PAST PAPERS: Physio May 2019

Question 1

QUESTION 1

Mrs Burg is a 70 y/o female who sustained a right distal radius fracture after slipping and falling on an outstretched hand. She has been managed in a below elbow plaster of Paris (POP) with a sling. You’re called to see her before she goes home.

1. 1 do you agree with the use of a sling for Mrs Burg? justify your answer. (3)
2. 2. Discuss what advice and exercises will be including in the session with Mrs Burg prior to discharge

Answer 1

1.1. i don’t support the use of a sling, from the mechanism of injury it resembles that of a Colle’s fracture where the distal 2,5-3 cm of the radius is fractured. this is common in osteoporotic women of which Mrs Burg is past 45 years thus postmenopausal. surgically managed through use of a below the elbow POP with thw wrist kept in wrist flexion, ulnar deviation, and pronation with no sling. CONSERVATIVE MANAGEMENT
• MANIPULATION UNDER ANAESTHESIA, THEN BELOW ELBOW POP FOR 6/52. THE WRIST WILL BE HELD IN SLIGHT FLEXION, ULNAR DEVIATION AND PRONATION.

1.2. CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK. Start isometric exercises in the 1/52 weeks, no forced passive movements such as wrist & elbow flexion, supination, radial deviation as this would irritate the radio-carpal joint .
auto-assisted wrist flexion/extension, pronation supination, radio-ulnar deviation with grade 1 and 2 OMT techniques for pain.
putty exercises for thumb and fingers, hand grip using a towel/difi-flex device, opposition, begin strengthening at 3 weeks.

Question 2

QUESTION 2
Miss Spark is 22 y/o female who sustsained a Monteggai fracture after walking in the rain. She was taken to the hospital and an open reduction internal fixation (ORIF) was performed using a plate. The elbow was immobilized in an above elbow POP . He rPOp[ was removed and she has been referred for physiotherapy.
2.1. State the differences between Monteggai and Galeazzi fractures(4)
2.2. List the contraindications and precautions you will adhere to when treating Miss Spark with the emphasis on the affected joints and the physiological movements.(4)

Answer 2

2. 1. Monteggai fracture
      - with proximal ulnar fracture
      - dislocation at (RAD-CAP)radial-carpal joint

Galeazzi fracture

• distal radius-ulnar joint (DRUJ) dislocation
• distal radius fracture

2.2. cast/POP is always removed after 3/52 weeks. Avoid gravity assisted movements for the first week.
avoid excessive over pressure with mechanical movements that may irritate the radius ulnar joint.
isometrics within pain, use grade 1-2 fro pain and 3-4 for ROM to increase monitotirng pain.
Physical exam=inspection=may or may not be obvious dislocation at radiocapitellar joint

Question 3

QUESTION 3
Mrs Smoak is a 65 year old female who complains of left hip pain that started three years ago, and progressively worsened. She complains of morning stiffness and pain when walking, standing for more than 30 minutes and getting in and out of the car. She works as a domestic worker. She visits her local hospital where she sees the doctor and x-rays are taken

the doctor has decided to do a total hip replacement (posterior approach)

3. 1. justify her possible diagnosis (4)
4. 2. describe the radiological features of her diagnosis (4)
5. 3. discuss the physiotherapy treatment of Mrs Smoak from day one post-op to discharge from hospital (12)

Answer 3

3. 1 . given that she stands for prolonged of periods of time due to work, the patient might have Osteoarthritis of the left hip. given the associated symptoms such as morning stiffness, pain wit hip flexion, adduction and internal rotation.
4. 2. -Joint space narrowing
      - osteophytes
      - subchondral bone sclerosis
      - subchondral cysts

3.3.
Treatment POD 0/1:
• 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
• Mobilise 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

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Question 4

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

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

Answer 4

intro
OA
, what is OA, primary and secondary
-causes adn effects
-surgical management
-signs and symptoms
-gait reeducation
Mr Richards ICF=participation, activities, environmental, personal
-THR management, contraindications & precautions
pre-operative, post-operative, and discharge criteria

Question 5

SECTION D: ESSAY
Mr Jonas is a left handed 52 y/o male plumber and owner of a plumbing business. He is a very involved father at home and helps his wife and children with daily chores and homework.
While working he slipped and fell on an outstretched hand. He sustained a left, displaced distal radius fracture that was managed operatively with a plate and screws at the local hospital. A protective POP was applied after an open reduction and internal fixation (ORIF) with the instruction to return after two weeks for cast removal. Mr Jonas missed his appointment and only returned after six weeks due to him being busy at work. The doctor is concerned after removing the cast and he refers him for immediate physiotherapy intervention.

Answer 5

COMMON INJURY, ESPECIALLY IN OLDER, OSTEOPOROTIC WOMEN.
• THE DISTAL 2,5 – 3 CM OF THE RADIUS IS FRACTURED.
• THERE IS OFTEN AN ASSOCIATED AVULSION # OF THE ULNAR STYLOID PROCESS OR A TEAR OF THE ULNAR COLLATERAL LIGAMENT.
• THE # OFTEN EXTENDS INTO THE RADIOCARPAL JOINT (ONLY SEEN ON CT SCAN)

           #CAUSE
• A FALL ONTO AN OUTSTRETCHED HAND.

           #DEFORMITY
• THE TYPICAL ‘DINNER-FORK’ DEFORMITY:

     #COMPLICATIONS • EXCESSIVE SWELLING, OEDEMA AND STIFFNESS OF THE HAND • MEDIAN NERVE COMPRESSION • MALUNION • STIFF SHOULDER • REFLEX SYMPATHETIC DYSTROPHY • SPONTANEOUS RUPTURE OF EXTENSOR POLICIS LONGUS TENDON

        #CONSERVATIVE MANAGEMENT
• MANIPULATION UNDER ANAESTHESIA, THEN BELOW ELBOW POP FOR 6/52. THE WRIST WILL BE HELD IN SLIGHT FLEXION, ULNAR DEVIATION AND PRONATION.

        #CONTRA-INDICATIONS AND PRECAUTIONS
• AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK.

     #SURGICAL MANAGEMENT
• ORIF (PLATES/K-WIRES) IF THE FRACTURE EXTENDS VERTICALLY INTO THE RADIOCARPAL JOINT. MAY BE IN A CAST POST SURGERY, FOR EXTRA SUPPORT.

  #CONTRA-INDICATIONS AND PRECAUTIONS • AVOID GRAVITY DEPENDANT POSITIONS OF THE HAND, ESPECIALLY FOR THE FIRST WEEK. • NO FORCED PASSIVE MOVEMENTS

#PHYSIOTHERAPY MANAGEMENT/GUIDELINES
• IN POP- EX’S TO NECK, SCAPULA, SHOULDER, ELBOW & FINGERS
• ISOMETRICS WITHIN PAIN
• FUNCTIONAL ACTIVITIES WITHIN POP & PAIN
• POP REMOVED- ↑SKIN CONDITION, ↑ROM, ↑MP
• HOME PROGRAMME
• SUPINATION & GRIP STRENGTH ++++
assessment tools: ROM with goniometer; dermatomes with toothpick=hard and cotton wool=soft; 1RM for dumb bells and theraband; putty for strength; digi-flex device; dynamometer

RISKS: Initial risk of being too tight due to
swelling, later risk of being too loose due
to atrophy.

     #ADVICE TO PATIENTS WITH POP ✓Do not wet plaster ✓Never poke objects down POP to scratch as may break skin ✓POP should never be too loose or too tight, if so, return to doctor ✓Check skin around edges of POP for chaffing etc ✓Do not walk directly on POP, use plaster shoe ✓Return to the doctor immediately if the POP breaks ✓If the pain continues to increase, return to the doctor immediately

                 #SUBJECTIVE HAND ASSESSMENT
 History (Past & Present)
 Occupation
 Sport
 Hobbies
 Home environment
 Psychological (Yellow flags)

                 #OBJECTIVE HAND ASSESSMENT
 Observation
 Pain
 Standardised tools (includes some function & strength tools)
 Wound
 Vascular
 Oedema
 Range of Motion
 Sensation
 Strength
 Dexterity
 Function/Occupation/Sport/Hobbies
 Special tests
 Questionnaires

          #Objective assessment
• WOUND/SKIN
• PAIN using
-Wong-Baker FACES Pain Rating Scale
-Numeric rating scale
-Visual Analog Scale (VAS)
• STANDARDISED TOOLS
• VASCULAR STATUS
• OEDEMA
• RANGE OF MOTION with GONIOMETERS
• SENSATION TESTING
• SPECIAL TESTS
• Beightons Hypomobility score
• QUESTIONNAIRES: the dash and quickdash outcome measure user manual (don't bother searching)