Week 3- Orthopaedic Management of the Upper Limb (Elective & Trauma) Flashcards
What are the elective upper limb orthopaedic surgeries
- total shoulder replacement
- reverse total shoulder replacement
- rotator cuff repair
- subacrominal decompression
- anterior stabilisation/ shoulder reconstruction
- distal biceps tendon repair
What are the traumatic upper limb orthopaedic surgeries
- # clavicle ORIF
- Humerus ORIF
- Olecranon ORIF
Radial head - Radial and Ulna shaft ORIF
- Compartment Syndrome
- Wrist ORIF
- Hand ORIF
What are indications and contraindications of a TSJR (total shoulder joint reconstruction)
Indications:
- hard to control pain, particularly if affecting sleep/ ADLs
- Glenside cartilage degeneration: preferred over ha I arthroplasty for OA/inflammatory arthritis
- Posterior humeral head subluxation
Contraindicated:
- insufficient Glenwood bone stock
- deltoid dysfunction
- active infection
- rotator cuff arthopathy
- irreparable rotator cuff
- brachial plexus palsy
What is the differences between a TSJR and reverse TSJR
In a TSJR the ball is on the head of the humerus whereas in a reverse TSJR the ball is on the scapular
What are the indications of a reverse TSJR?
- cuff tear arthropathy
- rotator cuff insufficiency
- pseudo-paralysis ( inability to alleviate the arm over 90degrees in the setting of a rotator cuff tear )
- antero-superior escape
- 3 and 4 part fractures
- failed arthroplasty
- RA
Who are TSJR’s appropriate for?
- low functional demand
- > 70yr of age
- must have sufficient glenoid bone stock
- must have a working deltoid muscle: main muscle for movement post op
- must have an intact auxiliary nerve
What is the post op physio for a TSJR
-chest physio, circulation exercises
-mobilise out of bed day 1
-ice
-shoulder immobiliser sling until week 6
-no WB through shoulder, no lifting
-exercises: elbow, wrist, hand and grip, c-spine
-precaution reverse TSR: no extension beyond neutral
-passive or active assisted motion only during early rehab: limiting factor in early rehab is risk of injury to the subscapularis tendon repair —> pendulum exercises, scapula setting/ positioning
-Progress to ER isometric
-Limit flexion to 120 degrees for revere TSR: risk of tear and pull-off subscapularis tendon rom anterior humerus, a tear will lead to anterior shoulder stability
—IR eccentric and isometric
Who are candidates for a rotator cuff repair?
- conservative management failed
- age
- Size of tear
- limited activity
- cooperative
What is the post op management of TSJR
- Arm supported in sling and binder +/- wedge
Day 0/1 up to 6 weeks
- 1st first by physio
- sling use
- passive and pendulum exercises
- other joint ROM exercises
- posture/ scapula stabilisation
- education re pain relief including ice, PDLs and ADLs
6-12 weeks: restoring ROM
- started within pain-free arcs
- active pendulum
- active assisted motion above 90 degrees abduction
- active assisted, then active motion in IR and ER with scapula stabilised
12-16 weeks: strengthening of the rotator cuff muscles
- diagonal and multi planar motions with Theraband
- plyometrics
- increase multiple-plane neuromuscular control
- sport/ work specific activity
What is subacromial decompression (SAD)
Procedure to increase the space available for structures that pass under the acromial arch
What are the indications of subacromial decompression
Conservative management failed
What is the post operative management for a subacromial decompression?
- Post operative Respiratory check if required (Circulatory care not a priority as patient will be mobile)
- Day 0-1 may commence - Neck, Scapular (LTs), Elbow, Wrist and Hand movements
- IF there is no muscle, tendon or joint disruption (only a SAD) – may commence active assisted shoulder ROM exercises on Day 1 and progress as tolerated. Exercises are then progressed as pain allows
- Education ++ re sling use, ice for pain relief
- +/-No abduction 3-6 weeks depending on Drs orders
Who is indicated for an anterior stabilisation/ shoulder reconstruction
- acute dislocation
- recurrent instability
What is a bank art lesion repair?
- bankart lesion is an avulsion of the anteroinferior glenoid labrum at its attachment to IGHL complex
- Procedure involves the re-suture of the capsule and glenoid labrum through drill holes of the anterior glenoid rim
- expect a little loss of ER post operatively
Note: bankart lesion typically occurs from repeated anterior shoulder subluxations
What is a Hillsachs lesion repair?
-it’s a fracture of the proterosuperoelateral humerus head
Capsular shift: shifts the shoulder capsule to tighten tissue and avoid excessive shoulder rotation
- Bone grafting/ tissue filling: uses bone (often from the pelvis) or soft tissue to fill the defects in the humeral head
- Disimpaction: lifts the compressed bone to restore the shape of the humeral head
- remplissage: this is an arthroscopic technique in which the rotator cuff and capsule is sewn into the bony defect to reduce the risk of recurrent dislocation
- shoulder replacement: this surgery is reserved as the last resort and is generally used for large defects in older patients
What is the post operative management after an anterior stabilisation/ shoulder reconstruction with/ without a bankart lesion repair or hillsachs lesion repair
Aim: avoid stressing the repaired structures until fibrous healing occurs at approx. 6 weeks
Exercises commenced day 1:
- neck, wrist, hand and scapular retraction exercises commenced immediately
- active elbow ROM exercises in IR and upper arm support
- early gentle isometrics to shoulder (if subscapularis has been detached- nit IR or Flex)
- Passive shoulder flexion <90 and ER <0 (protecting subscapularis)
What are the indications for a clavicle ORIF
- shortening and displacement >2cm
- Associated pathology of shoulder girdle and scapula fractures
- neurovascular repairs required
What is the post operative management after a clavicle ORIF- compression plate
- sling 1-2 weeks for comfort and wound
- NWB 6 weeks
- PROM: progressing as pain allows 0-6 weeks
- resistance ex’s from 6 weeks
What are the indications for humerus ORIF
- unacceptable deformity
- risk of displacement
What is the post operative management after a humerus ORIF
Weeks 0-3
• Immobilization and/or support for 2-3 weeks
• Pendulum exercises
• Gently assisted motion
• Avoid external rotation for first 6 weeks
Weeks 3 - 9 (clinical evidence of healing and no displacement is visible on the x-ray)
• Active-assisted forward flexion and abduction
• Gentle functional use week 3-6 (no abduction against resistance)
• Gradually reduce assistance during motion from week 6
Week 9 onwards
• Add isotonic, concentric, and eccentric strengthening exercises
• Treat joint stiffness if any present
What are indications for a distal biceps tendon repair
- biceps tendon avulsion
- young active patients
- failed conservation Mx
- needs to be repaired within 3 weeks of injury
What is the post op management after a distal biceps tendon repair
- immobilisation in broad arm sling/ full arm cast 6 weeks
- after 6 weeks: slowly return to full range of motion then strengthening
What are the indications for an olecranon ORIF (bridge plate)
-unstable displaced fracture of the olecranon
What is the post operative management of olecranon ORIF (bridge plate)?
- could be immobilised for a couple of days from pain
- Commence AROM as pain tolerates
- Resistance exercises commence at 4-6 weeks after confirmation of healing
- Nil loading elbow 6-8 weeks
What are indications for a radial head ORIF
Displaced or unstable #
What are the indications for a radial head arthroplasty
Irreparable #
What is the post operative management after a radial head ORIF or arthroplasty
- could be immobilised for a couple of days for pain
- commence AROM as pain tolerates
- Resistance exercises commence at 4-6weeks after confirmation of healing
- nil loading elbows 6-8 weeks
- arthroplasty: might have own protocol depending on surgeon
What are the indications for a radial and ulna shaft ORIF
Displaced closed fracture
What are the post op management after a radial and ulna shaft ORIF
- cast 6 weeks
- commence AROM and strengthening post cast removal
What is compartment syndrome
A painful condition caused by pressure build-up from internal bleeding or welling of tissue. This pressure can decrease blood flow.
What is the incidence for compartment syndrome
- <30% forearm fractures
- higher incidence in crush injuries
What is the indications for a compartment syndrome surgery
- unrelenting, worsening pain more than expected for the injury
- numbness and tingling in fingers
- colour change of limb
- pressure changes in limb
What is the procedure for compartment syndrome
Fasciotomy, often left open for a few days until swelling subsides then repaired
What is the the post op management for compartment syndrome
Casting to allow soft tissue to heal
What us the indications for a wrist ORIF
Displaced or comminuted (multi fragmentary) fracture
What is the post op management of a wrist ORIF
- cast 6 weeks
- commence AROM and strengthening post cast removal
What are the two types of finger or hand ORIFs
- compression plate: for simple fracture
- K-wire banding: for post avulsion fractures
What are the indications for carpal tunnel release
Severe carpal tunnel syndrome with sensation loss and pain
What are the post op management after carpal tunnel release
- cast/ splint 10-14 days
- stitches removed 10-14 days post
- gentle ROM commences
- Pain free movement commence wrist strengthening
What are the safe D/C guidelines for all patient after upper limb surgeries
- adequate support and asssistance in place
- equipment required at home
- mobilising independently
- safe on stairs
- Don and Doff Brace/sling
- Obs stable, wound healing, no infection
- pain managed appropriately
- follow-up OPD arranged
