Physical Therapist Fails To Address Potential Femur Fracture

This case involves an elderly male patient with paralysis on one side of his body who fell in his home. Initial imaging was unremarkable and negative for fractures and the patient was discharged home. 3 weeks later, the patient returned to the emergency room complaining of thigh and knee pain. Orthopedics was consulted and evaluated the patient for left knee contracture. He was discharged to a physical therapy facility to improve his contractures and muscle spasms. At the facility, the patient was still unable to extend his leg and continued to experience significant pain. He was placed on increasing doses of opioids to tolerate the physical therapy. The patient was discharged home after several months and followed up with a different physical therapist. The new physical therapist ordered plain film imaging of the hip and knee which revealed a left femoral neck fracture.

Question(s) For Expert Witness

1. How frequently do you work with patients who have developed contractures and muscle spasms?

2. Given the patient's inability to tolerate the PT regimen, under what circumstances is it acceptable to continue with therapy?

Expert Witness Response E-044407

I am very familiar with lower limb contractures for various populations. I have published research regarding stroke survivors and gait with robotic knee orthoses, some who had contractures. Therapy could continue for pain relief and strengthening while walking cannot be tolerated. Some attempt to increase function in the presence of pain is common, though when the pattern of pain suggests bony or severe soft tissue injury, MD referral is standard. I have published several papers regarding gait with orthoses in stroke survivors and have published papers regarding falls and fall-related injury in people with amputation.