Acute Orthopedics

What kind of injuries would you see in acute orthopedics?

• Fractures & multi-trauma

• Joint arthroplasty

• Spinal surgeries

Considerations in acute orthopedics: should be written as an ______ in the EMR

Order

What should an order in acute orthopedic include?

• Weight bearing status

  • Influences assistive device choice

  • Influences functional mobilty

• Motion limitations

• Limited weight lifting

What are the different weight bearing status’ a pt can have?

• Non-weight bearing (NWB)

• Toe-touch weight bearing (TTWB)

• Partial weight bearing (PWB)

  • Need a specific % or amount

• Weight bearing as tolerated (WBAT)

• Full weight bearing (FWB)

What equipment can you expect to see in acute orthopedics?

• Foley catheter

• IV line

• PCA pump

• SCD device

• JP or hemovac drain

• Bracing

• Abductor wedges

• Incentive spirometer

What are the goals of PT in acute orthopedics?

• Improve functional mobility WB status

• Improve assistive device use

• Improve adherence to precautions

• Manage pain/muscle guarding

• Prevent circulatory and/or pulmonary complications

  • DVT (through mobility)

  • Atelectasis/pneumonia (through incentive spirometry and movement)

• Increase ROM and/or strength

• Discharge planning

How do you prevent a DVT?

Mobility

How do you prevent atelectasis/pneumonia?

• Incentive spirometry

• Movement

What should you look for in a chart review for a PT exam in acute orthopedics?

• WB status

• Mechansim of injury

• PMHx

• PSHx

What should you look for during a med review for a PT exam in acute orthopedics?

• Side effects of anesthesia and opioids

• VTE prophylaxis w/ anticoagulant

What should you look for during a lab review for a PT exam in acute orthopedics?

• Low Hgb lvls

• Leukocytosis

What could low Hgb lvls indicate in acute orthopedics?

The pt went through surgery

When coordinating with other providers before a PT exam in acute orthopedics, what info are you trying to get?

• Last dose of pain meds

• Activity and mobility

• Clarify WB status if needed

• Cognitive status

What are some things you should do during a PT exam in acute orthopedics?

• Chart review

• Med review

• Lab review

• Coordinate w/ other providers

• FInd out home enviornment and at home support

• Vital sensitive assessment

• Skin assessment

• Sensation

• Pain

• ROM/strength

• Locomotion/balance

When doing a PT exam in acute orthopedics, which is more common, hypotension or hypertension? Why?

Hypotension cuz its a common med side effect

What is an example of a brand name opioid?

OxyContin

What is the generic name for OxyContin?

Oxycodone

What are some side effects of opioids?

• Hypotension

• Respiratory depression/apnea

• CNS depression

• Increase in ICP

• Dizziness

• Confusion

What are some brand names of some general anesthetics?

• Diprivan

• Ketalar

What is the generic name of Diprivan?

propofol

What is the generic name of Ketalar?

Ketamine

What are some side effects of a general anesthetic?

• Delirium

• Dysrhythmia (brady or tachycardia)

• Hypotension or hypertension

• Respiratory depressoin/apnea

• Diplopia

• Hypertonia

• Hyperlipidemia (Propofol)

• Decrease in CO (Propofol)

• INcrease in contractility and vasocontriction (Ketamine)

What are some side effects that are similar between opioids and general anesthetics?

• Hypotension

• Respiratory depression/apnea

What are the different ways a surgeon can go about doing a reduction of a fracture?

• Closed reduction

• Open reduction w/ internal fixation (ORIF)

What is a closed reduction?

• Noninvasive technique to fix a bone that does NOT require surgery

• Uses manual manipulation or traction

Describe an open reduction w/ internal fixation (ORIF)

• REQUIRES surgery

• Fixation devices are applied internally

What are some ways to externally immobilize a fracture?

• Cast

• Brace

• Splints

• Taping

• Traction

What are some ways to internally immobilize a fracture?

• Plates

• Rods

• Pins

• Screws

• External fixators

What reduction technique(s) can use external immobilization on a fracture?

• Closed reduction

• Open reduction

What reduction technique(s) can use internal immobilization on a fracture?

• Open reduction

When a pt is undergoing traction (a form of closed reduction) a pin is put in what bone?

The distal bone

How long would a pt be in a traction device?

1-3 days

A pt can get out of bed when in a traction device. True or false?

False

What is the point of a traction device?

Pull a distal part of a bone that has been fractured away from the proximal part to allow for more room between the bones so surgery can occur

What is the biomechanics of an external fixator?

• Stress sharing

What type of bone healing occurs with an external fixator device?

Secondary

What is the speed of recovery when a pt uses an external fixator device?

Fast

What is an advantage of having a pt use an external fixator device?

• Allows access to soft tissue if wounds are open

What are some disadvantages of an external fixator device?

• Pin tract infections

• Cumbersome

When would a pt use an external fixator device?

• Pt has soft tissue injuries that prevent ORIF

• Pt is too sick to undergo a lengthy surgery

What are some examples of injuries that an external fixator device would be used for?

• Open tibial fractures

• Severely comminuted distal radial fractures

Name two parts of the body you would often find an external fixator device

• Pelvis

• LE

How many minutes of therapy/day is considered low rehab post hip fracture in acute care?

17 minutes/day

How many minutes of therapy/day is considered medium rehab post hip fracture in acute care?

30 min/day

How many minutes of therapy/day is considered high rehab post hip fracture in acute care?

48.8 min/day

A pt who only recieves 17 min/day of rehab follwing a hip fracture in acute care is said to have highest odds of readmission on what days?

• 7

• 30

A pt who only recieves 17 min/day of rehab follwing a hip fracture in acute care is likely to be in what kind of hospital?

A large one

A pt who only recieves 38.8 min/day of rehab follwing a hip fracture in acute care has a high percentage chance of being…

A non-hispanic white individual

As a PT, what should you assess follwing a hip fx according to CPG?

• Knee extesion strength

• Verbal pain rating

• Gait speed

• TUG

• New mobility score

As the PT, why do we care about knee extensor strength following a hip fx?

A pt needs good knee extensor strength in order to ambulate and stand

As a PT, what should we provide for a pt follwing a hip fx according to CPG?

• Structured exercise

  • Progressive resistive strength

  • Balance

  • Weight bearing

  • Functional mobility training

• Early mobilization

  • Transfers out of bed

  • Amublation

• DAILY PT

As a PT, what should we consider when making a discharge plan for a pt who has suffered a fracture?

• The lvl of support they have at home

• The impact of their WB status on their ADLs

• Complexities of fracture and other injuries

• Other medical complications

• If they continue PT at discharge or wait until WB restrictions lifted

What is a joint arthroplasty?

A surgical reconstruction of articular surfaces w/ prosthetic components

What are some indications for a joint arthroplasty?

• OA

• RA

• Posttraumatic arthritis

• Pt no longer responding to conservative measures

What are some conservative measures to try with a pt before having them undergo a joint arthroplasty?

• Taking anti-inflammatories

• Modifiy exercise and mobility

• PT

• Use of an AD

• Weight loss

What occurs at pre-hab classes prior to a joint arthroplasty?

• Pt eduction on what to expect

• Initiate HEP

• Arrange adaptive equipment beforehand

• Educate pt on anti-coagulant injections

• Discuss post-op instructions w/ pt

• Gather pt history and home enviornment

  • Want to give them tips to improve safety and make it easier for them to move at home

• Teach a caregiver

In acute orthopedics, when does PT start for a pt who has undergone a joint arthroplasty?

POD 0 aka the day of surgery

Early mobilization following a joint arthroplasty has shown to increase…

• Functional mobility

• Shorter length of stay in hospital

• Enhanced recovery

• Increased likelihood of discharge home

After a pt has undergone a joint arthroplasty, what do you need to carefully monitor?

• Hemodynamic stability

• Surgical stability

• Pain

• Current cognitive state

• Response to anesthesia

A pt will not know until after they undergo their joint arthroplasty if they are going home on POD 0. True of false?

False! It will be discussed with the pt beforehand

What are some keys to success to be able to discharge POD 0?

• Liberalized NPO guidelines (aka eat closer to the surgery)

• Multimodal analgesia pre op

  • Lower doses of spinal anesthesia

  • Avoiding intrathecal opiates

  • Multidrug nausea/vomiting prophylaxis

  • Early post-op food and meds

• Involve the pt’s buddy

• Expect some drowsiness

  • Understand the half-life of pain meds!!

  • Add muscle relaxant to decrease opioid dose

The surgical approach for a hip arthroplasty is described in relation to what?

The greater trochanter position for dislocating the femur

What hip motion is done to dislocate the femur for a posterior/posteriorlateral approach?

Hip flexion

What hip motion is done to dislocate the femur for an anterior/anterolateral approach?

Hip extension

A pt often has better outcomes following an anterior approach for a hip arthroplasty. True or false?

False! There is not a difference in outcomes between approaches

Following a hip arthroplasty, how many weeks will a pt commonly have precautions?

8-12 weeks

What are the post-op hip precautions following a posterior approach?

• No hip flexion over 90 deg

  • aka keep your knee lower than your hip

• No IR to 0 deg

  • aka don’t let the toes point in

• No add to 0 deg

  • aka don’t cross your legs

What are the post-op hip precautions when the anterior approach is used?

• No hip ext

• No ER rot to 0 deg

  • aka don’t point toes out

• No add to 0 deg

What are some positive prognositc factors when considering a pt’s prognosis and tx post-TKA?

• Pre-op ROM

• Pre-op physical function

• Pre-op strength

What are some negative prognostic factors to consider when deciding a pt’s prognosis and tx post TKA?

• Higher BMI

• Depression

• Greater amount of comorbidities

• Tobacco use

• Lack of pt support

What is the disease that is not associated with worse functional outcomes for a pt post TKA?

Diabetes

What should a PT do w/ a pt who is getting/has gotten a TKA according to CPG?

• Pre-op exercise program

• Pre-op education

• Cryotherapy

  • For early post-op pain

• PA/early mobility

• Motor function training

• Post-op knee ROM exercises

• Neuromuscular E-stim (NMES)

• High intensity strength training & exercise program

• Supervised PT managment

Why would you do cryotherapy with a pt following their TKA?

It can help reduce pain

How soon should we start PT with a pt following a TKA?

Within 24 hours of the surgery

What are some outcome measures to do with a pt who has just undergone a TKA?

• 30 second STS test

• TUG

What are some indications of spinal surgery?

• Conservative management of symptoms has failed

  • Often occurs with degenerative disc disease or intervertebral disc herniation or rupture

• Fracture management (fusions, corpectomies)

• Stenosis (decompression, laminectomy)

• Hypermobile spinal segments (fusion)

• Deformities

  • Often from socliosis

• Spinal tumors

What is the purpose of a spinal fusion?

Stabilize a hypermobile or unstable joint

What is the purpose of a laminectomy?

Relieve pressure on a neural structure

What is the point of a spinal decompression surgery?

Relieve pressure on neural structures

What is the point of a discectomy?

Excision of protruding or herniated interdiscal material

What is the point of a corpectomy?

The removal of a part of the vertebral body

What is the point of a total disk replacement?

Replace a deranged vertebral disk

How is a spinal fusion done?

Use of internal fixation and/or a graft

What is removed during a laminectomy?

A lamina

What is removed for a spinal decompression surgery?

Elements of the vertebral column

What is removed for a discectomy?

• Part of or an entire intervertebral disk

A discectomy can be combinded with what other surgeries?

• Laminectomy

• Decompression

• Fusion

What surgery uses special instruments to remove fragments or components of a vertebral body?

Corpectomy

What should you focus on with a pt following a spinal surgery?

• OOB mobility

  • Sitting up, ambulation, stairs, car transfer

  • Log rolling (minimizes twisting)

• Education on proper body mechanics and precautions

• Bracing (if used)

What are the precautions following a spinal surgery (if used)?

• No BLT (bending, lifting, twisting)

• No lifting more than 10 lbs

• Minimize bending and twisting

Why might radiating pain and sensory changes that were present in a pt before spinal surgery persist after surgery?

Post-op edema

What things would cause you to inform a surgeron and RN when working w/ a pt post-spinal surgery?

• Acute increase in pain

• Bowel and bladder changes