PAST PAPERS: JUNE 2016

Question 1

SECTION C
QUESTION 1:
A 30 y/o male patient with a supracondylar fracture of the left femur is referred to you for treatment. He is in his first week of skeletal traction.
1.1. explain the contraindications and precautions to be observed during the physiotherapy management of this patient? (6)
1.2. outline a typical physiotherapy treatment of this patient’s left leg from the fourth week of skeletal traction (8)

Answer 1

1.1. No active or passive knee movement for ±3/52.
No resisted plantar flexion.
No stretches into dorsiflexion for ±3/52.
No combined knee extension with dorsiflexion while on traction.
General contra-indications.

1.2. These fractures are difficult to treat conservatively as the distal fragment is very mobile
Conservative Treatment
Skeletal traction through the tibial tuberosity or distal femur (6-8/52). The knee must remain flexed to about 40° to reduce the pull of gastrocnemius and allow correction of the deformity. Perform some isom. scar massage and heat. Once off traction, the patient is mobilized PWB with a brace for 6-8/52 and the FWB with a brace for another 6/52.
✓Check line of pull is parallel to shaft of fractured bone
✓Check that rope and weights are hanging freely
✓Check pin sites for signs of sepsis
✓Check that counter traction is applied if necessary
✓Check that the position of the patient relative to the traction is
correct
✓Check pressure areas
✓Check for all complications of immobilization. A patient on traction
is subject to all the usual complications of immobilization such as
DVT, chest complications, general deconditioning etc.
treatment at 4 weeks
Sitting up in bed SOEOB
Quiet activities such as crafts, board games, and television watching
Moving enough to be bathed and have your hygiene needs addressed=Increase bed mobility

Question 2

QUESTION 2

2.1. discuss the goals of rehabilitation during phase 1 after total shoulder arthroplasty. (13)

Answer 2

total shoulder arthroplasty
-✓sling for 4/52
-✓deltopectoral approach
-✓overall recovery 1-2 years
✓-passive=active-stretching- strengthening
-✓every patient is different. Progress according to patient funtional requirements and presentation
-✓avoid combination of ER and Abd above 80
-✓patient education is important

✓Phase I- immediate post surgical (0-4 weeks) goals:
Goals:
• Allow healing of soft tissue and maintain integrity of replaced joint
• PROM of shoulder
• AROM of elbow/wrist/hand
• Scapula setting and posture
• Diminish pain and inflammation
• Prevent muscular inhibition
• Independent with ADL (dressing, bathing, etc.) with modifications.
• HEP
• Cryotherapy (continious first 72h, then 5 x per day 20min)
• Patient educations and Precautions

Question 3

QUESTION 3
Mrs Hadebe is 66 years old and was involved in a car accident. She sustained an open comminuted fracture of her left tibia and fibula. the surgeon have managed this fracture with an external fixator. She also has fractured ribs and fractured right clavicle.
3.1. Discuss the advantages of using an external fixation fro Mrs Hadebe. (11)
3.2. How would you monitor the leg hygiene around the pin sites? (2)

Answer 3

advantages of external fixation
✓severe soft tissue injury and infected fracture sites-allows easy access for the wound cleaning and dressing, also minimized further soft tissue damage during surgery.
✓comminuted fractures can be held in goos alignment
✓applirf quickly, therefore useful in polytrauma patients
✓vascular adn nerve damage can also be repaired quickly
✓there is minimal interference with adjacent joints
✓the frame can be adjusted later to improve alignment
✓allows for early mobilization of limb and patient

3.2. ✓severe soft tissue injury and infected fracture sites-allows easy access for the wound cleaning and dressing, also minimized further soft tissue damage during surgery.

Question 4

SECTION D: ESSAY
QUESTION 3

Mr Richards is a 50 y/o male and leads am active lifestyle. He is married, has two young children and he owns an agricultural business. He is currently walks with a limp and has gluteal muscle weakness. Mr Richards was recently diagnosed with osteoarthiritis of the right hip. He has been referred to you because he will be having a total hip replacement, with a lateral approach. the prosthetic will be uncemented.

Discuss the physiotherapy management of Mr Richards from when you see him pre-operatively until six weeks post-surgery (50)

Answer 4

Osteoarthritis is the degeneration of the bone cartilage and the underlying bone itself, usually affects the middle aged and onwards. it is managed through physiotherapy and total hip replacement surgery (where Total Hip Replacement – Head of femur is replaced and the Acetabulum is lined with a synthetic joint surface), in this case with a lateral approach .

OA can be classified into PRIMARY "wear and tear” osteoarthritis,15%, affecting mostly post-menopausal women. SECONDARY which has a specific cause, such as an injury, an effect of obesity, genetics, inactivity, or other diseases, 85%, Dependent on load, Endemic, Mainly affects the elderly
 Due to wear and tear
 With genetic predisposition
 Its progressive
 Both destructive and progressive
 Not curable but manageable

Predisposing factors of Secondary Osteoarthritis
 Abnormal mechanical forces
 Increased bone rigidity
 Chrondrocyte dysfunction
 (Chrondrocyte: a cell which has secreted the matrix of cartilage and become embedded in it)

Causes of secondary osteoarthritis
 Congenital/developmental
 Inflammatory
 Infective
 Metabolic
 Traumatic
 Neuropathic
 Obesity
 Repetitive joint use
 Physical inactivity
 Genetics

Biomechanical risks
 Injury
 Obesity
 Deformity
 Instability
 Muscle weakness.

Lateral approach- lift gluteus medius & glut minimus, osteotomy of greater trochanter and reattached afterwards. the contraindications and precautions include:
• Do not cross legs (i.e. no hip adduction)
• Do not remove abduction pillow
• Keep leg in neutral- no excessive adduction/crossing legs.

Patient Education
Patient education NB NB NB:
• Pre-op. ↑Trust and confidence, ↓ anxiety and LOS
• Expectations from Physio and patient
• Precautions and abduction pillow
• Gait re-education with crutches/walking frame
• Navigating stairs with crutches/walking frame
• Pre-hab and Post-op exercises
• Signs of DVT/PE : Calf pain, groin pain, chest pain, SOB, severe swelling
• Crutches/walking frame 6/52
• Good functional hip ROM at 6/52 post-op

PHYSIOTHERAPY GUIDELINES
Treatment POD 0/1:
• Pre-op education including Precautions
• Post-op check – Heel doughnuts, Abduction pillow, DVT socks/IPCP, pulse, motor function, Vitals, Drip, wound and check that Palin drain is open.
• Encourage pt to sit more upright - ↓ Postural hypotension
• Encourage pt to eat and drink
• Make sure toilet raiser is in place
• Start bed exercises. Circulation drills UL’s and LL’s, Isom & A-A hip flex, abd and add. Then progress to active hip and knee flexion (Heel slide), Hip abd/add, knee flex and ext over side of bed.
• Sit over side of bed, feet on the ground. Patient get out on operated leg’s side of bed
• Demonstrate crutch walking
• Stand up with help of 2 people in case the patient experience drop in BP.
• If safe, proceed to mobilise to toilet
• Never leave patient by themselves in case of dizziness
• Correction of walking pattern. Heel toe, knee flexion and full extension
• Back to bed or sit out in chair (Raised chair with armrests)
• Remember to put abduction pillow back
• Progress to navigating stairs with the next session
• Sit out in chair for breakfast, lunch and dinner
• Mobilize in between treatment sessions with nursing staff.

Treatment POD 1/2:
• As above
• Navigating stairs with crutches/walking frame
• Progress walking distance
• Sit out in chair
• HEP
• 6/52 post-op: Full ROM, balance, proprioception, endurance, strengthening and functional exercises.

DISCHARGE CRITERIA:
• Minimal pain and inflammation
• Independent transfers and ambulation at least 30 m with appropriate assistive device.
• Safe and independent stair mobility (relevant level of mobility)
• Patient should know precautions
• Medically stabile and wound dry
• Someone at home to help the patient

OUTCOMES MEASURES
• WOMAC Questionnaire – Pain, function and stiffness
• Harris Hip Score
• HOOS
• 6 min walk test

General advice
• Remove loose mats at home
• No climbing ladder
• Avoid loose sand
• Bedside table should be on the operated leg’s side
• Use high chair with arm-rest. No camping chairs or lazy boys
• Don’t pivot on the hip. Lift feet when turning around
• Shower instead of bathing
• Golfer’s lift to pick something up from the floor
• Don’t bend forward when sitting to pick up handbag from the floor
• Don’t stretch for the blanket at the foot of the bed, use a braai tong

Question 4

SECTION D: ESSAY
QUESTION 3

Mr Richards is a 50 y/o male and leads am active lifestyle. He is married, has two young children and he owns an agricultural business. He is currently walks wiht a limp and has gluteal muscle weakness. Mr Richards was recently diagnosed with osteoarthiritis of the right hip. He has been referred to you because he will be having a total hip replacement, with a lateral approach. the prosthetic will be uncemented.

Discuss the physiotherapy management of Mr Richards from when you see him pre-operatively until six weeks post-surgery (50)