Post Surgical Management Flashcards
1
Q
Coagulation phase
A
- Begins immediately and lasts minutes
- Vasoconstriction, platelet aggregation, clot formation
2
Q
Inflammatory phase
A
- Begins immediately and within 48 hours wound is epithelialized
- Vasodilation, hematoma formation to bridge defect, increased capillary permeability, migration of leukocytes, influx of extrinsic/intrinsic inflammatory cells.
3
Q
Granulation phase (reparative phase)
A
- Fibroblasts appear in 2-3 days and are dominant by day 10
- Fibroblasts are dominant cell types, collagen synthesis
4
Q
Scar formation (maturation phase)
A
- Lasts weeks to months, can last up to a year.
- Collagen synthesis, rarely regain full elasticity and strength.
5
Q
Skeletal ligament injury grading
A
- Grade I: General structural integrity is intact though there may be bleeding, swelling, and edema present
- Grade II: partial tear, more bleeding and edema
- Grade III: complete tear
6
Q
Skeletal muscle healing phases
A
- Inflammatory: immediately and lasts for a few hours
- Proliferative: 1-6 weeks post op
- Remodeling: 7 weeks-1 year
7
Q
Sheathed tendon difference to be aware of
A
- Sheathed tendons have limited vascular supply and so rely more on diffusion of nutrients through synovial fluid.
8
Q
Skeletal muscle injuries
A
- DOMS: 12-48 hours, microtrauma
- Muscular contusion: local hematoma
- Muscular strain: tearing of muscle (2 joint muscles are most susceptible)
- muscle laceration: sliced, can cause significant limitations
9
Q
Bone healing inflammatory phase
A
- Hemorrhage, necrotic cells, hematoma and fibrin to bridge the gap
- Begins immediately
10
Q
Bone healing soft callus phase
A
- Fibrous and cartilagenouse tissu forms between fx ends, increased vascularity and increased growth of capillaries into fracture callus. Increase in cellular proliferation, osteoclasts remove dead bone fragments
- 1-6 weeks post injury
11
Q
Bone healing hard callus phase
A
- Woven bone develops when the callus converts from fibrocartilagenous, osteoclasts continue removing dead bone, osteoblast activity is abundant
- 4-6 weeks post injury
12
Q
Bone healing remodeling phase
A
- Woven bone changes to lamellar bone, medullary canal is then reconstituted, fracture diameter decreases to original width
- 6 weeks up to several months or years
13
Q
Neuropraxia
A
- Complete block of nerve transmission with intact nerve fibers, typically d/t stretch injury, blunt force trauma, or prolonged compression.
14
Q
Axonotmesis
A
- Nerve sheath remains intact but the axons become divided resulting in complete loss of motor function, sensation, and autonomic functions
15
Q
Neurotomesis
A
- A partial or complete severance of the axons and sheath. Most severe form of nerve injury
16
Q
Wallerian degeneration
A
- Axon distal to lesion becomes swollen day 1. Muscle innervated by the nerve ceases to contract 2-3 days after injury. Degeneration of nerve distal to injury via phagocytosis
- Immediately to about 3 days post injury
17
Q
Axonal regeneration
A
- Begins at proximal end of nerve at injury site. Axons and schwann cells invade the region. Axons create a “growth cone” to traverse the site of the transection. Schwann cells create myelin sheaths
- Begins 4th day. 1 mm/day growth rate, total time depends on the distance to be covered.
18
Q
Articular cartilage zones
A
- superficial: can heal independently
- intermediate: unable to repair
- deep zone
- Calcified zone: fibrocartilage typically fills defect but it is not as durable and can lead to eventual degeneration
19
Q
Red blood cell count normal values
A
- men: 4.32-5.72 trillion cells/L, women: 3.90-5.00 trillion cells/L
20
Q
Hemoglobin
A
- men: 13.5-17.5 g/deciliter, women: 12.0-15.5 g/deciliter
- low: anemia
- high: polycythemia vera, lung disease, dehydration, living at high altitude, heavy smoking, burns, excessive vomiting, extreme physical exertion
21
Q
Hematocrit
A
- men: 39-51, women: 34-46
22
Q
Creatine kinase
A
- men: 171 U/L, women 145 U/L
- > 2.5-3% = heart damage
- <2.5-3% = skeletal muscle injury
23
Q
Blood glucose
A
- 80-110 mg/deciliter
- <70 = hypoglycemic
- 100-125 = prediabetic
- > 126 = diabetic
24
Q
Effects of immobilization
A
- 6 weeks of immobilization can lead to a 40% decrease in strength
- Muscle atrophy begins in the first 24 hours
- Training prior to immobilization can limit atrophy
- Slow twitch muscle fibers are more adversely affected
25
Cervical discectomy pt presentation prior to surgery
- degenerative disc disease
- radiculopathy
- spondylitic myelopathy (gait abnormalities, and positive hoffman and babinski)
26
Muscles involved in cervical discectomy
- SCM, platysmus, anterior and middle scalene, longus coli muscles
27
Cervical discectomy reparative phase
- 0-3 weeks
- Focus on promoting dense connective tissue and woven bone, protect surgical site, promote nerve mobility and healing
- most of this is done at home
28
Cervical discectomy remodeling phase
- 4-52 weeks
- Focus on preventing scar formation, increase strength of affected muscles, provide stress to bone to encourage strengthening and remodeling, neural gliding, increased thoracic mobility.
29
4-8 weeks following cervical discectomy
- joint mobility for thoracic spine (do not asses cervical joint mobility)
- avoid neural stretching techniques, Do use glides, pt should perform neural glides while minimizing neck movement
- Proprioception/sensorimotor assessment
30
9-12 weeks following cervical discectomy
- cervical isometrics can be started
- can initiate UE exercises above 90 degrees
- continue to improve scapulothoracic mechanics
- use AROM to help manage pain and stiffness
- can use UBE now
31
13-52 weeks following cervical discectomy
- goal is to return to PLOF
32
Lumbar microdiscectomy indication for surgery
- lumbar disc herniation
- failed conservative treatment
- recurrent/severe radicular pain
- neurologic deficit
- increasing neurologic deficit
- cauda equina syndrome
33
Cauda equina syndrom
- numbness and tingling in saddle region
- changes in bowel or bladder function
- weakness in the legs or back
- considered a medical emergency
34
What to avoid during inflammation phase following lumbar microdiscectomy
- Driving or sitting >20 minutes
- loaded lumbar spine in flexion
- standing ROM
- end range motion assessment
- hip muscle strength testing
- slump testing
35
Focus during inflammation phase following lumbar microdiscectomy
- reinforcing neutral spine principles
- increase cardio, core strength, motor control, and endurance
- maintain nerve root mobility
- develop LE strength and flexibility.
36
Reparative/functional recovery phase following lumbar microdiscectomy: 4-6 weeks
- complete wound healing
- neural tension
- functional activity
- cardio endurance
- high intensity exercise (better than low intensity)
- minimal pain complaints (grade I and II spinal mobs)
- avoid loaded lumbar flexion and standing ROM if warranted
37
Remodeling phase following lumbar microdiscectomy: 7-11 weeks
- Focus is to return to PLOF
- ADLs without difficulty
- spinal movements in loaded positions
- end range testing/slump test
- continue functional training exercises
- spinal STM as needed for pain
- continue cardio conditioning
- no running until after 12 weeks
38
Prognosis following lumbar microdiscectomy
- delay of >6 months for surgery with severe symptoms is associated with poorer outcomes
- more trauma with a fusion means longer healing time
Success rate of 90-95%
39
Lumbar fusion: 1-6 weeks
- no lumbar ROM
- no hip flexor strength testing
- Avoid: no driving, BLT precautions, prolonged sitting
40
Lumbar fusion: 6-8 weeks
- restrictions: no lifting >10 pounds, no overhead lifting
- Exercise: work up to 30 minutes/day, 5 days/week. Light weight training, avoid loading the lumbar spine, spinal stabilization, aerobic activity
41
Lumbar fusion: 11 weeks-1 year
- functional activities
- resistance training
- avoid end range motion, flexion, and extension
- light joint mobs for pain management
42
Subacromial decompression rehab considerations
- deltoid portal holes
- bursa removed (will eventually regenerate)
- resection coracoacromial ligament
- resection of acromion, possible clavicle
- protocols usually start patient 1 week post op.
43
Subacromial decompression: 0-3 weeks
- focus on ROM, decreasing inflammation and pain, patient education
- typically no PT restrictions at this point
44
Subacromial decompression: 3-6 weeks (or more)
- focus on muscle strengthening/re-education with an emphasis on biomechanics
- work to normalize PROM
- strengthening for scapular muscles and RTC muscles
45
Subacromial decompression: 9-12 weeks
- focus on building muscle, endurance, improving biomechanics, work/sport specific training
- low weight high reps with emphasis on scapular stabilizers.
46
Rotator cuff repair
- Large tears, tears with significant muscle retraction, or poor tissue quality, and tears with delated surgical repair will be on a slower progression
47
Rotator cuff repair: 0-4 weeks
- focus on ROM, decreasing inflammation and pain, patient education.
- start PT 1-6 weeks post op
- defer testing for AROM, PROM, and muscle strength
48
Rotator cuff repair: 5-8 weeks
- focus on treating any cervical, elbow or wrist impairments, continue to manage pain and protect surgical site, progress ROM activities
- defer strength testing and resisted exercise
49
Rotator cuff repair: 8-13 weeks
- focus on restoring full ROM, improve strength, improve function
- resisted exercise in pain free ranges
- should be able to move through full AROM without compensation before resistance is added
50
Rotator cuff repair: 13-22 weeks +
- focus on maintaining full ROM, improve strength and endurance, improve function
- can take up to 26 weeks for tendon to fully heal
51
Predictors of poor prognosis with rotator cuff repair
- >65 y/o
- manual laborers
- co-morbidities/poor bone health
- incorrect dx
- tears >5cm/ poor tissue quality
- workers comp/secondary gain
52
SLAP repair patient presentation
- traction force on arm
- repetitive overhead activities
- impingement
- instability
53
Type I SLAP lesion
- fraying of the labrum without detachment from glenoid (debride)
- most commonly associated with age, RTC disease, and OA
54
Type II SLAP lesion
- separation of labrum from glenoid, unstable biceps tendon anchor (repair)
- most commonly seen in overhead athl;etes and are attributed to max ER in an ABDucted position
55
Type III SLAP lesion
- bucket handle tear that extends into biceps tendon (repair or debride)
- most commonly seen in manual laborers
56
Type IV SLAP lesion
- bucket handle tear that extends into biceps tendon (repair or debride)
- most commonly seen in manual laborers
57
SLAP repair: 0-4 weeks
- focus on protecting repair, ROM, decreasing pain and inflammation, patient education
- limit ROM below 90 degrees of flexion, avoid active ER, EXT, and ABD
- submax isos can start about 2 weeks for IR/ER progressing to bands by 4 weeks with 0 degrees of ABD, avoid bicep activation
58
SLAP repair: 5-8 weeks
- focus on treating any other impairments
- continue with pain and inflammation management
- progress ROM and strengthening: ROM above 90, active ER and move into ABDucted position, full ROM expected by week 10
- isotonic strengthening with minimal weight, no resisted bicep strengthening until week 12
-
59
SLAP repair: 9-24 weeks
- focus on restoring full ROM, improving strength and function
- week 10 = full ROM
- week 12 = can start bicep strengthening, running, UBE
- week 15 = more aggressive stretching
- can start return to throwing program
60
Standard TSA
- maintains normal biomechanics of shoulder
61
Hemiarthroplasty
- typically done for fx or avascular necrosis
62
Reverse TSA
- reverse joint orientation. Usually done if pt has irreparable RTC tear as it relies on deltoid to elevate arm
- goal with reverse is pain relief not ROM
63
TSA: 0-4/6 weeks
- focus on protecting tissues, PROM, decrease inflammation and pain, patient education
- limit ROM testing and defer testing for AROM, strength, weight bearing through arm
- limit ER pROM to about 30 degrees
64
TSA: 4-6/12 weeks
- focus on treating any other impairments, manage pain and inflammation, protect healing site, no heavy lifting, sudden motions, or weight bearing through arm.
- full PROM and start adding AROM and strengthening
- return to function
- caution with anterior capsule and subscap attachment.
65
TSA: 12-24 weeks
- focus on improving ROM, strengthening, and return to full function
- ROM goals: 140 flexion (PROM), 120 ABD, 60 ER, 70 IR (ER and IR in scapular plane). Pt should be able to actively elevate arm against gravity without compensation.
66
Carpal tunnel release pt presentation
- most common in women 35-44 y/o
- pronounced muscle atrophy and weakness
- loss of finger dexterity
- loss of 2 point discrimination
- severe pain
- (+) electrodiagnostic testing
67
Differential dx's for carpal tunnel
- C6 radiculopathy
- pronator syndrome
- reynaud's disease
- cubital tunnel syndrome
- pregnancy (usually resolves 6 months post birth)
68
Carpal tunnel release: 1-3 weeks
- focus on wound healing, maintain tendon excursion, prevent adhesions, maintain ROM, control pain and inflammation.
- AROM: tendon and nerve glides
- defer testing for grip/pinch strength, finger dexterity, neural tension testing, manual muscle testing. Avoid simultaneous wrist and finger flexion to minimize risk of bowstringing
69
Carpal tunnel release: 3-6 weeks
- focus on scar mobilization and desensitization
- ROM continue tendon gliding, nerve gliding, joint mobs, wrist flexion, stretching
- resistance exercises: isometrics, progress to isotonics, gripping and pinching, proximal joints, can assess strength.
- use caution with mobilization of carpal bones
70
Carpal tunnel release: 6+ weeks
- continue scar management
- progress resistance exercise
- work on functional activities
- pinch strength can take up to 6 months to return
71
Hip impingement
- CAM: abnormal femoral head butts up against acetabulum leading to shearing and compressive forces. (more common in younger men)
- Pincer: acetabulum is abnormally shaped, either deep or retroverted. More common in middle aged women
72
Hip labral tear presentation
- labral tears commonly are anterior or anterior/superior.
- groin pain with hip rotation
- pain with sports
- limited hip mobility: loss of hip IR and flexion ROM
- special tests: hip impingement test, FABER, fitzgerald test
73
Hip labrum repair: 0-4 weeks
- 50% weight bearing with crutches for at least 3 weeks
- ROM: no hip extension past neutral or ER. PROM, AROM, stretching in pain free range, flexion limited to 120 degrees, ABD to 45
74
Hip labrum repair: 5-7 weeks
- full weight bearing with normal mechanics
- PROM until ROM is normalized
- resisted exercise: NMR control, balance, proprioception, functional activities, bridge progressions
75
Hip labrum repair: 8-12 weeks
- no pain and full ROM
| - exercise should include multiplanar movements
76
Autologous chondrocyte implantation (ACI)
- rehab progression is slow, want to start working towards full extension initially and minimize flexion
77
ACI matrix production phase
- weight bearing restriction until week 12 but can start balance one these are lifted
- should have full ROM
78
ACI maturation phase: 12-26+ weeks
- wounds, periosteal, and chondrocytes harvest sites bone healed
- articular cartilage: matrix production continues, maturation phase 2-3 years after surgery
- focus on building strength and endurance, progress functional activities.
