Complex patient

what is lipohaemoarthrosis

presence of blood and fat in a joint cavity that nearly always signals an acute intra-articular fracture

you examine this x-ray and identify a fracture as well as associated blood and fat in the joint cavity, what is this phenomenon called

Lipohaemoarthrosis

posterior fat pad is visible on a lateral xray of elbow, identify this phenomenon, why it occurs and what is likely to also be found on xray

Positive sail sign

Visible posterior fat pad occurs when joint effusion (from injury) fills olecranon fossa, psuhing the posterior fat pad out and making it visible

A fracture is likely to be found if there is +ve sail sign

Describe traumatic fracture and provide example

Fracture caused by abnormal force e.g. MVA, fall

Describe pathological fracture and provide example

Fracture in bone weakened by disease e.g. osteoporosis, tumor

Describe periosthetic fractures

Fracture at the point of weakness around a prosthetic implant or prior ORIF

Describe open/compound fractures and an associated risk

Broken bone pierces skin, high risk of infection

Describe buckle/torus fractures and how they occur

compressive forces cause one side of bone cortex to buckle and bulge outward and other side remains intact

describe what the arrow is pointing at and how it occurs

torus/buckle fracture whereby compressive forces cause one side of bone cortex to buckle and bulge outward whereas the other side remains intact

describe greenstick fractures and how they occur

bending forces cause bone cortex to fracture on one side

Identify the 3 types of simple fractures

Spiral, oblique, transverse

Identify the 2 types of wedge fractures

Intact wedge, fragmentary wedge

Identify the 2 types of comminuted/multifragmentary fractures

Intact segmental, Fragmentary segmental

Scaphoid fracture

-most common MOI

-clinical finding

FOOSH + tenderness over asb

note a specific scaphoid view is required xray

Colles fracture

-Describe what occurs

-Most common MOI

-Clinical finding

-Common associated fracture

Transverse + partial fragmentation of distal radius that angles dorsally

FOOSH

Dinner fork deformity due to dorsal angulation of radius fragment

Associated transverse fracture of ulnar styloid

Describe what happens in a monteggia fracture

Fracture of proximal ulna + disclocation of radial head

Describe what occurs in a galeazzi fracture

Fracture of distal radius + disruption of distal radio-ulnar joint (DRUJ)

You examine an xray and find a fracture of the distal radius, what structure should you also examine for damage/pathology

Distal radio-ulnar joint (incase of galeazzi fracture)

You examine an xray and find a fracture of the proximal ulna, what structure should you also examine for damage/pathology

Radial head (incase of radial head dislocation in a monteggia

Describe what findings we would see in an ankle fracture with a grade A Weber classification

Fracture distal (below) to syndesmosis

Syndesmosis intact

Deltoid ligament intact

Usually stable

Describe what findings we would see in an ankle fracture with a grade B Weber classification

Fracture AT the level of the syndesmosis

Syndesmosis intact or partially torn

Deltoid may be torn

Variable stability

Describe what findings we would see in an ankle fracture with a grade C Weber classification

Fracture proximal (above) syndesmosis

Syndesmosis disrupted

Deltoid/medial malleolus involved

UNSTABLE - needs ORIF

you examine an xray and find an ankle fracture proximal to the syndesmosis

-what structure(s) will we most likely see damage involved in, as well (other than syndesmosis)

-can we expect this pt ankle to be stable or unstable? Is any specific treatment required?

We can expect medial malleolus or deltoid ligament to be involved

Unstable - requires ORIF

Identify the weber classification of ankle fracture given the following description - fracture distal (below) to syndesmosis, syndesmosis intact, deltoid ligament intact, usually stable

Weber A

Identify the weber classification of ankle fracture given the following description - fracture AT level of syndesmosis, syndesmosis intact or partially torn, deltoid ligament may be torn, variable stability

Weber B

Identify the weber classification of ankjle fracture given the following description - fracture proximal (above) to syndesmosis, syndesmosis disrupted, deltoid ligament or medial malleolus involved, UNSTABLE (ORIF)

Weber C

identify the structures affected in a trimalleolar ankle fracture

medial and lateral malleolus, posterior malleolus (distal posterior tibia)

Describe what occurs in a jones fracture and what specific imaging is needed to detect it and distinguish from lateral ankle sprain

Fracture of diaphysis of 5th metatarsal, AP/Oblique/Lateral foot views with foot fully dorsiflexed required

Identify what part of the 5th metatarsal is affected in a jones fracture

Diaphysis

what xray sign can we see in lisfranc injuries

gap between base of 1st and 2nd proximal metatarsals

Pt presents with pain and swelling over midfoot and bruising on sole of foot following a fall from height, what is your primary hypothesis for diagnosis without imaging

Lisfranc injury

Pt presents with pain over midfoot after dropping a couch on foot whilst moving house, upon xray inspection you find a gap between base of 1st and 2nd proximal metatarsals, what is your primary hypothesis for diagnosis

Lisfranc injury

What specific xray view is most specific for detecting lisfranc injuries

weight bearing AP view

Identify the most common MOI for fracture of 5th metacarpal and describe why this occurs

Punching with closed fist places big axial load on metacarpal head causing transverse (most commonly) fracture of metacarpal shaft/head

describe what ACTIVE movement would be lost in someone who has suffered mallet finger

DIP extension

describe what ACTIVE movement would be lost in someone who has suffered mallet finger and describe why this occurs

Hyperflexion injury at DIPJ avulses the extensor tendon attachment from dorsal base of distal phalanx, causing loss of DIP extension

Describe subcapital/intracapsular hip fractures

Fracture at or just below the femoral head

Describe subtrochanteric/extracapsular hip fractures

Fracture between greater and lesser trochanters, outside the capsule

Describe subtrochanteric hip fractures

Below lesser trochanter

Which garden classification of intracapsular hip fracture has BEST prognosis and describe it

Garden 1 - Incomplete/impacted fracture, facilitates vascular regrowth

Which garden classification of intracaspular hip fracture has WORST prognosis and describe it

Garden 4 - Complete, full displacement greater than 50%, bone ends fully seperated, highest AVN risk

Describe Garden 1 Intracapsular hip fractures

Incomplete/Impacted, bone ends impacted into eachother, best prognosis, facilitates vascular regrowth

Describe Garden 2 Intracapsular hip fractures

Complete/non-displaced, fracture line complete but minimal bone end shift, less stable but good prognosis

Describe Garden 3 Intracapsular hip fractures

Complete, partial displacement less than 50%, vascular compromise likely, worse prognosis

Describe Garden 4 Intracapsular hip fractures

Complete, full displacement greater than 50%, bone ends fully seperated, worst prognosis, highest AVN risk

What are the 3 clinical rules for dislocation/fracture

1. ALWAYS reduce the dislocation

2. ALWAYS check neurovascular status before AND after reduction

   1. ALWAYS obtain post redcution xrays to confirm satisfactory position

In displaced garden 3/4 fractures, what surgical management is indicated

Hemiarthroplasty, THR

Recall ALL of the ottawa ankle rules

Tenderness over posterior edge or tip of medial or lateral malleolus

Tenderness over navicular

Tenderness over base of 5th metatarsal

Inability to weight bear

Recall ALL of the ottawa knee rules

Age 55 or older

Unable to flex knee to 90deg

Unable to weight bear

Point tenderness at proximal fibular head

Isolated point tenderness of the patella

Identify the 6 core cardiorespiratory problems

Type 1/2 respiratory failure

Increased WOB/breathlessness

Sputum retention

Loss of volume

Pain

Reduced exercise tolerance

What should be included when educating a patient pre-operation, what should we also demonstrate to the patient

Role of physio

Expected post op experience

Effects of surgery

Early mobilisation

Pain relief importance

Demonstration of breathing exercises, circulation exercises, supported cough, bed mobility/transfers, post-op exercises

When performing a circulatory assessment how do we conduct a DVT screen

Assess the patients calf for swelling, redness, localised pain/tenderness, increased temperature, positive Homans sign (calf pain on passive ankle DF)

What would we see in a positive Homans sign and what does it test for

Calf pain on passive ankle dorsiflexion, tests for DVT

note low sens and spec, often false positives

If a patient has had spinal/epidural anesthetic used during their surgery/operation, what assessment is required and what should be included?

Neurological assessment - hip, knee, ankle strength and sensation

Identify some patient related risk factors for post-op complications

Smoking Hx

Age >60

Obesity (BMI >27)

Immobility

Pain

Medications

Identify some procedure related risk factors for post-op complications

Location - upper abdomen or thorax

Prolonged anesthesia >180mins

Emergency vs Elective surgery

Identify the most common post surgical complication and describe it

Atelectasis - collapse of avleoli, up to 10-15% of lung tissue can collapse within 15min of sedation

Clinical signs of post-surgical atelecatasis

Reduced PaO2, reduced lung compliance, reduced FRC

Non-productive cough, tachycardia, tachypnea, wheeze, chest pain

Changes on CXR, auscultation and percussion

Clinical signs of post surgical chest infection

SpO2 less than 90% on 2 consecutive days

Temperature >38 deg after day 1 post-op

Productive sputum

Abnormal breath sounds on auscultation

WCC raised

Infiltrates/consolidation on CXR

Opiod/narcotic analgesia side effects and mx for each one

Drowsiness/reduced respiratory drive - requires supplementary O2

Nausea/vomiting - managed with antiemetics

When should physiotherapists plan treatment times for post operative patients

Around analgesic onset

Identify benefits of early mobilisation

Prevents immobilisation effects

Increases minute ventilation

Increases cardiac output

Maintains muscle strength

Provide an example of how we can gradually progress mobilisation in stages

e.g. stage 1 - in bed exercises

Stage 1 - Breathing and circulation exercises in bed

Stage 2 - Sit out of bed (legs over edge, then chair)

Stage 3 - Walk short distances with appropriate aid

Stage 4 - Self care (hygiene, dressing)

Stage 5 - Progressive distance, stairs, independence

When should we commence mobilisation of patient

As soon as pt is haemodynamically stable

Identify some factors to consider before mobilising a pt

Incision location and type

Level of pain and adequacy of analgesia

presence of adverse effects (dizziness, N&V)

Attachments (IV lines, drains, catheters, O2)

Assistance available vs required

Equipment available (walking aids, chairs)

Pre existing conditions and premorbid mobility level

Identify the dislocating location for a posterior THR approach

Flexion >90deg, adduction past neutral, IR past neutral (or combined)

Identify the dislocating location for a anterior/anterolateral THR approach

Forced extension; flex or ext with Add+ER

THR post-op management (day 0, 0-1, 1-2, 2)

Day 0 - circulorespiratory exercises, hip ROM and quads (hip flexion limited to 90deg), IRQ, bridging/bed mobility

Day 0-1 - FWB, mobilise via unaffected side, rollator initially

Day 1-2 - Sitting, allow 30mins initially, progress as tolerated

Day 2 - Progress ROM/strength, balance ex, progress aid to 4WW/crutches/SPS, stairs, car transfer

*Discharge target day 3-5

Recall hip precautions post THR (lifelong; strict first 12 weeks)

No hip flexion beyond 90deg

No adduction past neutral

No IR past neutral

Do not sit in low chairs or cross legged

Do not lie on affected side

Do not squat or bend from hips

No twisting on affected leg in standing

No driving for 6 weeks until cleared by surgeon

Identify possible post-operative complications of THR

Dislocation, DVT, infection, component loosening

Identify possible peri-operative complications of THR

scaitic nerve damage (foot drop), poor acetabular positioning, acetabulum/femur fracture, excessive blood loss

Describe what occurs in a hip arthrodesis

Fusion of femur and pelvis at 15-20deg flexion, neutral abduction and rotation

Describe what occurs in a Girdlestones procedure (excision arthroplasty)

Surgery that removes femoral head and neck, results in limb shortening

Describe what occurs in a birmingham hip resurfacing and advantages of this procedure

Metal cap replaces femoral head and metal cup for acetabulum, preserves femoral head/neck, less bone resection, good long term outcomes

Physio Mx for a menisectomy

FWB, rapid rehab = ROM, SLR, IRQ, limit walking to manage swelling

Physio Mx for a meniscus repair

PWB or NWB on crutches, ROM, IRQ, SLR, manage swelling

Advantage of meniscal repair > menisectomy

Preserving meniscus reduces OA risk

Physio Mx for a ACL reconstruction

Surgeon dependent, usually FWB, clsoed chain exercises for 3months, no open chain for 6-12 weeks

Identify 4 types of ACL grafts that can be utilised for reconstruction

Synthetic (LARS), allograft (cadaveric), hamstring autograft, patellar tendon autograft

Advantage/Disadvantage of synthetic (LARS) grafts for ACL reconstruction

Adv - quicker return to sport

Disadv - no significant diff at 24 months, history of failures

Advantage/Disadvantage of allograft (cadaveric) grafts for ACL reconstruction

Adv - no donor site pathology, shorter op, replaced by new tissue

Disadv - rejection risk, rupture risk (esp donors >30-35yrs old)

Advantage/Disadvantage of hamstring autografts for ACL reconstruction

Adv - good strength, no anterior knee pain

Disadv - elastic creep leads to slightly lax graft

Advantage/Disadvantage of patellar tendon autografts for ACL reconstruction

Adv - strong, replaced b new tissue

Disadv - anterior knee pain, donor site pathology

What is the gold standard procedure for severe knee OA

total knee replacement

discharge criteria for those in rehab for TKR

SLR with <5deg lag, >/= 90deg flexion, stairs, independent HEP, target day 3-5

what procedure is used for those with medial tibiofemoral OA with varus/valgus deformity

High Tibial Osteotomy (HTO)

Describe what occurs in a HTO

Bone is divided and repositioned to align tibia and femur to distribute laod more evenly

TKR post-op management (Day 0 and 1 exercises, Day 0-1 mobility, Sitting, goals)

Day 0 ex - circulorespiratory exercises

Day 1 ex - Quads, active/assisted knee flexion (aim 90deg), IRQ, SLR

Day 0-1 mobility - FWB/WBAT, out of bed on unaffected side, progress rollator to crutches

Sitting - day 1-2, 30 min initally, apply ice

Goals - Knee flexion >90deg, extension 0deg, SLR, HEP independence, stairs

Clinical features of a displaced NOF#

pain, limb shortened and externally rotated, unable to WB

Clinical features of an undisplaced NOF#

pain, no limb orientation change, sometimes can WB, harder to detect may need MRI/CT/bone scan

Physio Mx for #NOF

Mobilise day 1 (generally WBAT unless young pt <65)

Easily fatigued (focus on functional activities only)

Analgesia pre mobilsiation, appropriate walking aid, miminise bed rest but ensure adequate rest time

Exercises similar to THR (Circulo-respiratory exercises, hip ROM & quads (hip flexion limited to 90°), IRQ, bridging/bed mobility) however, consult with nursing staff/surgeon

What 2 diagnostic features are ALWAYS present in psot operative delirium

Decreased attention

Disorganised thinking

Identify diagnostic features of post operative delirium

Decreased attention, disorganised thinking (always present)

Rambling/irrelevant/incoherent speech

Decreased consciousness, hallucinations/misinterpretations, disturbed sleep cycle, memory impairment, disorientation to time/place/person

Physio Mx for ankle fractures

NWB, moonboot day 1 if swelling allows, elevate 10 days, IRQ, SLR, hip/knee flexion, hip abd/add

Identify 3 TSJR indications

Hard to control pain, esp if affecting sleep/ADLs

Posterior humeral head subluxation

Glenoid cartilage degeneration (preferred over hemi for OA)

Identify 5 contraindications for TSJR

Insufficient glenoid bone stock

Rotator cuff arthropathy

Irrepairable rotator cuff

Deltoid dysfunction

Active infection

Identify 4 reverse TSJR indications

Cuff tear arthropathy

Rotator cuff insufficiency

Anterior-superior escape

3 or 4 part fractures

Identify factors in a pt that would make a reverse TSJR appropriate (not indications)

Low functional demand

>70yrs old

Sufficient glenoid bone stock

Must have working deltoid muscle

Must have intact axillary nerve

Why must someone have a working deltoid muscle to be an appropriate candidate for reverse TSJR

Deltoid is the main muscle for movement post-op, hence must also have workign axillary nerve

Post-op physio for TSJR

Circulation ex, mobilise out of bed day 1

Shoulder immobiliser sling until week 6

No WB through shoulder, no lifting

Exercises = elbow, wrist, hand + grip, c-spine

PROM = flexion 90deg, ER to 0deg

Progress to ER isometrics

Limit passive ER

IR eccentric and isometric