Joint Replacements and Hip Fractures

Fractures

• Closed (simple) fracture: The skin is intact 

• Open (compound) fracture: The bone breaks through the skin 

• Greenstick fracture: An incomplete break that's common in children 

• Transverse fracture: A break that runs straight across the bone

• Oblique fracture: A break that runs diagonally across the bone 

• Spiral fracture: A break that spirals around the bone 

• Compression fracture: The bone is crushed, making it wider or flatter 

• Comminuted fracture: The bone breaks into multiple pieces 

• Segmental fracture: The bone breaks in two places, creating a "floating" piece 

• Avulsion fracture: A break where a tendon or ligament attaches to the bone 

• Hairline fracture: A stress fracture, often in the foot or lower leg

• Malunion fracture: A fracture that doesn't heal in the correct alignment 

• Nonunion fracture: A fracture that doesn't heal at all 

• Stress fracture: A fracture caused by repetitive strain on the bone 

Stable fracture vs Unstable fracture

A stable fracture is a broken bone that is unlikely to move out of place, while an unstable fracture is a broken bone that has moved out of place. Unstable fractures are more serious and can cause nerve damage or paralysis. 

Treatment

• Stable fractures

  Can be treated with a cast, brace, or splint, or with activity modification. 

• Unstable fractures

  Require more intensive treatment, such as surgery, to fix the bone and stabilize the joint. 

Open reduction internal fixation (ORIF) 

• Involves surgically realigning the broken bone

• Requires a surgical incision

• Uses screws, plates, wires, or nails to stabilize the bone

• Can help restore normal function

• May have negative effects like nerve damage, swelling, and blood clots

closed reduction internal fixation (CRIF)

• Involves resetting the broken bone without surgery

• Does not require a surgical incision

• Can avoid injury to the medial circumflex femoral artery

• May have negative effects like increased intracapsular pressure and reduced blood supply to the femoral head

Hip fracture

•Medical management:

• Traction

• Casting (immobilization)

• Brace/functional cast

• External fixation

• Open reduction internal fixation- ORIF

• Gamma nail

• Closed reduction internal fixation- CRIF

•Weight bearing restrictions

• NWB- No WB

• TTWB- Balance, egg shell

• PWB- Up to 50% of body weight

• WBAT- Tolerance

• FWB- 100% of body weight

Types of Hip Fractions

1.Femoral Neck Fracture*

2.Femoral Head Fracture

3.Intertrochanteric Fracture*

4.Subtrochanteric Fracture

Femoral Neck Fracture

Includes: subcapital, transcervical and basilar fractures

⮚Intervention: Base upon displacement and viable circulation.

•Hip pinning- mild to moderate displacement, blood supply intact (internal fixation [reconnecting the bones])

•Hemiarthroplasty- severe displacement of femoral head, avascular site, nonunion, DJD (degenerative joint disease)

Femoral Head Fractures

Includes: Upper “ball’ of femur

⮚Intervention: Base upon displacement and viable circulation.

•Non-surgical approach- Limited WB

•Surgical approach- Full arthroplasty Vs. Hemiarthroplasty -severe displacement of femoral head, avascular site, nonunion, DJD

Intertrochanteric Fracture

Includes: Area between the greater and lesser trochanter, or outside the articular capsule.

⮚ Intervention: Open reduction internal fixation (ORIF); gamma nail or screw with a compression plate.

Subtrochanteric Fracture (mostly falls)

Includes: 1 to 2 inches below the lesser trochanter.

⮚Intervention:  Requires traction prior to ORIF.  Use aintramedullary rod or gamma nail with a long side plate.

Total Hip Replacement/Arthroplasty

Procedure: Removal of arthritic joint surfaces- femoral head and acetabulum (with stem inserted into femoral canal) using metal, plastic or ceramic components

Complications/Risks: Blood clots, infections, nerve damage, dislocation

• foot drop

Conservative treatment (prior to THR)

Long term fix: Total Hip Arthroplasty (THA or THR)

Approaches

1. Posterolateral Approach

• Traditional approach on back of hip/buttocks

• Required muscle/tissue cutting

2. Anterolateral Approach

• Newer approach, used with oscillating table

• Separation of muscles to access front of hip joint

Hip Precautions: Posterolateral Approach

•No hip flexion > 90 degrees

•No internal rotation

•No Adduction (no crossing legs)

•No extreme twisting at hips

Hip Precautions: Anterolateral Approach

•No external rotation

•No adduction ( no crossing legs)

•No hip extension

OT’s Role for Hip Replacement

•Occupational profile

• how were you prior to this?

•ADL

•IADL

•Safety

•Education

• (hip precautions)

• energy conservation

• dynamic standing tolerance

•Functional mobility

•AD/AE/DME training

•Pain management

Equipment

• a walker, cane, crutches

• a reacher

• a chair with armrests

• a hip cushion

• a sock aid, leg lifter, elastic shoe laces, and a long-handled shoehorn

• a non-slip bath mat

• a raised toilet seat

• toilet arm rests

• a long-handled sponge or brush

• a shower seat (chair) for a walk-in shower

• a tub seat and clamp-on tub bar for metal tubs

• a transfer bench for a fiberglass tub (your healthcare team will let you know which type to get)

• exercise equipment, like an elastic loop

• Abductor pillow

Transfer with a hip Replacement

•Proper DME – 2WW

•Sitting down

• Toilet transfers

• Surface <> surface

•Standing up

•Car transfers

Total Knee Replacements (TKR)

• Procedure: Removal of the arthritic bone

• Complications/Risks: Blood clots, infections, nerve damage

• Precautions

• Materials used for the replacement

  • Cemented Vs. Noncemented

  • Fixed Vs. Rotational plate

• TKA Vs. UKA (unicompartmental knee arthroplasty)

TKR Surgical Approach

• Incision (anterior portion)

• Remove/smooth joint surfaces

• Replace 3 components:

1.Tibial component

2.Femoral component

3.Patellar component

Knee Precautions

•Avoid pivoting/twisting at knee

•Do not kneel

•Do not squat

OT’s role in TKR

•Occupational profile

•ADL

•IADL

•Safety

•Education

•Functional mobility

• 2WW

•AD/AE/DME training

• CPM- Continuous passive movement

•Pain management

Shoulder arthroplasty/replacement (TRS)

1.Etiology

• Hemiarthroplasty

  • Only humeral head is replaced (humeral fx’s)

• Total shoulder arthroplasty (TSA) or Total shoulder replacement (TSR)

  • Humeral head replaced with ball & glenoid surface replaced with cap

• Reverse total shoulder arthroplasty (RTSA)

  • Humeral head replaced with cap & glenoid surface replaced with semi-circular ball

  • Rotator cuff tearing

  • failed TSR

2. Provides decreased pain, increases functional use of UE and enhances QoL

3. Complications

Post Surgical Precautions

•Immobilizer, sling

•Protocol for mobilization (per surgeon)

•Positioning of shoulder

•WB (per surgeon)

•Pain management

•CyroCuff

Traditional TSR Recovery

Week 1:

• AAROM/PROM

• 90 degrees flexion

• 45 degrees abduction

• 0 degrees shoulder extension (neutral)

• 30 degrees internal rotation (immobilizer position)

• Codman’s Pendulum

Week 2 -4 :

• Increase AAROM/PROM

Week 4 - 6 :

• AROM, strengthening, and WB restrictions lifted

Week 7+:

• Strengthening, stability WFL of AROM

Revers TSR Recovery Guidelines

Week 1:

• PROM

• 90-120 degrees flexion

• 90 degrees abduction

• 0 degrees shoulder extension (neutral)

• 30 degrees internal rotation (immobilizer position)

• Codman’s Pendulum

Week 2 -4 :

• Isometric exercises, AAROM, AROM (week 3-4)

Week 6 :

• AROM, strengthening, and WB restrictions lifted

Week 7+:

• Strengthening, stability, WFL of AROM

OT’s role for Shoulder replacement

•Occupational profile

•ADL

•IADL

•Safety

•Education

•Functional mobility

•AD/AE training

What else is so special about joint replacement

•Pain

•Hospital stay

•Outpatient/homecare/ rehab services

•Complications/risks: dislocation, degeneration of parts/materials, infections, blood clots, loosening of parts, fractures of proximal bones

•Psychological factors (fear, anxiety, sexual activity)

•What is OT’s role in a general joint replacement process?