PT7130- Orthopedics in Acute Care

2 different; WB; ROM; wait

Orders and Chart Review:

- May see physical therapy orders from ________________________ physicians

- Always refer to orthopedic guidelines:

→ ___________________ status (i.e., For every extremity affected, what is WB status?)

→ ____________________ guidelines

→ Exercise restrictions (i.e., no SLR after hip fracture and repair)

- What tests and measures did the physician order: x-ray, CT, MRI → _______________________ till post-op imaging has been completed

All joints; sensation; transfers; gait

Exam and Eval:

- Screen _____________________ ROM and strength

- Screen _______________________

- Assess edema/swelling

- Assess bed mobility and _______________________

- Assess balance, ______________________, and stairs

WB status

Always explain the ________________________ to the patient!

Weight-bearing; equipment use; community; fatigue

Other Considerations:

- Prior level of function

- Compliance /c current ________________________ restrictions

- Compliance /c ________________________ and safety

- Ability to self monitor, risks for falls, insight and judgement (consider evaluation environment)

- Speed and velocity of functional movement → More important for _________________________ ambulators

- Onset of ________________________

- Body mechanics

Orthopedic consult; holding

If a fracture is present, an _________________________ is almost always indicated.

- Follow orthopedic guidelines/restrictions/precautions

- Conservative or surgical management

- May require _____________________ on a PT consult (short-term)

Hospitalist

99% of the time, PT is held until orthopedics has been involved. If ______________________ can manage the fracture (i.e., pinky fx, great toe fx), then ortho is not consulted.

Non-urgent

- Stable fracture

- Intact neurovascular system

Elective

Failed conservative treatment.

Urgent

- Time frame for management: 24-72 hours

- Closed, unstable fractures

- Intact neurovascular system

Emergent

- Requires immediate attention

- Open fractures

- Fracture/dislocation with impaired neurovascular system

- Spinal injuries with deteriorating neurologic deficits

Fracture reduction

Alignment of fracture fragments.

Closed reduction

Noninvasviely /c manual manipulation.

Open reduction

Surgical stabilization /c hardware.

Open reduction internal fixation (ORIF)

Uses screws, plates, rods, and pins internally to promote immobilization for healing. → May requires additional external support /c external fixation.

External fixation

Provides alignment forces to fracture fragments and maintains reduction while healing.

Comminuted; open

External fixation is appropriate for severely _________________________ or _________________________ fractures.

ROM; vibrations; swelling

Therapy Implications of External Fixation:

- Maintain full _______________________ of all joints above and below external fixator

- Avoid any type of _________________________

- Clear drainage, slight bleeding, redness, and __________________________ at pin sites is normal

Chuck's pad

Do not lift /c rods of external fixation device! Use _______________________ to create a sling when possible.

Platform walker

What does image show?

Total joint arthroplasty

Used for severe degenerative arthritis or severe damage to joint. Also used when conservative measures are failed, such as pain medication, using assistive devices, activity/lifestyle modification, cortisone injections, lubrication injections.

Bilateral

Total joint arthroplasty can be elective vs. non-elective and/or _________________________.

Days; surgeons

Bilateral joint replacement → Either spread across several ______________________ in hospital. -or- Two different _____________________ on knees at same time in operating room.

Pre-op

Total joint arthroplasties may have PT _____________________ and post-op.

Length of stay; cost; function; milestones

Guidelines and Order Pathways:

- ↓ _________________________

- ↓ __________________________

- Improve ______________________ while mandating clinical activities

- ________________________ expected on certain post-op days

Total hip arthroplasty

Replace femoral head and acetabulum.

OA, AVN, infection, congenital disorders, trauma

What are some indications for THA?

Restricted; WBAT

THA Weight Bearing Restrictions:

Uncemented → WB almost always _______________________

Cemented → ________________________

Functional mobility

THA has total hip precautions and implications for __________________________.

Posterolateral approach

THA has highest risk of dislocation acutely /c __________________________ → Fall risk reduction.

Cemented THA

- Most common

- Widely accepted over last 20 years

Early; tolerated

Cemented THA Precautions:

- Allows _____________________ WB

- Activity as _________________________

Uncemented THA

- Attaches directly to bone without cement

- Implant has a topography that is conducive for new bone growth

- Bone grows into surface of implant

Limited; limited; longer

Uncemented THA Precautions:

- ____________________ WB initially

- ____________________ ROM initially

- _____________________ healing time

No hip flexion >90°, no IR, no adduction past neutral

What are THA precautions for posterolateral approach?

No hip extension past neutral, no ER, no adduction

What are THA precautions for anterolateral approach?

0 or 1; foot drop; quad; education; stairs; pivoting

Physical Therapy for THA:

- Post-op day ______________________ pending no complications

- Check sensation and strength → Sciatic n. and femoral n. palsy can lead to ______________________ and _____________________ weakness (always check ankle DF)

- Focus on gross mobility /c relation to new hip precautions → _______________________ on do's/don'ts /c regard to functional implication

- Focus on gait and _________________________, assistive device training and safety; avoid _________________________

Precuations; elevated; abductor pillow

Physical Therapy for THA Cont'd:

- Gentle HEP of AROM/PROM/AAROM hip within _________________________

- DME recommendations: _________________________ toilet, BSC, etc.

- Car transfers and rolling → Cannot roll onto operative side, can roll onto non-operative side /c __________________________ secured in place to maintain hip precautions.

Sensation; stand patient up

Anesthesia for THA:

Regional Nerve Block → Spinal (Epidural) -or- General Anesthesia

If spinal (epidural) was administered, check bilateral _______________________ along entire LE, do not ________________________ if sensation has not fully returned.

Total knee arthroplasty (tricompartmental)

Replacement of both condyles, tibial plateau, dorsal surface of patella.

Partial knee arthroplasty (unicompartmental)

Replacement of the worn femoral and tibial articulating surfaces (medial or lateral compartment) → 1/2 of femur

Quicker

Partial knee arthroplasty has ______________________ rehab, but usually depends on patient's pain tolerance and progress.

OA; traumatic; nonseptic

Indications for TKA:

- Severe _____________________

- RA

- _______________________ arthritis

- _______________________ arthropathy

Stair; assistive device; supine

Physical Therapy for TKA:

- ROM and strengthening exercises → Educate on exercises but let patient know that you don't expect them to do them post-op day 1

- Functional mobility, gait training, _______________________ training

- ________________________ safety

- Education on positioning while __________________________

ER; to sky; flexion; pillow

Post-TKA Positioning while Supine:

- No hip _______________________ → Bolstering to side of knee

- "Toes and knees ______________________ at all times"

- No prolonged knee _______________________ to avoid hamstring contracture

- No _________________________ beneath knees

Continuous passive motion (CPM) machine

What does image show?

Joint line

For CPM, _____________________ needs to line up /c joint of machine → May be responsibility of PT.

Conflicting; surgeon; should not

Continuous Passive Motion (CPM) Machine:

Not covered by insurance

- Evidence is _________________________

- __________________________ preference

- Uncomplicated TKA who does HEP _________________________ need this

3-6 hours; 100 ft ambulation; anesthesia

Rapid Recovery Programs:

Early mobilization ________________________ after operation

- Sitting EOB → _________________________

- Performed in recovery room /c adequate monitoring and close observation of vitals and tolerance

- May need to wait till __________________________ wears off to perform PT

Analgesic; quadricep; ↓

Benefits of Rapid Recovery Programs:

- Less _______________________ effects → Nausea and vomiting, orthostatic hypotension, dizziness

- Improved strength and ROM of ________________________

- _______________________ length of stay in hospital

Fail; obstructive sleep apnea

Most people are rapid recovery program patients unless:

- ___________________ PT day of

- Diagnosis of ______________________

Sepsis; antibiotic; cement spacer; immobilizer; leg length discrepancy

Total Joint Resection and Infection:

- ______________________ → Irrigation + debridement to clear infection, amputation as last resort

- Aspirate joint, take cultures

- _____________________ treatment, debridement, amputation

- Removal of joint for re-implantation

- ____________________ for the knee to maintain joint space, tissue length, and improve WB

- Knee __________________ for stability while joint is removed

- Education on shoe lift, gait training d/t ______________________

- May see varied WB status and bracing

Traction

Distractive force on an extremity to reduce a fracture, immobilize a joint, or decrease muscle spasm.

Alignment

Traction uses weights and pulleys to restore ________________________.

Skeletal traction

Pins and needles through bone.

Strict bedrest

What are PT implications of skeletal traction?

Skin traction

Boots, slings, belts applied directly to skin.

Can be removed intermittently

What are PT implications of skin traction?

Freely; isometric

PT Implications of Traction:

- Do not change positioning of HOB, FOB, placement of blankets, etc.

- Keep weights haning __________________________

- __________________________ or active exercise of uninvolved extremities