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 Table of Contents  
Year : 2019  |  Volume : 14  |  Issue : 4  |  Page : 394-396

A case of fracture shaft femur in a patient with transtibial amputation

Department of Community Health physiotherapy, Ravi Nair Physiotherapy College, DMIMS (DU), Wardha, Maharashtra, India

Date of Submission30-Nov-2019
Date of Decision05-Dec-2019
Date of Acceptance20-Dec-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Shalaka Dhankar
Department of Community Health Physiotherapy, Ravi Nair Physiotherapy College, DMIMS (DU), Sawangi (Meghe), Wardha - 442 004, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_190_19

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Transtibial amputation refers to the removal of the ankle joint and lower leg up to distal tibia and fibula. A 45-year-male came to physiotherapy department postoperatively after mid-shaft fracture femur with a history of below-knee amputation of the same extremity presenting with knee flexion deformity, fear of fall, and difficulty in ambulation. Patient underwent extensive physiotherapy to reduce the flexion deformity by improving flexibility of hamstring, after which the patient was subjected to gait training for re-educating the patient to use his prosthetic limb.

Keywords: Gait training, knee flexion deformity, mid-shaft femur fracture, transtibial amputation

How to cite this article:
Dhankar S, Bele A. A case of fracture shaft femur in a patient with transtibial amputation. J Datta Meghe Inst Med Sci Univ 2019;14:394-6

How to cite this URL:
Dhankar S, Bele A. A case of fracture shaft femur in a patient with transtibial amputation. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2021 Jun 15];14:394-6. Available from: http://www.journaldmims.com/text.asp?2019/14/4/394/289849

  Introduction Top

Amputation refers to the removal of part of the body. Transtibial amputation also commonly called as below-knee amputation is the removal of the ankle joint up to distal tibia and fibula. There are two types of transtibial amputation depending on the level, below-knee amputation of tibia and fibula up to 8 cm constitutes for 70% of disability while below-knee amputation up to lower one-third of the leg constitutes for 60% of disability.[1] Patellar-tendon-bearing prosthesis is the most commonly used prosthesis for patients with transtibial amputation.[2],[3]

Fracture shaft femur presents a clinical problem because of their variety and complexity.[4] Limb shortening and malalignment are some of the problems associated with fracture shaft femur more over knee contractures, and weakness of quadriceps muscle may interfere with the treatment protocol.[5],[6]

Even after a union of the fracture without any complications, disability following fracture may be prolonged because of associated problems and depending on the type of fracture[7] such as knee flexion deformity due to prolonged immobilization.[5]

Here follows a case of fracture shaft femur of 45-year-male with below-knee amputation for which the patient underwent extensive physiotherapy management.

  Case Report Top

This was a case report of a 45-year-male who came to physiotherapy with the chief complaint of difficulty to extend knee and fear of fall following fracture shaft femur. The patient was operated 8 months back by internal fixation. The patient presented a history of transtibial amputation of the same extremity 10 years back and was using prosthetic limbs for ambulation. On examination, there was mild knee flexion deformity developed because of prolonged immobilization, quadriceps had Grade 2 and hip abductors had Grade 3 on manual muscle testing (MMT), tightness of hip extensors, hamstring, and hip adductors was prominent on the affected side. The normal side had Grade 4 on MMT. The fracture was completely healed and presented with no further complications patient was unable to fix his prosthesis due to the knee flexion deformity and was anxious about weight bearing on his affected extremity and using his prosthesis for ambulation along with fear of fall.

The aim of treatment was to reduce the knee flexion deformity as soon as possible by improving the flexibility of hip extensors and hamstring along with a strengthening of quadriceps muscles. Proper positioning and Muscle Energy Technique (MET) (contract – relax) were used to stretch the muscles, the patient was taught self-stretching technique for the maintenance. For strengthening of quadriceps muscle, Russian current was used initially to progress the muscle to Grade 3 after which strengthening of quadriceps and abductors was done by using weights. To improve weight-bearing patient was taught kneel standing with weight shifts, quadruped position with weight shifts.

The challenge was to train the patient for using his prosthesis again for ambulation. Initially, gait training started with a temporary prosthesis with a walker progressing to axillary crutches to give the impression of weight-bearing to the patient and reduce his fear of fall. After this patient was shifted to stick, once the patient was confident enough, he underwent prosthetic training with a final prosthesis without any assistive device to make him functionally independent.

  Discussion Top

In the above-mentioned case report a 45-year-old transtibial amputation patient was given treatment for a mid-shaft femur fracture to re-educate him in using his prosthesis for ambulation. Treatment included MET (contract-relax) for stretching hamstring muscles as well as hip extensors and reduce knee flexion deformity. Ballantyne et al. in their study also suggested that the MET technique instantly helps in improving the passive range of motion.[8] Handel et al. concluded the effect of contract-relax technique in improving hamstring flexibility.[9]

Russian current was used to increase strength. It is a medium frequency current which is beneficial for functional training of the muscle and produce titanic contraction at 50–70 Hz. Amr Almaz Abdel-aziem in the study also suggested that Russian current is effective in improving torque of quadriceps muscle.[10]

Weight-bearing exercise in knee standing and quadruped position was important to improve weight-bearing and proprioception and is advantageous for proper ambulation.[11] Gait training using a different assistive device with temporary prosthesis helped in reducing the fear of falls. As the weight is transmitted through limb to the prosthetic shaft through sockets reduction in knee flexion deformity is important for proper fitting of the prosthesis and adequate weight transmission.[12],[13],[14],[15],[16],[17],[18],[19] Nolan and Lees also suggested the same considering demands on the intact limb.

  Conclusion Top

The case report concluded that it is difficult for amputation patients to recover after a reinjury in the form of fracture. Moreover, only treating the fracture condition is not sufficient but re-educating the patient again with prosthetic training is important for ambulation of the patient to make him functionally independent.

Declaration of patient consent

The authors certify that appropriate consent forms were obtained from the patient. In the consent form, the patient has given his consent for his clinical information to be published in the journal. The patient understands that their personal information will not be disclosed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar R. NIOH, Disability Assessment and Certification. Guidelines and Gazette Notification, Ministry of Social justice and Empowerment, GOI, No. DL33004/99 (Extraordinary). Part 2., Sec. 1; June 13; 2001.  Back to cited text no. 1
Radcliffe CW, Foort J. The Patellar Tendon Bearing below Knee Prosthesis. Berkeley, Calif, USA: University of California; 1961.  Back to cited text no. 2
Galdik J. The below-knee suction socket. Orthop Prosthet Appliance J 1955;9:4.  Back to cited text no. 3
Murphy FG. Fractures of the shaft of the femur. Surg Clin North Am 1957;37:195-212.  Back to cited text no. 4
Bucholz RW, Jones A. Fractures of the shaft of the femur. J Bone Joint Sur Am 1991;73:1561-6.  Back to cited text no. 5
Hennrikus WL, Kasser JR, Rand F, Millis MB, Richards KM. The function of the quadriceps muscle after a fracture of the femur in patients who are less than seventeen years old. J Bone Joint Surg Am 1993;75:508-13.  Back to cited text no. 6
Bucholz RW, Brumback RJ. Fractures of the shaft of the femur. In: Rockwood CA, Green DP, Bucholz RW, et al., editors. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 1827-918.  Back to cited text no. 7
Ballantyne F, Fryer G, McLaughlin P. The effect of muscle energy technique on hamstring extensibility: The mechanism of altered flexibility. J Osteopath Med 2003;6:59-63.  Back to cited text no. 8
Handel M, Horstmann T, Dickhuth HH, Gülch RW. Effects of contract-relax stretching training on muscle performance in athletes. Eur J Appl Physiol Occup Physiol 1997;76:400-8.  Back to cited text no. 9
Abdel-Aziem AA, Ahmed ET. Effect of Russian current stimulation on quadriceps strength of patients with burn. IJHRS 2013;2:123-30.  Back to cited text no. 10
Hachisuka K, Dozono K, Ogata H, Ohmine S, Shitama H, Shinkoda K. Total surface bearing below-knee prosthesis: Advantages, disadvantages, and clinical implications. Arch Phys Med Rehabil 1998;79:783-9.  Back to cited text no. 11
Nolan L, Lees A. The functional demands on the intact limb during walking for active trans-femoral and trans-tibial amputees. Prosthet Orthot Int 2000;24:117-25.  Back to cited text no. 12
Belekar V. A Comparative Study to Evaluate the Efficacy of Butorphanol as an Adjuvant to Epidural Analgesia for Rib Fractures. J Datta Meghe Inst Med Sci Univ 2017;12:166-9. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_105_17. [Last accessed on 2019 Sep 14].  Back to cited text no. 13
Mundada G, Khan S, Singhania S, Gupta V, Singh P, Khan S. Type-I Monteggia with Ipsilateral Fracture of Distal Radius Epiphyseal Injury: A Rare Case Report. Annals of African Medicine 2017;16:30-2. Available from: https://doi.org/10.4103/aam.aam_55_16. [Last accessed on 2019 Sep 14].  Back to cited text no. 14
Gaidhane A, Sinha A, Khatib M, Simkhada P, Behere P, Saxena D, et al. A systematic review on effect of electronic media on diet, exercise, and sexual activity among adolescents. Indian J Community Med 2018;43:S56-65. Available from: https://doi.org/10.4103/ijcm.IJCM_143_18. [Last accessed on 2019 Sep 14].  Back to cited text no. 15
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