Chapter 17 E-materials
Case Study 17.1
HPC
• Initially the injury was treated conservatively in a below knee cast to be non-weight bearing for 6 weeks until his fracture clinic appointment.
• In fracture clinic he had the ankle re-X-rayed, which showed an appropriate amount of callus formation and therefore the cast was removed.
• He was seen by the physiotherapist in the fracture clinic for his initial appointment.
• The referral from the trauma doctor stated that the patient was permitted to weight bear as tolerated in a walker boot and was allowed to be treated to achieve full range of movement.
• The boot was to be retained and gradually removed after 2–3 weeks.
Objective assessment
Observation (OBS)
• Alan was seen initially non-weight bearing with two elbow crutches.
• He was not keen to rest the foot on the floor during the subjective examination.
• The foot was found to be swollen, slightly red and covered in dry skin.
• There was slight tenderness around the lateral malleolus and the whole foot was warm.
Treatment
• A walker boot was fitted and Alan was taught a heel–toe gait pattern with the two elbow crutches weight bearing as tolerated.
• Reassurance was given that the fracture was healing and that it was strong enough to walk in the boot.
• At this stage the exercises were non-weight bearing.
• Active assisted ROM exercises with a towel to assist the movements of dorsiflexion, inversion and eversion were taught.
• Sitting over edge of the bed, heel–toe exercises, ankle dorsiflexion stretches and toe curling were also taught.
• Alan was taught how to use ice or contrast baths and elevation to control the swelling.
• Advice was given about the use of moisturiser and soaking, to help with the dry skin.
• Alan was warned that the ankle would swell and be painful as he began using it more. The need to take painkillers was emphasised.
• This advice may need to be followed for several months post injury.
• Alan was concerned about getting back to work and he was advised to seek help, making an appointment with the Citizens Advice Bureau, to help him manage his finances, whilst rehabilitating.
Management
• Alan has weaned from the boot over a 2-week period.
• He progressed to exercises in standing, with dorsiflexion stretches, calf stretches, single leg stand work and calf raises.
• The ankle ROM, muscle strength, knee to wall and single leg stand were monitored to ensure appropriate progression.
• Maitland’s and Mulligan’s mobilisations were introduced to improve dorsiflexion along with soft tissue mobilisation to the calf.
• Alan was referred into a lower limb class to introduce more demanding exercises and to provide the added confidence he needed prior to returning to work and eventually his sport.
• Alan was able to return to work at 13 weeks post fracture, gradually increasing the workload.
• He continued to attend as an outpatient to enable a return to football.
• It was decided that it was appropriate for him to return to football once he could stand on the leg using a balance board to ensure that his balance, strength and proprioception were sufficiently developed to cope with the demands of football.
• His running gait was rehabilitated which included cutting and jumping.
• He was advised to do some training prior to playing in order to regain his general fitness.
Case Study 17.2 Acute trauma preoperative management
Admission
• Admission to the trauma unit followed a road traffic accident in which he suffered a (R) midshaft femur fracture, a (L) tibial shaft fracture and a (R) chest injury consisting of rib 3 to 6 fractures and a pneumothorax.
• He was admitted via the accident and emergency department, where they inserted a chest drain.
• A CT of the body revealed no other injuries.
• From the notes prior to seeing the patient, the information gathered for the subjective examination was as follows.
Preoperatively
Day 1 assessment
• Bedrest (L) leg in a backslab elevated on a Braun frame and (R) leg in skin traction.
• Chest drain had drained 500 mL.
• Auscultation revealed reduced breath sounds in the (R) middle and lower lobe.
• He was breathing 2 L oxygen via nasal prongs and his saturations were 98%.
• Coughing and deep breathes were painful ++.
• He was prescribed paracetamol and codeine.
• He reported no numbness or altered sensation and had full power of all joints that were able to be assessed.
• The (R) ankle and toes were the only joints to be tested as leg was in skin traction; (L) hip and knee were able to be tested, but ankle in backslab.
• All skin colour, pulses and capillary refill were normal on testing.
• He had full AROM of his upper limbs, (L) hip and knee and his (R) ankle.
• Using the overhead ring, he was able to lift his bottom and shift himself around the bed, but this was very painful.
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