Overview of Dynamic Hip Screw (DHS) in Hip Fracture Management

Dynamic hip screw (DHS) physiotherapy protocol PDFs guide early mobilization, pain control, and weight‑bearing progression after intertrochanteric fracture fixation. They outline passive, active ROM, strengthening, gait training, and outcome measures for safe recovery. Evidence based protocol care PT

Indications for DHS Use in Intertrochanteric Fractures

Dynamic hip screw (DHS) physiotherapy protocol PDFs provide a concise framework for selecting patients who will benefit most from DHS fixation in intertrochanteric fractures. Key indications include stable or minimally displaced fractures classified as AO/OTA 31A1 and 31A2, where a sliding mechanism can achieve optimal fracture compression. The DHS is preferred when the fracture pattern allows a single lag screw to be placed centrally through the femoral head and neck, ensuring adequate purchase in the calcar region. Patients with good bone quality, typically younger or osteopenic individuals, are ideal candidates because the screw‑barrel construct tolerates early weight bearing without compromising fixation. Additionally, DHS is indicated when the fracture involves a vertical or oblique component that can be stabilized by the sliding plate’s ability to maintain alignment while permitting controlled axial compression. Contraindications such as highly comminuted, subtrochanteric extension, or severe osteoporosis often necessitate alternative devices like intramedullary nails or locking plates. Protocols emphasize that the surgical decision should be guided by preoperative imaging, intraoperative assessment, and the surgeon’s experience to maximize biomechanical stability and functional recovery. The PDF guides clinicians to document these criteria systematically, ensuring that physiotherapy progression aligns with the mechanical demands of the DHS construct.

Guidance documents weight‑bearing milestones and pain tracking scores.

Surgical Technique Essentials of DHS Placement

Dynamic hip screw (DHS) placement begins with the patient supine on a fracture table, allowing controlled traction of the affected limb. A standard anterolateral incision exposes the proximal femur, and the femoral neck is carefully reduced under fluoroscopic guidance. Traction is released once the fracture is aligned, and a 6‑mm or 7‑mm lag screw is inserted centrally through the femoral head into the neck, ensuring purchase in the calcar region. The lag screw is then advanced into the DHS barrel, which is pre‑loaded with a compression screw. Sliding the compression screw pulls the lag screw into the barrel, creating axial compression across the fracture fragments and maintaining reduction. The barrel is positioned so that the plate sits flush against the lateral femoral cortex, providing a stable construct. A vacuum drain is placed to evacuate hematoma, and the wound is closed in layers over the drain. The Medoff sliding plate, an evolution of the DHS, allows controlled axial compression in two planes, enhancing stability in vertical or oblique fracture patterns. Precise alignment and secure fixation are critical to prevent hardware failure and to facilitate early functional recovery.The surgical team ensures that the barrel is positioned to avoid impingement on the lateral femoral cortex, and fluoroscopy confirms the lag screw trajectory and compression. Postoperative imaging is reviewed to verify fracture alignment hardware placement before patient leaves operating room.

Immediately after DHS fixation, the patient is transferred to a recovery area where vital signs are monitored and a vacuum drain is observed for output. The incision is inspected for hemostasis, and the drain is clamped until the first postoperative hour. Pain control is initiated with a multimodal regimen: a scheduled dose of acetaminophen, a low‑dose opioid if needed, and a topical NSAID gel to the incision site. Early physiotherapy is introduced within the first 24 hours, focusing on passive range‑of‑motion exercises for the hip and knee to maintain joint mobility while protecting the fracture. Weight‑bearing status is determined by the surgeon’s protocol; most patients are placed on toe‑touch or partial weight bearing for the first 6 weeks, with progression guided by radiographic healing and clinical stability. Thromboembolism prophylaxis is started immediately with low‑molecular‑weight heparin or a mechanical device such as intermittent pneumatic compression, continuing until the patient is ambulating safely. The drain is removed once output falls below 30 mL in 24 hours, and the wound is dressed with a non‑adherent pad. The patient is encouraged to sit upright on the bed edge, perform ankle pumps, and practice hip flexion to 90° with a pillow for support. A structured postoperative checklist ensures that pain is controlled, the drain is functioning, the patient is mobilizing safely, and the weight‑bearing plan is followed. This comprehensive immediate care framework sets the stage for a successful rehabilitation trajectory and reduces complications such as deep‑vein thrombosis, infection, or hardware failure. The team checks for infection, maintains wound hygiene, and plans follow‑up imaging to confirm healing!

Early Mobilization Protocols and Thromboembolism Prophylaxis

Within the first 24 hours after DHS fixation, patients start a structured early mobilization program to prevent muscle atrophy and reduce venous thromboembolism (VTE). The protocol begins with passive hip flexion to 90°, knee extension, and ankle pumps while supine. Once pain is controlled, active assisted hip flexion/extension and gentle stationary cycling are introduced. Weight‑bearing status follows the surgeon’s plan; most patients remain toe‑touch or partial weight bearing for 6 weeks, progressing to full weight bearing after radiographic healing. Thromboembolism prophylaxis starts immediately with low‑molecular‑weight heparin (LMWH) or intermittent pneumatic compression (IPC). IPC is applied for 24 hours post‑surgery and continued until the patient ambulates independently. LMWH dosing follows institutional guidelines and continues for 10–14 days or until full weight bearing is achieved. The physiotherapist monitors range of motion, pain, and adherence to weight‑bearing restrictions. Education on early ambulation, proper footwear, and safe transfer techniques is provided to patients and caregivers. Regular assessment of calf circumference, ankle dorsiflexion, and gait patterns helps identify early signs of deep‑vein thrombosis, ensuring timely intervention. This integrated approach balances fracture protection with the benefits of movement, improving functional outcomes and reducing postoperative complications!

• Passive hip flexion to 90° – 3 sets of 10 reps.
• Passive knee extension – 3 sets of 10 reps.
• Ankle pumps – 3 sets of 20 reps.
• Active assisted hip flexion/extension – 2 sets of 10 reps.
• Stationary cycling – 5 min, 1–2 min rest, repeat 3 times.
• Heel‑to‑toe walking on flat surface – 3 min, progress to uneven ground.

Prophylactic measures include: LMWH 40 mg subcutaneously once daily for 10 days, IPC device set to 30 mm Hg for 24 hours, and early ambulation within 48 hours if no contraindications. Patients with a history of VTE receive extended prophylaxis up to 35 days. The physiotherapist monitors for signs such as calf swelling, pain, or redness, and reports any concerns to the surgical team immediately!

Patients receive written instructions on VTE signs, safe transfers, and assistive device use. Compliance is reinforced during each session, and any deviations trigger a multidisciplinary review. The goal is full weight bearing by week 12, with functional outcomes tracked via the Harris Hip Score and timed up‑and‑go tests. Documentation is maintained in the electronic medical record to ensure continuity of care. Adjunctive measures such as compression stockings are prescribed for patients with a BMI >30 or prior VTE history recordnow!!

Pain Management Strategies in DHS Recovery

Effective pain control after dynamic hip screw (DHS) surgery is essential for early mobilization and patient comfort. The protocol begins with multimodal analgesia: acetaminophen 1 g every 6 h, NSAIDs (unless contraindicated), and short‑acting opioids for breakthrough pain. Local infiltration of a long‑acting anesthetic (bupivacaine 0.25 %) at the incision site is performed intraoperatively to reduce immediate postoperative pain. Post‑operative ice packs (20 min on, 20 min off) are applied to the surgical site for the first 48 h to limit edema and nociception. Patients are instructed to use a pain‑rating scale (0–10) and report any pain >4/10, prompting an escalation to a scheduled opioid or nerve block. Non‑pharmacologic measures include gentle passive hip flexion/extension, ankle pumps, and breathing exercises to promote circulation and reduce sympathetic tone. Heat therapy is avoided until the incision is fully healed. The physiotherapist monitors pain levels before, during, and after each session, adjusting activity intensity accordingly. Early mobilization is only initiated when pain is ≤3/10 on the scale, ensuring that movement does not exacerbate discomfort. Education on proper positioning, use of assistive devices, and safe transfer techniques reduces mechanical stress on the healing fracture. A structured pain diary is maintained in the patient’s chart, facilitating communication among the surgical, anesthesia, and rehabilitation teams. By integrating pharmacologic, local, and therapeutic interventions, the protocol aims to achieve a pain score of <2/10 by week 2, allowing safe progression to weight‑bearing and functional training. Continuous reassessment ensures that pain is managed effectively throughout the recovery trajectory, minimizing the risk of chronic pain or delayed healing.

Structured Physiotherapy Rehabilitation Protocol

Structured physiotherapy protocol PDFs outline phased rehab: passive mobilization (weeks 0‑2), active ROM & strengthening (2‑6), gait training (6‑12), advanced strength & proprioception (3‑6 mo). Weight‑bearing and outcome metrics guide progression. Rehabilitation focuses on milestones and progressiondaily.

Phase I – Passive and Assisted Mobilization (Weeks 0‑2)

Dynamic hip screw physiotherapy protocol PDFs emphasize immediate postoperative care. Within the first 48 hours, patients are encouraged to remain in bed with the affected limb in neutral rotation, using a pillow to prevent abduction. Passive hip flexion and extension are performed by the therapist, keeping the knee in a 90‑degree flexed position to reduce shear forces. Assisted range‑of‑motion exercises involve gentle hip abduction and adduction while maintaining the hip in a neutral position. The goal is to prevent joint stiffness, maintain soft‑tissue elasticity, and stimulate circulation without compromising the fracture fixation. Pain is managed with scheduled acetaminophen and low‑dose opioids as needed, while ice packs are applied intermittently to control swelling. Thromboembolism prophylaxis includes graduated compression stockings and early ambulation when tolerated. Weight‑bearing status is dictated by the surgeon’s plan; most protocols allow partial weight bearing (20–30 % of body weight) with crutches or a walker, progressing to full weight bearing as radiographs confirm fracture consolidation. The physiotherapy protocol also incorporates gentle ankle pumps and quadriceps sets to preserve muscle tone and prevent deep vein thrombosis. Throughout this phase, the therapist monitors for signs of hardware irritation, such as increased pain or abnormal gait patterns, and adjusts the mobilization intensity accordingly. The structured approach ensures a safe transition from bed rest to early mobilization, laying the foundation for subsequent strengthening and functional training phases.

During the passive mobilization sessions, the therapist performs 10–15 repetitions of hip flexion to 90°, extension to 30°, and gentle circumduction, ensuring the limb remains within the safe zone defined by the surgical team. Assisted movements are limited to 30° of abduction and adduction to avoid excessive stress on the femoral shaft. Each session lasts 15–20 minutes, twice daily, with a rest period of at least 30 minutes between sessions to prevent fatigue. The therapist documents pain scores on a visual analog scale, noting any changes in swelling or skin integrity. If pain exceeds 4/10 or swelling increases, the session is paused and the surgeon is notified. The protocol also outlines the use of a continuous passive motion (CPM) machine for 30 minutes after each session, if available, to enhance joint lubrication and reduce adhesions. The patient’s home exercise program includes ankle pumps, heel slides, and seated hip flexion stretches, performed every morning and evening. Compliance is tracked via a logbook, and the physiotherapist reviews progress weekly during multidisciplinary meetings. This meticulous documentation supports evidence‑based adjustments and ensures alignment with the overall treatment plan.

Phase II – Active Range of Motion and Strengthening (Weeks 2‑6)

Dynamic hip screw physiotherapy protocol PDFs transition patients from passive to active movement during weeks 2‑6. The therapist initiates active hip flexion to 90°, extension to 30°, and controlled abduction/adduction within the safe zone, ensuring no pain or hardware irritation. Each session includes 3 sets of 10 repetitions, performed twice daily, with a 30‑minute rest interval. Strengthening focuses on the gluteus medius, maximus, and quadriceps through seated leg raises, straight‑leg raises, and mini‑squats with a weight‑bearing status of 40‑50 % as per surgeon guidance. Resistance bands are introduced for hip abduction, adduction, and external rotation, progressing band tension every two weeks. The protocol emphasizes proper gait mechanics, incorporating step‑length drills and heel‑to‑toe walking on a treadmill at 0.5 mph, gradually increasing speed as tolerated. Pain is managed with topical NSAIDs and scheduled acetaminophen, while ice is applied post‑exercise to control inflammation. Thromboembolism prophylaxis continues with compression stockings and early ambulation. The physiotherapist monitors joint ROM, muscle strength (using a handheld dynamometer), and gait symmetry, documenting findings in a standardized log. If the patient demonstrates ≥90 % symmetry and pain ≤3/10, the protocol advances to full weight bearing and higher‑intensity functional tasks. The structured progression ensures safe restoration of hip mobility, muscle power, and functional independence, preparing the patient for advanced gait training and community ambulation.

Phase III – Gait Training and Functional Mobility (Weeks 6‑12)

Dynamic hip screw physiotherapy protocol PDFs outline a structured gait training regimen beginning at week six, once the patient achieves pain‑free active ROM and 60‑70 % weight bearing. The protocol prioritizes progressive ambulation: first, assisted walking on a flat surface with a walker, focusing on heel‑to‑toe contact and a 90‑degree knee flexion during swing. The therapist employs metronome cues at 120 steps per minute, gradually increasing cadence by 10 % each session. Transition to a cane occurs once the patient demonstrates 80 % symmetry in step length and cadence. The protocol introduces stair negotiation drills, starting with a single flight of two steps, using handrails and a step‑height of 8 inches, progressing to a double flight by week ten. Functional mobility tasks—sit‑to‑stand, transfer from bed to chair, and obstacle clearance—are incorporated, with emphasis on hip extension and knee drive. Strengthening continues with closed exercises such as mini‑squats and heel‑elevations, now performed 3 sets of 12 reps, 3 times per week. Core stability is reinforced through planks and side‑plank holds, each held for 30 seconds, 3 repetitions. The protocol also addresses proprioceptive training using balance boards, progressing from static to dynamic stance. Pain is monitored using a visual analog scale; any pain >3/10 triggers a regression. Thromboembolism prophylaxis remains active with pneumatic compression and early ambulation. Outcome measures—Timed Up and Go, 6‑Minute Walk Test, and gait symmetry via motion capture—are recorded at baseline, week 6, and week 12. The goal is independent ambulation without assistive devices and return to prefracture activity levels by week 12, contingent on meeting all progression criteria.

Phase IV – Advanced Strengthening and Proprioception (Months 3‑6)

Dynamic hip screw physiotherapy protocol PDFs prescribe a high‑intensity strengthening schedule that begins at month three, once the patient tolerates full weight bearing and demonstrates 90 % gait symmetry. The program focuses on progressive resistance training of the gluteus medius, maximus, and quadriceps, using elastic bands, free weights, and functional equipment. Exercises such as single‑leg squats, lateral step‑ups, and hip abduction with ankle weights are prescribed 4 sets of 10–12 reps, 3 times per week, with load increments of 5 lb every two weeks. Core stability is advanced through planks, bird‑dog, and anti‑rotational side‑planks, each held for 45 seconds, 3 repetitions. Proprioceptive drills incorporate balance board work, single‑leg stance on foam pads, and dynamic perturbation training, progressing from static to dynamic tasks and balance training and core stability. The protocol also integrates plyometric elements—mini‑hop, lateral bounds, and single‑leg hops—once the patient achieves adequate strength and neuromuscular control, ensuring safe landing mechanics with a 90‑degree knee flexion. Pain thresholds are monitored using a 0–10 numeric rating scale, any pain >4/10 necessitates a temporary regression. Thromboembolism prophylaxis continues with graduated compression stockings and early ambulation. Outcome measures include the 30‑Second Chair Stand, the 6‑Minute Walk Test, and the Functional Reach Test, recorded at baseline, month 3, and month 6.

Progression Criteria and Weight‑Bearing Guidelines

Dynamic hip screw physiotherapy protocol PDFs outline a structured progression framework that aligns with radiographic healing milestones and functional performance. The initial weight‑bearing status is dictated by the fracture pattern and fixation stability. For stable intertrochanteric fractures fixed with a DHS, the protocol recommends toe‑touch weight bearing (20 % body weight) for the first 6 weeks, progressing to partial weight bearing (40 %) at week 7, and full weight bearing (100 %) by week 10, provided radiographs show cortical bridging and the patient demonstrates pain‑free gait symmetry. If the fracture is comminuted or the DHS construct is deemed less stable, the progression is delayed by an additional 2–4 weeks, with toe‑touch maintained until week 12 before advancing to partial weight bearing. Criteria for progression include: (1) radiographic evidence of callus formation and cortical continuity; (2) pain score ≤3/10 during ambulation; (3) ability to perform a 10‑step walk without assistive devices; (4) range of motion ≥80 % of the contralateral side; and (5) absence of mechanical complications such as screw back‑out or cut‑out. The protocol also specifies that any deviation from these criteria warrants a regression to the previous weight‑bearing level and a reassessment within 48 hours. A standardized weight‑bearing diary is maintained by the physiotherapist, documenting daily tolerance, pain levels, and functional milestones. This systematic approach ensures safe load application, optimizes fracture healing, and reduces the risk of hardware failure or delayed union. Clinicians emphasize adherence to weight‑bearing milestones and imaging to ensure optimal loading, minimizing hardware failure risk and promoting union.

Outcome Measures and Assessment Tools in DHS Rehabilitation

Dynamic hip screw physiotherapy protocol PDFs recommend a battery of validated outcome measures to quantify pain, function, and quality of life. The Visual Analogue Scale (VAS) and the Numeric Pain Rating Scale (NPRS) are recorded at each visit to monitor analgesic response. Functional status is captured with the Harris Hip Score (HHS) and the Oxford Hip Score (OHS), both of which assess pain, mobility, and daily activities. The Timed Up & Go (TUG) test and the 6‑Minute Walk Test (6MWT) provide objective gait speed and endurance data. Patient‑reported outcome measures such as the SF‑36 and the EQ‑5D‑5L are administered pre‑operatively, at 6 weeks, 3 months, and 6 months to track overall health status. Radiographic assessment at 6 weeks, 3 months, and 6 months evaluates fracture union, screw position, and potential complications. Strength is quantified using isometric dynamometry of the hip abductors and flexors, with results expressed as a percentage of the contralateral limb. Balance is assessed via the Berg Balance Scale (BBS) and single‑leg stance time. The protocol emphasizes that these tools must be administered by trained clinicians, recorded in a standardized electronic database, and reviewed in multidisciplinary meetings to guide individualized progression. Consistent use of these objective metrics ensures evidence‑based decision‑making and facilitates comparison across studies. The protocol also integrates patient goals, outcome reviews,and of exercises based on functional progress and pain dailytolerance.

Practical Resources – PDF Protocols and Case Report Summaries

Dynamic hip screw physiotherapy protocol PDFs compile evidence‑based exercise regimens, progression criteria, and outcome tracking sheets for clinicians and patients. The downloadable documents provide step‑by‑step guidance for each rehabilitation phase, from passive mobilization to advanced proprioceptive drills, and include illustrative diagrams of hip joint kinematics. Case report summaries embedded within the PDFs highlight real‑world application, detailing patient demographics, fracture classification, operative technique, and postoperative milestones. These narratives emphasize the importance of individualized weight‑bearing schedules, pain management strategies, and early mobilization protocols. Each summary concludes with measurable outcomes such as Harris Hip Score improvements, Timed Up & Go times, and radiographic union dates, offering a benchmark for practitioners. The resources also contain checklists for safety screening, thromboembolism prophylaxis, and patient education modules. By integrating protocol templates with case data, clinicians can tailor interventions, monitor progress, and adjust treatment plans in a structured, evidence‑driven manner.

Clinicians can access these PDFs through institutional repositories or professional societies, ensuring compliance with the latest orthopedic guidelines. The documents include patient worksheets, progress trackers, and safety checklists that align with perioperative protocols. By following the structured format, therapists can document identify deviations, adjust interventions, optimizing outcomes, reducing complication rates.