Complex Patient Management

When should medical imaging be undertaken? U F R M

• If clinical diagnosis is uncertain

• When treatment has failed

• Red flags

• Guide management

Systematic Approach of an X-ray/Plain radiography

1. Check patients details → name, side of body, date of xray

2. Consider clinical info → why do they require an x-ray?

3. Look at all images available → more than one view/compare

4. Bone and joint alignment → subluxation, dislocation, fracture

5. Bone cortex, texture & cortical outline → cortex = whiter

6. Joint spacing → degeneration

7. Soft tissue structures → swelling, joint effusion, myositis ossificans

ABCS → Alignment, Bone, Cartilage, Soft tissue

Advantages & Disadvantages of Computed Tomography (CT)

Advantages:

• Evaluation of bone and calcification

• Can be reconstructed into 3D images

Disadvantages:

• High amount of radiation

• poor differentiation of soft tissues (muscle vs fat)

• Limited ability to detect bone infiltration

Advantages & Disadvantages of Magnetic Resonance Imaging (MRI)

Advantages:

• Avoids radiation

• Excellence differentiation between tissue types

• Useful for identifying red flags

Disadvantages:

• Limitation apply to strong magnetic fields (e.g. metals)

• Highly sensitive by not always specific

T1 Images → Hyperintensity with FAT

T2 images → Hyperextensibility with WATER and FAT

Contrast images → gadolinium contrast highlights tears

What are 7 core problems within a complex patient?

1. Pain

2. Muscle strength and ROM

3. Balance

4. Muscle length

5. Decreased exercise tolerance

6. Neurological

7. Mental health

What is the AOOTA Classification? (classify orthopaedic fractures and dislocations)

• Bone Code (1 digit) – Identifies the bone:

  • 1 = Humerus

  • 2 = Radius/Ulna

  • 3 = Femur

  • 4 = Tibia/Fibula

  • 5 = Hand

  • 6 = Foot

  • 7 = Spine

• Segment Code (1 digit) – Identifies bone segment:

  • 1 = Proximal

  • 2 = Mid-diaphyseal

  • 3 = Distal

• Fracture Type (letter) – Indicates complexity:

  • A = Simple (extra-articular)

  • B = Wedge

  • C = Multi-fragmentary

What are the 4 main causes of fractures? TAPP

Traumatic, pathological (disease), periprosthetic (mechanical weakness), avulsion (pulling)

Why is fracture classification important?

Ensures standardisation, consistent description, and reflects severity

What are the components of the AO/OTA alphanumeric code?

B L T G S Q Um

Bone → Location → Type → Group → Subgroup → Qualifications → Universal modifiers

What are the simple fracture groups?

Spiral, Oblique and Transverse

What defines a wedge fracture?

a triangular piece of bone is created, usually because the bone has been compressed from one side; wedge may be intact or fragmentary

What defines a Multi-fragmentary fracture?

Many fracture lines and fragments; previously called “complex.”

What are the three end‑segment fracture types? EPC

Extra‑articular (A), Partial articular (B), Complete articular (C)

What is the difference between open and closed fractures?

Open fractures communicate with the external environment (e.g. femur poking through the skin)

What is an incomplete fracture?

Cortex not fully broken; includes greenstick, torus, buckle.

6 types of bone alignment

What is a scaphoid fracture?

What is a Colles fracture?

What is a Monteggia fracture?

What is a Jones fracture?

SF- FOOSH, most common

Colles - Distal radius fracture with dorsal displacement and angulation

Monteggia - Proximal ulna fracture + radial head dislocation

Jones - Fracture of the 5th metatarsal diaphysis

What is a Weber A fracture?

What is a Weber B fracture?

What is a Weber C fracture?

Weber A - Below syndesmosis; usually stable

Weber B - At level of syndesmosis; variable stability

Weber C - Above syndesmosis; unstable; requires ‘Open Reduction Internal Fixation’

What is a Lisfranc injury?

Lisfranc - crush injury, gap between 1st & 2nd prox. MT heads

What are the three hip fracture regions? S I S

Subcapital (intracapsular), intertrochanteric, subtrochanteric

Garden Classification System - 1 to 4

1 → best outcome, bone ends are impacted into one another

2 → less stable, minimal displacement, anatomically normal position

3 → complete fracture, partial displacement

4 → complete fracture with total displacement, bones are separated

When is an ankle X‑ray required (Ottawa Rules)?

• Pain in malleolar zone

• Bony tenderness (medial/lateral)

• Inability to weight bear

When is a knee X‑ray required (Ottawa Rules)?

• Age ≥55

• Inability to bear weight

• Inability to flex to 90°

• Patella or fibular head tenderness

When is a foot X‑ray required (Ottawa Rules)?

• Pain in midfoot

• Tenderness at base of 5th MT or navicular

• Inability to weight bear.
  

How are dislocations coded in AO/OTA?

Distal bone number + “0” + region letter + [direction modifier]

What must always be checked after a dislocation?

Neurovascular status + post‑reduction films

What is a Salter‑Harris II fracture?

Fracture through the growth plate of a child’s bone

What are the 6 core cardiorespiratory problems?

1. Respiratory failure

2. Increased work of breathing

3. Sputum retention

4. Loss of volume

5. Pain

6. Decreased exercise tolerance

What are the steps of the clinical reasoning cycle?

P C P P G A E R

Consider patient → Collect cues → Process info → Identify problems → Establish goals → Take action → Evaluate → Reflect

What information is essential in a pre‑op assessment?

• Presenting condition

• PMHx

• Social & functional history

• Investigations

• Planned procedure

• Special orders

• Baseline respiratory status

• Pain

What does the pre‑op physical assessment include?

• Observation

• Palpation

• Auscultation

• Cough

• LL assessment

• Special tests

What should be taught pre‑operatively?

Breathing exercises, circulation exercises, supported cough, bed mobility, transfers, post‑op exercises

What subjective info is gathered post‑op?

• Pain

• Cough

• Shortness of breath

• PMHx

• Smoking

• Social/functional history

• Nausea

• Dizziness

• Drowsiness

• P&N/numbness

What must be documented post‑treatment?

• Distance mobilised

• Assistance level

• Tolerance

• Effect

• Adverse events

What problems does physio treat in ortho patients? P S B Ml Et N

• Pain

• Decreased strength/ROM

• Balance issues

• Decreased muscle length

• Decreased exercise tolerance

• Neurological issues

What to look for in a pre-screening of a respiratory assessment?

C RR Exp A

Cough – Effective? Productive?

Observe RR – Work of breathing

Normal bi-basal expansion

Auscultation - Normal breath sounds

What to look for in a pre-screening of a circulatory assessment - DVT

Commonly seen in the calf and assessed by looking for:

• Swelling of the calf

• Redness of the calf

• Localised pain/tenderness

• Increased temperature on palpation

• Positive Homan’s sign (calf pain on passive ankle dorsiflexion

What are the 4 cardinal signs of Orthopaedic Musculoskeletal Assessment?

1. Mobility Level (Independence)

2. Range of motion

3. Muscle Strength

4. Balance

What are the 3 mobility classifications? ASI

1. Assistance (hands-on)

2. Supervision (verbal cues only)

3. Independent

What are the 6 Signs and Symptoms: Post-surgical chest infection

1. SpO₂ <90% after 2 days

2. X-ray findings

3. Temp >38°C after day 1

4. Productive sputum

5. Abnormal auscultation

6. Increased white cell count

What are 3 common post‑op respiratory complications?

Atelectasis (reduced PaO2, FRC, lung compliance), chest infection, hypoxemia

2 types of atelectasis?

Obstructive

• Bronchial obstruction occurs and there is progressive collapse of the airways distal to the obstruction.

Non-Obstructive

• Compressive (surgery; tumor; pneumothorax; hemothorax; abdominal content weight; pleural effusion)

• Passive (loss of negative pressure in pleural space)

• Adhesive (loss of pulmonary surfactant)

• Cicatrizing (wound that leads to scarring).

What reduces mucociliary clearance?

• Medications

• Dehydration

• High FiO2

• Decreased cough

• Pollutants

What are the routes of pain relief?

Slower Acting

• Oral (paracetamol, tramadol)

• Subcutaneous narcotic (morphine)

• Intramuscular narcotic (morphine)

Faster Acting

• Intravenous - (morphine, fentanyl)

Continuous Acting

• Epidural (ropivocaine, fentanyl)

• Nerve Block - continuous infusion or local infiltration in theatre

Patient Controlled - Intermittent

• Patient Controlled Analgesia - PCA

Operative Anaesthetic

• Spinal (wears off 3-4 hours post surgery)

• General (associated with respiratory complications - atelectasis…)

ITU (sedatives)

Neuromuscular blocking agents

Time to action (5-30minutes) - plan your treatment times around this where possible

What is the physio approach to decreased exercise tolerance?

• Early mobilisation

• Sit out of bed

• Short walks

• Self‑care

• Exercise testing

• Aerobic/anaerobic/strength training

Operation Type - Total Hip Replacement, Prosthesis & Management

Most commonly used prosthesis:

• 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

Day 0 → hip ROM, bridging, bed mobility

Day 1 → mobilize out of bed, rollator

Day 2 → sitting 30 mins initially depending on symptoms

THR - 2 approaches + their advantages/disadvantages

Posterior - Most common, easiest for surgeon

• dislocating position - flex more than 90, FADIR

Anterior + Anterolateral - more difficult for surgeon,

• dislocating position - forced extension + ADDER

Complications → sciatic nerve damage, DVT, re-dislocation, infection, loosening of components

Operation Type - Birmingham Hip Resurfacing

• All-metal bearing couple is used to preserve, rather than replace, a patient’s femoral head and neck

• Goals: indep. mobility, home exercise program, stairs & car

Operation Type - 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.

Meniscectomy: loose fragment excised, flap or oblique tear

Meniscal repair: only if located in periphery of meniscus as adequate blood supply for healing

Chondroplasty: removal or repair/smoothing of cartilage

Ligament repair and replacement: e.g. Anterior Cruciate Ligament reconstruction

Arthroscopic Knee Surgery - 3-way patella realignment

Tibial tuberosity transfer

• Removing the tibial tuberosity medially

Lateral release

• Releases tight lat. retinaculum + vastus lateralis

Medial Plication

• folding/tucking/tightening of medial structures

Operation Type - High tibial osteotomy (knee)

Proximal part of the tibia is cut and realigned to change how weight is distributed through the joint.

Factors: under 65, not overweight, 90deg flexion, non-smoker, higher activity level

Total Hip Replacement - Post Op. Management

Day 0 or 1 - hip ROM, quad exercises, bridging, bed mobility as aim, get out of bed on un-affected side

Day 1 Sitting - 30 minutes initially

Day 2 - progress ROM/strength, balance exercises, stairs, car transfers

Operative Type - Total Knee Replacement

Femoral and tibial metal component with a polyethylene spacer

• Gold standard for OA patients

• Post-op → analgesia, nerve blocks, pain busters

• Goals → knee flexion, indep. mobility, single leg reach

Day 0-1 Exercises/Mobility - quad exercises, flee flexion, mobilization, out of bed un-affected side, sitting allowed 30 mins, ice

Operative Type - Uni-compartmental knee replacement

Procedure similar to TKR, however only one compartment is replaced

• other compartment must be healthy

Operative Type - ACL Reconstruction + Indication

Indications: Significant functional disability due to instability

• Synthetic grafts (carbon fibre)

• Allografts (cadaver tendon donation)

• Autografts (hammys tendon)

Operative Type - Toe deformity surgery

Procedure: Osteotomy (cutting & replacing bones) of 1st Metatarsus Valgus

What are 4 examples of fracture complications? An Ji Du C

1. Avascular necrosis

2. Joint instability

3. Delayed union of fracture site

4. Complex Regional Pain Syndrome (CRPS)

Physio role in trauma surgeries? (5)

1. Joint mobilisation

2. Swelling management

3. Pain management

4. Walking aids

5. Exercises

Surgical Management - Open Reduction Internal Fixation (ORIF)

4 Causes of Hip Fractures

1. Simple fall - direct blow to the hip

2. Trip and fall - rotational force

3. Spontaneous - pathological

4. Traumatic fall - MVA, skiing etc

(Displaced) or (Undisplaced)

Clinical Features of a Hip Fracture (displaced vs undisplaced)

Displaced

• pain

• limb shortened / externally rotated

• unable to weight-bear

Un-displaced

• pain

• no change in limb orientation

• can sometimes weight-bear

• sometimes difficult to pick up on

• Xray → MRI/CT or bone scan for diagnosis

Hip Surgical 4 Management Types

Garden I & II → Cannulated screws (un-displaced)

Garden III & IV → Hemiarthroplasty (displaced)

Intertrochanteric → dynamic//compression/Richards hip screw

Subtrochanteric → pin & plate

1’s or 2’s a pin or screw, 4’s or 3’s a hemi-arthroplasty

Signs and Symptoms of Post-op Delirium

• Decreased attention, disorganized thinking, irrelevant speech, disturbed sleep cycle, disorientation, memory impairment