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W11 Flashcards

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1
Q

Orthopaedic Physiotherapy

A

branch of physiotherapy related to the preparation for, or rehabilitation from orthopaedic surgery or related to an orthopaedic hospital admission.

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2
Q

Comprehensive medical history including

A

Respiratory: Smoking Hx, COPD, Recent URTI/LRTI
Cardiac: IHD, MI, Angina, Arrythmias
Metabolic: T2DM, Peripheral Vascular Disease
Musculoskeletal: OA, OP, Previous injury
Past surgical history

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3
Q

Functional and social history including

A

Previous level of function: Mobility status, exercise tolerance, level of assistance
Activities of Daily Living (ADL): Personal cares, home/domestic duties
Social circumstances: Home environment, social/family support, domiciliary services, financial stresses

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4
Q

Managing deterioration and reviewing of current patient vital signs

A

Cardiovascular: HR, BP, Hb
Respiratory: O2 Saturation, RR,
Systemic signs: Temperature

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5
Q

Medication review including

A

Type of medication: Analgesic, cardiac, respiratory
Timing & dosage
Mode of delivery: IV (quickest acting), subcutaneously, intramuscularly, oral (slowest acting

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6
Q

Subjective Assessment purpose

A

is to confirm what you know from your preparation, clarify any missing information and find out how the patient is feeling

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7
Q

pain status

A

Where is it and is it expected
Severity (VAS) including at at rest and with movement
Recent analgesia and effectiveness

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8
Q

current physical symptoms

A

Dizziness, lightheaded or feeling faint
Nausea – recent medication to address & effect
Drowsiness or level of consciousness

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9
Q

respiratory status

A

Cough, SOB, Chest pain

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10
Q

neuro status

A

P&N or numbness

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11
Q

Social and Functional History

A

Lives with..
Home environment e.g. stairs, railings
Services
Supports
Falls history
Mobility aid
Ex tolerance

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12
Q

objective assessment 3 main oarts

A

observation
system assessment
functional assessment

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13
Q

systems Assessment

A

Respiratory
Circulatory
Neurological
Musculoskeletal

A systematic approach ensures you minimise the risk of missing elements

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14
Q

Respiratory screening assessment

A

Cough – Strength? Effective? Productive?
Observe RR – Work of breathing
Palpation for bibasal expansion
Auscultation - Normal breath sounds? Added sounds

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15
Q

Circulatory assessment
Assessing for Deep vein thromboses (DVT) `

A
  1. Swelling of the calf
  2. Redness of the calf
  3. Localised pain/tenderness
  4. Increased temperature on palpation
  5. Positive Homan’s sign (calf pain on passive ankle dorsiflexion)
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16
Q

Circulatory assessment
Assessing for Compartments syndrome

A

Pain to passive stretch, increased compartment tightness or increased pressure measures
Late signs = Palour, Paraesthesia, Pulses, Paralysis
May need surgical management = fasciotomy

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17
Q

Neurological Assessment

A

reflexes, power, sensation will help assess patient’s ability to mobilise

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18
Q

Musculoskeletal Assessment

A

Specific to body region affected
Observation
Active movement
Passive movement
Muscle strength
Stability
Sensation

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19
Q

Slower Acting routes for drugs

A

oral
Subcutaneous narcotic (e.g. morphine)
Intramuscular narcotic (e.g. morphine)

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20
Q

Faster Acting routes for drugs

A

Intravenous - (morphine, fentanyl)

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21
Q

Continuous Acting routes for drugs

A

Epidural
Nerve Block - continuous infusion or local infiltration in theatre

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22
Q

time for drugs to act

A

5-30mins

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23
Q

Side effects of narcotic anal

A

Drowsiness & reduced central respiratory drive therefore require supplementary O2 at rest
Nausea and vomiting

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24
Q

Reasons for Elective Lower Limb Orthopaedic Surgery

A

degenerative conditions
trauma/ injury
deformities and congenital conditions
chronic soft tissue conditions
ligament and meniscal injuries
reconstructive and revision procedures

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25
common Arthroplasty
Total hip replacement (THR) Total knee replacement (TKR) Uni-compartmental knee replacement (UKR) Total ankle replacement (TAR)
26
common arthrodesis
fusion
27
common arthroscopies
Poor evidence in arthritic knees and incidence declining Indicated when locking or foreign body present
28
common procedures for Meniscal and Ligamentous Injury
Labral repair of the hip Anterior Cruciate Ligament (ACL) Reconstruction of the knee Meniscal repair or debridement of the knee Patella re-alignment +/- stabilisation
29
Bony Malalignment common procedures
High tibial osteotomy - Corrective procedure for varus / valgus knee alignment to delay arthroplasty Hallux valgus (Bunion) - Osteotomy to realign the 1st metatarsal
30
ERAS Components preoperative
Medication modification Patient education (cease smoking, reduce weight, increase physical activity) Haematology assessment (address anemia) Carbohydrate drink 2 hours before surgery Loading dose of analgesia pre-surgery
31
ERAS Components intraoperative
Preference spinal anaesthetic Regional anaesthesia – nerve blocks Multimodal pain management (opioid sparing)
32
ERAS components postoperative
Early mobilization 2-3 hours post op Early removal of attachments Multimodal pain control Discharge planning
33
Benefits of ERAS in Joint Replacement
Reduced pain and opioid use Shorter hospital stays Faster functional recovery Lower complication rates Improved patient satisfaction
34
Total Knee Replacement
Femoral component Tibial component Polyethylene spacer Gold standard for treatment of severe OA
35
Total Knee Replacement complications
Fracture DVT Infection Loosening of components Ongoing knee pain
36
TKR – Post Op Management goals
Knee Flexion > 90 degrees Knee extension 0 degrees SLR with minimal lag Independence with HEP Independent mobility on stairs
37
Day 1 – Discharge post TKR
Swelling management (very important) - Don’t SOOB for too long - Elevation and compression with ice, polar pack, cryo-cuff Continue quads rehab – aim for SLR with minimal lag Graded knee flexion aiming for 90 Gait re-education with appropriate aid
38
Criteria for Discharge TKR
independent mobility inc stairs knee flexion greater than 80 degrees SLR with minimal lag independent HEP
39
Uni-Compartmental Knee Replacement
Procedure like TKR, however only one compartment is replaced. The other compartments must be healthy. Rehabilitation can be quicker than TKR Aim up to 120° flexion
40
Total Hip Replacement goal
To attain a durable, pain free and functional joint
41
THR – Operative Approach posterior + and - ves
Posterior bc easier for surgeon hw dislocation a possibility during sitting and excessive hip flexion.
42
THR- operative approach Anterior & Anterior-lateral _ and - ves and dislocating positions
Advantage - decreased chance of posterior dislocation as posterior capsule not affected. Minimal invasive incision, ?lower infection rate, able to use intra-op fluoroscopy Disadvantage – more difficult for surgeon, greater risk of infection in obese Dislocating position: Forced extension Flex or extension with Add and ER
43
Peri-operative Complication with THR
Sciatic nerve (posterior approach) damage can lead to short term neuropraxia and subsequent 'foot drop’. Poor positioning of acetabular component could increase chance of dislocation. Fractured acetabulum; fractured femoral shaft; excessive blood loss
44
Postoperative Complications of THR
DVT Dislocation Infection Loosening of components
45
THR goals
Independent mobility w appropriate aid Independent with home exercise programme Independent mobility on stairs
46
Day 0 (Day of Surgery) THR management
Commence Circulo-Respiratory exercises LL neurological assessment Stand/Mobilise WBAT
47
Day 1 Mobility THR management
Progress mobility as indicated Out of bed on un-affected side - care not to flex > 90 degrees Rollator initially with 2P Assist SOOB – aim 60mins dependant upon patient symptoms
48
Day 2 – Discharge THR management
exercises, mobility & Considerations for Discharge Planning
49
Considerations for Discharge Planning THR
Aim for discharge day 2-4 Occupational Therapy review for ADLs Home Exercise Program Consider F/U Physiotherapy
50
after a THR do not immediately
Do not sit in low chairs Do not cross legs Do not lie on affected side Do not squat down to ground Do not bend from hips to pick things up
51
Arthroscopy- what is it
Performed through small portals to allow an irrigation cannula, a fibre optic viewer and light source, and surgical instruments into the joint.
52
Advantages of Arthroscopic Surgery:
Rapid recovery No hospitalisation and no or limited need for walking aides
53
Uses of Arthroscopic Surgery:
To establish or define accuracy of diagnosis Help decision making and planning of surgery Observe and record progression
54
Menisectomy is used for
loose fragment excised, flap or oblique tear
55
management of a meniscectomy
FWB, rapid rehabilitation including ROM ex's, SLR, IRQ, swelling management
56
Meniscal repair
only if located in periphery of meniscus as adequate blood supply for healing
57
management of meniscal repair
– Altered WB status (NWB/TWB/PWB), restricted ROM in ROM brace
58
+ves of meniscal repair
by retaining some meniscal integrity aim for reduction in incidence of degenerative joint changes that commonly occur following a total menisectomy
59
Chondroplasty
surgery of the cartilage
60
meniscal Repair is dependent on 2 critical factors
Location of the tear Red Zone vs Red/White Zone vs White Zone Type of tear Transverse vs bucket handle vs posterior horn
61
Indications for ACL Reconstruction
Significant functional disability due to instability
62
Intra-articular reconstruction of ACL
Allografts (Cadaver) Autografts (Hamstrings, patella tendon) Synthetic grafts
63
Allografts +/-ves
Advantages No donor site pathology Shorter op Eventually fully replaced by new tissue Disadvantages Graft rejection Allograft ruptures - especially using grafts from older donors (>30-35 yrs a risk factor)
64
hamstring autografts +ves and -ves
Advantages: Good graft strength and no anterior knee pain Disadvantages: Evidence of elastic creep in graft due to poorly-aligned collagen fibres. This may produce a slightly lax graft
65
patella tendon autografts +ves and -ves
Advantages: Strong Biological Eventually replaced by new tissue Disadvantages: Anterior knee pain Donor site patholog
66
4 primary methods of fixation
Direct fixation – using interference screws (including bioabsorbable screws) where the fixation device is in direct contact with the graft; Indirect fixation – Uses cortical suspensory devices such as an Endobutton Combination – Direct fixation tibial side and suspensory fixation on the femoral side Tape Locking Screws – polyethelene tape and screw interface to create a short graft with no direct contact with graft
67
Manage pain and swelling
Analgesia RICE
68
management of quads control
Static quads, SLR with focus on no lag +/- splint
69
mobility management
Safe mobility with appropriate aid and normal gait pattern
70
ROM management
Aiming for slow return to flexion Extension – TLS aim for early return to full extension, Suspensory fixation delay extension and avoid early hyper extension
71
education management
Managing swelling & pain Exercise prescription Risks Follow up rehabilitation
72
Tibial tuberosity transfer:
Surgically moving the tibial tuberosity medially
73
Lateral release of Tib tuberosity transfer
Used in isolation or as adjunct to other procedures Releases tight Lateral Retinaculum and Vastus Lateralis May be performed arthroscopically or as open procedure
74
medial placation for MPFL reconstruction
pilication= folding in & suturing of tucks Tightening of medial structures (Medial retinaculum, VMO
75
3 way - patella realignment: Management
Immobilised in extension in Richard’s Splint for 6 weeks No active Flexion, Extension or SLR for up to 6/52 Only Knee or quads exercise - static quads Generally WBAT
76
Lateral release without tib tuberosity transfer Management
Early activation of quads and ROM exercises Mobilise FWB and progress exercises as pain and swelling allow
77
Aim of Osteotomy
To divide the bone and reposition the fragments to realign the tibia and distribute weight bearing forces more evenly through the knee
78
Osteotomy +ves and -ves
Advantages: Does not destroy articular cartilage as tibio-femoral joint not directly operated on Can later progress to TKR Reduces OA pain Disadvantages: Causes considerable discomfort and long period of rehab Not a cure for OA but may slow deterioration Symptoms may reoccur
79
High Tibial Osteotomy Factors associated with favourable results
< 65 years of age or ‘long life expectancy’ Not overweight (risk of failure/recurrence of deformity if overweight –Coventry et al 1993) 90 degrees flexion < 15 degrees flexion contracture Higher activity level (HTO instead of TKR) Early uni-compartmental OA with corresponding varus or valgus deformity Ligamentous stability Non- smoker
80
High Tibial Osteotomy post op management
Commence circulo-respiratory exercises day 0 Commence rehab exercises day 1 May SLR in Richard’s splint If staple fixation - no knee flexion 4-6 weeks If plate / screws fixation - may commence gentle knee flexion day 1 or 2 Mobilise day 1 - NWB with Richard’s splint Management can vary dependent on Dr
81
Toe Deformity Surgery is called what
Scarf or Chevron’s
82
Toe Deformity Surgery management
Patient mobilised with surgical shoe (HWB) Walking aid not essential but may require a stick or crutches depending on balance and pain

musculeoskeletal (13 decks)

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