Week 2- Orthopaedic Management of the Lower Limb (Elective & Trauma) Flashcards
What are common conditions for elective orthopaedic surgeries?
- osteoarthritis/ rheumatoid arthritis of the hip
- osteoarthritis and meniscus lesions of the knee
- ligamentous instability of the knee eg ACL
- subluxing/ painful patella-femoral joint
- toe deformities
What is the goal of a total hip replacement?
To attain a durable, painless, functional hip
What are the most common prosthesis for THR?
Originally was metal on metal however had poor results due to friction and metal fragments
Now:
- metal on polyethylene: ball is metal, socket is plastic or plastic lined (polyethylene)
- ceramic on polyethylene: ball is ceramic, socket is plastic or plastic lined (polyethylene)
- ceramic on ceramic: ball is ceramic, socket is ceramic lined
- ceramic on metal: ball is ceramic, socket is metal lined
What are the two surgical approaches for THR?
- posterior
- anterior & antero-lateral
Posterior approach to THR:
- most commonly used
- advantage: easier for surgeon
- disadvantage: dislocation is a possibility during sitting and excessive hip flexion
- dislocation position: Flexion> 90 degrees, adduction past neutral, internal rotation past neutral; combined flexion, adduction and internal rotation
Anterior and anterior-lateral THR approach:
-becoming more common
-advantage: decrease chance of posterior dislocation as posterior capsule not affected
-disadvantage: more difficult for surgeon
—dislocating position: forced extension; flexion or extension with add and er
-may be indicated for alcoholics or other patients who may be unable to adhere to routine hip precautions postoperatively
What are the post operative complications of THR?
- DVT
- Dislocation
- Infection
- Loosening of components
What are the peri-operative complications to THR?
- Sciatic nerve (posterior approach) damage can lead to short term neuro praxis and subsequent ‘foot drop’
- poor positioning of acetabular component could increase chance of dislocation
- fractured acetabulum; fracked femoral shaft; excessive blood loss
What is the post operative presentation of a THR?
- Epidural, PCA, nerve block +/- O2
- IVC, IDC
- Abduction wedge, heel wedge
- SCUDs
What are the post op goals after a THR?
- Independent mobility with appropriate aid
- Independent with home exercise programme
- Independent mobility on stairs and car transfer
What are day 0/1 exercises for post op management after a THR?
• Commence Circulo-Respiratory exercises Day 0
• Commence hip ROM and quads exercises Day 0-1
• Active/assisted hip flexion and abduction on powder board
-Note – hip flexion limited to 90 degrees
• Inner Range Quads (IRQ)
• Bridging and bed mobility
• Note - SLR may be used as an assessment test for LL strength but is not a
recommended strengthening exercise post THR due to the high acetabular
pressures created
What is day 0/1 mobility post operative management of a THR?
- Routine uncomplicated THR will be FWB
- Day 1 – aim to mobilise
- Out of bed on un-affected side - care not to flex > 90 degrees
- Rollator/ESF initially
When can a patient sit after a THR?
Day 1-2, 30mins initially, dependant op pts symptoms
What are day 2 after a THR exercises and mobility?
Exercises:
• Progress ROM and strength functionally e.g. standing hip/knee flexion, abduction, extension; mini squats etc
• Balance exercises
Mobility: • Progress mobility from -Rollater/ESF to -4ww/crutches/SPS • Stairs • Car transfers
What are THR advice and education on discharge?
Hip precautions – to be adhered to lifelong (strictly for first 12wks)
• Avoid combination of dislocating positions
• Do not sit in low chairs
• Do not cross legs
• Do not lie on affected side
• Do not squat down to ground
• Do not bend from hips to pick things up
• No twisting on the affected leg in standing
• No driving first 6/52 until cleared by Drs
Considerations for Discharge Planning:
• Aim for discharge day 3-5
• Occupational Therapy review for ADLs before discharge. Home environment eg bathroom rails, raised toilet seat etc
• Home Exercise Program handout
• Consider F/U Physiotherapy - Home physio or outpatients appointment
What is a revision THR?
- failed or loose prosthesis is removed and replaced by new prosthesis
- staged (septic vs 1 op (aseptic)
What is the Birmingham hip replacement?
A conservative approach to hip arthroplasty: an all-metal bearing couple is used to preserve, rather than replace, a patient;s femoral head and neck
Features include:
- less bone resection than conventional total hip arthroplasty
- excellent long term clinical outcomes
- functionally optimised metallurgy and design
What are the goals of a TKR?
- independent mobility with appropriate aid
- independent with home exercise programme
- independent with mobility on stairs and car transfer
What is arthroscopic knee surgery?
Performed through small portals to allow an irrigation cannula, a fibre optic viewer and light source, and surgical instruments into the joint
Uses:
- to establish or define accuracy of diagnosis
- help decision making and planning of surgery
- observe and record progression of knee joint disorder
- perform operative procedures
Advantage of Arthroscopic surgery:
- rapid recovery
- no hospitation and usually WBAT (weight bear as tolerated)
What are 4 types arthroscopic knee surgery procedures and describe them?
- Menisectomy: loose fragment exercised, flap or oblique tear
- management: FWB, rapid rehabilitation including ROM exercises, SLR, IRQ, limit walking to manage swelling - Meniscus repair: only if located in periphery of meniscus as adequate blood supply for healing
- management: mobilised PWB or NWB crutches, other rehabilitation as above
- advantages: by retaining some meniscal integrity aim for reduction in incidence of degenerative joint changes that commonly occur following a total menisectomy - Chondroplasty: removal or repair/ smoothing of cartilage
- management: WB dependent on extend or surgical repair, other rehabilitation as above - Ligament repair and replacement: eg ACL reconstruction
- management: Dr, dependant, most FWB, close chain exercises for 3/12
What are the 3 way patella realignment, arthroscopic knee surgery and what is the management?
- Tibial tuberosity transfer
- surgically moving the tibial tuberosity medially - Lateral release
- used in isolation or as adjunct to other procedures
- releases tight lateral retinaculum and Vastus lateral is
- may be performed arthroscopically or as open procedure - Medial plication
- “plication” is the folding in and suturing of tucks
- tightening of medial
Management:
• Immobilised in extension in Richard’s Splint for 6 weeks
• No active Flexion, Extension or SLR for up to 6/52
• Only Knee or quads exercise - static quads
• Generally WBAT
Lateral release without tibial tuberosity transfer • Management
• Early activation of quads and ROM exercises
• Mobilise FWB and progress exercises as pain and swelling allow
Describe high tibial osteotomy?
Aim:
- to divide the bone nad reposition the fragments to realign the tibia and distribute weight bearing forces more evenly through the knee
- medial tibiofemoral compartment osteoarthritis
Advantages:
- does not destroy articular cartilage as tibio-femoral joint not directly operated on
- can later progress to TKR
- reduces OA pain
Disadvantages:
- Causes considerable discomfort and long period of rehabilitation
- Not a cure for OA but may slow deterioration
- Symptoms may reoccur
Favourable result factors:
- <65 years of age or ‘long life eexpectancy’
- not overweight
- 90 degrees of flexion
- <15 degrees flexion contracture
- higher activity level (HTO instead of TKR)
- early uni-compartmental OA with corresponding virus or vagus deformity
- ligamentous stability
- No-smoker
Post op management:
-Commence circulo-respiratory exercises day 0
-Commence rehab exercises day 1
• May SLR in Richard’s splint
• If staple fixation - no knee flexion 4-6 weeks
• If plate / screws fixation - may commence gentle knee flexion day 1 or 2
- Mobilise day 1 - NWB with Richard’s splint
- Management can vary dependent on Dr
What are complications of a TKR?
- Fracture
- DVT
- Infection
- Loosening of components
- Ongoing knee pain
How is a TKR designed?
- Femoral component - metal
- Tibial component - metal
- Polyethylene spacer
- Patella posterior component- Polyethylene
What are the gals of a post op TKR?
- Knee Flexion >/= 90 degrees
- Knee extension 0 degrees
- SLR
- Independence with HEP
- Independent mobility on stairs
What is the presentation of a TKR post op?
- Epidural, PCA, local infiltrates, pain busters, regional nerve blocks
- IVC, IDC
What is the management of a TKR post op?
Day 0-1 Exercises
• Commence Circulo-Respiratory exercises Day 0
• Commence quads exercises Day 1
• Active/assisted knee flexion – aiming for 90 degrees
• IRQ, SLR
Day 0-1 Mobility
• Routine uncomplicated TKR will be FWB/WBAT
• Day 1 – aim to mobilise
• Out of bed on un-affected side
• Rollator/ESF initially progressing to crutches as able
Sitting
• Allowed Day 1-2, 30 minutes initially, dependant on pts symptoms
• Application of ice
What is the criteria for discharge after a TKR?
- independent mobility including stairs with appropriate aid
- knee flexion >90 degrees
- SLR with minimal quadriceps ‘lag’ (<5 degrees)
- Independent HEP
What are conditions for discharge planning a TKR?
- aim for DC within 3-5 days
- provision of HEP
- Follow-up Physiotherapy
What is a uni-compartmental knee replacement?
- procedure similar to TKR, however only one compartment is replaced
- other compartment must be healthy
- rehabilitation can be quicker than TKR
- aim up to 120 degrees flexion
What are the the 3 intro-articular reconstructions for an ACL reconstruction?
- Synthetic grafts (LARS)
- Allografts (Cadaver)
- Autografts (Hamstrings, patella tendon)
What is the indication for an ACL reconstruction?
Significant functional disability due to instability
Explain synthetic grafts
• Great appeal for using synthetic grafts to replace a torn ACL
• Several synthetic ligaments have come and gone but none have met
the qualifications needed for a lasting ACL substitute
• Examples have included Dacron, carbon fibre and Gortex grafts
- LARS (ligament advancement re-inforcement system)
- Quicker return to function, sport
- No difference at 24 months (T. Nau, P. Lavoie, N. Duval, 2011)
Explain Allografts:
Cadaveric tendon donation
Advantages:
- no donor site pathology
- shorter op
- eventually fully replaced by new tissue
Disadvantages:
- graft rejection
- allograft ruptures- especially using grafts from older donors (>30-35yrs a risk factor)
Explain autografts:
Hamstring graft- gracious or semitendinosis (most common)
Advantage: good graft strength and no anterior knee pain
Disadvantages: evidence of elastic creep in graft due to poorly-aligned collagen fibres. This may produce a slightly lax graft.
Patellar tendon Advantages: -strong -biological -eventually replaced by new tissue Disadvantages: -anterior knee pain -donor site pathology
What is the Physiotherapy management of an ACL reconstruction?
Post op Presentation:
• Knee bandaged +/- Richard’s splint
Rehabilitation Exercises: (Commence Day 0)
• Largely surgeon protocol driven.
• Majority no open chain exercises 6-12wks
• Example
-Commence Circulo-Respiratory exercises if indicated Day 0
-Co-contraction exercises
-Active-assisted knee flexion
-SLR with co-contraction in splint (avoid IRQ due to shear stress on graft)
-Mobilise on crutches – WB status surgeon dependent
-Follow up physio within 2/52
Considerations for Discharge:
• Independent mobility, organise follow up physio
What is toe deformity surgery?
Procedure: Osteotomy of 1st Metatarsus Valgus
Management:
- patient mobilised with surgical shoe/ Darcy boot (HWB)
- walking aid not essential but may require a stick or crutches depending on balance and pain
What are complications of fractures
• General -Shock -Infection -Gas gangrene • Respiratory complications -General -Post-operative -Local (rib/thoracic spine) • Thrombo-embolic complications -Deep venous thrombosis and pulmonary embolism -Fat embolism • Metabolic response to trauma (rhabdomyolosis) • Crush/compartment syndrome • Pressure areas • Falls
Late and local to # site • Union -Delayed union -Non-union -Mal-union -Cross union -Growth disturbance (epiphysis) • Avascular necrosis (AVN) • Myositis ossificans (MO) • Volkmann’s ischaemic contracture • Complex Regional Pain Syndrome (CRPS) • Joint complications -Instability -Hypo-mobility -Biomechanical
What is the general treatment after an orthopaedic fracture?
TREATMENT • accurately and concisely prescribe & document treatment • joint mobilisation • swelling management • pain management • weight-bearing (WB) status • walking aids • exercises • fitting of orthoses
PLAN / FURTHER MANAGEMENT • short term goals (while in-patient) • further reassessment/treatment • frequency/progression of treatments • discharge criteria • equipment • home programs • referrals
What is the pre op management of a trauma?
• Preoperative management is important if able •
- Respiratory complications
-Circulatory complications
-Surgical delays
• Many patients are unable to be seen prior to surgery due to their time of arrival on the ward, direct admission from theatre, or they are in an unstable condition
What is conservative management to a fracture
- Auto-fixation
- Traction
- Casting and Bracing
What is surgical management of fracture?
- open reduction and internal fixation (ORIF)
- external fixation
NOF
Fractured neck of femur
• Occur mostly in Elderly, average age 80yr
• Females: Males = 4:1
• Mortality rate: 8-10% within 30 days, 21-29% 1 year
Regional Queensland 24.9% (Chia, 2013)
• 50% decreased mobility, 1/3 regain pre-morbid function
• Associated perioperative complications: pre-op hypoxia, post-op delirium, anaemia, representation within 30days, CHF, acute renal impairment, MI
What are the 4 causes of hip fractures
• Simple fall - common in the elderly - land on the hip (direct blow) • Trip and fall - common in elderly - catches foot (rotational force) • Spontaneous - pathological - e.g. osteoporosis+++ • Traumatic fall - e.g. MVA, skiing , etc.
What are the clinical features of a hip fracture?
• Displaced
- pain
- limb shortened / externally rotated
- unable to weight-bear
• Undisplaced
- pain
- no change in limb orientation
- can sometimes weight-bear
- sometimes difficult to pick up on
- xray → MRI/CT or bone scan for diagnosis
What are possible complications at the time of a hip fracture in the elderly?
- pre-existing 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
What are complications of hip fractures?
- Avascular necrosis
- Non-union / mal-union
- Dislocation
- Shortening of leg
- Infection
- Non-healing of wound
- Penetration of metal-ware
- Metal-ware loosening
- 2° osteoarthritis
What are the 4 types of surgical management?
- Garden I & II
- cannulated screws
- Dynamic hip screw (DHS) - Garden III & IV
- Hemiarthroplasty
- THJR - Interochanteric
- DHS
- Richards compression screw (RCS)
- Compression hip screw (CHS) - Subtrochanteric
- DHS, CHS
- Extramedullary fixation (pin & plate)
- IM reconstruction nail
What are the general WB guidelines for hip fractures?
What is the Physiotherapy management of a #NOF
- Mobilise usually day 1 —> mobility ax
- Often easily fatigued —>concentrate on functional activities only
- Coordinate 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
Aims:
- 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
What is the Physiotherapy management of a #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.
What is 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: dementia, anticholinergic drugs, prev delirium, indoor falls, prev stroke, depression, impaired hearing or vision
• Causes: anaemia, CHF, severe hypotension, pulmonary
complications, increase in cortisol levels, UTI, fevers, feeding issues
• Polypharmacy, hypoglycamia, hypoxaemia, metabolic encephalopathy
Signs: • Decreased attention • Disorganised thinking – • rambling/irrelevant/incoherent speech • + at least two of the following: -Decreased level of consciousness -Disturbance – misinterpretations or hallucinations • Disturbed sleep cycle -Incr/decr psychomotor activity -Disorientation T/P/P - Memory impairment
What is the general fracture management guidelines of the tibial plateau or supracondylar knee fracture
- 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.
What is the general fracture management guidelines of the patella fracture and ORIF with tension band wiring
- sometimes go into an IROM brace locked in extension or limited ROM, only to be removed for showering & gentle flexion exercises
- usually mobilise WBAT, Day1
- provide with lifting strap for self-assistance of injured leg
What is the general fracture management guidelines of the fractured tibia or 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 backslap or moonboot for 2 weeks for comfort and to avoid foot-drop
- patient advised to rest with leg in elevation+++ for 10 days post-op.
What is the general fracture management guidelines of an ankle fracture
- usually ORIFd with plates and screws
- usually mobilise NWB in backslab or moonboot, Day 1 (unless swelling is an issue)
- patient advised to rest with leg in elevation+++ for 10 days post-op.
- Exercises: IRQ, SLR, hip and knee flexion, hip abd/add
What is the general fracture management guidelines of a fractured pelvis
- usually mobilise WBAT as soon as patient is able to move independently across the bed
- if more than one ramus is #d, progression of mobility is usually slower due to pain
Note rarely surgically repaired unless an unstable or open pelvis fracture
