Orthopedics

Orthopedics

Branch of medicine that deals with bones, muscles, joints,
ligaments, tendons

Orthopedic injuries

• Congenital/Developmental
• Infection
• Inflammation
• Arthritis
• Metabolic Dysfunction
• Tumors
• Injury/Trauma

Role of OT and orthopedics

 Adaptive Equipment
 Environmental Adaptation
 Compensatory Strategies
 Splinting
 Positioning
 Education
 Symptom Management

What does a general orthopedic evaluation look like?

• Upper Extremity:
• Pain Assessment
• Observe the entirety of the upper
extremity
• Positioning, guarding, edema,
bruising, overall skin condition
• Proximal to Distal Evaluation:
• Cervical spine, shoulder complex
• Elbow/Wrist assessment
• Provocative Testing: A test to elicit a
response indicating a specific condition
or irritation of a group of
muscles/nerves.
• Peripheral nerve assessment

What does a geenral orthopedic evaluation look like for a “functional assessment”

• Pain Assessment
• Observe the entirety of person in
context
• Positioning, guarding, compensation,
hand placement
• Proximal to Distal Evaluation:
• Cervical spine, shoulder complex
• Pelvic Alignment, postural assessment
• Gather an accurate history of how their
injury impacts function

Principles of joint protection and fatigue management

JOINT PROTECTION
• Listen to pain
• Maintain strength and ROM
• Use all joints in most STABLE anatomic and functional plane.
• Avoid positions of deformity
• Play to strength!
• Ensure correct movement patterns
• Avoid one position for too long
• Avoid starting an activity if it cannot be easily stopped
• Balance rest and activity
• Reduce force and effort

Fatigue management

Attitudes and Emotions
Body Mechanics
Work Pace
Leisure Time
Work Methods
Organization

What are the ways we can promote good joint health?

Ergonomics, therapeutic exercise, making sure the client can recoop as needed. Physical agent modalities, sitting in 90-90-90. Avoiding too much pressure to not reinjure the body part

Arthritis

Translates to “joint inflammation” Note of Pharmacology see pg.948 in Pedretti, NSAIDS- tylenol. Cortizone shots, arthiritis topical cream, tumeric, canabis, acupuncture. PRP- plasma rich protein where they take out the white blood cells.

Osteoarthritis

 27 million Americans
 Incidence increases with age
 “non-inflammatory” in nature, due to degeneration/cartilage
destruction
 Commonly impacts neck, spine, hips, knees, DIP, PIP, CMC
 Stiffness in morning usually less than 30 minutes

Rheumatoid Arthritis

 1.5 million Americans
 3:1 female to male ratio
 Systemic inflammation, includes fever, malaise, extraarticular
manifestations
 Stiffness in morning can last 1-2 hours to all day

Joint Precautions and Protection

 Respect pain
 Avoid fatigue
 Maintain ROM and strength
 Avoid placing stress on an inflamed or unstable joint
 Finding stable anatomic and functional planes
 Avoid positions of “deformity”
 Squeezing, pinching, twisting
 Use the strongest joint available
 Ensure correct movement patters
 Avoid staying in one position for prolonged periods of time
 Do not start a task without a plan for immediate stopping of the activity.
 Balance rest and activity
 Reduce force and effort (with or without equipment)
 Caution with resistive exercises: practice attention to body mechanics
 Extra attention to sensory impairments
 Fragile skin could develop and needs to be treated with caution

Treatment options: Non-operative

 Activity Modification
 Weight Loss
 Cane/walker
 Medications:
NSAIDs
Nutritional supplements
 Injections:
Corticosteroid
Viscosupplementation

Weight Bearing Status:

 Non-Weight Bearing (NWB)
 Partial Weight Bearning (PWB)
 Touch-Down/Toe-Touch Weight Bearing
(TDWB/TTWB)
 Weight Bearing as Tolderated (WBAT)
 Full Weight Bearing (FWB)

knee

flexion/extension, ACL, MCL, PCL, femur, tibia, fibula, patella

Total Knee Replacement (TKR)- Implants

Femoral component

Tibial component

patellar component

Knee arthoplasty- Knee Replacement- Implants

Total Hip Replacement

 Intervention of choice for Osteoarthritis and Rheumatoid arthritis after conservative treatment is no longer effective.
 If cement is used to fix the prosthesis interface no weight bearing precautions.
 If biological fixation used weight bearing restrictions are applied
 Traditional anterior or posterior approach or minimally invasive anterior or posterior approach

Hip

Pelvis, acetabulum, femur- external rotation, internal rotation, abduction, adduction, flexion, extension

Total hip arthoplasty implants

stem, neck, femoral heal, polyethylene liner, acetabular cup

Anterior- lateral

MIS- minimally invasive surgery

No movement restrictions

posterior

(mostcommon)- no hip flexion greater than 90 degrees, no internal rotation, no adduction

Total Hip precautions and Rehab Considerations

 Pain
 Mental Status
 Edema
 Function-introduction of
 adaptive equipment

Hemipolar Arthoplasty of Hemiarthroplasty

Common intervention for a femoral head that has poor blood supply, non union, and degenerative joint disease.

Rehab Considerations:
 Hip Precautions - Anterior or
Posterior
 Weight Bearing, see below
 Pain
 Mental Status
 Edema
 Function
May accompany repair of a femoral neck fracture which requires weight bearing precautions.

anterior

no external rotation, no adduction, no extension

Femoral Neck Fracture

Adults over 60, more frequent in women. Osteoporotic bone fracture can occur from rotation or slight trauma (even standing).

Intertrochanteric Fracture

Mostly in women but in a slightly higher age group. Caused by direct trauma or force over trochanter (fall).

Subtrochanteric Fracture

Younger than 60, direct impact to the hip (fall, motor vehicle accident)

Open Reduction Internal Fixation

 Common intervention for extracapsular fracture, between the greater and lesser
trochanter.
 Uses hardware to hold bone in place while it heals.

ORIF Rehab Considerations

Pain- 0-10, type,
location
 Precautions- Weight bearing, usually 6-8
weeks, though dependent on healing
 Mental Status
 Edema
 Functional mobility, person/ environment fit

Extra Information

 Traditional versus minimally invasive, 10 inch incision versus 2- 2
inch incisions.
 Videos are available on Youtube to get a sense of trauma the joint undergoes and extent of
muscle disturbance
 Antibiotic spacers are used to treat infections of replacements.
 Adaptive Equipment

Total Shoulder Replacement

 Total Shoulder
Arthroplasty (TSA)
 Hemiarthroplasty (humeral head replacement)
 Potentially a combination of rotator cuff repair AND replacement.

OT Considerations phase 1 (shoulder)

 PROM is typically the first level of therapeutic activity with the impacted
extremity
Note: PROM is NOT stretching.
 Allowance of healing
Maintain integrity of joint
Gradual increase of PROM
Reduced pain and inflammation
Reduce muscular inhibition
Increase independence of ADL with modifications to maintain joint integrity

OT precautions Phase 1 (shoulder)

 Sling continuously for 3-4 weeks
 Avoid shoulder hyperextension and
anterior capsule/subscapularis stretch
 No AROM
 No lifting
 No IR
 NWB
 No soaking of shoulder
 No Driving

OT Considerations phase 2 (shoulder)

 Typically 4-6 weeks out
 Goal is to restore full PASSIVE ROM
 Gradual restoration of active motion
 Pain Control
 Continued healing: Do not stress healing tissues
 Re-establish dynamic shoulder stability
(i.e. functional use and balance)

Ot precautions Phase 2 (shoulder)

 Sling gradually decreased
 Continued avoidance of shoulder hyperextension and anterior capsule stretch
 Avoid repetitive movements like AROM and activity against gravity
 No lifting
 No full weight bearing
 No sudden movements

OT considerations phase 3 (shoulder)

 Goal is for restoration of strength, power and endurance
 Regain neuromuscular control
 Return to functional activities

OT Precaustions phase 3 (shoulder)

 No lifting more than 5-6 pounds
 No sudden lifting or pushing

OT considerations Phase 4 (shoulder)

 Advanced Strengthening (typically 4-6
months out)
Maintain and Gain
Return to recreational activities