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OCS > Post Surgical Management > Flashcards

Post Surgical Management Flashcards

1
Q

Coagulation phase

A
  • Begins immediately and lasts minutes

- Vasoconstriction, platelet aggregation, clot formation

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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.
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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

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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.

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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
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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
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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.
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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
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9
Q

Bone healing inflammatory phase

A
  • Hemorrhage, necrotic cells, hematoma and fibrin to bridge the gap
  • Begins immediately
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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
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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
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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
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13
Q

Neuropraxia

A
  • Complete block of nerve transmission with intact nerve fibers, typically d/t stretch injury, blunt force trauma, or prolonged compression.
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14
Q

Axonotmesis

A
  • Nerve sheath remains intact but the axons become divided resulting in complete loss of motor function, sensation, and autonomic functions
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15
Q

Neurotomesis

A
  • A partial or complete severance of the axons and sheath. Most severe form of nerve injury
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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
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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.
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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
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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
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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
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21
Q

Hematocrit

A
  • men: 39-51, women: 34-46
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22
Q

Creatine kinase

A
  • men: 171 U/L, women 145 U/L
  • > 2.5-3% = heart damage
  • <2.5-3% = skeletal muscle injury
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23
Q

Blood glucose

A
  • 80-110 mg/deciliter
  • <70 = hypoglycemic
  • 100-125 = prediabetic
  • > 126 = diabetic
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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
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25
Q

Cervical discectomy pt presentation prior to surgery

A
  • degenerative disc disease
  • radiculopathy
  • spondylitic myelopathy (gait abnormalities, and positive hoffman and babinski)
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26
Q

Muscles involved in cervical discectomy

A
  • SCM, platysmus, anterior and middle scalene, longus coli muscles
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27
Q

Cervical discectomy reparative phase

A
  • 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
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28
Q

Cervical discectomy remodeling phase

A
  • 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.
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29
Q

4-8 weeks following cervical discectomy

A
  • 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
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30
Q

9-12 weeks following cervical discectomy

A
  • 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
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31
Q

13-52 weeks following cervical discectomy

A
  • goal is to return to PLOF
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32
Q

Lumbar microdiscectomy indication for surgery

A
  • lumbar disc herniation
  • failed conservative treatment
  • recurrent/severe radicular pain
  • neurologic deficit
  • increasing neurologic deficit
  • cauda equina syndrome
33
Q

Cauda equina syndrom

A
  • numbness and tingling in saddle region
  • changes in bowel or bladder function
  • weakness in the legs or back
  • considered a medical emergency
34
Q

What to avoid during inflammation phase following lumbar microdiscectomy

A
  • Driving or sitting >20 minutes
  • loaded lumbar spine in flexion
  • standing ROM
  • end range motion assessment
  • hip muscle strength testing
  • slump testing
35
Q

Focus during inflammation phase following lumbar microdiscectomy

A
  • reinforcing neutral spine principles
  • increase cardio, core strength, motor control, and endurance
  • maintain nerve root mobility
  • develop LE strength and flexibility.
36
Q

Reparative/functional recovery phase following lumbar microdiscectomy: 4-6 weeks

A
  • 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
Q

Remodeling phase following lumbar microdiscectomy: 7-11 weeks

A
  • 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
Q

Prognosis following lumbar microdiscectomy

A
  • 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
Q

Lumbar fusion: 1-6 weeks

A
  • no lumbar ROM
  • no hip flexor strength testing
  • Avoid: no driving, BLT precautions, prolonged sitting
40
Q

Lumbar fusion: 6-8 weeks

A
  • 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
Q

Lumbar fusion: 11 weeks-1 year

A
  • functional activities
  • resistance training
  • avoid end range motion, flexion, and extension
  • light joint mobs for pain management
42
Q

Subacromial decompression rehab considerations

A
  • 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
Q

Subacromial decompression: 0-3 weeks

A
  • focus on ROM, decreasing inflammation and pain, patient education
  • typically no PT restrictions at this point
44
Q

Subacromial decompression: 3-6 weeks (or more)

A
  • focus on muscle strengthening/re-education with an emphasis on biomechanics
  • work to normalize PROM
  • strengthening for scapular muscles and RTC muscles
45
Q

Subacromial decompression: 9-12 weeks

A
  • focus on building muscle, endurance, improving biomechanics, work/sport specific training
  • low weight high reps with emphasis on scapular stabilizers.
46
Q

Rotator cuff repair

A
  • Large tears, tears with significant muscle retraction, or poor tissue quality, and tears with delated surgical repair will be on a slower progression
47
Q

Rotator cuff repair: 0-4 weeks

A
  • 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
Q

Rotator cuff repair: 5-8 weeks

A
  • 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
Q

Rotator cuff repair: 8-13 weeks

A
  • 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
Q

Rotator cuff repair: 13-22 weeks +

A
  • focus on maintaining full ROM, improve strength and endurance, improve function
  • can take up to 26 weeks for tendon to fully heal
51
Q

Predictors of poor prognosis with rotator cuff repair

A
  • > 65 y/o
  • manual laborers
  • co-morbidities/poor bone health
  • incorrect dx
  • tears >5cm/ poor tissue quality
  • workers comp/secondary gain
52
Q

SLAP repair patient presentation

A
  • traction force on arm
  • repetitive overhead activities
  • impingement
  • instability
53
Q

Type I SLAP lesion

A
  • fraying of the labrum without detachment from glenoid (debride)
  • most commonly associated with age, RTC disease, and OA
54
Q

Type II SLAP lesion

A
  • 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
Q

Type III SLAP lesion

A
  • bucket handle tear that extends into biceps tendon (repair or debride)
  • most commonly seen in manual laborers
56
Q

Type IV SLAP lesion

A
  • bucket handle tear that extends into biceps tendon (repair or debride)
  • most commonly seen in manual laborers
57
Q

SLAP repair: 0-4 weeks

A
  • 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
Q

SLAP repair: 5-8 weeks

A
  • 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
Q

SLAP repair: 9-24 weeks

A
  • 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
Q

Standard TSA

A
  • maintains normal biomechanics of shoulder
61
Q

Hemiarthroplasty

A
  • typically done for fx or avascular necrosis
62
Q

Reverse TSA

A
  • 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
Q

TSA: 0-4/6 weeks

A
  • 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
Q

TSA: 4-6/12 weeks

A
  • 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
Q

TSA: 12-24 weeks

A
  • 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
Q

Carpal tunnel release pt presentation

A
  • 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
Q

Differential dx’s for carpal tunnel

A
  • C6 radiculopathy
  • pronator syndrome
  • reynaud’s disease
  • cubital tunnel syndrome
  • pregnancy (usually resolves 6 months post birth)
68
Q

Carpal tunnel release: 1-3 weeks

A
  • 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
Q

Carpal tunnel release: 3-6 weeks

A
  • 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
Q

Carpal tunnel release: 6+ weeks

A
  • continue scar management
  • progress resistance exercise
  • work on functional activities
  • pinch strength can take up to 6 months to return
71
Q

Hip impingement

A
  • 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
Q

Hip labral tear presentation

A
  • 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
Q

Hip labrum repair: 0-4 weeks

A
  • 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
Q

Hip labrum repair: 5-7 weeks

A
  • full weight bearing with normal mechanics
  • PROM until ROM is normalized
  • resisted exercise: NMR control, balance, proprioception, functional activities, bridge progressions
75
Q

Hip labrum repair: 8-12 weeks

A
  • no pain and full ROM

- exercise should include multiplanar movements

76
Q

Autologous chondrocyte implantation (ACI)

A
  • rehab progression is slow, want to start working towards full extension initially and minimize flexion
77
Q

ACI matrix production phase

A
  • weight bearing restriction until week 12 but can start balance one these are lifted
  • should have full ROM
78
Q

ACI maturation phase: 12-26+ weeks

A
  • 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.

OCS (11 decks)

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