Orthopedic Conditions Flashcards
3 orthopedic etiology classification
Cumulative/repetitive stress
Acquired (genetic predisposition/disease process)
Traumatic injury or surgery
Why are there increased ortho injuries in older adults?
Decreased muscle mass, bone strength, visual acuity
Increased complications due to frailty, poor nutrition, decreased cognition, and polypharmacy
Types of hip surgery
Hip pinning, ORIF
Partial/THR to tx fractures, hip pain, damage, inflammation
10% risk of hip dislocation s/p THR
Hip sx approaches
Anterior
Lateral/anteriolateral
Posteriolatet
Anterior Approach
Decreased invasiveness, muscle sparing to reduce damage to muscles
Increasingly more popular, internervous, between tensor fascia lata abdominal sartorious superficially
Decreased risk of hip dislocation, avoids hip abductor
Increased wound complications
Difficult femoral exposure
Risks lateral femoral cutaneous nerve paresthesias
Increased rate of intraoperative fx
Lateral/anteriolateral hip approach
Minimally invasive, side approach, decreased vascular complications
Least commonly used, impairs hip abductors, interval exploited at tensor fascia lata and gluteus medius
Provocative positioning = hip extension and ER
Posteriolateral hip approach
Minimally invasive, increased ease of revision, extensile
Not in a true internervous plane, dissecting gluteal maximus and fascia lata, avoids hip abductors
Posterolateral hip precautions
No bending past 90*
No adduction LE, crossing midline
No rolling on unoperated side x6 weeks
Do not twist at trunk in standing
Sleep on back x 6 weeks
Provocative position = hip flexion, adduction, IR
Risk factors for THA dislocation
Prior hip sx
Advanced age
Drug/alcohol use
Neuromuscular disease
Malposition
Assessment of Hip
Pain at rest and activity
ADLs/IADL limitations
DVT risk
Cognition-delirium common issue, cognition deficits leads to more recovery secondary to compliance with weight bearing, precautions, and HEP
Understanding/ability to follow precautions
Support/access to equipment
Intervention for hip injuries
Education/training on fall prevention, precautions, caregiver training, self management, joint protection
Home modifications
Utilizing occupation based treatment such as ADL training, functional mobility training, compensatory strategies
Beneficial activities: walking, swimming, golf, cycling, dancing
Activities to avoid: football, handball, hockey, tennis, martial artd
Joint protection principles
Avoiding excessive loads, built up handles, carrying items with 2 hands
Self management
Empowers older adults to self manage aspects of hip injury = increased physical and psychosocial outcomes
Manage fatigue, dealing with emotions, communicating with MDs, goal setting, monitor change in health status
Shoulder
4 joints and 15 muscles
Clavicle, scapula, humerus
Joints: SC, AC, GH
Ligaments: joint capsule (group of ligaments that connect humerus to sock, clavicle to acromion, clavicle to scapula)
Bursa: closed space between2 moving surfaces with lubricating fluid inside, B/N RTC and outer muscle later (subdeltoid bursa)
RTC
Tendons and muscles (SITS), holds humeral head at GH joint
Shoulder dislocation
Caused by force that separates humeral head and glenoid process
Sx: pain, swelling, bump due to ball
Sublux humeral head migrates but slips back into place
Shoulder Separation
AC joint becomes separated when ligaments attached to clavicle are torn or partially torn away from shoulder back
Sudden forceful blow to shoulder or fall
Bursitis
Tendonitis/impingement syndrome cause inflammation at bursa sacs
Impingement syndrome
Caused by excessive squeezing or rubbing of the RTC and shoulder blade, pain is from inflamed bursa over RTC and/or inflammation of RTC tendons, calcium deposits in tendons
Can lead RTC tear
Sx: pain/stiffness, sudden pain reaching overhead, may spread to arm, pain may get better with rest
Tendinosis
RTC and/or bicep tendon become worn out and inflamed secondary to being pinched by surrounding structures
RTC tear
1+ tendons becoming inflamed by overuse, aging, falling on outstretched hand, collesion
Adhesive Capsulitis
Severely restricted movements secondary to lack of use due to pain, intermittent periods of use, inflammation and adhesions grow between surfaces decreasing synovial fluids, restricted space humeral head and shoulder capsule
Initially pain with movement, later stages pain subsides ROM restrictions remain, PROM/AROM affected
1st ER, asymmetrical scapular movement, tendon/spasms at traps, palpate upper trap
Shoulder injury dx
Xray images of tissue, bones, organs
MRI of organs structures, ligaments, muscles
CT xray sliced axial images of bones, muscles, fat, or organs
emg nerve function
US internal organs
Arthroscopy minimally invasive dx and tx procedure for joint conditions, degenerative/arthritic changes, tumors, and bone d/s
Conservative shoulder treatments
Modifying activities
Rest shoulder and manage pain
Increase strength and flexibility (exercise may be contraindicated with RTC tear or dislocation)
Most surgeries need immobilization for 4-6 weeks
Shoulder replacement surgery
Remove damaged areas of bone and replace with plastic/metal
Used to tx OA, RTC injuries, fx, RA, osteonecrosis
Anatomic total shoulder
Both ball and socket replaced
Reverse total shoulder
Reverse implants of ball and socket
Preferred in severe RTC damage
Partial shoulder replacement
Only replaces humeral head, only used for humeral head damage
Risk of shoulder replacement sx
Dislocation
Fx
Implant loosening
RTC fail (wear after total/partial, better with reversed)
Nerve Damage = numbness, weakness, pain
Blood clot
Infectiin
Assessment of shoulder injuries
-pain/ROM (some movements may be contraindicated, ie fx/sublux)
-assess at rest looking at position of scapula, muscle bulk, bony defects, and assymetry
-assess cervical spine
-specialized/provocative test (RTC maneuvers test integrity of infraspinatus, supraspinatus, subscapularis, and teres minor)
-ability to understand sling/movement restrictions
-health literacy, language barriers
-support/access to equipment ie reacher
Specialized shoulder test: supraspinatus test
Abduct BUE to 90* and 30* anteriorly with forward flexion, push up against manual resistance
Empty can test
Abduct BUE to 90* and 30* anteriorly with forward flexion, push downward
Positive with pain and weakness
Also used in impingement
Infraspinatus/ teres minor testing
Apply lateral resistance, flex forearms to 90* with palm supinated, ER
Positive with pain and weakness
Subscapularis testing/internal rotation lag sign
Bring arm behind back, passively lift off back, actively hold away from back, unable to hold means subscapularis tear
Lift off test
Test subscapularis
Ask pt to IR shoulder by bringing UE behind back with back of hand on back, actively move hand away from back against resistance
Pain with weakness test positive
Serratus anterior testing
Standing lush up against wall, positive if winging of scapula noted
Shoulder Impingement Assessment
Supraspinatus inflamed secondary to repetitive trauma to subacromial portion, pain at night, weakness overhead, tenderness at anterior joint line when palpating and IR
Test: Neers, empty can, Hawkins kennedy
Neer test
Probate forearm, passively flex arm until overhead reducing subacromial space
Positive if painful
Hawkins Kennedy Test
Elbow and shoulder at 90* flexion, examiner supports arm at elbow, passively IR and cross body adduction
Positive with pain
Bicep Tedinopathy
Inflammation or degeneration of long bicep head causes anterior shoulder pain
Seen with RTC tear or impingements
Speeds Test
Extend elbow and supinate forearm, flex shoulder against resistance, examiner palpates anterior joint line
Positive with pain for bicep tendinopathy
Yergason’s test
Flex elbow at 90* partially pronate arm (neutral), ask to supinate against resistance, examiner palpates at origin of bicep tendon
Positive with pain
AC Joint pain
C/O pain localized on AC
Pain at night in sidelying
Assessed with palpation
Crepitus, step off sensation means AC separation
AC joint pain: scarf test
Place hand of the affected side on contralateral shoulder, push at elbow for cross body adduction and palpate AC joint
Positive with pain or crepitus
AC joint disease: painful arc test
Abducted shoulder to 180* , pain at 150 to 180* is positive AC joint disease
Shoulder instability
C/o shoulder pain with giving way sensation, humeral head partially/completely leaving glenoid fossa
Congenital hyperlaxity of capsule/ligaments
Acquired after traumatic injury
Sulci Test
Shoulder instability
Apply downward pressure on humerus by pulling at wrist and observing lateral aspect at deltoid region, if sulcus appears it is positive
Apprehension and relocation test
Shoulder instability
Preferably done in supine
90* elbow flexion and abducts shoulder to 90*
Examiner applies downward pressure with one hand at wrist other hand behind shoulder
If dislocates or positive with pain or discomfort
Apply downward pressure pressure on anterior aspect of shoulder, pain/apprehension disappear if instability present
Labral tears/ SLAP lesion
Glenoid labrum is ring of cartilage around glenoid fossa, most commonly damaged at superior portions including part of bicep tendon
Athletes with repetitive overhead
O’Brian Test
Labral tears
Pt flexes shoulder to 90* adducting 10* ask pt to bring arm upward against resistance
Positive with pain
Crank’s Test
Labral tear
Passively flex elbow at 90* and abduct shoulder to 90*, one hand on shoulder and other on elbow
IR then ER
Positive with any pain or metallic sound
Adhesive Capsulitis Intervention
ROM exercises, activity-based tasks incorporating ROM, joint mobilizations and steroids
Some promising evidence show benefits of exercise beyond pain threshold with end range maximizing protocol and therapeutic exercise
Shoulder fx intervention
Inconclusive evidence of use of therex
Strong support of ROM for nondisplaced humeral fx required to wear sling/immobilizers
RTC tear intervention
Moderate support of conservative tx (joint mobs, ROM, progressive strengthening)
Post surgical mgmt with rehab such as progressive tendon forces and continuous passive motion
General shoulder pain intervention
Resistive exercise increase function and decrease pain
Shoulder conditioning program when combined with joint mobility
Moderate support for magnetic therapeutic devices and biofeedback
Subacromial impingement intervention
Therapeutic exercise and activity based tasks
PAMs
Joint mobilization
Steroid Injections
Strong evidence of taping for short term decreased pain
Complex fractures
Bones broken with surrounding soft tissue severely traumatized or comorbdities
Types of fractures: stable
broken ends line up/barely out of place
Types of fractures: open/compound
Skin may be pierced by bone or blow that breaks skin at time of fx, bone may or may not be visible
Types of fractures: transverse fx
Horizontal fx line
Types of fractures: oblique
Angled pattern fx
Fracture types: comminuted
Bone shatters to 3+ pieces
General medical
Tx for fractures
Cast immobilization, functional cast/brace (controlled movement of nearby joints), ex fix, ORIF
OT assessment of complex fx
Cognitive screening for adherence to restriction, delirium post sx
Pain
Psychosocial needs
Ability to follow restrictions
Access to AE/support
ADL/IADL
OT intervention for fractures
Occupation based activity to increase motivation while attending to client factors without direct focus
Decreased pain and disengagement
Elbow fracture intervention
ROM exercise s/p immobilization
Hip fx intervention
Multi-disciplinary approach focused on early mobilization, home modifications, education/training, fall prevention, ergonomics, safe pt handling for caregivers, functional mobility
Shoulder fx interventions
Rom exercises for nondisplaced humeral fx requiring sling/immobilizer following sx
Wrist and hand fx intervention
Moderate evidence for strength training non-affected extremity
Wrist early continued exercise/ROM, boxer fx (5th metacarpal =splinting and buddy taping)
