Orthopaedic Lower limb Flashcards
Contraindications to “hip arthroscopy”
to do this, traction of the hip is necessary
- Obesity
- Osteoporosis
- Arthritis without mechanical symptoms
- Hip dysplasia (misalignment of the hip joint = loose)
Post-opereration of “hip arthroscopy”
LOS (Legth of stay) …. _____ in hospital
Overnight
discharged with crutches
Height of the crutches should be from the _______ / _________ to the bottom of the heel, and ensure there are stoppers in the end of the crutches.
wrist crease / greater trochanter
Stairs with crutches: how to go upsrairs
GAS
Good leg => Affected leg => Sticks/crutches
Stairs with crutches: how to go downsrairs
SAG
Sticks/crutches => Affected leg => Good leg
why have a “hip joint replacement”?
and when?
- Pain with activity
- Pain at rest
- Loss of movement
- Loss of strength
- Limp
- when can’t sleep at night (lying on the OA side)
What is involved in “hip joint replacement”? (the implants)
4 components
- Cup
- Cup liner
- Stem
- Ball
(materials: metal on plastic > ceramic on ceramic, metal on metal … failure is now defined on a cellular level)
THJR surgical approach: Posterior - has risk of posterior instability (dislocation) when movement occurs in which direction?
flexion, IR and adduction
avoid: Crossing legs
THJR surgical approach: Anterior - has risk of Anterior instability (dislocation) when movement occurs in which direction?
extension, ER and adduction
How much does it cost for THJR?
$25.000 - 30.000 (not iincluding rehab after discharge)
In the year of 2000, there were an esstimated __ million osteoporotic fractures world wide of which ___ million were at the hip.
9 million osteoporotic fracture
1.6 million hip
where is the incision site for THJR?
over the greater trochanter
THJR surgery takes about __ - __hrs; lose blood about ___ - ___mls; incidence of blood transfusion is approx ___ %; post-op Anaemia lasts approx __ - __ weeks; LOS is about __ - __ days
- 1 - 2hrs
- 400 - 600mls
- 25%
- 4 - 6 weeks
- 3 - 7days
Discharge (after THJR) when able to
- transfer independently
- walk safely on crutches
- climb and descend stairs
- wound healing and temperature normal (medically stable)
For Total Hip joint arthroplasty, Day 0 post-op PT is better than Day 1 post-op in terms of LOS. T or F?
(Chen et al, 2012)
True in this study but … (POD 0: 2.8days, POD 1: 3.7days)
There were several limitation in this study:
-Hip and Knee px were combined
-intervention not clearly described
-25 px seen by PT Day 0 vs 111 px Day1
[*not all px medically stable post-op Day 0]
-whether PT were experienced or not wasn’t documented
-Adverse event not recorded
Post-op PT treatment for THJR
- Education: hip precautions, driving (cushion under thigh), sitting (seat back so that hip is not so flexed)
- Mobilise
- Exercise programme (work on glutes)
Rehabilitation timeline: 2 x crutches - __ - __ weeks; 1 x crutches: __ - __ weeks; independent normal activity: __ - __ weeks; Return to work: __ - __weeks
- 2 - 8 weeks
- 2 - 12 weeks
- 8 - 12 weeks
- 6 - 8 weeks (dependent on type of work)
THJR: Risk and complication rates are approx __ %; Dislocation risk at its highest in the first __ weeks after surgery
- 5 %
- 6 weeks
Blood clot or DVT can occur in up to __ % of ppl undergoing THJR, and risk can be reduced by _________ , use of __________ and _______ for 6 weeks.
- 30%
- early mobilisation
- elastic stocking
- Aspirin
Type of surgery: Extracapsular (trochanteric) fracture - ________; Displaced Intracapsular fracture - _________; Undisplaced Intracapsular fracture - _______.
- Dynamic hip screw (facilitate bone healing; allow movement)
- Total arthroplasty
- Screws
What is “Hemi-arthroplasty”?
-replaces only the ball portion of the hip joint, not the socket portion.
(In a total hip replacement, the socket is also replaced.)
There is limited literature on acute care PT for hip fracture; however, focus is on ____________ in acute care to restore independent returen to ADLs
early mobility
transfer training, ambulation training, assistive device training, ROM/strengthening exs
What is the mortality rate of Px who have a hip fracture in NZ?
27% px died within 12 months of their injury
NZ hospitals 1999-2000
What is the risk associated with a displaced intracapsular fractured NOF (neck of femur)?
avascular necrosis of point head of the femur, mainly due to the poor blood supply to that area (disrupt the blood supply to the cartilage margins or from the circumflex femoral arteries)
Why are older females at risk of hip fracture?
- the loss of bone density that occurs after menopause (osteoporotic) (loss of hormone = oestrogen)
- women live longer than men and are exposed longer periods to a reduced bone density and other risk factors for fractures
If Px is medically stable & can hold the unaffected leg up in the air while in bed for about 10sec (strong enough to hold themselves) you do
- assisted AROM ( support le, so that the px’s heel doesn’t slide on bed [protect skin])
- stand with crutches (bed up to 45 degrees [don’t want excessive hip flexion])
40% of women who had fracture will not regain their previous level of independence. T ot F?
True
Px’s WB status is dependent on 3 things (affects rehab)
- quality of the fixation
- type of fracture
- quality of bone stock (older ppl poor healing)
Surgical management of “Shaft of Femur #”
Intramedullary nail
How would you grade the degenerative changes on X-ray?
Kellgren Lawrence Scale –
•Grade I: doubtful narrowing of joint space and possible osteophytic lipping
•Grade II: definite osteophytes, definite narrowing of joint space
•Grade III: moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour
•Grade IV: large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour
3 components of TKJR (implant)
- Femoral component
- Plastic spacer
- Tibial component
TKJR procedure: An incision is made on the anterior aspect of the knee joint. The _____ is always sacrificed (removed); the ____ may be removed; The patella may be resurfaced.
- ACL (no longer needed, as the design of the artificial implant will provide the stability)
- PCL (as above)
Name two other types arthritis that may require a patient to undergo a total knee arthroplasty
- Rheumatoid arthritis.
- Post-traumatic arthritis. This can follow a serious knee injury. Fractures of the bones surrounding the knee or tears of the knee ligaments may damage the articular cartilage over time, causing knee pain and limiting knee function.
What are some of the post-operative complications that can arise as a result of TKJR?
- Blood clots (in the leg veins are the most common complication of knee replacement surgery. (DVT) => elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin the blood.)
- Implant problems (surfaces may wear down and the components may loosen.)
- Continued pain (A small number of patients continue to have pain after a knee replacement. This complication is rare, however, and the vast majority of patients experience excellent pain relief following knee replacement.)
- Neurovascular injury.
What is INR Tests (International Normalized Ratio) ?
a test of blood clotting, which is primarily used to monitor warfarin therapy - (11-13 seconds) – measures how well the body clots blood
What is likely to be the WB status on TKJR POD 1?
should be tolerated (pain controlled by PCA)
When is it likely that the catheter and IV luffer removed?
Day 2 (within 24-28hrs)
TKJR Discharge plan
-3-5 days depending on progress
Goals prior to discharge:
• Independently toilet & shower
• Walking and getting in and out of bed on your own
• 90 degrees knee flexion
• Able to walk up and downstairs with crutches
• Able to ride exer-cycle
TKJR is designed for running, jumping, dancing, tennis.
T or F?
False
it is designed for every day activities … walking, golf, tramping; not designed for impact loading activities
After TKJR, there will be no pain. T or F?
False
TKJR will get rid of most but not necessarily all of the pain
What ROM do you need to climb the stairs? sit in a chair without using hands? tie shoelaces while seated?
(Fitzsimmons, 2010)
climb the stairs - 83 degrees
sit in a chair without using hands - 90 degrees
tie shoelaces while seated - 103 degrees
Rehabilitation: aiming to get 90 degrees knee flexion by ? 115 degrees by?
- 3 - 5 days (before discharge)
- end of 3months
apply CPM if indicated by surgeon POD 1 (withing the first 24 hrs) what is CPM?
Continuous passive motion … decrease swelling, increase blood flow, prevent knee stiffness
Ppl with OA will lose the strength of quadriceps by ___ - ___% after TKJR, and takes a year to recover.
20 - 40%
so pre-op, try to strengthen the quads
6MWT a good test to measure quadriceps strength. T or F?
True
thre is a high correlation between quadriceps strength and 6 MWT
What factors may affect TKJR outcome?
- age
- BMI
- Quads strength
- Pre-op pain and function
- ROM
- Deformity
- degree of arthritis
- Gender
What is “Ondansetron” used for?
Is used for post-operative nausea and vomiting. Well tolerated for patients >65, given orally an hour before anesthesia (16mg)
Contraindicated when combined with morphine due to severe hypotension and loss of consciousness
When can a person start to drive post TKJR?
generally in about 5 days (depending on L or R knee; R knee may take longer to start to drive as reflex will decrease); therefore, should get driving clearance from surgeon
How would you reply if he questions you as to whether his new knee will set the metal detectors off at the airport?
The sensitivity of metal detectors varies and it is unlikely that your prosthesis will cause an alarm. You should carry a medic alert card indicating you have an artificial joint, just in case.
Is intensive rehabilitation for total knee arthroplasty after discharge from hospital beneficial?
Yes, intensive rehab resulted in longer distances walked by the treatment group immediately after the program, 2 months and 8 months down the track. It was also found that there was less pain, stiffness and difficulty performing daily activities immediately after and 2 months later.
Discuss the mechanism of injury and gender commonly associated with a femoral shaft fracture
Greatest incidence is in young men (<40) and is sustained in high energy trauma accidents (e.g. car accidents, sporting accidents, pedestrian struck by a car and motorcycle accidents, falls from a height).
Those older than 35 tend to sustain proximal femur fractures due to low-moderate energy trauma, e.g falls
Femur fractures are normally treated operatively using __________. This procedure is known to reduce morbidity, blood loss and risk of infection and is known to take about ________. During this procedure, a specially designed metal rod is inserted into the marrow canal of the femur.
- intramedullary nailing
- 50 minutes
The estimated blood loss for a closed fracture of the femur is _____; therefore, fractures of the femur should be considered a potential cause of _________.
- 1000-1500 ml. (THJR: 400 - 600ml)\
- hypovolaemic shock (results when you lose more than 20% (one-fifth) of your body’s blood or fluid supply …. The average adult has a blood volume of roughly 5 liters (=5000ml) or one-eleventh of the body weight.)
decreased Haemoglobin level and effect on post-operative mobility:
The decision on whether to mobilize anemic patients is based on whether they are symptomatic.
-Shortness of breath – from reduced perfusion matching as less haemoglobin for oxygen to bind to.
-Tachicardia
-Increased RR
(norm men: 130-180 g/L women: 115-165 g/l [or 12-18g/dl])
[to mobilise >7 g/dl]
Likely WB status for a px with spiral fracture of the mid shaft of femur
10 days of TWB (touch weight bearing)
POD 1, PT interventions/education for spiral fracture of the mid shaft of femur might consist of
-Transfer training
-Ambulation training
(Assistive device prescription and training)
-ROM/strengthening exs (bed/chair/stand/step)
-Focus is on early mobility in acute care to restore independent return to ADLs
Ankle fracture: Weber Classification of Ankle Fractures
- Type A: # fibula distal to the syndesmosis
- Type B: at the level of the tibial plafond
- Type C: above the syndesmosis with disruption of sydesmosis
Treatment of ankle fracture: Weber Classification of Ankle Fractures Type A, B, C
Type A: Moon boot
Type B & C: operate + plaster (to decrease swelling => 10days later replaced with a fibreglass cast) NWB for 6 weeks
________ are commonly placed around a broken bone soon after the injury, which can be molded to the patient to allow the swelling to go down. After a week to 10 days, _________are usually fitted when the swelling has subsided, and then after that has been removed ________may be applied.
- Plaster casts
- Fibreglass casts
- Moon boot
