Exam 2

Question 1

List the 8 indications for surgery for musculoskeletal disorders

Answer 1

a. Incapacitating pain at rest or with functional activities.
b. Marked limitation of active or passive motion.
c. Gross instability of a joint or bony segments.
d. Joint deformity or abnormal joint alignment.
e. Trauma resulting in significant tissue damage.
f. Significant structural degeneration
g. Chronic Joint swelling.
h. Failed conservative (non-surgical) or prior surgical management.
i. Significant loss of function leading to disability as the result of any of the preceding factors.

Question 2

Identify and describe the 7 components of preoperative patient education.

Answer 2

a. Overview of the plan of care: Gives the patient an explanation of what their plan of care might look like and an idea of what to expect post-operatively.
b. Postoperative precautions: Advise patient of postoperative precautions/contraindications,
c. Bed mobility and transfers: Demonstrate and teach patient how to move/ preform safe transfers, while maintaining postoperative precautions.
d. Initial postoperative exercise: teach patient any exercises that will be started during the very early postoperative period which include Deep-breathing, active ankle exercises, gentle muscle-setting exercises.
e. Gait training: Teach patient to use assistive device postoperatively.
f. Wound Care: Explain and reinforce postoperative care of the surgical incision for optimal wound healing.
g. Pain Management: educate patient on correct use of cryotherapy for postoperative pain management.

Question 3

Describe the steps/process to inspect a surgical incision site.

Answer 3

a. Check for signs of redness or tissue necrosis along the incisions and near sutures.
b. Palpate along incision and note signs of tenderness and edema.
c. Palpate for evidence of increased heat.
d. Check for signs of drainage.
e. Assess integrity of an incision crossing a joint during and after exercise.
f. As the incision heals, check the mobility of the scar.

Question 4

What are the signs of infection of a surgical incision?

Answer 4

Redness, pain, inflammation, oozing

Question 5

What factors influence the progression and outcomes of a post-operative rehab program?

Answer 5

Transitional sequences of tissue healing, by the permitted level of activity, by the degree of protection or by sequential numbering.

Question 6

List 5 potential postoperative complications.

Answer 6

DVT and Pulmonary Embolism, joint subluxation, restricted motion from adhesions and scar tissue formation, Failure, displacement , or loosening of the internal fixation device.

Question 7

What would you do as a PTA if you suspected your patient had a DVT?

Answer 7

Alert Supervising PT, If a patient presents with signs or symptoms of possible pulmonary embolism, immediate medica referral is warranted for a definitive diagnosis and management.

Question 8

What is the difference between an open approach versus an arthroscopic approach?

Answer 8

An open surgical procedure involves an incision of adequate length and depth through the necessary superficial and deep layers of skin, facia, muscles, and joint capsule that allows the operative field to be fully visualized by the surgeon during the procedure. However, and arthroscopic procedure is used as a diagnostic tool and as a means of treating a variety of intra-articular disorders. Involves very small incisions.

Question 9

How long after a tendon repair should end-range stretching, and high-intensity resistance exercise be withheld? Why?

Answer 9

Vigorous stretching and high-intensity resistance exercise should not be initiated for at least 8 weeks after repair, when healing of tendon is mature.

Question 10

Name two examples of a procedure that can be identified as a tendon transfer or realignment.

Answer 10

For a patient with significant neurological deficit, a tendon transfer from one bony surface to another is sometimes indicated to prevent deformity and improve functional control. Another example would be for a child with cerebral palsy, the transfer of the distal attachment of the flexor carpi ulnaris to the dorsal surface of the wrist changed the action of the muscle tendon unit from a wrist flexor to a wrist extensor. This overall can prevent wrist flexion contracture and improve active wrist extension for functional grasp.

Question 11

How are the positions of a joint determined for arthrodesis? Why is proper positioning important?

Answer 11

The optimal joint position for arthrodesis is somewhat dependent on the functional needs for goals of each patient and may vary between or even within patients for some joints. Eliminates pain and creates stability

Question 12

What are the contraindications of a total joint arthroplasty?

Answer 12

Active infection in the joint
Chronic osteomyelitis
Systemic infection
Substantial bone loss or malignant tumors that prohibit adequate implant fixation.
Significant paralysis of muscles surrounding joint
Neuropathic joint
Inadequate patient motivation

Question 13

What does ORIF stand for? When might it be used?

Answer 13

ORIF stands for Open Reduction and Internal Fixation. Used to stabilize and maintain alignment of the fracture site as it heals.

Question 14

Describe the differences between autograft, allograft, and synthetic graft. (Do not just give the definitions - also include what is similar, different, and when they might be used and any long-term risks), benefits, and rehab considerations for each.

Answer 14

Autograft: uses a patients own tissue harvested from donor site in the body.
Risks include need for two surgical procedures and potential for negative consequences at the donor site.

Allograft: Uses fresh or cryopreserved tissue that comes from a source other than the patient, typically from a cadaveric donor. Associated with several risks, such as disease transmission from donor, compromised graft strength, and failure secondary to immunological rejection.

Synthetic graft: Materials such as Gore-Tex and Dacron offer an alternative to human tissue and have been used on a limited basis for ligament reconstruction in the knee. Have a high rate of failure and have not maintained their integrity over time.

Question 15

How can the risk of a patient developing a DVT be reduced? What is your role as a PTA in reducing the risk?

Answer 15

Educating the patient on things they can do or avoid on the daily basis to reduce the risk of developing a DVT. For example, elevating legs when lying in supine or when sitting. No prolonged periods of sitting, especially for the patient with a long-leg cast. Initiating ambulating as soon as possible after surgery. Actice “pumping” exercises. Use of compression stockings.

Question 16

Why is important for the PT and PTA to know the risk factors in the prevention of DVTs

Answer 16

Early recognition and Intervention, It can help minimization of complications and allows PTA’s to give adequate patient education

Question 17

What is “Functional Articulation”? Please give one example in the upper extremity.

Answer 17

Typically refers to the range of motion and movement capabilities of a joint that are necessary for performing daily activities or functional tasks. In the context of physical therapy or rehabilitation, it often involves assessing and improving the joint’s ability to move through its full range of motion in a way that supports the patient’s functional goals. One example is the Scapulothoracic Articulation. There is considerable soft tissue flexibility, allowing for scapula to slide along thorax and contribute to all upper extremity motions.

Question 18

What effects does faulty posture have on the shoulder girdle? What muscles are shortened in a forward head posture vs what muscles are weak/lengthened?

Answer 18

With faulty scapular alignment, muscle length and strength imbalances occur not only in the scapular muscles, but also in humeral muscles, altering the mechanics of the GH joint.

For a forward head tilt, shortened muscles are the pec minor, levator scapulae, and scalenus muscles.

Muscles that present with weakness are in the serratus anterior or trapezius muscles.

Question 19

Irritation of what nerve roots may cause pain in the shoulder region? What other organs may refer pain to the shoulder?

Answer 19

Nerve roots C4 or C5. Heart, gallbladder, diaphragm.

Question 20

What structure is at the most risk of impingement in the subacromial (suprahumeral) space?

Answer 20

Weak infraspinatus and teres minor muscles or inadequate external rotation may result in impingement of the soft tissues in the suprahumeral space.

Question 21

Describe Bankart, SLAP, and Latarjet lesions and repairs.

Answer 21

A Bankart lesion involves an open or arthroscopic repair of a Bankart lesion, which is the detachment of the capsulolabral complex from the anterior rim of the glenoid commonly associated with traumatic anterior dislocation. During repair an anterior capsulolabral reconstruction is preformed to reattach the labrum to the glenoid lip.

SLAP is a tear of the superior labrum. Some SLAP lesions are associated with a tear of the proximal attachment of the long head of the bicep’s tendon and recurrent anterior instability of the GH joint. An arthroscopic repair involves debridement of the torn portion of the superior labrum, abrasion of the bony surface of the superior glenoid, and reattachment of the labrum and biceps tendon with tacks or suture anchors.

A Latarjet lesion involves transferring the tip of the coracoid process and coracobrachialis tendon to the anterior glenoid rim to provide mechanical block to humeral head of anterior motion. It has been used primarily as a salvage procedure after a Bankart repair fails to prevent recurrent instability. It can be performed as an open or arthroscopic approach, with no differences noted in outcomes between this procedure and Bankart repair.

Question 22

What are some common activity limitations and participation restrictions due to shoulder disorders?

Answer 22

Inability to reach overhead, behind head, out to the side, and behind back leading to difficulty dressing (putting on jacket, or coat, fastening undergarments being their back for women). Reaching into back pocket of pants to retrieve wallet. Self-grooming. (combing hair, brushing teeth, washing face)

Question 23

You are helping a patient with shoulder AAROM following a motor vehicle crash with no broken bones noted on the x-ray. What position should the G-H joint be in when attempting to fully abduct the shoulder?

Answer 23

External Rotation

Question 24

Please describe appropriate shoulder positioning following

Answer 24

Total Shoulder Arthroplasty:
For supine, Arm immobilized in sling that is worm continuously, elbow flexed to 90 degrees. Forearm and hand resting on abdomen. Forward flexion (10 to 20 degrees), slight abduction, and internal rotation of the shoulder, head of bed elevated about 30 degrees.

Reverse Total Shoulder Arthroplasty:
The arm is positioned in the sling with the shoulder abducted to approximately 30 to 40 degrees and the elbow flexed to around 90 degrees.

Rotator Cuff Repair with abduction orthosis (pg 599):
The position and duration of immobilization of the operated shoulder after rotator cuff repair depends on many factors, including the size, severity and location of the tear and type and quality of the repair. The size of the cuff tear partially determines whether the operated arm is supported in a sling (shoulder adducted, internally rotated, elbow flexed to 90 degrees) or in abduction orthosis or splint(shoulder elevated in the plane of the scapula approximately 45 degree shoulder internally rotated and elbow flexed. Patients supported in an abduction splint may require assistance from a family member to support the operated arm in 45 degrees shoulder position when the splint is removed for exercise, dressing or bathing.

Question 25

What is adhesive capsulitis? What are the phases of the condition and how long does each phase last? Who is at most risk for developing the condition?

Answer 25

Also known as frozen shoulder, `is characterized by the development of dense adhesions, capsular thickening and capsular restriction, especially in the dependent folds of the capsule, rather than arthritic changes in the cartilage and bone as seen with RA or OA. There are 4 stages. Stage 1: less than 3 months. Stage 2: typically, between 3- 9monthsafter onset. Stage 3: Occurs between 9-15 months after onset. Stage 4: Can last 15-24 months after onset. Patients with diabetes mellitus and thyroid disease are at increased risk.

Question 26

What is the difference between rotator cuff tendinitis, rotator cuff tear, and bicipital tendinitis?

Answer 26

For rotator cuff tendinitis, common symptoms include pain and tenderness in the shoulder, especially with overhead activities or reaching movements. Pain may worsen at night, particularly when lying on the affected side. There may also be weakness and limited range of motion in the shoulder joint. However, a rotator cuff tear occurs when one or more of the tendons of the rotator cuff muscles are partially or completely torn. Lastly, with bicipital tendinitis the lesion involves the long tendon of the biceps muscle in the bicipital groove beneath or just distal to the transverse humeral ligament. Swelling in the bony groove is restrictive and compounds and perpetuates the problem. Symptoms include pain in the front of the shoulder, which may radiate down the arm. Pain may worsen with overhead activities, lifting, or reaching movements. There may also be tenderness and swelling in the area of the bicep’s tendon.

Question 27

What is the mechanism of injury that typically results in GH anterior dislocation? What is the focus of rehab post dislocation?

Answer 27

Direct trauma or sports injuries. Activity restriction is recommended for 6-8 weeks in a young patient. Provide protection, slowly increase shoulder mobility. Increase stability and strength or rotator cuff and scapular muscles. Restore functional control.

Question 28

What are the precautions for rehabilitation following glenohumeral stabilization surgical procedures?

Answer 28

SLAP:
For SLAP lesions where the biceps tendon is detached, progress rehabilitation more cautiously than when the biceps remain intact. Limit passive or assisted elevation of arm to 60 for the first 2 weeks and 90 degrees at 3 to 4 weeks postoperatively. Avoid positions that create tension in biceps.

Bankart:
Limit external rotation, horizontal abduction, and extension during first 6 weeks postoperatively.

Latarjet:
Patients should avoid activities that could place excessive stress on the repaired shoulder joint, especially during the initial stages of rehabilitation. This may include avoiding overhead reaching, heavy lifting, or sudden movements that could strain the shoulder.

Question 29

Phase of Healing for Rotator Cuff Repair

Time frame

Appropriate PT interventions/exercises

Answer 29

Maximum Protection Phase (Protection Phase)
3 to 4 weeks after fully arthroscopic or mini open repair of small or medium tears or 6 to 8 weeks after repair after large or massive tears.
Control pain and inflammation, prevent loss of mobility of adjacent regions, prevent shoulder stiffness/restore shoulder mobility. Prevent or correct postural deviations, develop control of scapulothoracic stabilizers, prevent inhibition and muscle atrophy of GH musculature.

Moderate Protection Phase (Controlled Motion)
Begins around 4 to 6 weeks post operatively and extends an additional 6 weeks.
Increase strength and endurance and reestablish dynamic stability of the shoulder musculature.

Minimal Protection (Return to Function)
6 months or more.
Passive strengthening of GH musculature and joint mobilization.

Question 30

Describe 3 common nerve injuries/irritations in the elbow

Answer 30

Radioulnar symptoms from the C5 and C6 nerve roots have been reported in patients with lateral elbow pain and from the C6 and C7 nerve roots with medial elbow pain. Nerve disorders in the elbow involve the Ulnar nerve, Radial nerve and the Median nerve.

Question 31

Please list 3 muscles of the elbow and forearm. Describe how an injury to each muscle will affect functional activities.

Answer 31

Biceps brachii, Triceps brachii and Forearm Supinator.

Biceps Brachii: This can impair tasks like lifting objects, performing bicep curls, or even simple actions like turning a doorknob.

Triceps Brachii: challenging to perform activities that require pushing, such as pushing open a heavy door, pushing oneself up from a seated position, or pushing objects away from the body.

Forearm supinator: challenging to perform everyday tasks that require supination, such as turning a key, using a computer mouse, or carrying objects with the palm facing upward.

Question 32

Describe 3 surgical options for a displacement of the radial head

Answer 32

Open reduction and internal fixation: this procedure involves surgically realigning the fractured radial head back into its proper position (reduction) and then stabilizing it using internal fixation devices such as screws, plates, or wires. This is the preferable technique if stable fixation can be achieved and if able to repair ligamentous damage. However not amendable to nonreducible fractures and less practicable than radial head excision.

Low-profile Fixation: By using low-profile fixation techniques, surgeons aim to achieve stable fracture fixation while optimizing patient comfort, range of motion, and functional outcomes following surgery. Improved forearm rotation and flexion with decreased scarring compared to other techniques. Immediate mobilization to the elbow is permissible.

Excision of the radial head: For severely comminuted, nonreducible and unstable fractures; no potential for mechanical blockage of joint motion from malalignment of fracture fragments or internal fixation; early ROM permissible.

Question 33

What is the difference between a “pushed elbow” and a “pulled elbow”?

Answer 33

A “pulled elbow” is most commonly seen in children. It occurs as a result of a forceful pull on the hand such as when a child jerks away from a parent or caregiver. The force causes the radius to translate distally with respect to the ulna. The head of the radius is then unable to glide proximally in the annular ligament when supination is attempted, resulting in the person holding the forearm in pronation. The patient guards against motion into supination.

A” pushed elbow” refers to the proximal subluxation of the radius which may result from falling on an outstretched hand. The radial head is pushed proximally in the annular ligament and impinges against the capitulum.

Question 34

Describe exercises that are appropriate for each phase of healing for the patient who has had surgery on the elbow/forearm.

Answer 34

Maximum Protection Phase: The maximum protection phase for a Total elbow arthroplasty extends approximately over a 4-week period, includes control of inflammation, pain, and edema with use of medication as needed, application of cold, and regular elevation of postsurgical arm. Emphasis is also placed on careful inspection of wound, protection of soft tissues as they begin to heal and early ROM exercises to offset the adverse effects of immobilization without jeopardizing the stability of the prosthetic joint.

Moderate/Minimal Protection Phase: By about 4-6 weeks postoperatively, soft tissues have healed sufficiently to withstand increasing stresses. The focus of rehabilitation during the intermediate final phases is to improve ROM to the extent achieved intraoperatively, regain strength and endurance of elbow musculature and use of operated arm for functional activities with a permanent lifting restriction of 1- 2 pounds of repetitive lifting and 5-6 pounds for 1 time lifting.

Question 35

Why is bicipital tendinitis discussed in the shoulder and elbow chapter? What rehab considerations are needed at the elbow joint in patients with this condition?

Answer 35

Bicipital tendinitis involves inflammation or irritation of the long head of the biceps tendon, which attaches to the top of the glenoid fossa of the scapula within the shoulder joint and travels down the bicipital groove of the humerus. While bicipital tendinitis primarily affects the shoulder joint, it can also have implications for the elbow joint due to the anatomical connections and biomechanical relationships between the two joints. As a result, dysfunction or inflammation of the biceps tendon can impact both the shoulder and elbow joints.

Question 36

What is meant by myositis ossificans? How does it affect joint motion? What patient education is necessary for this condition?

Answer 36

Refers to the only ossification of muscle. More often, the term is used to describe HO or bone formation in the muscle-tendon unit, capsule or ligamentous structures. It can affect joint motion by the restriction of Range of Motion: The presence of abnormal bone formation within the muscle can restrict the normal movement of the joint. Pain and Discomfort: Myositis ossificans can cause pain and discomfort, particularly during movement of the affected joint. The presence of abnormal bone tissue within the muscle can irritate surrounding tissues and nerves, leading to pain and tenderness. Impaired Functionality: Depending on the extent of bone formation and its location within the muscle, myositis ossificans can impair the functionality of the affected joint. Activities that require full range of motion or strength in the joint may be limited or difficult to perform. Patient education for myositis ossificans is essential to help individuals understand the condition, manage symptoms, and prevent further complications. Understanding the nature of the condition can help patients cope with their symptoms and make informed decisions about treatment options.

Question 37

What forearm and wrist motions might need to be limited while a patient is healing from trauma to the elbow joint? Why?

Answer 37

Forearm Pronation and Supination These motions can put strain on the injured structures around the elbow joint, particularly if there is instability or fractures present. Limiting pronation and supination helps to minimize stress on the healing tissues and prevents exacerbation of pain or displacement of fractures.

Wrist extension and flexion. Excessive wrist flexion or extension can transmit forces to the elbow joint, potentially aggravating the injury or hindering the healing process.

Question 38

ROM: Forearm Pronation

Answer 38

0-80 degrees

Question 39

ROM: Forearm Supination

Answer 39

0-80 degrees

Question 40

ROM: Elbow Flexion

Answer 40

0-140 degrees