Recovery from broken leg - already frail beforehand

[Kilve]

My husband's aunt (mid-late 80s) fell a couple of weeks ago and broke her leg, top of femur. Her injury was complicated by the fact she was already not very mobile and had had pain on that side for a while (though previously just managing stairs and covering up how little else she could do/how much she was relying on her dh). So she did not immediately seek help, in the hope it would get better by itself (I know!) but struggled on for a bit before getting to the hospital. She is a committed doctor-avoider so also has other less desperate ongoing issues she has basically been living with and telling no-one about.

Leg has now been successfully pinned and she is still in the hospital and seeing a physio. But here is my worry - I am not sure she is getting anything like enough help and encouragement to get moving again.

She is in a small hospital, only one step up from a cottage hospital really and seems to be getting just one physio visit a day, Monday-Saturday, that basically gets her to stand up and take a tiny weeny step. Which obviously takes ages, but that seems to be it. I can't think two steps per day is going to get her anywhere fast . One of her ongoing issues is swollen feet I think due to varicose but I think the immobility may be making it worse and vice versa.

They are otherwise getting her in and out of bed, dressed, to toilet etc but I don't think there is much other active attention to mobilising her. What should she be getting?

We are not the closest relatives in terms of family, so we might not have a full picture here. And none of us are less than 3 hours drive away (yes, family do hope they'll move closer when this is sorted)

However what I wanted to ask was from others' experience, what level of re-ablement attention does she need? Is one half-hour session 5-6 days pw enough? What could/should she do for herself in bed/in a chair, what should she ask for, and what is people's experience of re-ablement at home (eg visiting physios etc) and can this work too? She's in quite a rural area and so far as I can tell there is no provision for in-patient re-ablement in that region - it certainly hasn't been mentioned that I know of.

Her dh no longer drives - they live in a small town (GP but no hospital there) and regular visits to a physio/gym are out of the question anyway as basically she needs the physio to be able to get in and out of a car - so she either needs to be in a residential facility, or physio needs to come to her I think.

Sorry this is a ramble but mainly asking what people have experienced as 'enough' to get moving again, when someone appears on the cusp of permanent loss of mobility. Thanks.

Sorry this is an awfully long OP but saves ppl missing the detail..pls share experiences in you can 🙏🙏

Without meaning to be snarky,what physio do you think should be having? It's really important to stand and mobilise daily and that's what she's able to do so far. Physio once a day is good,any more and you get exhausted and it's counterproductive, as she improves she will be able to do more but remember the saying 'don't run before you can walk.'

Nothing will happen at the weekend as everyone is off so that's normal in a hospital.

Wrt to when she's home, decisions and help will be put in place before she is discharged. One thing at a time.

Thank you @LoafofSellotape No I do mean just standing/walking at the moment, but I just felt one x per day was quite little? I don't get the feeling she is exhausted after it, she is happy for dsis to stay and chat immediately afterwards etc?

It's a sad and frightening fact, that 50% of elderly people who have a major break, eg leg, hip, never get to go home. I did some falls prevention training a few years back and that was one of the opening lines.

So much about orthopaedic recovery is down to the motivation of the patient, not just their underlying physical condition, although that can have a bearing obviously.

Unless Aunty is on a rehab ward, one physio visit per day, 6 days per week is pretty good, yes maybe all she's up to for the moment.

Questions to ask of the staff

is there an orthopaedic rehab service in her area and can she be referred ?
is Aunty being encouraged to get up and walk by herself, but isn't or is it that she can't ?

Is there a discharge plan in place ?
Has she seen / been referred to OT to get this rolling ?

If she's only managing a few steps, and it's taking up most of a session. She probably isn't capable yet, of doing much more.

Just because you can chat doesn't mean physically you are able to do more physio. The act of getting out of bed safely and taking one step is huge, two steps can feel like a marathon.

She probably spends the rest of the day sleeping and recovering once visitors have gone.

Physios are excellent at pushing you to you capability,if there's a chance she can do more they'd get her doing it!

One physio visit a day is loads!

The physio will also have advised the nurses on the ward on appropriate moving and handling for her, what is safe for her to do and what she needs assistance for - so if all this is being done for her this is because it isn't safe for her to do it with less help.

This is all pretty reassuring so thank you everyone - and some good advice/questions which we will pursue. So thanks again

Yes @DPotter that's exactly what I am worried about. I will pass on that stat to her immediate family who are the ones most closely involved.

And absolutely get the point about how much is in her hands. Perhaps its unsurprising but she doesn't always seem to feel she's worth making the effort for (even if it's her making the effort iysim). Which does worry me, however understandable it is

She only broke it a couple of weeks ago. She's 80 plus so the healing process will be slower. She isn't going to be able to do masses of weight bearing walking on it yet.

A friends dad broke his top of femur a few months ago and was delayed in getting diagnosed, operated on. Post hospital he went to a rehabilitation centre for around 2 months where I think he was in a wheelchair most of the time and then home with 4 career visits a day for 6 weeks. Getting home helped him hugely and he was ready for the carers to end. But it was a 2-3 month process to get back on his feet properly.

I will pass on that stat to her immediate family who are the ones most closely involved

I wouldn't, it's upsetting and easier to cope with if it's a slow realisation. She's getting good care by the sounds of it, better a cottage hospital than a massive busy/ noisy one. There's nothing worse than someone being impatient because you're not getting better fast enough.

It might be that things have to change and she can't live at home but it's too early to tell at the moment.

It's really good that she's able to weight bear at all after only a couple of weeks, depending on the break some people can't weight bear for weeks.

Don’t discount what the nurses/HCAs are doing - getting her to get up to the toilet, move from bed to chair etc is physiotherapy, even if not delivered by a physiotherapist themselves.

if she’s receiving 30 mins x6 days a week, they are in fact exceeding standards , which is for a total of two hrs/week.

I just checked my friends messages. Her dad was diagnosed with a spiral fracture of femur and operated on in mid April.

He moved to a rehab centre in mid May and went home with 6 weeks of care visits in mid August. He is managing at home with no help now and he lives alone.

So diagnosis to regained independence was 5+ months.

This is all really reassuring. I must say I m shocked that the standard is 2 hrs pw but yes, agree that being got in and out of bed, dressed etc are all physiotherapy in theur way.

Thanks again

That's more than I had and I paid for private physio and didn't have a budget. You need time to recover in between sessions.

@Kilve when I was a junior doctor I used to deal with a lot of families complaining their relative wasn't getting enough physio.

There seems to be a belief with physio that more=better.

Actually all your relatives activities at this point count as rehab, as the nurses are doing this on direction of the physio. And you can't 'physio' someone better who is too tired or confused or weak to participate, or who plain doesn't want to.

Physios will often leave instructions for exercises to do on your own. Some patients will practice almost obsessively and some will do nothing and then moan at the physio they aren't getting better. Most physio happens when the physio isn't there by the patient practising their instructions.

Thank you @AnnaMagnani

Anaesthetising for NOFs used to be my main interest… It’s a life-threatening injury that is often precipitated by other medical issues (taking all-comers, the 30-day mortality is 10% and at 1-year it’s about 30%). The physiological response to the injury and the surgery is quite impressive and it can take quite some time and energy to recover. You can easily lose a litre or two of blood from a broken femur before they start operating and that can put a huge strain on everything else. Some people do bounce back quickly (usually younger folk who’ve tripped on something and been operated on quickly) but a lot won’t get back to their pre-injury state. A step-deterioration in mobility would be quite normal (so if someone were completely independently mobile they may now need a stick, or if they used sticks pre-injury they might need a frame, etc). The physio may to some extent be limited by the medical issues going on (she should definitely have seen an orthogeriatrician), however it sounds like they’re doing pretty well in what they’re providing.
Probably just as important as formal physio is a combination of rest, mental stimulation when she’s not resting (visitors, news from the outside, knitting, reading, whatever floats her boat!), nutrition, etc. By two weeks post injury they’ll almost certainly have started discharge planning and have a rough idea what the target is so hopefully she/her NoK has been involved in some of that chat. Astonishing recoveries do happen sometimes, but they’re more the exception than the rule - for the unlucky remainder it’s much more of a hard slog.

Thanks so much @Greybeardy - Im sure she's if anything too prepared for a loss of mobility (may see it as more inevitably severe than perhaps it is? Eating is also a worry as she has adigestive problems (not sure what) that she hasn't had any treatment for afaik (we weren't aware till this week!) and has lost weight in the past few years. And of course being in hospital she isn't really sleeping that well, finds the anti pressure sore moving mattress v uncomfy etc.
But I am really getting the message that gentle repetition, eating and sleeping are all key, and that progress will be slow but is nonetheless possible. Thank you.