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)
THA overview
Day 0
- Mobilise 2-3 post in WBAT
- Hip ROM, quads, circuloresp, inner range quads, bridging and bed mobility
Day 1
-progress mobility
Day 2 - discharge
- progress ROM and strength functionally (mini squats)
- balance, mobility, stairs
Discharge education
- avoid diss positions, no low chairs, no cross lgs, dont lie on affected side, dont squat to ground, bend to pick up, twisting, no driving in first 6 weeks
Meniscectomy
Management - FWB, rehab include ROM, SLR, IRQ and limit walking to manage swelling
Meniscal repair
Mobilised NWB crutches, ROM restriction to limit shear forces, still have ROM exercises, SLR, IRQ and manage pain and swelling
ACL repair
ROM brace (Richards splint) to 90 Slow return to flexion, 110 over first 2 weeks and full by 6
Pelvic fracture management
Stable normally conservatively
- system maintenance (cardio, resp, neuro)
- teach bridge and block rolling
- WBAT on aid, hip and knee strength with decreasing pain
- Address balance for further falls
- Discharge when independent with aid
Unstable -Normally surgical not traction -Ant ex fix is temporary Post op rehab variable due to high impact trauma, need notes RIB 48 hrs -> TWB 6-8/52
Acetabular fractures
Often need THA
Wound closer for burns
Superficial = 7-10 days
Superficial partial thickness = 14 days
Deep partial thickness = >14 days
Full thickness = 3 weeks
List of physical impairments
Limb shortening ▪Weight transmission ▪Muscle loss ▪Muscle imbalance ▪Loss of joints ▪Loss of sensation ▪Changed base of support ▪Change to circulation ▪Impaired heat loss ▪Increased energy cost of ambulation
5 stages of fracture healing
Tissues destruction and hematoma formation -
Inflammation and cellular proliferation (up to 2 weeks)-
Callus formation (2-4 weeks) - Woven bone formation
Consolidation (8 weeks) - Woven bone to lamellar bone, clinically and radiographically united
Remodelling (2 months - 2 years) - resorption and formation
Discectomy and microdiscectomy
Discectomy
Often done with partial laminectomy
Microdiscetomy
Just a smaller incision, meaning the recovery time is smaller and surgical trauma is minimised just to less soft tissue effected.
Inadequate decompression or Dural tearing
Lumbar spine stenosis and symptoms
Lumbar spine stenosis
IV disc loose fluid with age (less resistance to compression), loosing height meaning disc can bulge into vertebral canal. Spinal facet joints can thicken and enlarge with arthritis, further limiting the canal. Spinal stenosis = narrowing the canal
Symptoms:
- Lower back pain
- Pine, needles, numbness in legs
- Cramping and weakness in legs
- mediating pain with forward flexion
(need to decompress)
Laminectomy
Laminectomy
Removal of piece of lamina to decrease pressure on spinal cord or nerve root. Cannot do more than 2 due to decrease in stability, this case would require fusion.
Management of decompressive surgery (discectomy/laminectomy)
- Circuloresp, neurological checks, log roll for comfort
- Regular changes of positions
- Transverse and multifidus activation
- Mobilise day 0-1 on orders
- Need to be intendent on stairs and HE for discharge (day 0/1)
Spinal fusion techniques
Instability, deformity (scoliosis, kyphosis, spondylolisthesis) or other conditions (osteomyelitis, TB)
Techniques:
- Bone grafts
- Unable to correct spinal deformity
- Used before fusion
- Requires bracing after if done alone
- Posterior lumbar fusion
- Screws
- Anterior lumbar interbody fusion
- For high grade spondylolisthesis
Spinal fusion management
Management:
- +/- Bracing (need for just bone graph)
- Circuloresp, neuro checks
- Don’t sit for long periods, log roll for comfort
- Exercise day 1
- Multifidus and transverse
- Ind3pdent on stairs and HEP for discharge (day 2-3)
Scoliosis treatment and management
Treatment:
Depends on angle of curve
<15 - advice on exercise, muscle strengthening and posture
15-30 - bracing
> 30-40 - surgery
Post OP:
- Post op immobilisation, balance and movement will feel different
- Circuloresp exercises, log roll, exercises dat one, mobilise day 1-2 (one stage)
- If two stage then after first circuloresp, log roll, no SLR, hip/knee flexion then after stage 2 same as one stage
- Discharge when independent on stairs and HEP
Neural mobiltiy exercises
Program for after spinal surgery to mobilise neural structures, limit scarring and relieve pain and symptoms.
- stage 1 - DF and PF ROM, hip abd/add, hip rotations in neutral → DF/PF in small SLR
- stage 2 - knee ext in some hip flex (some gentle SLR)
- stage 3 - progress with increasing hip flexion
Spinal fractures
Cervical
Stable - collar for 6 weeks. System ass/maintence (neuro!), log roll
Unstable - skull tongs or stabilisation +/- halo brace (impacts balance, log roll in/out bed). Systems ass/maintenance (neuro!), chest maintenance
Thoracic
Often stable - brace, systems, log roll (avoide rotation/flexion), mobilise with aid
Lumbar has same physio
What is OA
- Disorder that involves multiple joints
- ECM degeneration and cell stress along with maladaptive repair processes
- Begins first as a molecular issue (abnormal joint tissue metabolism) this then progresses to have anatomic and/or physiologic abnormalities such as cartilage degeneration, bone remodelling, osteophyte formation, joint inflammation all of which contribute to loss of normal joint function.
- Important to remember that these issue can but don’t always relate to symptoms
A common misconception is that it is just wear and tear of articular cartilage but OA is a WHOLE joint disease (meniscus, labrum, cartilage, synovium, muscles, subchondral bone). Not just mechanical, also contains inflammatory and metabolic aspects
Dfferences between OA and R
OA:
- Gradual onset of symptoms, +/- joint stiffness that is no longer than 30 mins, Activity related joint pain, >45 age, Imaging (osteophytes, reduced joint space, bony contour deformity)
Rheumatoid:
- Faster onset, Hot swollen joint, Stiffness longer than 30 mins, Systemic features, More common bilaterally
Specific features of OA in hip and knees
Knee:
- Pain in knee (either whole or just joint lines)
- Instability and giving way (pain inhibition of quads or from structural deformities)
- Crepitus
- Loss of full ROM (osteophytes, joint shape)
- Varus or valgus
- Muscle atrophy and weakness
- Synovial thickening
Hip:
- Pain in variety of areas around hip and thigh
- Loss of ROM
- Muscle atrophy
When should surgery be considered for OA
After first and second line treatment have been trialled and the patient has true mechanical locking.
Stages of wound healing
Inflammation (1-5) -
Cellular proliferation (3-5 - 3w)
Fibroblast secrete collagen and ground substance, fibroblasts differentiate into myofibroblasts.
Myo cause wound contraction to pull edges of wound together.
Underlying cause of contracture. Wounds is closed at the end of this phase, scar tissue created.
Remodelling (3w- 12-18m) -
Collagen forms cross links to increase tensile, ground substance more dense, collagen orientation less random. Scars are adaptable during this phase.
Contracture development
Scar tissue, contractures due to myofibroblasts. These are first seen 5-7 days but peak at 4-5 months. Scare contracture force left unopposed by resistance.
Conservative burn management
Silver based dressings
ASIA impairments UL motor
C5 - elbow flexors C6 - wrist extensors C7 - elbow extensors C8 - finger flexors T1 - 5th abduction
ASIA impairments LL motor
L2 - hip flex L3 - knee ext L4 - Ankle DF L5 - toe ext S1 - Ankle PF
Grades for ASIA
A - Complete (no sensory or motor in sacral)
B - Sensory Incomplete (Sensory but no motor below level and includes sacral)
C - Motor incomplete (Motor below level and more than half muscles grade <3)
D - Motor incomplete (Motor below level and more than half muscles grade >3)
E - Normal
Sensory for ASIA
28 dermatomes tested using 3 point scale:
0 - absent
1 - impaired (feels different)
2 - normal (same as reference)
This scale is used for light touch and then for differentiation between sharp and blunt
Level of neurological injury
Lowest segment with normal sensory and motor on both sides
Early SPI rehab
Pressure redistribution is important:
- Pressure lifts, pressure leans or tilt in space equipment. Do this every 20-30 mins
- Balance
- Bed mobility
- Transfers
Functional electrical stimulation
Functional electrical stimulation
This is the application of electrical current to paralysed muscle to restore or improve function. It is applied to achieve a functional task.
30-60 mins of exercise 3 times per week is requirede
