Case studies in orthopaedics

CHAPTER SEVEN Case studies in orthopaedics



Anne-Marie Hassenkamp, Diane Thomson, Sophia Mavraommatis, Kaye Walls



Case study 1: Rotator Cuff Repair 166

Case study 2: Decompression/Discectomy 168

Case study 3: Fractured Neck of Femur 170

Case study 4: Total Knee Arthroplasty/Replacement 172

Case study 5: Anterior Cruciate Ligament Reconstruction 175

Case study 6: Fractured Tibia and Fibula 177

Case study 7: Achilles Tendon Repair 178

Case study 8: Idiopathic Scoliosis 180

Case study 9: Legg–Calvé–Perthes Disease 182

Case study 10: Surgical Intervention for Cerebral Palsy 185


Introduction


Orthopaedics is a wide area of practice for physiotherapists and one which we encounter in most settings be it in a hospital (e.g. elective surgery, trauma or disease) or a community setting (e.g. post-operative, injury, secondary issues and long-term musculoskeletal problems). Due to the wide spectrum of orthopaedics the therapist is likely to encounter patients of all ages, from all backgrounds and with various health beliefs. Each one of these factors can have a huge influence on therapy management.


Excellent communication and team working skills are essential. The orthopaedic physiotherapist is an integral member of the multidisciplinary team (MDT) and works closely with surgeons. The clinical reasoning and problem-solving approaches used are directed by the medical intervention. Clearly, a good knowledge of what is a normal change and what is a pathological one is of paramount importance. Higgs & Titchen (2000) remind us that knowledge is an essential element for reasoning and decision making, and how both of these are considered central to clinical practice. The therapist working in these settings has to have excellent anatomical, physiological and pathological background knowledge within a framework of an understanding of the psychosocial influences on rehabilitation goals. Atkinson (2005) advises the adoption of the longpublished movement continuum (Cott et al 1995) as a good framework for orthopaedic reasoning. The changes from the person’s preferred movement capacity (PMC) to their current one (CMC) is the orthopaedic physiotherapist’s frame of reference. The process of getting from one to the other engages the therapist in educational as well as treatment situations which need the collaboration of the patient. Orthopaedic therapy goals therefore have to be patient-centred and collaborative rather than following a prescribed protocol.


This makes orthopaedic physiotherapy an ideal training ground in reasoning for the starting professional. The hypothetico-deductive reasoning model (Elstein et al 1978) adopted by junior physiotherapists is particularly well suited to this surgically directed arena as it stems from research in medical reasoning and hence mirrors that of the surgeon in charge of the patient. Pattern recognition (Higgs & Jones 2000) – a sign of the more expert professional – allows for a quick integration into the clinical puzzle of many different pieces virtually simultaneously. Orthopaedic practice is an ideal setting for physiotherapists to become more aware of and more secure in their cognitive skills as well as honing them to expert level.



CASE STUDY 1 Rotator cuff repair



Subjective assessment



PC


50-year-old female admitted for an arthroscopic left rotator cuff repair.


The indications for surgery are:


image large rotator cuff tear demonstrated by MRI

image pain interfering with work as unable to use arm effectively above 90°

image night pain waking her 2–3 times per night

image failed course of conservative treatment including cortisone injection (twice) and physiotherapy over last 4/12


HPC


Intermittent shoulder pain for about 18/12


Aggravated by reaching, particularly if sustained or repeated


Patient felt excruciating pain while hanging curtains but worked through the pain for the rest of the day


Was unable to sleep that night due to severe pain


Attended A&E where X-ray showed no abnormality


She was referred for physiotherapy which has now been ongoing for several months to no effect


GP had given cortisone injections on two occasions which didn’t help


Patient was then referred to an orthopaedic surgeon who organized an MRI and diagnosed a full thickness rotator cuff repair. She was listed for surgery



SH


Self-employed curtain maker. Has employed help for the time she will be off work


Lives with husband


Smoker



Objective assessment



Observation


Increased thoracic kyphosis in relaxed standing/sitting but is able to actively correct this to a reasonable level


Mild forward head posture and protracted shoulders which she can control


Cervical and thoracic movements appear fine



Pre-operative treatment aims


Teach bed exercises for circulation


Teach deep breathing exercises to maintain good chest expansion


Explain post-operative management and introduce post-operative precautions. This is done with her husband present and it is explained that he will need to help with the exercises post operation


Provide any written information sheets about post-operative care and discuss



Post-operative treatment aims (for 0–6 week period)


Monitor respiratory and circulatory status during immediate post-operative period


Protect healing of soft tissues. Maximum protection phase


Prevent negative effects of immobilization


Monitor and assist in pain control


Re-establish scapula stability


Encourage good posture


Arrange out patient/community physiotherapy as appropriate



1st day post-surgery


Breathing exercises are checked looking for basal expansion and clearance of any sputum


Patient is mobilised out of bed as soon as able wearing a blow-up abduction pillow


She is taught:


image scapular setting exercises in side lying and sitting, scapula protraction/retraction for proprioception. Full range of neck movements

image passive external rotation to full range minus 20° for 3/52 in lying. Passive elevation to shoulder level for 3/52. Passive movements are preferablydone by a family member or carer. This person will need to be taught this before patient is discharged

image that at 3/52 both elevation and external rotation can be encouraged into full passive range both in lying and in sitting. Aim for full passive range soon after 6/52 post operation (Gibson 2007)

image good postural alignment using a mirror in sitting and standing


After 6/52


Start weaning from the immobilisation device and use her arm for light use at waist level


Increasing ROM in all directions including behind the back


Isometric internal and external rotation in neutral can be started to strengthen the cuff


Progression to resisted and anti-gravity exercises will be as stability and pain permit


Correct postural positioning is important throughout


Pain will be monitored and addressed by her GP if necessary



Questions



1. What are the rotator cuff muscles and what is their function?

2. The rotator cuff is said to be part of a force couple. What does this mean?

3. The causative mechanisms for rotator cuff disease are divided into intrinsic and extrinsic factors. What are these?

4. Why are we concerned about the scapula position for this patient?

5. Why does this patient need good postural advice?

6. What are the complications of rotator cuff repair and what can be done to minimise the impact of these?

7. What will be included in the discharge planning for this patient?

8. What is the expected long-term outcome for this shoulder?


CASE STUDY 2 Decompression/discectomy



Subjective assessment



PC


36-year-old male architect presents with a prolapsed intervertebral disc (PIVD) and is booked for a spinal decompression (L4/5) the next morning.


The aims of surgery are to:


image decrease pain

image decompress the spinal nerve

image improve dural mobility to prevent adverse neural tension

image prevent or reduce neurological damage


HPC


History of recurrent back pain (but no leg pain) for many months with an insidious onset


7/52 ago, moved house and a few days later developed severe low back pain radiating into his right buttock and then, a few days later, into his right leg all the way down to his foot


He was convinced that rest would alleviate this very sharp pain


When this didn’t help, he was offered conservative treatment which also did not improve matters


From thinking that he had a back strain he now started to worry that something quite serious was happening


He also developed numbness on the outside of his lower leg


A review with his consultant resulted in him being booked for surgery



Objective assessment



Investigations


MRI – showed clear protrusion of L4/5 intervertebral disk onto the spinal nerve root and due to the worsening nature of his signs and symptoms it has been decided to decompress his lumbar spine



Observation


Patient has marked contralateral shift (away from his painful side)


Can only sit for a very brief time


Marked decrease in straight leg raise on the affected side


Abnormal gait pattern of a shortened stride length on the affected side



Pre-operative treatment aims


Teach him bed exercises for circulation, breathing exercises and log rolling in bed


Explain post-operative management and precautions


Provide written information of post-operative management


Fit him with a temporary lumbar corset



Post-operative treatment


Read operation report and check for any special instruction by surgeon


Check wound if appropriate


Reduce anxiety


Identify and prevent any post-operative complications


Monitor and restore respiratory function


Check for any neurological abnormalities


Get patient mobilised in his corset once muscular control of quadriceps and gluteus maximus has been demonstrated


Educate patient regarding life after discharge:


a. Recognition and prevention of complications

b. Ergonomic advice

c. Self-managed home exercise programme especially core stability and neural stretches (Shacklock 2005)

d. Advice on home activities including sitting, driving, working

Enhance patient’s self-efficacy in his body



Discharge criteria


Usually discharged after 2–4 days depending on surgical procedure, wound state, neurological and muscular control


Able to get dressed independently


Able to use the toilet independently


Sit for a minimum of 10 minutes


Able to manage stairs



Questions



1. What is a slipped disc?

2. What are the classic clinical features of a prolapsed intervertebral disc?

3. What is the differential diagnosis of prolapsed discs?

4. What red flag elicited in an examination of low back pain will need immediate action by a doctor?

5. Why is postural education and exercise important for this patient?

6. What psycho-social problems might influence this patient’s treatment outcome?


CASE STUDY 3 Fractured neck of femur



Subjective assessment



PC


65-year-old very slightly built woman admitted via A&E with fractured neck of femur on the right


Once the diagnosis has been confirmed by X-ray she is considered for total hip replacement (THR)


The indications for surgery are:


image reduction of fracture

image reduction of pain

image increase of function


HPC


Patient fell on uneven paving stones in the street and immediately realised that she had ‘broken something’


Was in severe pain, unable to weight bear and had to be admitted to hospital by ambulance



SH


Lives alone, has a daughter in another city


Completely independent and is a retired archivist



Objective assessment



Observation


Her right leg appeared shortened and in external rotation in the A&E department



X-ray


Confirms fractured neck of femur – Garden classification stage III



Pre-operative physiotherapy aims


Introduce yourself to patient


Find out about her anxieties


Explain post-operative regime while still in bed


Explain post-operative regime once she has been allowed to mobilise


Breathing exercises


Explain role of MDT



Post-operative physiotherapy aims (rehabilitation starts on 1st day post surgery)


Read operation report in notes and look for specific post-operative instructions by surgeon


Reduce patient’s anxiety


Check for post-operative complications


Respiratory check and care as appropriate


Start with vascular function maintenance (foot and ankle pumps)


Introduce joint movement and muscle tone around the hip especially abduction and flexion, quadriceps and gluteus strength


Bed mobility (especially bridging for toilet purposes)


Keep abduction wedge when patient lies supine or lies on operated side


Education about ‘do’s and don’ts (focussing on joint preservation and weight bearing)


Confer with MDT (especially social worker) regarding possible hurdles to discharge (remember, she lives alone)


Start mobilising with two crutches (usually by day 2–3 but check with medical colleagues)


Reduce walking aid support to one stick (usually by day 4)


Discharge usually by day 5 by which time she will need to be able to get in and out of bed on her own, sit to stand without help and manage to walk up and down a flight of stairs


Overall aim: to enhance patient’s self-efficacy in her body



Questions



1. What is the Garden classification of fractured neck of femur and how does it influence surgical management?

2. Is it typical for a fall to result in such severe injury in an elderly person?

3. What are possible post-operative complications?

4. What actions should the patient avoid until 6 weeks post operatively?

5. How would you start and then progress muscle re-education?

6. What could you do to assist this patient with her possible anxiety?


CASE STUDY 4 Total knee arthroplasty/replacement



Subjective assessment



PC


71-year-old female admitted for an elective right total knee arthroplasty/replacement (TKR). The indications for surgery are:


image patello-femoral and tibia-femoral osteoarthritis demonstrated on X-ray

image pain interfering with and day-to-day activities including walking

image loss of right knee extension

image night pain

image failed course of conservative management and physiotherapy


HPC


Intermittent right knee pain and stiffness for at least 10 years but managed her pain with analgesia and rest


Past 2 years pain has become more constant, her standing and walking tolerance has decreased and she is experiencing night pain


The patient had one course of physiotherapy which included exercises, manual therapy and hydrotherapy. Therapy improved right knee extension but had no effect on pain


Patient was referred by GP to an orthopaedic consultant where X-ray showed patello-femoral and tibial-femoral osteoarthritis


The patient was offered an elective TKR



PMH


Nil of note



SH


Lives in a house with her husband who is fit and well


No downstairs toilet and she does all the cooking and cleaning


The patient is originally from Italy and still works in the family restaurant



Objective assessment



Gait/observation


Antalgic gait, predominately weight bearing on her left lower limb


Uses a stick on the right side


There is a slight right knee varus deformity and a palpable patello-femoral joint crepitus


There is no evidence of joint effusion or swelling



Functional level


Transfers independently in standing, sitting and supine positions


Step-to pattern up and down stairs leading with left lower limb



ROM


Right knee ROM between 10° and 100° flexion


All other peripheral upper and lower limb joints have normal range of movement



Pre-operative treatment aims


Teach bed exercises for circulation


Teach deep-breathing exercises


Explain post-operative management and introduce post-operative precautions


Record right knee range of movement in the medical notes


Teach patient to use appropriate walking aids correctly, including stairs


Provide any written information sheets about post-operative care and discuss



Post-operative treatment aims (day 1 and 2 post surgery)


Read surgeon’s post-operative instructions regarding mobilisation


Discuss with the MDT the patient’s health status and pain relief


Assess bed exercises for circulation


Assess deep breathing exercises to maintain good chest expansion


Control post-operative knee joint swelling


Commence knee joint passive and active range of movement according to the surgeons protocol


Mobilize the patient according to the surgeons protocol for TKR



Post-operative treatment aims (day 3 to discharge date)


Discuss with patient and MDT the discharge goals


Assess post-operative knee joint swelling


Safe progression of all transfers between supine, sitting and standing


Gait education with the appropriate use of walking aids


Safe progression of stair mobility


Progress active range of knee movement to 0–90°


Assess the need of post-discharge physiotherapy?


Education of the patient to include:


a. Prevention of complications

b. Self-managed home exercise programme

c. Advice on home activity and gradual return to full independence

Continuous passive motion machines, slings and springs and sliding boards are often used to increase the range of movement of the operative knee


The discharge date is agreed when the patient can mobilise independently with or without walking aids, can mobilise on stairs independently and has achieved 90° degrees knee flexion



Questions



1. What are the short-term and long-term goals for this patient and how can the therapist plan the post-discharge rehabilitation programme?

2. What is osteoarthritis?

3. What are the clinical features of osteoarthritis?

4. What can be considered conservative management for knee joint osteoarthritis?

5. Give examples of different types of total knee prosthesis

6. What are the post-operative complications of total knee replacement?


CASE STUDY 5 Anterior cruciate ligament reconstruction



Subjective assessment



PC


35-year-old male is admitted to the ward for an elective left knee anterior cruciate ligament reconstruction (ACLR).


The indications of surgery are:


image left anterior cruciate ligament (ACL) rupture

image patient is self-employed and he is not responding to conservative management


HPC


Patient injured his left knee 10/52 ago playing rugby when he fell forwards and sideways while the left foot remained fixed on the ground


He felt immediate pain and was unable to continue with the game


Pain and swelling increased over the next 2 hours


X-rays taken in A&E were negative for fractures


He was prescribed anti-inflammatories, referred to physiotherapy, given elbow crutches and advice on ice, rest and elevation


A clinic appointment to see an orthopaedic consultant was arranged


The patient had a physiotherapy assessment within 5/7 post injury and therapy focused on reduction of swelling and gentle mobility exercises


1/52 post injury the knee swelling had not reduced and the patient was still unable to weight bear on his left lower limb


Soft tissue injury was difficult to assess and an urgent MRI scan was arranged which showed rupture of the left ACL and a medial collateral ligament tear


The orthopaedic surgeon discussed conservative and surgical options and the patient consented to surgery as one of his main concerns was the physical requirements of his job and that he was self-employed



SH


Self-employed carpenter


Married with two young children


Plays rugby twice a week with friends and he is otherwise fit and well



Objective assessment



Observation


Patient partially weight bearing with elbow crutches


Slight muscle wasting of the left quadriceps muscles compared to the right lower limb


Tenderness, heat and some swelling of the left knee joint but the patellofemoral joint is visible and palpable



ROM


The patient has lost 5° of knee extension and has 100° flexion


Restricted by pain and swelling


Knee extension is most painful movement



Special tests


Anterior drawer test in 70° knee flexion = positive (anterior tibial displacement) approximately 2 cm) was not conclusive due to pain and swelling


Valgus stress instability was not conclusive due to pain and swelling


Active Lachmans’ test was not assessed due to pain and swelling


All other peripheral joints were documented as normal



Pre-operative treatment aims


Discuss aims and surgery procedure


Explain that post-operative pain and swelling is a common presentation


Discuss immediate post-operative plan


Discuss and give written information of the post-operative protocol and rehabilitation programme


Teach immediate post-operative knee joint exercises including patellofemoral mobilisations to maintain range of movement


Teach safe mobilisation with elbow crutches



Post-operative treatment aims (day 1 and 2 post surgery)


Read surgeon’s post-operative instructions regarding mobilisation


Minimise swelling with advice on rest, ice and elevation


Advise patient on the importance of adequate pain relief


Mobilise partially or fully weight bearing according to surgeon’s protocol. Encourage normal gait pattern and safe mobility on stairs. Mobilise with cricket bat splint or brace depending on surgeon’s protocol


Commence active range of movement as instructed by surgeon’s protocol. Common protocols aim to achieve 0–90° of active range of movement by week 2 post surgery


Encourage resting position in knee joint extension


Plan discharge goals



Discharge goals


Reiterate ACL post-operative rehabilitation protocol and graft protection


Discuss the importance of a graduated rehabilitation regime and good muscle control


Discuss return to work according to surgeons protocol


Review home exercise programme


Review safe mobilisation on elbow crutches


Re-assure the patient that immediate post-surgical pain and swelling will gradually reduce


Arrange post-discharge out-patient physiotherapy appointment



Questions



1. What is the role of the cruciate ligaments in knee joint stability?

2. Describe common ACL mechanisms of injury.

3. Why is reconstruction using grafts preferable to repair of torn tissue? What type of grafts can be used in ACL reconstruction?

4. Considering your patient’s profession what might be a better choice of graft for his ACL reconstruction?

5. The patient has post-operative pain and swelling and this is increasing his anxiety about his return to work. How can the therapist re-assure him and address this anxiety?

6. What is the clinical reasoning behind open and closed kinetic chain exercises in ACL reconstruction?


CASE STUDY 6 Fractured tibia and fibula



Subjective assessment



PC


36-year-old male admitted via A&E for surgery after a motorbike accident a few hours earlier which resulted in several open transverse and crush fractures of his right tibia and fibula


He also has deep friction burns on his left side from sliding on the road surface



HPC


Patient suffered massive blood loss due to the open nature of his fractures


He was referred for immediate surgery


Pedal pulses were weak but present and it was therefore decided to use an internal fixator to pin his leg


After the surgery he was transferred to the high-dependency unit where his medical condition resulting from the blood loss can be monitored



SH


Self-employed motorcycle courier and a trained motorbike mechanic


Lives with his partner and their three young children


Patient and partner juggle their work schedule so that both look after their children without outside help



Post-operative aims


Read the operation report and check for any special post-operative instructions


Check chest and start with breathing exercises


Re-assure patient and advise him on process of rehabilitation


Pain relief


Check wounds (do not forget the left side with the burns) and distal pulses


Advise patient on vascular exercises (e.g. foot and ankle pumps) for his left leg. No muscle contractions of his right lower leg yet as this may put strain on the bone ends


As the patient will be non-weight bearing when he mobilises he will need to work his upper body and non-operated leg to achieve the endurance needed for this high effort walking pattern



Questions



1. How are fractures classified?

2. What is an internal fixation?

3. What are the possible disadvantages of an ORIF?

4. What are the classic healing times for fractures?

5. What are the complications of fractures in general?

6. What model of rehabilitation and clinical reasoning might be useful for Mike?


CASE STUDY 7 Achilles tendon repair



Subjective assessment



PC


41-year-old male has undergone an Achilles tendon (TA) repair 1/7 ago. You have been asked to ensure that he is safe to go home today on crutches



HPC


He ruptured his TA (the first time) 5/12 ago


Treatment consisted of full leg plaster for 3/12 followed by out-patient physiotherapy


3/7 ago he was walking on level ground when it re-ruptured


Previous diagnosis had been Achilles tendinopathy



SH


Lawyer working in city and travels in by underground


Single and lives alone in first floor flat


He plays squash at club level. Until 2 years before he had also been playing rugby at club level. From then till his TA ruptured first time he was refereeing rugby at least one game each weekend



Objective assessment



Observation


Strong, fit looking man despite the long period of recent inactivity, with a below knee cast, the foot position being full plantar flexion


Able to easily lift cast in all directions, has full mobility


Circulation appeared normal



Post-operative instructions


Below knee cast with ankle in full plantar flexion 4/52, non-weight bearing


Cast changed to reposition the foot into neutral, i.e. the ankle is at right angles, for a further 2/52, and a walking cast applied for weight bearing


Cast removed 6/52 post surgery and out-patient physiotherapy to commence


(Dandy & Edwards 2003)



Post-operative treatment aims



image To be clear with post-operation instructions

image To ensure safety with crutch walking on the flat and on stairs

image To support the patient psychologically

Elbow crutches were supplied and fitted. Instructions for use were discussed and he was taken to the staircase for stair practice. No problems were encountered – balance, transfers and on ascending/descending the stairs. Throughout the session he revealed what an extremely difficult time he was having adapting to this long period of inactivity. This was discussed and the patient decided with help, that regular visits to the gym to work on upper body and contralateral leg (the unaffected leg) strength would give him some means of having control on this situation. He was deemed safe to go home and was discharged



Questions



1. What is a tendinopathy?

2. How is a TA rupture diagnosed?

3. What muscles make up the TA and what is their function?

4. What are the stages of healing and how do they apply to this tendon?

5. Describe the progressive changes you think occur in the normal gait pattern when using crutches.

6. What are the complications of poor crutch walking?

7. What exercise therapy will likely to be incorporated into his rehabilitation once his plaster has been removed?


CASE STUDY 8 Idiopathic scoliosis



Subjective assessment



PC


15-year-old girl admitted with idiopathic scoliosis.


Scoliosis is thought to be progressing (Cobb angle 40°, Risser four)


Booked in for a single stage anterior fusion in 2/7


The aim of the surgery is:


image to stabilise the spine

image to prevent further deterioration

image to correct the deformity


HPC


Change in patient’s spine was noticed by her mother 6/12 ago


GP referred to consultant


Pre-admission 8/52 ago – stayed overnight, met the MDT


Postural advice with emphasis on symmetrical weight bearing was given


Investigations including new spinal X-rays and chest X-ray, blood tests, ECG and sleep studies were carried out



SH


Sitting GCSE exams at the end of year and very worried about having time off school


Used to play netball but lately finds it too difficult but would like to be able to play again


Not involved in other sport as she feels awkward



Objective assessment



Observation


Right rib ‘hump’ (thoracic right convex) with right shoulder protracted and a prominence of the right hip, i.e. the trunk has shifted to the left Curves well hidden under loose clothing



Leg length


Indicates a shortening of right leg



Neurological signs


Nil



Single leg stance


Difficult on both sides due to asymmetrical weight distribution



Gait


Normal



Pre-operative treatment aims


Respiratory assessment – record lung function in medical notes to ascertain pre-operative values


Explain post-operative management and introduce post-operative precautions


Provide any written information sheets about post-operative care and discuss



Post-operative treatment aims


Identify and prevent post-operative complications


Restore respiratory function


Restore active muscle control


Safe, functional rehabilitation and progression of mobility


Education of the patient to include:


a. ergonomic advice

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Mar 17, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Case studies in orthopaedics

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