Approach to the orthopaedic patient in the consult room

Question 1

Describe the approach to orthopaedic cases

Answer 1

Logical and methodical
Ask questions which generate a baseline information:
- Facilitates implementation of a bespoke management plan
- Establishes data that future assessment can be compared to

Question 2

The dynamic assessment of orthopaedic cases consists of which two components?

Answer 2

Subjective gait assessment
Objective gait analysis

Question 3

How is subjective gait assessed?

Answer 3

VAS – visual analogue score
NRS – numerical rating systems
Descriptive

Question 4

How is objective gait analysed?

Answer 4

Force plate
Pressure sensitive walkway

Question 5

How is lameness assessed on the thoracic limbs?

Answer 5

• Assess when patient walking towards you
• Head Position
• Short stance phase on lame leg
• Fast swing phase on non-lame leg

Question 6

How is head position used to assess lameness in the thoracic limbs?

Answer 6

Attempts to shift weight caudally
Head will rise when lame leg in stance phase of gait cycle
Head will drop when lame leg is in swing phase

Question 7

How is lameness assessed on the pelvic limbs?

Answer 7

Assess when patient walking away from you you
Head Position
Short stance phase on lame leg
Fast swing phase on non-lame leg

Question 8

How is head position used to assess lameness in the thoracic limbs?

Answer 8

Attempts to shift weight cranially
Hip hike – hip rises vertically when lame leg in stance phase of gait cycle
Head will drop when lame leg is in stance phase

Question 9

Describe the physical exam of orthopaedic patients

Answer 9

1. Assess Soft Tissue
   - Muscle mass and symmetry
   - Joint effusions
   - Tendinous insertions
2. Palpate Long-Bones
3. Assess Joints
   - Range of motion
   - Periarticular thickening
   - Crepitus

Question 10

What are the 4 elements of the therapeutic strategy in the non-surgically lame patient

Answer 10

Exercise modification
Physiotherapy
Weight management
Analgesia

Question 11

What are the 5 aims of therapy in non-surgically lame patients?

Answer 11

• Decrease lameness
• Increase exercise tolerance
• Increase ROM of joints
• Increase muscle mass
• Decrease analgesia requirement

Question 12

What is the standard analgesia therapy in lame patients

Answer 12

NSAID + Paracetamol +/- Amantadine or Gabapentin

Question 13

How is exercise modification used in lame patients?

Answer 13

Aim: To establish a baseline level of exercise that the patient can tolerate without exacerbation of their clinical signs
1. Lead restricted exercise: reduce to 25% of a typical walk, 2-3x daily
2. Increase length of each walk by 5 minutes every 7 – 14 days - Aim for a maximum duration, Typically 40 mins
3. Introduce off-lead work when lead-restricted target achieved - usually introduce at the end of each walk
The same rules apply in the garden!

Question 14

How can you assess your therapeutic strategy?

Answer 14

Initially, reassessment performed after 6 – 8 weeks
When stable review every 6 months