post op exam - week 2

if its healing

respect it! know procedure and how it limits ability to use muscles and joints

if there is discharge or cellulitis

refer it! call physician and send to ED

before you start the examination you myst know

date of surgery, the type of surgery, and post op protocol

for post op exam what elements may be eliminated from the examination process

selective tissue tensioning (no need for special tests diagnosis), AROM (allow healing), MMT (allow time to heal)

what additional elements are included in the post op exam

incision site examination, pain management, systemic signs of infection, neurovascular downstream

pt history clinical pearls

how are you feeling after surgery, is your pain adequately managed, when are you returning to activities, tell me what you are not supposed to do with xyz

observation +

general appearance (febrile, gaurded), posture, skin, symmetry (girth specific to body part and downstream), incision site (length, approximation, drainage, peri-incision erythmea) signs and symptoms of (infection, circulatory and neurologic compromise)

signs of infection

pt cold, shivering, pale, surgical site erythematic, streaks and cellulitis, elevated body temp, purulent discharge

if you suspect post-op infection refer

immediately!

is pitting edema concerning?

following a surgery yes! grade is on a scale of 0-4 and based on every 2 mm of pitting edema

why should you do a vascular screen post op?

2-3 % of post op patients will be hospitalized again within 6 weeks for blood clots which is 1/45 pts post TKA or total hip. Could be lift or limb threatening!

what is included in a vascular screen

examining limb color, size, temperature, distal pulses, capillary refill, tenderness along venous system (popliteal vein or brachiocephalic vein)

capillary refill greater than how many seconds is concerning?

5 seconds! 3-5 seconds is a gray area.

signs of ischemia (lack of blood flow)

parasthesia, pain, pallor, pulselessness, paralysis

ischemia may be due to

extreme swelling or a blood clot

deep vein thrombosis is

the formation of a blood clot d/t decreased blood flow

signs and symptoms of a DVT

deep pain, tenderness, diffuse / whole limb swelling, reddish or blue skin discoloration, skin warm to touch

wells clinical prediction rule for DVT

- active cancer

- paralysis; paresis; recent immobilization of LE

- recently bedridden for greater than 3 days or major surgery within 4 weeks of application of decision rule

- localized tenderness along distribution of the deep venous system

- entire LE swelling

- calf swelling greater than 3 cm compared to asymptomatic LE

- pitting edema

- collateral superficial veins (non-varicose)

- then -2 points if an alternative diagnosis is likely or greater than that of DVT

wells clinical prediction rule for DVT results

if greater or less than 0 - probability of 3%

1 or 2 - probability of 17%

3 or greater - probability of 75%

post op neuro screen for extremity surgery

peripheral nerve sensory distribution distal to surgical site and peripheral nerve motor function

post op neuro screen for spine surgery

nerve root sensory distribution (dermatomes) and nerve root motor function (myotomes)

neurologic screen clinical peral

expect peri-incision anesthesia ex) ACL surgery cuts infrapatellar branch

post op movement screen

- proximal / distal to the site is indicated nerve function and circulation

- movement of the joint / segment may be indicated (AROM if not contraindicated, PROM with surgery specific contraindications)

what is typically the best form of motion to screen in a post op pt with both AORM and PROM indicated

AROM because the personal will self limit, they protect themselves, teaches pt it is okay to move, circulatory benefits from muscle contraction

post op examination palpation examines

warmth, turgor, tenderness, skin / scar mobility 7-10 days post op

what is the goal of skin / scar mobility

to ensure collage is laying down in a way that allows motion

in a post op exam do you do selective tissue tensioning?

no! you typically do not need to determine a diagnosis, it will be extremely painful, and may impact healing

What parts of the exam would you do for a subacromial decompression

everything but length testing because the terminal ROM with overpressure will lead to lots of pain. For AROM and MMT keep within a comfortable pain range

what parts of the exam would you do for rotator cuff repair

no AROM, shoulder MMT, and length testing because you do not want to tear the rotator cuff that has been sewn. With PROM avoid IR if supraspinatus and infraspinatus are the muscles that have been repaired.

what parts of the exam would you do for a bankart repair

Avoid full abd, flx, and ER with AROM and PROM, with MMT complete at pt's side, no joint mobility, no length testing. But it is good to do elbow / wrist / hand MMT.

why do elbow / wrist / hand MMT for a shoulder repair

to ensure nerves are intact after surgery

common elements of post of exam

appropriate history, review of systems / system review, observation which includes girth and incision inspection / description, neurovascular screen, movement screen, palpation

what related problems do you not want to miss

DVT, infection, unmanaged pain

prior to selective tissue tensioning what should you ask

what tissue is healing, what stress is appropriate, when can stress be applied

how should you test for lateral epicondylopathy

strength and length testing of the wrist extensor muscle group

how should you test joint arthropathy

AROM / PROM, flex, ext, pro, sup. and joint mobility tests

how should you test an RCL sprain

joint stress testing via varus stress test

how should you test cervical radiculopathy

cervical AROM, followed up with spurlings test

how should you test triceps tendinopathy

strength and length testing of the triceps muscle

how should you test for radial nerve entrapment

upper limb tension test