Trauma Orthopaedic Flashcards
General management - treatment - includes
• accurately and concisely prescribe & document treatment • joint mobilisation • swelling management • pain management • weight-bearing (WB) status • walking aids • exercises • fitting of orthoses
General management - plan/further management- includes
• short term goals (while inpatient)
• further reassessment/ treatment • frequency/progression of treatments • discharge criteria • equipment • home programs • referrals
pre operative management is important if able
- what are some of the complications associated
respiratory complications
circulatory complications
surgical delays
give some examples of when pre operative management can’t be performed
time of arrival on the ward, direct admission from theatre, or they are in an
unstable condition
average age of #NOF
80
F v M #NOF
4:1
Mortality rate associated with #NOF
8-10% within 30 days, 21-29% 1 year
§ Regional
Queensland 24.9% (Chia, 2013)
What percentage end up with decreased mobility #NOF
50%
what fraction regain premorbid function #NOF
1/3`
List some associated perioperative complications with #NOFs
pre-op hypoxia, postop
delirium, anaemia, representation within 30days, CHF, acute
renal impairment, MI
Hip fracture causes
simple fall
trip and fall
spontaneous
traumatic fall
simple fall
common in the elderly
land on the hip (direct blow)
trip and fall
common in the elderly catches foot (rotational force)
Spontaneous
pathological
eg. osteoporosis
traumatic fall
eg. MVA, skiiing, etc
Clinical features of a displaced hip fracture
pain
limb shortened/ext rot
unable to WB
Clinical features of undisplaced hip fracture
pain
no change in limb orientation
can sometimes WB
sometimes difficult to pick up on Xray - MRI/CT or bone scan for diagnosis
Possible complications at the time of hip fracture in the elderly
pre-exitsting co-morbidities (physical/mental)- additional fractures - pain - delayed assistance (cold, lying on hard surface, etc.) - haematoma / damage to soft tissues - hospitalisation / change in environment - surgery / anaesthetic
Hip fracture complications
§ Avascular necrosis § Non-union / mal-union § Dislocation § Shortening of leg § Infection § Non-healing of wound § Penetration of metal-ware § Metal-ware loosening § 2° osteoarthritis
Classification of hip fracture
subcapital /intracapsular fracture
intertrochanteric/extracapsular fracture
subtrochanteric fracture
Slide 14
Garden classification system is for what
intracapsular fractures
Type 1 garden classification fracture
Type I fractures have the best outcome. The
bone ends are impacted into one another, which
facilitates vascular re-growth.
Type II Garden classification fracture
Type II fractures are not impacted and are thus
less stable. However there is minimal
displacement of the bones from the anatomically
normal position, and this is beneficial.
Type III Garden classification fracture
Type III fractures are complete but there is only partial displacement (<50%).
Type IV Garden classification fracture
Type IV fractures are complete with total
displacement (>50%). The two ends of bone are
completely separated.
Surgical management for Garden I &II
§ Cannulated screws
§ Dynamic hip screw (DHS)
surgical management for intertrochanteric
§ DHS § Richards compression screw (RCS) § Compression hip screw (CHS)
surgical management for Garden III &IV
§ Hemiarthroplasty
§ THJR
surgical management for subtrochanteric
§ DHS, CHS
§ Extramedullary fixation
(pin & plate)
§ IM Reconstruction nail
general WB guidelines
slide 19
Physiotherapy management for # NOF
§ Mobilise usually day 1 à mobility ax
§ Often easily fatigued à concentrate on functional activities only
§ Co-ordinate with nursing staff
§ Can generally WBAT, except if fixation stability = fragile or it is a
relatively young patient, (about < 65 yrs ), in which case they are
usually TWB or NWB only
Physiotherapy managment for #SOF
§ Usually rodded / nailed
§ Usually mobilise TWB, Day 1. Will be NWB if pin & plate
§ Need to work on knee flexion and quads. Promote regular
independent active work
§ Patient advised to rest with leg in elevation+++ for 10 days post-op.
Post op delirium
§ Early detection is key to management
§ Poorly recognized, misdiagnosed as dementia
or depression
§ Generally reversible, but poor prognosis
§ Develops quickly, fluctuates during day
Risk factors for post op delirium
dementia, anticholinergic drugs, prev delirium,
indoor falls, prev stroke, depression, impaired hearing or vision
causes of post op delirium
anaemia, CHF, severe hypotension, pulmonary
complications, increase in cortisol levels, UTI, fevers, feeding issues
(Lundstrom, 2004)
polypharmacy, hypoglycamia, hypoxaemia, metabolic encephalopathy
early aims of #NOF treatment
literature supports what
- early mobilisation (Day 1-2 post-op)
- encourage ambulation WBAT/TWB
- encourage maximal functional
independence - ensure adequate pain relief
- provide appropriate walking aid/s
- ensure patient safety at all times
- discourage prolonged bed rest, but
ensure adequate rest periods
Function outcomes - physio role
§ Level of assistance required for lying ↔ sitting ↔ standing § Balance § Willingness to weight-bear through # leg § Distance walked § Frame → crutches § ↑ and ↓ steps / ramp
Physio intervention - physio role
Early mobilization § Consider analgesia prior to mobilizing § Provide walking aids § Mobility status, ward function § Assess transfers § Falls prevention program § Exercises § Chest Physiotherapy § Circulation exercises § Hip precautions (if indicated)
EBP guidelines
Daily evaluation by geriatricians and orthopaedic
specialists
§ Early mobilisation
§ Transfer to a rehabilitation unit or home by Day 3
post-op.
§ Dedicated team with orthopaedic and geriatric
leadership has lead to improved efficiency and quality
of care for patients
§ Exercises: bridging (for Hemi), IRQ, hip and knee
flexion, knee abduction
general fracture management guidelines for #tibial plateua /supracondylar knee #
- usually ORIF’d with plates and screws +/- bone graft, or nailed
- usually to be fitted with IROM brace with open range 0°- 90°
- usually mobilise NWB, Day 1
- need to work on knee ROM and quads. Promote regular
independent active work - patient advised to rest with leg in elevation+++ for 10 days post-op.
general fracture guidelines # patella and ORIF with tension band wiring
- sometimes go into an IROM brace locked in extension or limited
ROM - sometimes go into knee brace which is to be removed for showering
& gentle flexion exercises - usually mobilise WBAT, Day1
- provide with lifting strap for self-assistance of injured leg
General fracture guidelines #Tibia/fibula (shafts)
- usually rodded / nailed → mobilise TWB, Day 1
- also can be ORIFd with plate and screws or fixed with an
external fixateur → mobilise NWB - need to work on knee flexion, dorsiflexion and quads.
Promote regular independent active work (SQ, IRQ, SLR, hip
+knee flexion, hip abd/add) - will often be given a BKPOP or aircast walker for 2 weeks for
comfort and to avoid foot-drop - patient advised to rest with leg in elevation+++ for 10 days
post-op.
