Orthopaedic Patients

Question 1

What history do we need to take about a possible orthopaedic patient?

Answer 1

Duration of lameness
Onset - acute/gradual? Any obvious triggers?
Progression - static? Deteriorating/improving?
Continuous / intermittent?
Effect of exercise/rest
Effect of ground surface e.g. grass vs concrete?
Which limb(s)?
Occupation?
Concurrent problems?

Question 2

What can we observe about the stance of orthopaedic patients and what do these indicate?

Answer 2

Asymmetry - paw taking most weight is flatter/harder to lift up when standing
Kyphosis - shifting weight from pelvic to thoracic limbs
Scoliosis - shifting weight to one side
Frequent sitting - pelvic limb lameness
Frequent lying down - thoracic limb lameness
Angular limb deformities

Question 3

What can we evaluate about a patient’s gait?

Answer 3

Stride length
Head nodding
Scuffing of nails
Ataxia, paraparesis, paraplegia (signs of neurological disease!)
Circumduction with stifle pain
Lateral sway/bunny hopping with hip pain
Head bobbing (sink to the sound side!) with thoracic limb lameness

Question 4

What can we palpate when standing during an orthopaedic examination?

Answer 4

Asymmetry
Swelling
Muscle atrophy
Joint enlargement
Abnormal conformation

Question 5

What can we examine when in lateral recumbency during an orthopaedic exam?

Answer 5

Joints - SPIRM (swelling/joint effusion, pain, instability, range of motion, manipulation)
Limbs - SAP (swelling, muscle atrophy, pain)

Question 6

What tests can we perform to test the integrity of the cranial cruciate ligament?

Answer 6

Cranial draw test
Tibial compression test (tibial thrust)

Question 7

How can we test for hip laxity/dysplasia?

Answer 7

Ortolani test

Question 8

What further diagnostics can we perform once we have localised lameness?

Answer 8

Imaging - radiography, ultrasounds, CT/MRI
EMG
Arthrocentesis

Question 9

What are the indications for arthrocentesis?

Answer 9

Persistent/cyclical fever
Lameness localised to a joint

Question 10

How do we prepare for arthrocentesis?

Answer 10

Patient anaesthetised/sedated in lateral recumbency
Strict aseptic prep
Equipment - sterile hypodermic and spinal needles, 2.5-5ml syringes

Question 11

How do we carry out arthrocentesis?

Answer 11

Use bony landmarks to guide needle
Do not move needle whilst aspirating
Blood aspirated from soft tissues - iatrogenic contamination streaks vs real change of pink fluid

Question 12

What do we do with fluid aspirated during arthrocentesis?

Answer 12

Small volume - make a smear
Large volume - EDTA cytology, plain pot proteins, culture if infection possible

Question 13

What does normal synovial fluid look like?

Answer 13

Viscous
Clear
Small volume

Question 14

Describe how to take a sample from the scapulohumeral joint.

Answer 14

Gentle traction by assistant to open up joint
Needle inserted distal to acromion and directed perpendicular, slightly dorsal and medial

Question 15

Describe how to take a sample from the cubital (elbow) joint.

Answer 15

Flex elbow to 45 degrees
Needle started from point level and perpendicular to epicondylar crest alongside anconeal process

Question 16

Describe how to take a sample from the carpal joint.

Answer 16

Flex carpus to 90 degrees
Insert needle perpendicular to skin
Aspirate all joints
Avoid neurovascular bundle

Question 17

Describe how to take a sample from the MCP/MTP/IP joints.

Answer 17

Use needle with short bevel (spinal needle) to allow entire tip of needle to be within joint and avoid contamination

Question 18

Describe how to take a sample from the coxofemoral joint.

Answer 18

Hip abducted and internally rotated to open joint
Needle inserted from craniodorsal to greater trochanter, angled medially and caudoventrally

Question 19

Describe how to take a sample from the stifle joint.

Answer 19

Stifle partially flexed
Needle inserted lateral to patella ligament, midway between patella and tibial tuberosity, angled caudomedially until it hits bone

Question 20

Describe how to take a sample from the femoropatella joint.

Answer 20

Stifle extended
Needle inserted at angle between patella and femur towards proximal

Question 21

Describe how to take a sample from the tarsal joint.

Answer 21

Joint partially flexed
Palpate and manipulate joint to feel the articulation
Angle needle perpendicular to skin into joint
Fluid obtained from craniolateral or caudolateral aspect of joint

Question 22

What are the stages of healing?

Answer 22

Post-op (24-48hrs)
Regeneration phase (day 5 - 3 weeks+)
Remodelling phase (6 weeks - 1 year)

Bone healing occurs in regeneration and remodelling phases

Question 23

Describe care for patients in the post-op stage of healing.

Answer 23

Consider pain, oedema, healing tissues
Analgesia
Cryotherapy
Rest
Easy movement only (non-weightbearing/supported weightbearing)

Question 24

Describe care for patients in the regeneration phase of healing.

Answer 24

Still fragile, new collagen fibres and bone calluses forming
Controlled lead exercise
Passive/active ROM exercise

Question 25

Describe the remodelling stage of healing.

Answer 25

Consolidation = cellular to fibrous tissue, strength and alignment Maturation = vascularity returns and metabolic rate returns to normal Introduce active exercise e.g. hydrotherapy

Question 26

How can we manage patients with cruciate disease?

Answer 26

Surgery = TPLO/TTA and lateral suture Obesity common factor - weight-loss programme Hydrotherapy can be used but must be stopped immediately post-op when stitches in place Active exercise

Question 27

What factors affect what rehabilitation we offer to fracture patients?

Answer 27

Degree of fracture(s) and site Pre-existing disease Degree of soft tissue damage Presence of open wounds

Question 28

How can we rehabilitate fracture patients?

Answer 28

Adequate analgesia Restricted exercise Cold compress Minimal PROM exercises Supportive dressing?

Question 29

How can we nurse patients with external fixators?

Answer 29

Can be difficult to apply treatments! Cold compress parts of limb Massage/PROM Active exercises useful due to reluctance to flex/extend limbs esp. distal limb

Question 30

How can we nurse patients who have had joint surgery?

Answer 30

Cryotherapy immediately post-op Pressure dressing 12-24hrs PROM/massage Adequate analgesia

Question 31

What care should we provide for THR/elbow/knee replacement patients?

Answer 31

Walked slowly in controlled manner Kept settled and calm - consider mild sedation Clear signage - must be handled by experienced staff

Question 32

How can we rehabilitate patients with tendon injuries?

Answer 32

PROM after 3 weeks' rest Exercise limited for 3-6 weeks Tendon still not full strength at 6 weeks!

Question 33

What are the main considerations around rehabilitation?

Answer 33

Return to function (weightbearing, ROM, muscle-building), minimise stress on surgical site Requires full understanding of condition Subjective vs objective Continually assessed and altered to suit stages of healing Multimodal analgesia

Question 34

Describe cryotherapy.

Answer 34

Early application effective - initial 72hr period Vasoconstriction Analgesic effect Reduced tissue oedema 15mins 3x daily ideal

Question 35

Describe heat/warm therapy.

Answer 35

Temp. of 46 degrees C sufficient Care - reduced sensation, risk of burns! Before exercise = increased blood flow = increased elasticity

Question 36

Describe the benefits of massage.

Answer 36

Increased blood flow = improved oxygen supply = aid removal of waste products = helps muscle work more efficiently, alleviates pain Venous and lymphatic return Mobilises adhesions Prepares muscles for exercise and aids recovery after exercise

Question 37

List some assisted physiotherapy exercises.

Answer 37

Assisted standing Weight shifting Side bending, cervical flexion/extension Balance boards/swiss balls Muscle stimulation

Question 38

List some active physiotherapy exercises.

Answer 38

Slow walks Stair climbing Sit to stand, down to sit Treadmill walking