Msk System Flashcards
Examination Definition
Examination findings from history, systems review, and tests and measures should drive the decision making process
Components of an Examination
Patient History
Medical record review
- diagnostic test review: imaging
- medication review
- coordination w/ other providers
Pt interview
Tests and Measures
- mental status
- observations
- integumentary
- pain
- ROM & Strength
- Posture
How is pt history obtained
– Medical record
– The patient
– The pt’s caregivers
What does pt history include
General demographics
Social history
Employment/work
Growth & development
General health status
Family history
Medical/surgical history
Current condition(s) & CC
Functional status & activity level
Medications
Clinical tests
Activity Status
Complete bedrest
Bedrest /c bathroom privileges
Dangle
Up in chair /c assist
BRP when A&O
Up in hall
Up as tol
Up ad lib (up as desired)
Walk /c assistance
Activity as tolerated
Walk /c assistance
Diagnostic Tests Review
Radiography (X-ray)
CT Scan
MRI
Bone Scan
Mylegrophy
Radiography (X-ray)
good for fractures, bone loss and foreign bodies. It is cheaper and faster than other imaging
CT Scan
a more detailed X-ray, enhanced x-ray imaging
MRI
Good for soft tissue, nerves. More accurate than CT and xray but takes longer and is more expensive
Bone Scan
metabolic status of the skeleton. Subtle fracture by comparing the metabolic status of one part of the bone to the other
Mylegrophy
Image of Spinal cord, nerve root, dura mater w/ contrast dye. Spinal stenosis or compression that may be a result of disk rupture
Medication Review
Residual effects of general anesthesia
Pt could be woozy, confused, delirious, and/or weak.
Medication Review Pain medications (opioid analgesics)
•Type of pain medication, its side effects, and dosing schedule.
Medication Review
Anticoagulant (heparin, warfarin)
o Antiembolism stockings
o Pneumatic compression devise
Interventions:
General PT goals
– Decrease pain and/or muscle guarding.
– Prevent circulatory & pulmonary complications.
–Prevent ROM & strength deficits.
– Improve functional mobility while protecting the involved structures.
PT considerations w/ interventions
– Physician orders.
– Need for equipment use during mobilization activities.
– Medical status, social support system, & ability to abide by all safety precautions.
Traumatic Fracture Classification
The classification of the fracture
- Linear fx: parallel to the long axis of the bone.
- Oblique fx: diagonal to the long axis of the bone.
- Spiral fx: encircles the bone.
- Transverse fx: horizontal to the long axis of the bone.
- Comminuted fx: two or more fragments (ex: wedge-shaped)
- Segmental fx: 2 or more fxlines at different levels of the bone.
- Compression fx: the bone is crushed (common in the vertebrae).
Factors Contributing to Bone Healing
Favorable
• Early mobilization
• Early weight bearing
• Maintenance of fracture reduction
• Younger age
• Good nutrition
• Minimal soft tissue damage
• Patient compliance
Unfavorable
• Presence of growth hormone
- Tobacco smoking
- Presence of disease (DM, anemia, neuropathy, or malignancy)
- Vitamin deficiency
- Osteoporosis
- Infection
- Irradiated bone
- Severe soft tissue damage
- Distraction of fracture fragments
- Bone loss
- Multiple fracture fragments
- Disruption of vascular supply to bone
- Corticosteroid use
Fracture: Immediate complications
Delayed complications
- Loss of fixation or reduction.
- Delayed union (due to unfavorable healing factors).
- Nonunion (failure of fxto unite).
- Malunion (angular or rotary).
- Pseudarthrosis (false joint at fxsite).
- Posttraumatic arthritis.
- Osteomyelitis.
- Avascular necrosis.
- Complex regional pain syndrome.
Fracture Fixation Methods
Fx According to Body Region (UE)
Shoulder girdle fx
Proximal humerus & humeral shaft fxs.
Distal humeral & proximal forearm fxs.
Fxs of the shaft of the radius and ulna.
Carpal, metacarpal, & phalangeal fxs.
Fx According to Body Region (Pelvis & LE)
Pelvic fx
Acetabulum fx
Proximal Femur fx
Femoral Shaft fx
Distal Femur fx
Patella fx
Tibial Plateau fx
Calcaneal fx
Fx According to Body Region (Spine)
Less frequent than fxsto the extremities.
~ half sustain spinal cord or peripheral nerve root injuries.
Spine Fx primary goal
Primary goal is preservation of neurologic function.
Mechanical stability must be provided to unstable segments.
Spine Fx Standard treatment
Standard treatment: closed reduction & stabilization (external
Spine Fx PT management
PT management:
– Goal: protecting the fracture & surgical site during all functional mobility activities.
– “Cleared” for mobility?
– Teach proper “logroll” techniques, posture, body mechanics and use of orthotics.
– Strengthening and ROM exercises (based on clinical presentation)
What is a Joint Arthroplasty?
Surgical reconstruction of articular surfaces w/ prosthetic components (elective).
Indications of a Joint Arthroplasty
Indication:
– Painthat is no longer responsive to conservative measures.
– Loss of function & motion.
Joint Arthroplasty PT to consider
• PT to consider:
– Preoperative history (medical & rehab management).
– Impairments & activity limitations.
– Surgical technique, prosthesis type, fixation method.
– Soft-tissue disruption & repair.
– Type of anesthesia.
What is a Hip Arthroplasty
- Replacement of the femoral head, the acetabulum, or both (most common) with prosthetic components.
- Due to severe hip arthritis, avascular necrosis, hip infection, or congenital disorders.
Hip Arthroplasty complications
Complications: fx, loosening, hematoma, heterotopic ossification, infection, dislocation, nerve injury, vascular damage, PE, MI, CVA, & limb-length discrepancy.
Hip Arthroplasty Cemented vs. Cementless
Hip Arthroplasty Surgical Approaches
Posterior: Dislocates w/ excessive flex, add, & int. rotation
Anterior: Dislocates w/ excessive ext, add, & ext. rotation
PT After Hip Arthroplasty
- Early postoperative functional mobility training, patient education about movement precautions during ADLs, and strengthening of hip musculature.
- Early mobilization: to prevent DVT
- All peripheral innervations should be examined
- Achieve safe functional mobility (i.e., bed mobility, transfers, and ambulation with AD).
• Educate the patient about hip dislocation precautions and activity restrictions.
– Movement of the operated hip can decrease postop pain
THA Common activity restrictions
– Avoid hip motion into prohibited ranges based on dislocation precautions dictated by the surgeon
– No sitting on low surfaces
– No sleeping on operative side
THA Posterolateral or Posterior Dislocation Precautions
- No hip flexion beyond 90 degrees
- No internal rotation past neutral
- No hip adduction past neutral
THA Anterolateral or Anterior Dislocation Precautions
- No hip extension and external rotation
- In some cases, no active hip abduction
THA Therapeutic Exercise
- Deep breathing
- antiembolism exercises (ankle pumps)
- PROM, AAROM, AROM
- Isometrics for glutes in supine
- Isometrics for quads supine
- strengthen noninvolved limbs
- aerobic exercise program
THA Transfer Training
- Use appropriate assistive device.
- Elevation of the bed can facilitate sit-to-stand transfers.
- Use proper height chair to facilitate transfers (hip precautions).
THA Gait Training
- Use appropriate AD.
- Avoid pivoting on the operated extremity (small steps when turning).
- Stairs training before discharge.
What is a Knee Arthroplasty
- Replacement of the articular surfaces with prosthetic implants.
- Indications: end-stage arthritis w/failed conservative measures.
Unicompartmental(UKA)
– Osteoarthritis or osteonecrosis confined to one compartment.
– Intact cruciate & collateral ligaments.
– Goal: preservation of the articular cartilage of the healthier compartment.
• Shorter recovery.
• Maintain the normal kinematics.
What is a Total Knee Arthroplasty (TKA)
Replacement of femoral condyles, the tibial articulating surface, and the dorsal surface of the patella.
TKA (Surgical techniques)
- Anterior midline incision (common)
- Parapatellar retinacular approaches
- Subvastusapproach
- Midvastusapproach
TKA Complications
Complications: thromboembolism, infection, joint instability, fractures, patellar tendon rupture, patellofemoral instability, component failure or loosening, and peroneal nerve injury.
TKA Patient Edu
•Patient education should include:
–Proper positioning
• Avoid the use of pillows directly under the knee. Why?
• Use of continuous passive motion (CPM), if ordered.
• Use of knee immobilizer, if ordered.
– Activity restrictions & WB limitations
– Therapeutic exercise program
TKA PT Postop
– Improving knee ROM & strength.
– Maximizing independence & safety with all mobility activities.
– PT to confirm restrictions on weight bearing or any activity/movement precautions with the surgeon.
TKA Strengthening exercises
– Isometric -> active-assisted -> active quadriceps & hamstring exercises through the full available ROM.
TKA Therapeutic exercises
• Deep breathing & antiembolism exercises (e.g., ankle pumps).
• PROM, AAROM, and AROM.
– Knee extension & flexion (e.g., heel slides)
- Isometrics for gluteal, quadriceps, & hamstring muscles in supine
- Straight-leg raises with isometric quad setting to ensure full knee-extension ROM
- Active exercises for hip abduction & hip adduction in supine or standing
Minimally Invasive Hip & Knee Arthroplasty
Minimally invasive surgery(MIS) refers to a variety of procedures & techniques that are used to decrease the amount of soft-tissue injury during surgery.
- significant clinical advantage of MIS over conventional surgery has notbeen supported in the literature.
What is a Shoulder Arthroplasty
• Indicated for pts w/ severe pain & limited ROM
• Total shoulder arthroplasty (TSA): replacing both the humeral & glenoid surfaces.
– Better outcomes (pain, ROM, function, and revision rates).
• Hemiarthroplasty: replacing only the humeral head.
THA Most Commonly used Prosthesis
Unconstrained type
Success of TSA is associated w/ …
– Accurate surgical placement of the prosthesis.
– Reconstructing the anatomic congruency of the joint.
– Proper orientation of the prosthetic components and preservation of structural length and muscular integrity.
TSA complications
- RC tear
- GH instability
- humeral fracture
TSA Common Precautions
- Avoid AROM
- No lifting, pushing, pulling
- No excessive shoulder extension and IR
- No excessive stretching ex) ER
- No weight beraing on TSA arm
- No driving for 3 weeks
TSA PT (pt edu)
- Use of ice for the management of pain & inflammation
- Proper positioning for comfort & procedure integrity
- Avoid lying on the involved shoulder
- Use a towel roll under the elbow when supine
- Bringing the hand to the mouth w/ the elbow held at the side of the trunk
- Therapeutic exercise program
Reverse Total Shoulder Arthroplasty (rTSA)
Indications:
– Rotator cuff arthropathy.
–Failed shoulder arthroplasty.
– Multiple failed rotator cuff repairs.
– Malunion of the tuberosity fracture.
• Center of rotation is more inferior & medial.
• Shoulder stability & function to rely heavily on the deltoid muscle.
• The new position of the deltoid allows it to elevate the arm in the presence of rotator cuff deficiency.
Spine Surgeries
- Fusion:
- Purpose- Stabilization of hypermobile or unstable joints
- Procedure- Use of internal fixation (e.g., Harrington rods)
- Laminectomy
- Purpose- Relieve pressure on neural structures
- Procedure- Removal of the lamina
- Discectomy
- Purpose- Excision of protruding or herniated interdiscalmaterial
- Procedure- Removal of a portion of or the entire intervertebral disk
- Corpectomy
- Purpose- Removal of part of the vertebral body
- Procedure- Use of special instruments to remove fragments of the vertebral body
- Total disk replacement
- Purpose- Replacement of deranged vertebral disk
- Procedure- Removal of damaged vertebra disk and replacement with artificial implant
Spinal surgery PT
- Early mobilization, education on proper body mechanics, & gait training
- Educate on movement precautions if applicable (see next slide)
- Coordinate treatment w/ the administration of pain medication
- Educate relaxation techniques or breathing exercises pain management
- The amount of time in sitting is limited to 30 minutes
- Check orders for brace or any restrictions on activity
- Braces when OOB, but applied in supine. Educate proper donning & doffing
Spinal Surgeries Precautions
Microdiscectomy/laminectomy
- 10-lb lifting precaution recommended by the surgeon.
- Mobilize as tolerated & avoidany excessively painful motions.
Fusion
- Minimizing bending & twisting with activity.
- Lifting restrictions per the surgeon.
- Use of braces or corsets if prescribed.
Anterior approach surgeries
- Splinting pillow to promote deep breathing & coughing.
- A corset may be prescribed to aid patient comfort with activity.
Kyphoplasty & Vertebroplasty
Vertebral augmentation is a surgical intervention used for progressive symptomatic osteoporotic vertebral compression fractures.
Kyphoplasty
golden standard for compression fracture restores height of the vertebrae. Insert inflatable balloon to allow placement of polymethylmethacrylate cement
Vertebroplasty
Injecting a polymethylmethacrylate (PMMA) cement into the vertebral space to stabilize the compression fracture.
PT after Vertebroplasty or Kyphoplasty
- immediately postoperatively is to increase functionalmobility.
- walkingprogram is the primary source of exercise immediately postoperatively.
- Consult with the surgeon for any activity restrictions
- Encourage the use a logroll technique when getting in and OOB
- Good body mechanics
What are Casts
A cast is a circumferential rigid external dressing used to maintainoptimal skeletal alignment of a stable fracture.
Cast Complication
•Complications:
– Nerve compression.
– Skin breakdown.
– Compartment syndrome.
What are External Fixators
Aluminum or titanium percutaneous pins or wires inserted into the long axis of a bone that connect externally to a frame.
Purpose of External Fixators
– Severely comminuted fractures
– Unstable pelvic fractures
– Fxs w/ severe soft-tissue or vascular injuries
– Significant bone loss
•Allows for early functional mobilization
What is Traction
A system of weights & pulleys restores the alignment of bone & muscle.
Most commonly used for femur fx(internal/external fixation has become the preferred method of stabilization).
