Orthopaedic Physiotherapy Review

Flashcards covering key concepts and details from the lecture notes.

What is the role of an orthopaedic physio?

Restore Safe Function, Help set patient expectations, Manage pain, Restore ROM + strength, Optimise load management, Provision of walking aids, Management of post-op recovery, Discharge planning + onward referral.

List the steps of preparation for patient contact.

1. Documentation review, 2. MDT Communication / Handover, 3. Review end of bed charts, 4. Observations, 5. Analysis + Plan, 6. Intervention + evaluation

What should be considered during documentation review when preparing for patient contact?

Handover sheet, Medical records, Review admission note (HPC, management plan, medical history, family history), Review Post-Op restrictions, Considerations – contact precautions, medication, pathological investigations

What information should be gathered during MDT Communication / Handover in preparation for patient contact?

Bed allocations (patient location + assigned nursing staff), Introduction to patients medical team, Enquire overnight status + current presentation, Clarification on weight bearing status from doctor

What patient observations should be made in preparation for patient contact?

Patient (posture, colour, consciousness, breathing), General function (bed mobility, UL function), Attachments (Epidural, catheters, Fluids, Drains, hearing aids, walking aid), Apparatus (Splints/braces, Compression stockings, Flowtrons)

What is the purpose of the Analysis + Plan step in preparation for patient contact?

Based on info gathered from S + O assessment, Use ICF framework to build prioritised problem list (impairments, limitations, restrictions)

What is the purpose of the Intervention + Evaluation step in preparation for patient contact?

Based on problem list + management plan, Conduct appropriate interventions for rehab stage + patient presentation, Modify interventions as required, Evaluate effectiveness of chosen intervention (how patient tolerated)

List common inpatient medications.

1. Anticoagulants = reduce clotting risk (e.g. Aspirin, Heparin), 2. Anti-emetics = reduce nausea + vomiting (e.g. Ondansetron), 3. Anti-inflammatories = aid pain + swelling (e.g. Ibuprofen, Celebrex), 4. Antibiotics = address infection risk (e.g. Cephalexin)

Describe slow-release analgesia.

15 – 30 min to work, Lasts up to 12 hrs, e.g. Paracetamol, Tramadol

Describe immediate-release analgesia.

Few minutes to work, Most effective 30 mins after dose (shorter acting), e.g. Tramadol, Morphine-based

List side effects of opioid medications.

Sedation, Dizziness, Decrease central respiratory drive, Nausea + vomiting, Constipation

List four types of anesthesia routes.

1. General, 2. Spinal block, 3. Epidural, 4. Regional

What are the potential respiratory complications of General anesthesia?

Slowed body functions (CV + respiratory) and potential respiratory complications

What is the impact of anethesia on post-op presentation?

Affect post-op presentation (Pain control, symptoms, drowsiness, muscle strength, balance, sensation)

Describe spinal block anesthesia.

Small needle punctures dura (administered below L2 to avoid SC), Drug is injected in the CSF

Describe epidural anesthesia.

Delivered outside the dura in the epidural space, Larger dose than spinal block, More segment specific (cervical, thoracic, lumbar (unilateral), Indwelling catheter is used (up to 48hr)

Describe regional anesthesia.

Regional nerve block (outside the CNS), Blocks sensory + motor function unilaterally (used for joint replacement), Can take up to 72hr to wear off

List of components of the SOAPIER format.

S = subjective assessment, O = objective assessment, A = analysis, P = plan, I = intervention, E = evaluation, R = review

Why is documentation important?

Legal = have adequate records for all patient encounters + communications, Ethical = duty of care + code of conduct, Clinical = accurate documents for continuity of treatment

List general documentation rules.

Use the SOAPIER format, Black ink + legible, Patient name + DOB on each side of page, Date, time + discipline at start of each entry, Record informed consent

List common inpatient abbreviations.

= fracture, HPC = history presenting condition, WB = weight bearing, LL / UL = lower limb + upper limb, Mx = management, ADL = activity of daily living, NAD = no abnormality detected, PCA = patient controlled analgesia, ORIF = open reduction internal fixation

What do you do during a subjective assessment?

Balance active listening + targeted questions, Establish patient history, current condition, management plan, Use open + clarifying questions

What do you document from a subjective assessment?

Summary of answers (concise)

What do you do during an objective assessment?

Clinical observations, Outcome measurements, Establish baseline of affected limb

What do you document from an objective assessment?

Clinical observations, Assessment results

What do you do during an intervention?

Manual therapy, Positioning, Exercises, Education, Assistive device prescription

What do you document about an intervention?

Documentation of interventions in current session, Make sure that it can be replicated

Describe the steps of a respiratory assessment.

Observe -> Feel -> Test, Observe normal breathing + deep expansion, Respiratory rate +pulse, Auscultation + cough, Vital signs (O2 sats, HR, BP)

Describe the steps of a neurological assessment

Level of consciousness (alert + orientated, PPT), Cognition (Delirium or Situational), Sensation (Dermatomes + peripheral nerve ), Motor function (Myotomes)

Describe the steps of a vascular assessment.

Observe -> Feel -> Test, Signs of infection / oedema / rash, Temperature, Palpate for tenderness

Describe the steps of a musculoskeletal assessment.

General observations of movement, ROM + strength, Functional task assessment

List respiratory interventions.

Aim = improve resp function by optimising ventilation, increase lung volume, improving secretion clearance

List vascular interventions.

Medical options = anti-coagulants, anti-embolism stockings, flowtrons, Physio = educate, mobilise, positioning, calf pumps

List musculoskeletal interventions.

Rehab = muscle strength, endurance, condition, balance, Functional task training = bed mobility, gait re- education

What do you do to evaluate an intervention?

Observe how patient tolerated intervention, Re-assess anything that can be influenced by intervention (pain, symptoms), Progress intervention based on evaluation

What do you document about your evaluation?

Intervention listed // evaluation follows

What do you do during a review?

Plans for next session, Outline frequency of treatment, Instructions for MDT, Highlight urgent referrals, Discharge plans

What do you document about your review?

Specific intervention, Evaluation, Review via nursing staff

Describe the different types of transfers.

1. Bed mobility = rolling in bed, 2. Transitions = supine -> sit, sit -> stand, stand -> sit, 3. Transfer = one surface to another (Stand to sit, pivot, hoist, STS)

What are the goals of transfers?

1. Safety, 2. Active patient involvement, 3. Move towards independence

Describe the principles of self-protective behavior

1. Use body weight, 2. Steady stance, wide BOS, 3. Use whole body, 4. Keep load close, 5. Get patient to be as active as possible

What are the risk considerations for assistive bed devices?

Cognitive functions, fall history

Describe the Sara Stedy device.

Non-powered standing aid, Facilitates STS with active patient involvement, Assists with transfers from seated position

Describe the Sara Plus device.

Powered standing aid, Increased safety = sling that lifts + lowers patient, Suitability = patient with reduce functional capacity

What type of patient is suitable for floor hoists?

Fully dependent patient

Describes non-weight bearing status.

All weight through aid (no weight through affect limb), Use Swing through + Swing to

Describe touch weight bearing status.

Aid + affected leg simultaneously then unaffected leg, Very light touch to ground with affected limb

Describe partial weight bearing status.

Aid + affected leg simultaneously then unaffected leg, 50 % BW

What are influences on gait pattern?

1. Weight bearing status, 2. Physical capability / impairments, 3. Prior experiences with aids, 4. Type of walking aid, 5. Environment needed for mobility, 6. Flooring , lighting

Describe gait patterns for NWB.

With crutches = Swing to + Swing through, With frame = Swing to

Describe gait patterns for PWB / WBAT

Elbow crutches = Step to + Step through, Walker + Axillary crutches = Step to + Step through, Fixed frame = Step – to

Standing / Sitting with crutches

Utilise steady chair, bed, rails, Place injured limb slight ahead (avoid placing weight through), Make H-shape on unaffected side, Ensure ferrules are flat on ground

Standing / Sitting with frame

Utilise steady chair, bed, rails, Ensure ferrules are flat on ground, Avoid patient pulling up from frame

What are the principles of stairs / steps?

Up – (ABC): Unaffected leg leads, Followed by affected then crutches, Down – (CBA): Crutches first, Operated leg leads followed by unaffected leg, Unaffected leg takes primary weight bearing at all times, Walking aid is lower than or level to the step

What are the key points for care of waking aids?

1. Ferrules = no cracks, splinters or sharp edges, 2. Brake = working, 3. Screws + clips = intact, tight + functioning, 4. Padding = support areas properly padded

List evaluation markers

Pain, Assistance level, Perceived exertion score, Distance ambulated, Walking cadence, Limp, Balance

What is Wolff's Law?

Bones become thicker + stronger over time to resist forces placed upon them (thinner + weaker if no forces to act against it)

What is Dye's envelope of function?

1. Sub - physiological loading = too little stress -> weakness, 2. Supra – physiological loading = too much stress -> adaption / strength, 3. Supra – physiological loading = too much stress -> injury, 4. Zone of homeostasis = optimal stress -> maintenance

List causes of fractures

1. Direct trauma (crush), 2. Indirect trauma (fall onto arm + forces transmit), 3. Pathological causes (cancer), 4. Fragility + insufficiency (osteoporosis = insufficiency of calcium), 5. Stress (chronic overload of bone), 6. Avulsion

Describe avulsion fractures.

Sudden muscle contraction = tendon / ligament pulling a bone fragment away from attachment, Due to indirect trauma / stretch / strong muscle action, Aetiology = younger female adolescents + slightly older male adolescents (always @ apophasis (site of ligament / tendon attachment) in adolescents), Often in pelvic area = large muscles with explosive forces, Ligamentous most common = ankle, knee, wrist (increased instance in adults)

List the management steps for avulsion fractures.

1. Confirm diagnosis + establish degree of avulsion (with x-ray imaging), 2. Attain orthopedic consultation = if surgical intervention required, 3. Period of NWB / reduced WB / immobilisation, 4. Pain management via medication, 5. Gradually restore ROM, 6. Regain strength + stability, 7. Sport specific rehab

Describe pathological fractures.

Abnormal bone that is already weakened by disease (tumor or metabolic disease), Due to trauma or spontaneously (via minor forces), Most common = proximal humerus, femur shaft, ribs, vertebral body

Describe fragility / insufficiency fractures.

Type of stress fracture in fragile bone + can result from normal levels of bone stress (walking / standing), Fragility fracture = weakened bone break following minimal trauma, Underlying causes = osteoporosis, rheumatoid arthritis, long term steroid use, radiation therapy, metabolic disorders, Most common = pelvis, tibia, feet

List the management steps for fragility / insufficiency fractures

Initial treatment depend on location + degree of fracture, Long term = weight bearing exercises to target bone density

Describe stress fractures.

Microscopic fracture from repeated biomechanical stress (commonly in weight bearing bones), Overuse injury caused by increase in activity frequency / intensity, Bone stress reaction -> stress fracture, Diagnosis = MRI scan

List the management steps for stress fractures.

1. Stop aggravating activity, 2. Offload bone = crutches, walking boot (pain guides offloading), 3. Maintain fitness (lower load bearing activity – swimming, walking, cycling), 4. Prevention strategies = education + address modifiable risk factors, 5. Treat the person (may need professional involvement)

Describe articular injuries.

Intraarticular = fractures that cross joint surfaces, Resulting from blunt force trauma, Articular cartilage = damaged, Impede healing time + management, Link with post traumatic arthritis

Describe a subluxation.

Joint surface displacement without fracture, Partial dislocation which relocates spontaneously, Results = stretching ligaments + soft tissue damage -> joint instability

Describe a dislocation.

Joint surface displacement without fracture, Total malalignment of joint + severe ligament stretching, Soft tissue injury = joint instability

What is key to remember about clinical fracture assessments?

Mechanism of injury, Audible noise of injury, Gradual increase in pain with loading volume / frequency, Immediate response (swelling), Pain pattern (immediate or delayed), Factors that increase risk of fracture

Subjective fracture assessment.

Deformity present, Swelling / bruising, Abnormal movement, Boney crepitus present, Pain on bony palpitation

Imaging assessment options

X- rays = fractures + dislocations, Computerised tomography = spinal fractures + dislocations, MRI = soft tissue, neuro structures + patients with multiple injuries

Conservative fracture management

Demographic = elderly + paediatric, Indications = medical contraindications, inadequate bone quality, closed + undisplaced fractures

What are the surgical indications for fractures

Malunions that failed to response to non-operative management, Indications = fractures that are open, unstable, intraarticular, displaced, pathological or complex, Fractures known to heal poorly conservatively, Significant avulsion fractures, Fractures in patients who poorly tolerate prolonged immobilisation

Reduction in fracture management

Fractures requiring realignment of bone fragments (displaced)

Define closed reduction in fracture management

Closed manipulation = fragments grasped via soft tissue + manually manipulated in acceptable position (under sedation), Mechanical traction = traction applied using weights or a screw device (femoral shaft + spine fractures)

Aims of fracture immobilisation

Prevent further displacement, Relive pain, Prevent movement that interferes with bone union

Signs that POP cast is too tights

Vascular: Distal swelling (not reduced with elevation), Distal segments feel cold + clammy, Distal skin appear blue, Neurological: Paraesthesia in sensory field of compressed nerve, Pain: Vascular / neural compression

Manage of unstable, open infected fractures

Anchorage of bone fragments to external device using pins inserted into proximal + distal fragments of long bone fracture, Allows for adjustment of fragment ends

Preservation of function dependent on?

Cause of fracture, Fracture classification (soft tissue, shape / line, displacement / stability), Position / site of fracture, Type of immobilisation, Stage of healing, Comorbidities / medication

Primary (direct) bone healing requirements

Bone end in apposition + rigidly fixed = no movement, No callus formation, Osteoclasts – cross the fracture, Osteoblasts – lay down new bone

Secondary (indirect) bone healing definition

Motion minimised by internal / external fixation, Process = haematoma -> fibrocartilaginous callus -> bony callus -> remodelling

How we know when fracture is healed?

Radiological + imaging evaluation / comparison, No mobility between fragments, No tenderness on firm palpation over site, No pain on loading / application of stress

Explain local management through stages of healing

Provide splints + braces as appropriate, Review + provide education = weight bearing + post-op restrictions, Strategies for pain + swelling management, Safe + suitable bed mobility + transfers, Gait aid + gait pattern -> WB status, Safe + suitable exercise program, Educate importance of exercises for preservation of function + recovery

Explain early physio management

Provide splints + braces as appropriate, Review + provide education = weight bearing + post-op restrictions, Strategies for pain + swelling management, Safe + suitable bed mobility + transfers, Gait aid + gait pattern -> WB status, Safe + suitable exercise program, Educate importance of exercises for preservation of function + recovery

Post-op general care

Pain + swelling management, Cardiorespiratory management

How to manage pain and swelling Post-op

Elevation, Compressive, Education of pain medication, Gentle movement

How to conduct cardiorespiratory management Post-op

Encourage deep breathing + sitting upright, Ensure effective cough, Teach ankle pumps = circulation

Post-op rehab goal

Preserve joint movement -> safely restore affected mobility

Describe post-op rehab steps

Bed mobility, Transfers, Gait training

Unstable features require modifications of…

Extended period of immobilisation, NWB until sufficient callus formation, Initial priority of = protect fracture site

Physio modifications that avoid contraction of muscles that stress site (NWB, gravity eliminated, passive ROM)

Provide hands-on support with bed mobility + transfers, NWB gait education

List Intrinsic fracture complications

• Delayed union / Malunion / Non-union, Avascular necrosis, bone length, Post traumatic osteoarthritis, Tendon fraying

Extrinsic fracture complications

Vascular, nerve or soft tissue injury, Joint stiffness, Muscle weakness (damage / disuse atrophy), Deep vein thrombosis, Fat embolism

Paediatric Fractures: Child bone presence

Cartilaginous disc separating epiphysis from metaphysis = responsible for longitudinal growth of long bones, Increase flexibility = increased porosity (likely to bend than break)

List the different types of metaphyseal fractures

Buckle: bone buckles with longitudinal force @ distal radius, Greenstick force bends on side of cortex + breaks it @ other side, Toddler’s = spiral fracture of distal tibia

Rapid paediatric fracture recovery

Callus within 2 wks, Consolidation within 4-6 wks

How to restore paedatric fracture

Restore ROM, strength, function, Functional + play rehab, Use of splints, casts + braces

Management of Proximal Femur Fracture

Surgical – considered within 36 hrs, Considerations, Facilitate early mobilisation + FWB Physio – Acute = Bed mobility, progression

Mechanism of Patella / Tibial Trauma

Conservative: immobilisation in full extension splint 1. MPFL Reconstruction: Conservative:, Surgical:, E.g. ORIF, Patellectomy, POP cast