Orthopedics

Question 1

What are the 3 Main group Hip fractures?

Answer 1

Proximal femur,distal femur and femoral shaft

Question 2

What classification is given to the proximal fractures?

Answer 2

The garden classification

Question 3

What is the garden classification Type 1?

Answer 3

It is where there is low complication rate, there is also minimal interference with blood flow and there’s no requirement of reduction but fixation with multiple screws and pins and plates

Also the fracture is incomplete and undisplaced and the femoral head is titled in a vagus position

Question 4

What is the garden classification Type 2 ?

Answer 4

It’s the same as the type one but the only difference is that it is a complete displaced fracture

Question 5

What is the garden classification Type 3?

Answer 5

It is a complete and displaced fractures with some continuation between fractures ends

Question 6

What is the garden classification Type 4?

Answer 6

It is a complete and displaced fracture with no continuation of fracture ends also has a high complication rate which could lead to non union and avascular necrosis and loss of blood supply to femoral head

Question 7

What treatment is done to a type 3 graden fracture?

Answer 7

Reduction and internal fixation with sliding screw plate and pins and if there’s manipulative Reduction then treat as for type 4

Question 8

What treatment is done with type 4 garden fracture?

Answer 8

In young fit patients- Reduction and internal fixation with a sliding screw plate and pins and if manipulative reduction fails the ORIF is to be done

In older patients- There should have surgery done but rather hemi athroplasty( Moores Prosthesis) because there’s a high rate of non union

Question 9

What are the indication for Moores Prosthesis?

Answer 9

In patients with Rheumatoid disease and minimal athrutis of hip
And also patients with failure of closed reduction of a displaced intracapsular fracture

Question 10

What are the diffrent types of surgical approaches that may be used to insert hemi athroplasty?

Answer 10

Posterior approach
Anterior approach
Lateral approach

Question 11

What is the Posterior approach?

Answer 11

When a hip is dislocated through flexion,addiction and internal rotation
The soft tissue(fascia,gluteals and capsule are exposed and vulnerable to the stress of sitting
So abduction pillow is placed between legs to prevent re-dislocation

Question 12

What are the physiotherapy precautions for the posterior approach?

Answer 12

No combined hip flexion,addiction and internal rotation exercises in bed
Also slouch sitting and high sitting
Once drains are removed patient can feWB and fit TED stockings may be worn
Also no squatting 6 months after post opp

Question 13

What is the physiotherapy precautions for lateral approach?

Answer 13

Legs should be kept in a neural position avoid adduction and abduction
Also hip and knee flexion is to be avoided
Legs may not be crossed

Question 14

What is the anterior approach?

Answer 14

Patient is nursed in half lying position
And this happened due to extention,external rotation and abduction and anterior muscles are exposed and hip is vulnerable

Question 15

What are the physiotherapy precautions with the anterior approach?

Answer 15

Avoid excessive hip extension when patient can walk
Also avoid bridging with bed pan but rather use sitting positing and lifting with monkey chains

Question 16

What are extracapsular fractures?

Answer 16

So this is a common injury that occurs in the elderly usually Mal union occurs and not non union because the blood supply to he fragments is not disturbed and most complications are those related to prolonged immobilization

Question 17

What treatment is done on extracpsular fractures?

Answer 17

Internal fixation to prevent Mal union and to ensure early mobilization and optimum fixation with Zimmer screw plate with compression

Question 18

What are physiotherapy precautions with those who have extracapular fractures?

Answer 18

Avoid abduction beyond neural
Avoid excessive rotation-internal or external
If able to walk commence with PWB on walking frame (2nd post opp)
When walking turn towards the affected leg

Question 19

What is a subtrochanteric fracture?

Answer 19

Usually a fracture that happens below the lesser trachanter cause by major trauma in young adults
Also severe local soft tissue injury to be expected

Question 20

What is the treatment for a subtrachanteric?

Answer 20

It’s non operative but usually during bed rest patient tends to go into flexion and abduction because of pull on glute medius and minimus muscles along with the ilopsoas so a Thomas splint or skeletal traction
No sitting after gumming but half sitting can be done
No hip flexion there will be steering strain at fracture site which delays union
ORIF to prevent prolonged bed rest and Mal union

Question 21

What are the physiotherapy precautions for subtrochentic fractures?

Answer 21

Assessment
Bed exercises keep heel on bed for knee and hip flexion
Avoid straight leg raising until.theres knee locking at quadriceps
When walking caution patient when getting out of bed

Question 22

What are the causes of femoral shaft fractures?

Answer 22

Falling with foot anchored-spiral fracture
Direct blow -transverse fractures
Gunshot wound-comminuted fractures

Question 23

What is the management for femoral shaft fractures?

Answer 23

Non operative in infants under 15kg
Gallows or Bryant traction may be used
Union is clinically obvious when baby turns to prone

Children over 2 years
Thomas splint and balanced skin traction and fracture is soundly united after 6-Weeks
Rehab will take another 3-4 weeks

In adults
Skeletal traction a Denham pin is used and inserted proximal tibia on lateral aspect to prevent injuring peroneal nerve
Thomas splint is used with balanced or fixed traction
When fracture is healed 6 weeks after leg can be placed in a cast with crutches

Question 24

What are intra-medullary implants ?

Answer 24

AO nails,Multiple Enders nails,Kutcher nails

Question 25

What is the physiotherapy management for people with inter medullary implants?

Answer 25

Stability both longitudinally and laterally
Post operative routine is dependent on fracture stability e.g when there’s a bicortical contact at fracture site the patient can FWB
When there is longitudinal stability but insufficient lateral stability e.g fractures with butterfly fragments a cast brace may be used for additional support and patient should PWB
Commuinited fractures should stay on traction for 3 weeks and fixed with an interlocking nail to avoid major shortening and should FEWB/NWB

Question 26

What are supracondylar fracture ?

Answer 26

Due to the position of the Gastrocnemius muscle the distal fragment of femur is pulled posterior so a Thomas splint is not adequate so Pearson knew piece must be fitted and knee flexed at 40 degrees and releasing pull of gastronemii

Question 27

What are the physiotherapy precautions of the supracondylar fracture?

Answer 27

No strong dorsi or plantar flexion
No dorsiflexion with knee extension

Question 28

What is the ORIF for supracondylar fractures?

Answer 28

Due to stiffness at the knee there’s a difficulty obtaining reduction so internal fixation is recommended a blade plate or 90 degree Zimmer

Also for Communited fractures then an interlocking nail can be used and added protection of a cast brace

Question 29

What is an intracondylar fracture and it’s treatment?

Answer 29

When there’s joint incongruity and there might be a risk of osteoarthritis
And ORIF AND Early mobilization

Question 30

What are condylar fractures and their treatment?

Answer 30

Same with intracondylar but there’s a risk of avascular necrosis
And can be treated with ORIF and screws

Question 31

What is the physiotherapy management for condylar and intracondylar fractures?

Answer 31

Early movement done by the patient
Bed exercises where heel is kept on bed for hip and knee flexion
Teach patient to roll in prone by pinching legs together by knees and ankles and supporting the injured site rolling towards unaffected

Walking -When patient can get 90 degrees knee flexion and knee quad looking then PWB otherwise support foot of unaffected leg when getting out of bed

Question 32

What are the complications of a fracture of the femur?

Answer 32

Non union
Mal union
Knee stiffness because the quadriceps are damaged and there are adhesions from fracture site

Question 33

What are the complications of Rx of femur fractures?

Answer 33

Skin traction-excorition and blistering may occur when more than 5kgs is applied
Skeletal traction-pin track is usually trouble free when place at upper tibia and Denham is ideal
Open reduction-open reduction and internal fixation can cause infection