EOS Flashcards
NWB Gait with walking Aid
Start with tripod position
- Step to gait (crutches move together and feet move together)
- Step through gait (crutches forward together, limbs forward together past crutches)
PWB Gait with walking aid
Start with tripod position
- Step to (crutches and affected limb together, unaffected follows)
- Step through (crutches forward with affected unaffected follows and goes beyond)
- 4 point reciprocal - RC, LL, LC, RL
Transfers
Transfers ( both crutches in one hand, standing using arm rest or bed, transfer crutches)
Stairs - always lead with good leg and crutches stay with bad
Shrinker sock measurement
Above knee - thickest part and 5cm above distal stump
Below knee - patella and 5cm above distal stump
K level classification
0- unable 1 - in house 2- some in community 3- fully community 4- above expected level
Hypertrophic scar and its risk factors
Redness (increased blood supply), raised and thick (build of granulation tissue), less pliability (minimal regen of elastin fibres), reduced skin stretch (from changes in ground substances and constant contraction through myofibroblast activity). Altered sensation (painful, itchy)
Main risk factor is the time of healing (longer = increased risk)
Site of scar (across joints), depth of wound, skin grafting
Skin grafting increases risk, full thickness has highest increase
Positions for acute stage management
Neck - slight extension (30) Shoulder - 90 abd Elbows - full ext Hips - neutral rotation Knee - full ext Feet - plantar grade
Factors that contribute to contracture development
Depth of wound, TBSA, duration of immobilisation, muscle weakness (unable to oppose force), race and skin type, growth spurts, other pathology leading to more immobilisation (heterotopic ossification or factures)
3 phases of wound healing
Inflammation (1-5 days)
Proliferation (3-5, 3 weeks). Fibroblasts synthesising collagen and ground substance. Fibroblasts differentiate into myofibroblasts (contraction). Wound is closed by the end of this phase (scar tissue)
Remodelling (3 weeks – 12//18 months). Collagen forms cross links to increase tensile strength of scar tissue. Orientation of collagen becomes less random and more parallel.
Surgical burn management
Moving down with increased burn depth (also means increased difficulty for healing)
- Autograft (gold standard)
- Surrounding joints immobilised to allow graft to take
- Spilt thickness (donor site will heal on its own) or full thickness (site requires split thickness to cover)
- Meshed grafts allow better and earlier taking as well as exudate being able to be evacuated from under. Non meshed are better aesthetically but are more fragile in early stages and nurse will need to prick to evacuate.
- Cultured autologous keratinocytes
- Large TBSA burns can be covered without donor sites, nil rejection. It is fragile due to limited dermal attachments
- Homograft - Cadaver allograft
- Acts almost like a bandaid as tissue rejection will occur in 7-14 days
- Can be used over autograph to increase rigidity
- Skin substitutes
- Materials are removed and often require grating after
- Flaps
- When skin graft is not enough to cover a wound, cover exposed bone/tendon ect
- Either skin or muscle flaps
- Flaps are transferred with their own blood supply
Escharotomy and fasciotmy description as well as their considerations for burns patients
Escharotomy
Incision into burnt skin to restore distal circulation
Fasciotomy
Relieve swelling and pressure via incision
When mobilising make sure that only light ROM for Fasciotomy. Can mobilise with escharotomy need to observe for bleeding.
Physio in grafting phase
Stop to allow graft to take
Should have maintained full ROM prior to grafting
Immobilise joint above and below graft
Maintain ROM in other areas
Physio managment in acute stage burn injury (pre graft)
- Assessment (sub/obj)
- Respiratory
- Oedema
- Elevation
- Breathing exercises (prox lymphatics)
- Active exercise for muscle pump (while elevated)
- Compression bandage in hands or lower limb (DONT if peripheral vascular disease)
- Exercise
Minimise risk of contracture (movement in opposite direction)
ROM -> resisted - Early mobility
Mobilised day 1 post burn if able in FWB- Escharotomies down legs
- Exposed Achilles
- Burns to soles of feet (need adequate protection)
- Positioning
- Need to be in anti deformity positions (+/- splints)
- Pain management
Physio management in scar maturation
Scar assessment
-Location, skin mobility/contracture, strength and function
Contracture prevention:
- Exercise (ROM, hold/contract relax, strength, CV)
- Splinting to avoid positions
Other scar management
- Compression garments
- Contact media
- Scar massage
- Surgical
Long term outcomes and considerations for burns
Not just about skin
With >20% TBSA = hyper metabolism. Need to start early gym and CV to prevent wasting
Exercise also decreases risk of heterotopic ossification (deep joint pain + decreased ROM)
Shorter time to fatigue (worse with increased TBSA)
Often have itch, need to avoid (moisturise, massage, medication)
Skin care:
- loss of lubrication so moisturising required
- Sun protection more important
- Heat intolerance
Key components of objective assessment after ortho
- Respiratory
- Deep breaths
- Cough
- Circulatory
- DVT (specific to patient, Achilles repair may have these)
- Swelling of calf
- Redness of calf
- Localised pain/tenderness Increased temperature
- Positive Homan’s sign (calf pain on passive DF)
- Ankle Circles
- Compartment syndrome, bleeding into connective tissue
- palor, pain, paraesthesia, pulses, paralysis
- DVT (specific to patient, Achilles repair may have these)
- Neurological
- Dermatome sensation
- L2-L5
- Musculoskeletal
- Specific to affected region
Do functional assessments
5 P’s of compartment syndrome
- palor, pain, paraesthesia, pulses, paralysis
Important TKA management goals
- Knee flexion >/= 90
- Knee ext 0 (critical for gait and shock absorption)
- Single leg raise with no lag
- Independence with HEP
- Independent mobility on stairs
Physio management overview TKA
Day 1
- Circuloresp and qauds exercises
- Knee flex (90)
- SLR
- FWB so mobilise with rollator
Day 2 (discharge) -Swelling management, more quads (no lag), GAIT edu and knee flex
Discharge criteria
-SLR (<5 lag), knee flex >80, independent mobility including stairs, home exercises
Hip replacement dislocation positions
Post - flex >90, adduction past neutral, IR past neutral (knee to elbow) possible during sitting
Ant - force ext. Flex or ext with add and ER (block ant)