Exam 1: Thursday 8/20/15 Flashcards
How does a hip fracture manifest clinically?
~Pain in groin (the neck of the femur is located in the groin)
~Loss of the mobility in whole LE
~Visible deformity if displaced- shorten leg
~Can have a dislocated hip (will look similar to a displacement)- internal rotation, flexion, adduction
How can the health care team diagnosis a hip fracture?
~Radiograph
~MRI
Is a radiograph or MRI more definitive when diagnosing a hip fracture?
MRI
What will be done after a hip fracture is diagnosed?
Fix it or not fit
Don’t WB through the hip fracture if there is a fracture through….
Intertrochantric and intracapsular
Won’t fix a hip fracture if…
~bone density decreased ~Older ~nursing home (?) ~immobile ~dementia ~decrease cardiac health
How to fix the hip fracture?
Surgery!!
Different types of surgery for a hip fracture
~Nailing ~Compression screws ~THR ~Subtrochantic fracture nailing ~Oblique subtrochantic and intertrochantric- Locking plate ~Intracapsular- a few screws ~Intracapsular- compression screws
Details on Subtrochantic fracture nailing
~Usually performs this when there is a fracture somewhere on the subthrochatric (on the shaft)
~Has intramedullary canal in the shaft of the femur
~We can put the “pipe”/ nail through the intramedullary canal
~Physician drills in and all the medullary material is drained out
~measures how big the canal is; too small- moves; too big- more little fracture
~Will put large screw down the canal and then a screw through the neck of the femur
~There is distal screw to keep it from moving
Details on oblique subtrochantic and intertrochantric- Locking plate
~Long hardware that is bendable
~Sits on the outside of the bone
~Compression screws through the bone
Details on Intracapsular- a few screws
~Put 2 screws through the neck with washers
~Washers in place so that the screws cant be pulled through
~This is done so that a new neck is made
Details on Intracapsular- compression screws
~Has a plate attached to it that has a curve shape to shape to the femur with a few little screws to keep it in place
~A long compression screw through neck to help compress everything down
In oblique subtrochantic and intertrochantric- Locking plate, If the pt started to feel like there is a catch and/or loss of ROM, what do you do? (why?)
Take it seriously!!
~Body does a good job at move the screws in more or out of place
~The longest screw is the most important one to make sure it stays in place
Doctors may forget to give us a WB status. If this happens…
Default to NWB if there is not a WB status from the doc
Why do we have to get pts up (directly after surgery, etc)?
to prevent pneumonia/ DVTs
When would you not get a pt up?
~If there is dementia bc they do not remember not to WB
~also if they cannot maintain the WB status
**rely on nursing to help
TTWB stand for
toe touch weight bearing
WBAT stand for
weight bearing as tolerated
PWB stand for
partial weight bearing
*Bringman tells them that you can walk on it, but don’t bear too much weight through it
___ can be more stress on the joint bc …..; ____ is less because
NWB can be more stress on the joint bc you are holding up the LE; TTWB is less because the muscles can relax
What are some good tricks to help pts have feedback on the amount of force being put through the LE?
Packet of saltines, plastic plate, our foot
Fracture that has not been fixed: restrictions?
~No- only if the doc gives you some
~Pain is the only limiting factor
What are some possible cause of a pt passing out?
~Meds!
~Prolong bed rest
~Lack of food
~loss of blood
More details on how the meds can cause a pt to pass out
~Pain med can make them loopy
~Meds are off- hyper or hypo tension
More details on how prolong bed rest can make a pt pass out
Being in bed for too long can lead to orthostatic hypotension
More details on how lac of food can make a pt pass out
the pt hasn’t eaten since before the surgery the night before!
More details on how blood loss can make a pt pass out
the pt has just had surgery which can lead to loss of blood; the loss of lead can lead to a decrease of Hgb
What do you need to talk to the pt about before they go home?
~Prior level of function
~What is their house like?
~Equipment
~Level of ind- do you have people to help
Details on the surgical site
~Some places will not let you look at the surgical site (nursing/ docs job)
~Coverderm is the normal bandage used
~Look on bandage for strike through
~Need to make sure that there is no infections
Do hip repairs normally have drains?
no
hip replacements: can have 2 different types
~Hemi arthroplasty
~total
Hemi arthroplasty: details
~Replace half
~Get rid of the bone and replace it with the arthroplasty down into the intramedullary canal with bone cement
~Screw on a new femoral head
~Keep acetabulum
Which half is normally replaced?
~Typically replacing head and neck (not acetabulum)
A hemi arthroplasty is typically preformed on what type of fractures
Typically an higher intertrochantic or intracapsular
What are the benefits of having a hemi arthoplasty?
~Benefit is less trauma and there is not much bone to work with
~Want to keep as much of the acetabulum for as long as possible; if you have to have another hip replacement- can eventually have no bone to work with in this area
Precautions for a hemi arthoplasty
~Depends on the approach
~If done correctly, should be WBAT
Approaches for a hip replacement
~posterior/ lateral
~anterior
Posterior/ lateral hip precautions
~flexion 90
~no adduction past neutral
~no IR
Posterior/ lateral hip precautions
These because the capsule has been cut, which normally would have kept the hip from dislocating
What are some everyday tasks that can cause a posterior/ lateral displacement?
~Flexion- Siting up, tying shoes, shaving legs, bathing, picking up something, getting into a chair that is low, don’t lead forward
~IR- don’t point toe in, turning to the hip that wasn’t worked on
~Adduction- getting in and out of bed, sleeping
Anterior hip precautions
~extreme extension (lunges)
Bringman stated anterior is better than posterior/ lateral bc
~Less pain because you are cutting through less arteries
~Physician is cutting through/ moving around more important stuff
Implant criteria for a THA/ TKA
~Resistant to wear (durable)
~Approximate normal anatomy
~Biocompatibility
~High standard of production (no recalls)
Be able to describe the process of a THA to the pt!
~2 main component- the acetabular and the neck/head
~Will lay on your back and your feet in boots attached to the table so that the surgeon can manipulate the pt easier
~3-6 in incision near the groin
~Move aside muscles (no muscles are cut during the procedure)
~Will dislocate the hip
~Remove any OA, etc bone in the acetabulum and shape the acetabulum for the prosthesis
~Insert prosthesis to the acetabulum
~Remove the head and part of the inner neck/shaft for the neck
~Insert the prosthesis
~Relocate the hip with the new components
~The surgeon will test out the hip to make sure that it moves correctly and will take radiographs to make sure there is proper placements
~Close the incision after moving muscles in place
How long is it going to last?
Should last 10- 15 years (it is getting longer)
What will eventually fail?
~the boney attachment is the part that fails bc of forces and impact (over time it acts as a wedge and wears down)
~acetabular component and the top of the femur (greater trochanter) are the 2 parts that are most likely to cause the failure over time
activity precautions for THA
~causes the wear and tear
~high impact activities: running, jumping, tennis, basketball, when feet leave the ground
rehab for a THA
~strengthen
~stretching
~get them up day of surgery and walk them
~ant- 4 way hip, ankle pump, gluts set, SAQ, LAQ,
~post- have to make sure that they don’t do flex ex about 90* on a 4 way hip
~out pt- WALK!, continue exercises
Who are you more worried about having a dislocation: someone doing really well or a little old lady that is scared to get up?
Person doing well- can do too well and push too hard
What happens after a dislocation?
need to put it back in (physician)
What can to prevent a hip dislocation (or what do you do after)?
~can put a knee immobilizer on
~hip spika
~locking hip
Details on a hip spika
~can have skin breakdown
~will have to wear this for months
~hard to put on without dislocating hip again
~never fits well
Details on a locking hip
~reducing the amount of ROM that the hip can move
~locks hip in place
~hardware you place into the joint
What are the two main types of total knee arthroplasty?
~unicompartmental/ partial
~full
Details on unicompartmental/ partial
~if you only have problems with one side of the knee
~get to keep ACL/PCL can keep either MCL or LCL
~not very common
~ROM easier to get
~Exercises, therapy very similar
~Usually less swelling
Do you normally see a unicompartmental/ partial or a full TKA?
Typically see full compared to unicompartmental
Details on TKA
~Replace all ligaments; sometimes can save MCL/LCL
~BE able to draw this!!
~don’t do a SLR with a knee extension lag- you are reinforcing it!
Therapy for a TKA
~a lot more therapy then total hip ~check strength and ROM (knee flex/ ext) ~walking ~take BP ~exercises (ankle pumps, quad sets, heel slides, SLR, SAQ/ LAQ, 4 way hip)
TKA- what meds, what is normally attached, etc right after surgery
~will have a drain
~some will sometimes use a recirculator
~nerve block to help with pain (sensory block)
~can still lose a little motor (need to assess if they will be able to WB through the leg)
What is a recirculator?
large drain that takes the blood that drained and put is back into you
What can you do if the leg is wobby?
put a knee immobilizer
TKA- measurements
~you care more about extension more than flexion
~it’s harder to get extension and will walk funny if you do not get it
TKA- gait training
~need to educate and training their gait
~they have been compensating for many years, trying to get back to pre injury/ pre OA gait
TKA- out pt therapy
~all the same ex from the hospital should be done at home (check the exercise to make sure they are doing right)
~gait training
~ROM
~balance
~functional activities
~increase mobility
~scar mobilization and patella mobilizations
what is something that can go wrong?
~decrease ROM ~infection ~falls ~problems with the arteries and nerves ~death
Something that can go wrong details: decrease ROM
have to go in to mobilize under anesthesia
Something that can go wrong details: infection
~everything becomes more difficult (ROM, strength, etc)
~Can get in during surgery or get in from strike through
~dangerous b/c of the bone (bone now has hole)
~pump them full of antibiotics- hard to get antibiotic to the bone
~at a higher risk of osteomyelitis
What happens if an infections become bad enough?
~Will go in and do a IND (irrigation and debridement)
~can wash it out first; can go in and take out the joint
~take bone cement and antibiotic paste- shape into and put in where the prosthetic used to be
~can put in antibiotic beads through the hole (will not be doing ROM, etc with pt)
~when the infection is gone, put in a new prosthetics
What happens if an infection gets bad enough that an IND will not fix it?
~fuse bone or amputation
Something that can go wrong details: falls
~impacts the ground/ too much flexion- swelling and pops open the wound
~can lead to infection
Something that can go wrong details: problems with the arteries and nerves
~need to check if there are nerve/ blood supply damage post surgery
~cant move/ sensation issues/ increase pain/ N/T/ blood supply issues
~can loss a limb due to the lack of blood supply
Something that can go wrong details: death
~caused by a DVT
~most likely going happen on the ortho floor
What are two things that a DVT can lead to?
~stroke (usually ischemic stroke; if we find it in time, we can give them TPA)
~PE (SOB quickly)
