle was the car transfer to get her to the airport and from the airport to the new facility, which she and her father performed successfully.

††††††††††† In an acute care setting, flexibility is essential due to its ever-changing nature.† Re-assessment occurs at every step.† This patient started out on a direct path home after a devastating injury.† She had wonderful family support but was realistic enough to know her limits.† Goals had to change mid-stream.† This case is a example of the coordinated efforts required by all involved in a patientís care: the doctors, nursing staff, therapists, PRM, family members and, most importantly the patient.

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