The Use of a Hip Pain Clinical Practice Guideline (CPG) to Identify Femoral Neck Fatigue Fractures in

Initial Entry Training (IET) Soldiers at Ft. Jackson, SC.

MATTHEW J. SHORT

CPT, SP, MPT, CSCS

STAFF PHYSICAL THERAPIST

MONCRIEF ARMY COMM HOSP

WHAT IS A CPG?

CPG = Clinical Practice Guideline

Systematically developed statements that assist a provider’s ability to properly manage specific clinical circumstances

GOAL = to effect consistent application of sound patient evaluation and prevent errors that may result in future serious injury

DEFINITIONS

TMC = Troop Medical Center

UCC = Urgent Care Center

FNFF = Femoral Neck Fatigue Fracture

Fatigue Fracture = overuse injury to normal bone

- Result from muscle fatigue which leads to excessive repetitive loading insufficient to cause an acute fracture.

DEFINITIONS BCT = Basic Combat Training

AIT = Advanced Individual Training

SIT = Soldier in Training

PTRP = Physical Training and Rehabilitation Program

- A rehabilitation company for SIT’s who sustain an injury while training. Injury must be serious

enough to cause them to miss mandatory requirements for graduation. Soldier must be able to recover from injury and return to full duty in 3-5 month time frame.

WHY IMPLEMENT A HIP PAIN CPG?

WHY A HIP CPG?

Primary Goal = To prevent mismanagement of femoral neck fatigue fractures (FNFF) leading to a completed frank fracture of the femoral neck.

- Avoid Soldiers breaking after being returned to duty without the proper diagnosis.

In FY04, there were 30 Soldiers in Training at Fort Jackson that underwent surgical pinning to repair a completed FNFF

WHY A HIP CPG?

No SIT (0%) at Fort Jackson has ever returned to full duty after surgical fixation.

A completed FNFF requiring surgery is a permanent, life-altering injury with complications to include avascular necrosis, malunion, nonunion, and ongoing orthopedic care.

WHY A HIP CPG?

Visuri, et al:Visuri, et al:- 12 displaced FNFF- 12 displaced FNFF’’s treated with surgical fixations treated with surgical fixation- 60% experienced complications the most common - 60% experienced complications the most common being avascular necrosisbeing avascular necrosis

Lee, et al:Lee, et al:- 42 military recruits received surgical fixation- 42 military recruits received surgical fixation- Each patient followed for an average of 5.6 years- Each patient followed for an average of 5.6 years- 14.3% showed delayed union- 14.3% showed delayed union- 23.8% developed avascular necrosis (8 treated w/ - 23.8% developed avascular necrosis (8 treated w/ THA)THA)- Most injuries caused by running after an average - Most injuries caused by running after an average of 3.5 monthsof 3.5 months

WHY A HIP CPG?

Weistroffer, et al:Weistroffer, et al:- 25 service members were contacted 5-7 years - 25 service members were contacted 5-7 years after being diagnosed with a FNFFafter being diagnosed with a FNFF

- 17 of the patients received surgery- 17 of the patients received surgery- Each patient completed a Musculoskeletal - Each patient completed a Musculoskeletal Functional AssessmentFunctional Assessment- 68% continued to feel - 68% continued to feel ““somewhat somewhat

botheredbothered””- 36% stated they felt - 36% stated they felt ““disableddisabled””- Only 3 service members remained in the - Only 3 service members remained in the serviceservice

PERCEIVED PROBLEM

Prior to the CPG we interviewed 18 patients that had received surgical pinning.

- We believe all four (40%) of the above surgeries may have been prevented had the patients been placed on crutches and had a bone scan performed

-Of the 10 seen, 4 were returned to duty without a bone scan being performed

-10/18 Patients presented to the TMC/UCC with complaint of hip pain

HIP PAIN CPG

EFFECTIVE MAY 2004 - ALL Soldiers-in-Training (SIT) presenting to the BAS/TMC/UCC with a complaint of hip pain will receive:

1) Bone Scan (ordered and scheduled)

2) X-ray (AP Pelvis)

3) Crutches toe-touch weight bearing until cleared by bone scan; e.g. results have ruled out a femoral neck fatigue fracture (FNFF)

HIP PAIN CPG

If the bone scan is (+) for a FNFF:1) The SIT will remain on crutches for 6 weeks

2) Refer to physical therapy

If the bone scan is (-) for a FNFF:1) If asymptomatic and gait is normal/non-

antalgic, SIT may return to training

- Profile as appropriate

2) If pain and/or antalgic gait continues, refer to physical therapy

- Continue crutches

Hip Pain Clinical Practice Guideline Primary Care Provider:

YES

NO YES NO

A Soldier In Training (BCT, AIT, OBC) presents with hip pain. Soldier must receive: 1. Crutches TTWB 2. AP Pelvis x-ray 3. Profile no run, jump, march, etc.

Tension sided = Refer to Ortho (today) Crutches x 6 weeks TTWB

Compression sided = Refer to PT (today) Crutches x 6 weeks TTWB

Order and schedule bone scan Continue profile until after B.S. is resulted

Tension sided = Refer to Ortho (today) Crutches x 6 weeks TTWB

If pain has resolved and gait is non-antalgic; d/c crutches and return to duty. Profile if appropriate

If pain and antalgic gait continues; continue crutches and refer to PT.

Compression Sided or Lesser Trochantor = Refer to PT (today) Crutches x 6 weeks TTWB

X-ray (+) for FNFF?

Bone scan (+) for FNFF?

DATA

0

2

4

6

8

10

12

14

16

MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR

Pre CPG (56)

CPG (98)

FNFF's Sent to PTRP Pre and Post CPG75% Increase in FNFF detection

0 1 2 3 4 5

# of Surgeries

JUN 05

MAY 05

APR 05

MAR 05

FEB 05

JAN 05

DEC 04

NOV 04

OCT 04

SEP 04

AUG 04

JUL 04

JUN 04

MAY 04

APR 04

MAR 04

Mismanaged Patients

DATA # OF FEMORAL NECK SURGERIES

Start of CPG

DATA

Femoral Neck Surgeries:- FY 04 = 30

- Mismanaged = 5 (3 prior to CPG)

-2 Completed (all prior to CPG)

- FY 05 = 14 (as of 6 Jul 05)- Mismanaged = 1

- 0 Completed

DATA

0

100

200

300

400

500

MAY JUN JUL AUG SEP OCT

Bone Scans Pre vs Post CPG18 % increase in bone scans

2003 (1929)

2004 (2280)

PERFORMANCEIMPROVEMENT

From 1 – 30 May 04 all SIT’s referred to PT for hip pain were evaluated and CPG compliance was documented in regard to bone scan and crutches.

Results:

n = 56

Total non-compliance = 29 patients or 52%

After re-educating the TMC staff mostly by e-mail and one to one conversations, more data was collected to measure CPG compliance from 1 – 30 SEP 04.

Results:

n = 86

Total non-compliance = 25 patients or 29%

FINAL THOUGHTS

FINAL THOUGHTS

As the symptoms and signs of early femoral neck stress fracture are non-specific and subtle, a high index of clinical suspicion should be maintained in all SIT’s.

Early diagnosis is essential to prevent progression to a displaced fracture.

QUESTIONS??