PAST PAPERS: MAY 2017

Question 1

Section A
QUESTION 1
Mrs Reese is a 50 y/o female who sustained a Garden IV fracture on her right femoral neck. The Orthopaedic surgeon has inserted a dynamic hip screw and she is day two post surgery when she was referred to you.
1.1. describe a garden type IV fracture?(2)
1.2. state the reason why early fixation is indicated in this patient. (2)
1.3. Explain the rationale for the contraindications and precautions to be observed during the assessment and treatment of Mrs Reese(6)

Answer 1

1. 1.complete femoral neck fracture with full displacement. femoral neck usually lies in neutral in acetabular rotates back to its anatomical position. fracture is fully displaced.
2. 2. because the patient is post-menopausal increasing the risk of osteoarthritis. • Displaced femur neck fractures. ✓Fracture cannot be reduced by closed manipulation

1.3. with THR and the insertion for the dynamic hip screw, hip flexion, adduction, and internal rotation are contraindicated as they would cause posterior dilocation of the femoral head at the acetabulum.
no trunk flexion beyond 90 degrees as this would irritate the joint
no torsion or twisting forces as this would disloacted the hip
have adduction pillow between the legs to avoid hip flex,add, IR
sleep on unaffected side when in side lying to avoid gravity and load bearing on affected side.
gravity is your friend and PWB is allowed in the first 3 weeks.
• Do not cross legs (i.e. no hip adduction past midline)
• Do not remove abduction pillow
• Avoid combined hip flexion, adduction and internal rotation at least for 6/52
• Hip internal/external rotation >45°= dislocation
• No hip flexion > 90°= dislocation and pain
• No SLR=posterior dislocation
• No side lying 6/52
• Cemented – FWB, Un-cemented – Toe-touch
• seats

Posterior approach (continued)
• Abduction pillow post-operative
• Elevated toilet seat= to avoid exessive hip flex
• Elevated chair with arm rests= support and slow sitting rather than throwing weight onto joint with force
• 1st 6/52 only sleeping on back. After 6/52 pt may sleep on unoperated side with pillow between the knees and only after 12/52 pt may sleep on operated side again with pillow between the knees.
• No driving for 6/52= impaired ability, increased risk of re-injury

Question 2

QUESTION 2
MIss Noel is a 20 year old female who sustained a Monteggai fracture after falling while walking in the rain. She was taken to the hospital and open reduction internal fixation (ORIF) was done using a plate. The elbow was immobilized in an above elbow plaster of Paris (POP). her POP was removed and she is referred for physiotherapy.
2.1 State the Differences between a Monteggai and Galeazzi fracture (4)
2.2. Describe the contraindications and precautions you will adhere when treating Mrs Noel.
2.3. Identify a common complication in elbow fractures
2.4. State how this complication can be avoided
2.5. Discuss the physiotherapy management of the patient after removal of her POP.

Answer 2

2. 1. Monteggai fracture
      - with proximal ulnar fracture
      - dislocation at (RAD-CAP)radial-carpal joint

Galeazzi fracture

• distal radius-ulnar joint (DRUJ) dislocation
• distal radius fracture

2.2. cast/POP is always removed after 3/52 weeks. Avoid gravity assisted movements for the first week.
avoid excessive over pressure with mechanical movements that may irritate the radius ulnar joint.
isometrics within pain, use grade 1-2 fro pain and 3-4 for ROM to increase monitotirng pain.
Physical exam=inspection=may or may not be obvious dislocation at radiocapitellar joint

2. 3.bone displacement and damage to the ulnar collateral ligament/ instability
3. .4. bone reduction or skin traction/ Above elbow POP.

2.5. Education on proprioception Consideration of the client’s grip strength
1RM restrictions are also crucial during these sessions, advising clients on ways to move whilst adhering to the restrictions. Since safety is paramount, it’s essential that client’s are proficient and comfortable using these devices prior to discharge.
on the application and removal of slings post upper extremity fractures.
Soft tissue massage, particularly to manage oedema and swelling
Scar management post surgery
Ice therapy
Stretching exercises to regain joint range of movement
Joint manual therapy and mobilizations to assist in regaining joint mobility
Structured and progressive strengthening regime
Balance and control work and gait (walking) re-education where appropriate
Taping to support the injured area/help with swelling management
Return to sport preparatory work and advice where required

Question 3

QUESTION 3
tabulate the differences between osteoarthritis and rheumatoid arthritis under the following heading causes, features, clinical diagnosis. (12)

Answer 3

OSTEOARTHRITIS
                  #Causes	
•Congenital/developmental
Inflammatory
Infective
Metabolic
Traumatic
Neuropathic
Obesity
Repetitive joint use
Physical inactivity
Genetics	•	

                   #Features
 Pain
 Stiffness
 Tenderness
 Deformity
 Limp
 Instability
 Grating Sensation
 Swelling
•	Progressive cartilage destruction
•	Subarticular cyst formation
•	Remodelling of bone ends with osteophytes
•	Capsular fibrosis
•	More changes with age
•	↓ in water content
•	↓ in tensile strength
•	Stiffness of collagen
•	↓ glycosaminoglycan length and fragmentation (glycosaminoglycan: long unbranched polysaccharides consisting of a repeating disaccharide unit)
•	Damage to the chondrocytes (a cell which has secreted the matrix of cartilage and become embedded in it)
•	Changes similar to OA may occur in immobilization	

                                   #Clinical diagnosis (JOSS)
Radiological features of Osteoarthritis
•	Joint space narrowing
•	Osteophytes
•	Subchondral bone sclerosis
•	Subchrondral cysts

RHEUMATOID ARTHRITIS
#causes
 Systemic inflammatory disorder
 Affects connective tissue throughout the body
 Thought to be auto immune (the normal immune response is directed against an individual’s own tissue, including the joints, tendons, and bones)
 The cause of Rheumatoid arthritis is not known (Investigating possibilities of a foreign antigen, such as a virus)
 Response may be genetically determined
 3% of population

                                 #Features 
•	Synovitis
- Swelling
- Warmth
- Tenderness
•	Destruction
- Limitation of joint movement
- Isolated tendon ruptures start to appear
•	Deformity
- Ulnar drift of fingers
- Subluxation of MCPs
- Clawed toes
- Contractures and muscle wasting
- Genu Valgus

                         #Clinical diagnosis •	Soft tissue swelling •	Periarticular osteoporosis •	Narrowing of the joint space by stage 2 •	Marginal bony erosions by stage 2 •	Articular destruction •	Joint deformity are obvious by stage 3

Question 4

SECTION D: ESSAY ortho
Mr Earl is a 66 y/o who is a retired contractor. He is a retired building contractor. He lives with his wife in a single story cottage. He has a small vegetable garden that he works in daily and walk to town (about 1.6 km) every morning to go and sell a few vegetables. He also walks to a social club twice a week and to church on Sundays. Sometimes he is called upon by friends to do a maintenance on their houses and this helps bring extra income.

Mr Earl has had right knee pain for 20 years after he once fell off a ladder and injured his knee. He did not receive any treatment for this injury, but was off work for about a month. He has now been admitted to hospital for a total knee replacement becuase he has been diagnosed with stage 3 osteoarthritis of the knee. He is referred to you for physiotherapy management. He is in good healthand is fit from active lifestyle. He has question about why the operation is necessary and how it will affect his function afterwards.

Discuss your management of Mr Earl, from when you see him pre-surgery until six months post-surgery

Answer 4

Types of Osteoarthritis and their pathophysiology

   *PRIMARY  Considered “wear and tear” osteoarthritis  15%  Mostly post-menopausal women

       *SECONDARY
 Has a specific cause, such as an injury, an effect of obesity, genetics,
inactivity, or other diseases
 85%
 Dependent on load
❑ Endemic
 Mainly affects the elderly
 Due to wear and tear
 With genetic predisposition
 Its progressive
 Both destructive and progressive
 Not curable but manageable

            #Predisposing factors of Secondary Osteoarthritis  Abnormal mechanical forces  Increased bone rigidity  Chrondrocyte dysfunction  (Chrondrocyte: a cell which has secreted the matrix of cartilage and become embedded in it)

                    #Causes of secondary osteoarthritis
 Congenital/developmental
 Inflammatory
 Infective
 Metabolic
 Traumatic
 Neuropathic
 Obesity
 Repetitive joint use
 Physical inactivity
 Genetics

               #Biomechanical risks
 Injury
 Obesity
 Deformity
 Instability
 Muscle weakness

           #Cardinal Features of Osteoarthritis  Progressive cartilage destruction  Subarticular cyst formation  Remodelling of bone ends with osteophytes  Capsular fibrosis  More changes with age  ↓ in water content  ↓ in tensile strength  Stiffness of collagen  ↓ glycosaminoglycan length and fragmentation (glycosaminoglycan: long unbranched polysaccharides consisting of a repeating disaccharide unit)  Damage to the chondrocytes (a cell which has secreted the matrix of cartilage and become embedded in it)  Changes similar to OA may occur in immobilization

             #Radiological features of Osteoarthritis
 Joint space narrowing
 Subchondral bone sclerosis
 Subchrondral cysts
 Osteophytes

                  #Signs & symptoms of Osteoarthritis
 Pain
 Stiffness
 Tenderness
 Deformity
 Limp
 Instability
 Grating Sensation
 Swelling

With the Kellgren-Lawrence rating scale what i s the Grading of Osteoarthritis

                   #Grades
 Grade 1: Doubtful narrowing of the joint space and possible osteophytic lipping
 Grade 2: definite osteophytes and possible narrowing of the joint space
 Grade 3: Moderate multiple osteophytes, definite narrowing of the joint space, some sclerosis and possible deformity of bone contour
 Grade 4: large osteophytes, marked narrowing of the joint space, severe sclerosis, definite deformity of the bone contour

            #Medical management of Osteoarthritis Aims is to control pain and improve function and health related quality of life. Analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs) Rx of co-morbidities

               #Nonpharmacological therapy of Osteoarthritis  Patient education  Prophylactic (a medicine or course of action used to prevent disease)  Self-management programs (e.g., Arthritis Foundation SelfManagement Program)  Personalized social support e.g. weight loss programme (if overweight)  Aerobic exercise programs

           #Physiotherapy guidelines for Osteoarthritis  Range-of-motion exercises  Muscle-strengthening exercises  Hydrotherapy  Assistive devices for ambulation  Taping/strapping  Appropriate footwear  Lateral-wedged insoles (for genu varum)  Bracing  Home exercise programme  Assistive devices, bracing, and footwear  In OA Knee management- Hemiarthroplasty (HEP) or TKR important in assisting manual therapy.  Pre operative exercise programme 8/52 - Aerobic exercises, balance exercises - LL strengthening & stretching - ↑functional outcome post TKR  In OA Hip – HEP vs. Manual therapy - Manual therapy is better for ↓pain, ↑ROM, ↑hip function  Multidisciplinary team approach

ICF impairments, HEP