Week 4- Orthopedic Conditions Flashcards
PART 1: PT EVALUATION
PART 1: PT EVALUATION
What are some MSK conditions we may see in acute care?
- Bone fractures, including multitrauma situations
- Surgical repair of fractures
- Joint replacements
- Spinal surgeries
- Soft-tissue surgeries
What are 5 main parts of a MSK exam?
- Medical chart review
- Any restrictions?
- Diagnostic imaging
- Medication Review
- Patient Interview
MSK Exam:
- Includes a medical _____ _______.
- What are some restrictions we may see?
- What are the types of imaging used with orthopedic conditions?
- medical chart review
- Weight-bearing (NWB, PWB, TTWB, WBAT, FWB), ROM, Orthotics, Exercise protocols
- Radiography, CT, MRI, Bone scan, Myelography
Diagnostic Imaging:
- ___________ is the standard for detecting injury to ______ as well as evaluating intraoperative and postoperative positioning of a procedure.
- _________ are better for subtle/complex bone fractures and injuries to soft tissue.
- ______ are best for diagnosing spinal disc injuries and soft tissue injuries.
- ___________ assess bone density related to tumors and avascular necrosis as examples.
- __________ is an x-ray/CT scan with a contrast dye to look for spinal conditions.
- Radiography
- CT
- MRI
- Bone scan
- Myelography
What are the components of a MSK exam?
- Observation
- Pain
- Cardiopulmonary
- Integumentary
- Sensation
- ROM
- Strength
- Reflexes
- Balance
- Posture
- Functional mobility
- Outcome measure tool
- When should pain levels be taken?
- Is there guaranteed pain with orthopedic conditions?
- before, during, after
- Yes
With integumentary, note if there is drainage and look at the skin condition ________ to the injury/surgery.
distal
With sensation, assess ________.
distally and around surgical site
Balance assessment is essential, why?
Pain and joint dysfunction related to the injury/surgery will impact sensory input and ability to maintain/regain balance.
List some pain scales that are used.
- Numeric 0-10
- VAS
- Wong-Baker Faces
- Nonverbal Pain Scale (NVPS)
- Brief Pain Inventory
- McGill Pain Questionnaire (regular and short form)
- Shoulder Pain and Disability Index (SPADI)
- Lower Extremity Functional Scale
What (2) pain scales can be used for nonverbal patients?
- Wong-Baker Faces
- Nonverbal Pain Scale (NVPS)
When looking for outcome measures, what drives your decision making?
What information do I need in order to assess patient ability, safety, and discharge needs?
MSK Considerations:
- Decrease _____ and/or ______ guarding
- Prevent _________/________ complications
- Prevent _____ and ______ deficits
- Improve ___________ mobility while protecting the involved structures
- Post-op _________ effects
- Effect of pain and pain medication(s)
- _____ restrictions
- Patient education on post-op precautions
- Determining appropriate AD
- Modifying _________ based on restrictions/precautions
- Will any of the above increase ____ risk?
- pain and/or muscle guarding
- circulatory/respiratory
- ROM and strength
- functional
- anasthesia
- WB
- mobility
- fall
What is the best way to have patients learn their restrictions?
-Teach them the restrictions and then have them verbalize them back to you.
PART 2: JOINT REPLACEMEMENTS
PART 2: JOINT REPLACEMEMENTS
What are the 2 types of Knee Arthroplasties?
- Unicondylar (unicompartmental) Knee Replacement
- Total Knee Replacement
Unicondylar (unicompartmental) Knee Replacement:
- Only one compartment (medial or lateral) is replaced
- Indicated when one compartment has degeneration and _______ and ________ ligaments are intact.
- _______ allow for the preservation of normal knee kinematics.
- Facilitates _________ recovery
- cruciate and collateral
- Does
- quicker
Total Knee Replacement:
- Replacement of the femoral condyles, the tibial articulating surface, and the dorsal surface of the patella.
- Post-op WB status usually _____ but ALWAYS confirm, never assume.
WBAT
Total Knee Arthroplasty (TKA):
- What is the usual reason for surgery?
- Post-op WB status = ______ usually
- What are some post-op concerns?
- ____ machines are sometimes used.
- What are their precautions?
- Severe joint degeneration resulting from OA, RA, or trauma.
- WBAT
- DVT, PE, infection, pain, edema, patellar tendon rupture, patellofemoral instability, component failure or loosening, and peroneal nerve injury
- CPM (continuous passive motion)
- No specific movement restrictions.
Total Knee Arthroplasty (TKA):
- What are the (3) evaluation components?
- What are the requirements for D/C home?
- P/AROM goni
- Skin inspection at surgical site
- Immediate D/C planning
- Independent with HEP
- Safe with household mobilization
TKAs have become “____ procedures” in which patients return same day as surgery.
“day procedures”
With TKAs post-op protocol will vary depending on the surgeon, however AROM and strengthening typically begin ___________.
immediately
With a TKA we are typically aiming to achieve __-__ degrees knee ext-flex. There is also a big focus on _________ mobility.
- 0-90 degrees
- functional
What is the usual reason for Total Hip Arthroplasty (THA)?
Degenerated joint surface or repair following a fall.
With THAs, post-op WB status usually _____ but ALWAYS confirm, never assume.
WBAT
What are the precautions for THAs?
- Posterolateral approach: no hip flex past 90, no adduction past midline, no IR past neutral
- Anterolateral and 2-incision approaches: limit hip ext especially with ER
- Avoid sleeping on surgical side
- Avoid sitting on low surfaces
What are the possible complications of THAs?
- Dislocation
- Aseptic loosening
- Hematoma formation, heterotopic ossification
- Infection
- Nerve injury, vascular damage
- DVT → PE
- MI, CVA
- Leg-length discrepancy
What are the S/Sx of hip dislocation?
- Excessive pain with motion
- Abnormal internal or external rotation of the hip with limited active and passive motion
- Inability to WB through LE
- Shortened limb (leg length discrepancy)
Total Hip Arthroplasty (THA):
- What are the (5) evaluation components?
- What are the requirements for D/C home?
- P/AROM goni
- Skin inspection at surgical site
- Measure leg length
- Assess for possible neurapraxia, esp femoral and sciatic nerves
- Immediate D/C planning
- Independent with HEP
- Safe with household mobilization
- Independent with precautions
Will some patients require continued PT in inpatient setting?
Yes
Post-op Protocol will vary, however:
- ______ wedge is often used.
- Possibly knee immobilizer to prevent ________.
- Adaptive equipment such as what?
- Prescribe appropriate AD.
- AROM/strengthening
- _________ mobility (avoid pivoting on surgical LE, elevated bed)
- ABD wedge
- hip flexion
- long handled reachers, shoehorns, leg lifter, elevated toilet seat
- functional
What is the usual reason for Total Shoulder Arthroplasty (TSA)?
Degeneration of joint surfaces.
What is the difference between a total shoulder arthroplasty and a shoulder hemiarthroplasty?
- TSA- humeral and glenoid surfaces replaced
- shoulder hemiarthroplasty- only humeral surfaces replaced
- What is the most common approach to gain access to the humeral head with TSAs?
- What is another that is becoming more popular and why?
- Deltopectoral (most common)
- Lesser tubercle osteotomy (LTO), reduces amount of subscap dysfunction after surgery
What are some complications with TSAs? (3)
- rotator cuff tearing
- glenohumeral instability
- humeral fracture
TSA Common Precautions:
-Avoid shoulder _________.
-No _______/________/_______ objects with involved upper extremity.
No excessive shoulder motion behind back, especially into ______.
No excessive stretching, especially into ____.
No supporting body weight by hand on involved side.
No driving for __ weeks.
- AROM
- lifting/pushing/pulling
- IR
- ER
- 3 weeks
TSA Patient Education:
- Use of ______ for the management of pain and inflammation
- Proper positioning for comfort and maintenance of the integrity of the surgical procedure (no lying on involved shoulder, use towel under elbow when supine).
- Bringing the hand to the mouth with the ______ held at the side of the trunk.
- Therapeutic exercise program/HEP.
- To decrease distal edema, hand, wrist, and elbow active range-of-motion (AROM) exercises and ice packs may be used.
- Squeeze a ball or sponge will help maintain ______ strength.
- ice
- elbow
- grip
What are some immediate TSA post-op exercises that can be done? (3)
- Supine passive forward flexion with elbow flexed (Patient may passively move involved arm by using opposite hand to guide the movement).
- Supine passive external rotation with arm at side and elbow flexed to no more than 30 degrees (Patient may passively move involved arm by using a wand or cane).
- Pendulum exercises, clockwise and counterclockwise.
When are reverse TSAs (rTSA) performed?
-When a patient presents with rotator cuff arthropathy, failed shoulder arthroplasty, multiple failed rotator cuff repairs, malunion of tuberosity after fracture.
Are rTSA protocol and precautions similar to TSAs?
Yes`
Joint Infection:
- How will they present?
- What are the treatment options?
- fever
- wound drainage
- persistent pain
- erythema
- Antibiotics
- Debridement with prosthesis retention or removal
- 1 or 2 stage reimplantation
- Arthrodesis (fusion)
- Amputation (life-threatening conditions)
Joint Resections:
-Removal of infected hardware and cement (___________)
-__-step process for reimplantation (Removal of hardware, period of IV antibiotics and antibiotic spacers)
Implant new prosthesis
-Possible ____ restrictions when spacers in place prior to new implantation
-Decreased pain tolerance during this period may adversely affect patient participation in PT
-Girdlestone procedure: may leave significant LLD
- resection
- 2-step
- WB
PART 3: SPINAL SURGERIES
PART 3: SPINAL SURGERIES
Are there any cures for neck/back pain caused by things such as degenerative disc disease and herniation?
No
What are some types of spinal surgeries performed?
- Discectomy
- Decompression
- Laminectomy
- Fusion
- Total Disc Replacement
Discectomy:
- What is a discectomy?
- Usually accompanied by ____________.
- Also often done with _______: ACDF (anterior cervical discetomy and fusion)
- Often done on ___________ basis.
- Orthotic _______ usually not required.
- Removes disc fragments and herniated disc material that compress adjacent nerve roots.
- laminectomies
- fusing
- outpatient
- bracing
Decompression:
- Removal of _________ elements of vertebral column (lamina, spinous processes).
- Foramen widened to provide ________ relief on neural elements.
- posterior
- pressure relief
Laminectomy:
- More _________ surgical procedure.
- Lamina excised to provide more space and relieve _______ on neural elements.
- Orthotic _________ usually not required.
- involved
- pressure
- bracing
Fusion:
- _________ or ________ approaches.
- Acts to ____________ hypermobile or unstable joints.
- Fusion material: ________ (i.e., pedicle screws, interbody cages, plates) and ____.
- Bone source: allograft or autogenous (iliac crest usual site).
- Will orthotic bracing be prescribed?
- anterior or posterior
- stabilize
- hardware or bone
- Yes, exact type depends on location of surgery
A _________________ is an alternative to fusion and is becoming more common.
Total Disc Replacement
What are some complications of spinal surgery?
- Neurological Injury
- Infection
- Cauda Equina Syndrome
- Dural tear with CSF leak
- Nonunion
- General surgical complications
List the spinal precautions for spinal surgery.
- Log-rolling technique for getting in/OOB
- Avoid excessive trunk flexion while seated
- Limit extended periods of sitting
- Lifting restrictions to < 5-10 pounds (may vary depending on protocol)
- There are no LE WB restrictions
What is a good way to remember spinal precautions?
BLT
-No bending, lifting (<5-10lbs), no twisting
Spinal Surgery Evaluation Components:
- ______/_______ ROM and strength assessment may be limited by spinal precautions.
- Emphasize ___________ mobility.
- Know wearing schedule of ________.
- Ensure ________ knows schedule and how to don/doff.
- Adhere to post-op spinal _________.
- Emphasize proper body _________.
- Schedule pain meds _______ to PT visit.
- Neck/trunk
- functional
- orthotic
- patient
- precautions
- mechanics
- prior
With spinal surgeries, they typically have ________ hospital LOS. The initial HEP will be ______ (only) and we will prescribe ____ as necessary for transition to home.
- short
- walking
- AD
PART 4: TRAUMATIC FRACTURES
PART 4: TRAUMATIC FRACTURES
What are the (5) ways fractures can be classified?
- Skin Integrity: Open or Closed
- Site of Fracture: Articular, Epiphyseal, Diaphyseal
- Classification: linear, oblique, spiral, transverse, comminuted, segmental, compression
- Extent: Incomplete or Complete
- Relative Position: Non-Displaced or Displaced
Fractures can be managed both ________ and _____________.
- Nonoperatively (Conservatively)
- Operatively (elective, urgent, emergency)
Fracture reduction (putting pieces back together) can be done either _______ (_________) or ______ (________).
- Closed (noninvasive)
- Open (invasive) = ORIF
Fracture immobilization can be either _________ (cast) or _________ (ex-fix).
- noninvasive
- invasive
Fracture Complications:
- ________ union, ____union, ___union.
- Loss of fixation or reduction.
- Deep vein _________, pulmonary or fat _________.
- ______ damage, such as paresthesia or paralysis.
- ________ damage, such as blood vessel laceration.
- _____________ syndrome: 5 Ps
- Infection.
- Delayed union, nonunion, malunion.
- thrombosis, emboli
- nerve
- arterial
- Compartment Syndrome
What is the difference between delayed union, nonunion, and malunion?
- Delayed union: Healing slowed down.
- Nonunion: No healing.
- Malunion: Abnormal healing.
What is Compartment Syndrome?
- A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues.
- The pressure decreases blood flow, depriving muscles and nerves of needed nourishment.
What are the 5 Ps of Compartment Syndrome?
- Pain
- Pallor
- Paresthesia
- Pulselessness
- Paralysis
Favorable Factors for Bone Healing:
- Early __________
- Early ____________
- Maintenance of fracture reduction
- _________ age
- Good ________
- Minimal _____-_______ damage
- Patient ___________
- Presence of _______ _______
- mobilization
- weight bearing
- younger
- nutrition
- soft-tissue
- compliance
- growth hormone
Unfavorable Factors for Bone Healing:
- Tobacco smoking
- Presence of disease, such as diabetes, anemia, neuropathy, or malignancy
- ________ deficiency
- Osteoporosis
- Infection
- Irradiated bone
- Severe ____-_______ damage
- Distraction of fracture fragments
- Bone loss
- Multiple fracture fragments
- Disruption of _________ supply to bone
- _____________ use
- vitamin
- soft-tissue
- vascular
- corticosteroid
Pelvic Fractures:
- Categorized according to disruption of the ___________.
- What are the (3) types and explain them.
- What usually causes pelvic fractures.
-pelvic ring
- Type A: No disruption, is painful, but heals well.
- Type B: Partial disruption.
- Type C: Complete disruption, requires surgical fixation.
-MVC, can cause life threatening hemorrhaging.
Femur Fractures:
- _________ is associated with femoral shaft fractures.
- __________ can also occur due to a femur fracture and can cause hypovolemia and shock.
- Proximal femur fractures are subdivided into what (3) fractures?
- High energy trauma
- Hemorrhaging
- trochanteric, head, and neck
Tibial plateau fractures are usually due to _______ ______ to the proximal tibia and can cause complications at the popliteal artery and peroneal nerve.
direct trauma
Calcaneal fractures are most often associated with ______ loading and direct trauma.
axial loading
Both LE and UE fractures in the acute care setting are more than likely due to ________ _________ or ______________.
- medical complication
- multitrauma
Multitrauma Fractures:
- What is the most common cause of multitrauma?
- These patients may have multiple ____ restrictions.
- MVC
- WB restrictions
PART 5: MEDICATIONS
PART 5: MEDICATIONS
What are NSAIDs used for?
NSAIDs are relatively inexpensive and are frequently the first line of medication used to relieve pain and reduce inflammation.
What are the (3) main areas of adverse affects with NSAIDs?
- GI
- Kidney
- Heart
What are opioids used for?
Opioids are used mostly to treat moderate to severe pain.
What are the 2 most common side effects of opioids?
- Constipation
- Respiratory Depression
What is PCA?
Patient Controlled Analgesia
-Patient can self-administer analgesic: as-needed and preprogrammed.
What are common side effects of anasthesia?
- Neuromuscular weakness (drowsiness)
- Impaired airway clearance
- What is the most common AE of antibiotics?
- Which antibiotic can cause C.diff?
- Which antibiotic can cause tendon rupture?
- diarrhea
- Clindamycin
- Fluoroquinolones
