Orthopaedic Patients Flashcards
What history do we need to take about a possible orthopaedic patient?
Duration of lameness
Onset - acute/gradual? Any obvious triggers?
Progression - static? Deteriorating/improving?
Continuous / intermittent?
Effect of exercise/rest
Effect of ground surface e.g. grass vs concrete?
Which limb(s)?
Occupation?
Concurrent problems?
What can we observe about the stance of orthopaedic patients and what do these indicate?
Asymmetry - paw taking most weight is flatter/harder to lift up when standing
Kyphosis - shifting weight from pelvic to thoracic limbs
Scoliosis - shifting weight to one side
Frequent sitting - pelvic limb lameness
Frequent lying down - thoracic limb lameness
Angular limb deformities
What can we evaluate about a patient’s gait?
Stride length
Head nodding
Scuffing of nails
Ataxia, paraparesis, paraplegia (signs of neurological disease!)
Circumduction with stifle pain
Lateral sway/bunny hopping with hip pain
Head bobbing (sink to the sound side!) with thoracic limb lameness
What can we palpate when standing during an orthopaedic examination?
Asymmetry
Swelling
Muscle atrophy
Joint enlargement
Abnormal conformation
What can we examine when in lateral recumbency during an orthopaedic exam?
Joints - SPIRM (swelling/joint effusion, pain, instability, range of motion, manipulation)
Limbs - SAP (swelling, muscle atrophy, pain)
What tests can we perform to test the integrity of the cranial cruciate ligament?
Cranial draw test
Tibial compression test (tibial thrust)
How can we test for hip laxity/dysplasia?
Ortolani test
What further diagnostics can we perform once we have localised lameness?
Imaging - radiography, ultrasounds, CT/MRI
EMG
Arthrocentesis
What are the indications for arthrocentesis?
Persistent/cyclical fever
Lameness localised to a joint
How do we prepare for arthrocentesis?
Patient anaesthetised/sedated in lateral recumbency
Strict aseptic prep
Equipment - sterile hypodermic and spinal needles, 2.5-5ml syringes
How do we carry out arthrocentesis?
Use bony landmarks to guide needle
Do not move needle whilst aspirating
Blood aspirated from soft tissues - iatrogenic contamination streaks vs real change of pink fluid
What do we do with fluid aspirated during arthrocentesis?
Small volume - make a smear
Large volume - EDTA cytology, plain pot proteins, culture if infection possible
What does normal synovial fluid look like?
Viscous
Clear
Small volume
Describe how to take a sample from the scapulohumeral joint.
Gentle traction by assistant to open up joint
Needle inserted distal to acromion and directed perpendicular, slightly dorsal and medial
Describe how to take a sample from the cubital (elbow) joint.
Flex elbow to 45 degrees
Needle started from point level and perpendicular to epicondylar crest alongside anconeal process
Describe how to take a sample from the carpal joint.
Flex carpus to 90 degrees
Insert needle perpendicular to skin
Aspirate all joints
Avoid neurovascular bundle
Describe how to take a sample from the MCP/MTP/IP joints.
Use needle with short bevel (spinal needle) to allow entire tip of needle to be within joint and avoid contamination
Describe how to take a sample from the coxofemoral joint.
Hip abducted and internally rotated to open joint
Needle inserted from craniodorsal to greater trochanter, angled medially and caudoventrally
Describe how to take a sample from the stifle joint.
Stifle partially flexed
Needle inserted lateral to patella ligament, midway between patella and tibial tuberosity, angled caudomedially until it hits bone
Describe how to take a sample from the femoropatella joint.
Stifle extended
Needle inserted at angle between patella and femur towards proximal
Describe how to take a sample from the tarsal joint.
Joint partially flexed
Palpate and manipulate joint to feel the articulation
Angle needle perpendicular to skin into joint
Fluid obtained from craniolateral or caudolateral aspect of joint
What are the stages of healing?
Post-op (24-48hrs)
Regeneration phase (day 5 - 3 weeks+)
Remodelling phase (6 weeks - 1 year)
Bone healing occurs in regeneration and remodelling phases
Describe care for patients in the post-op stage of healing.
Consider pain, oedema, healing tissues
Analgesia
Cryotherapy
Rest
Easy movement only (non-weightbearing/supported weightbearing)
Describe care for patients in the regeneration phase of healing.
Still fragile, new collagen fibres and bone calluses forming
Controlled lead exercise
Passive/active ROM exercise
Describe the remodelling stage of healing.
Consolidation = cellular to fibrous tissue, strength and alignment
Maturation = vascularity returns and metabolic rate returns to normal
Introduce active exercise e.g. hydrotherapy
How can we manage patients with cruciate disease?
Surgery = TPLO/TTA and lateral suture
Obesity common factor - weight-loss programme
Hydrotherapy can be used but must be stopped immediately post-op when stitches in place
Active exercise
What factors affect what rehabilitation we offer to fracture patients?
Degree of fracture(s) and site
Pre-existing disease
Degree of soft tissue damage
Presence of open wounds
How can we rehabilitate fracture patients?
Adequate analgesia
Restricted exercise
Cold compress
Minimal PROM exercises
Supportive dressing?
How can we nurse patients with external fixators?
Can be difficult to apply treatments!
Cold compress parts of limb
Massage/PROM
Active exercises useful due to reluctance to flex/extend limbs esp. distal limb
How can we nurse patients who have had joint surgery?
Cryotherapy immediately post-op
Pressure dressing 12-24hrs
PROM/massage
Adequate analgesia
What care should we provide for THR/elbow/knee replacement patients?
Walked slowly in controlled manner
Kept settled and calm - consider mild sedation
Clear signage - must be handled by experienced staff
How can we rehabilitate patients with tendon injuries?
PROM after 3 weeks’ rest
Exercise limited for 3-6 weeks
Tendon still not full strength at 6 weeks!
What are the main considerations around rehabilitation?
Return to function (weightbearing, ROM, muscle-building), minimise stress on surgical site
Requires full understanding of condition
Subjective vs objective
Continually assessed and altered to suit stages of healing
Multimodal analgesia
Describe cryotherapy.
Early application effective - initial 72hr period
Vasoconstriction
Analgesic effect
Reduced tissue oedema
15mins 3x daily ideal
Describe heat/warm therapy.
Temp. of 46 degrees C sufficient
Care - reduced sensation, risk of burns!
Before exercise = increased blood flow = increased elasticity
Describe the benefits of massage.
Increased blood flow = improved oxygen supply = aid removal of waste products = helps muscle work more efficiently, alleviates pain
Venous and lymphatic return
Mobilises adhesions
Prepares muscles for exercise and aids recovery after exercise
List some assisted physiotherapy exercises.
Assisted standing
Weight shifting
Side bending, cervical flexion/extension
Balance boards/swiss balls
Muscle stimulation
List some active physiotherapy exercises.
Slow walks
Stair climbing
Sit to stand, down to sit
Treadmill walking
