Although a thorough social history includes a routine set of questions that aid in getting to know a patient, it is important to look beyond a job title or a tobacco history to learn more about a patient’s identity. Often as practitioners, we aim to solve an immediate problem, but it is important to first determine how patients’ life will be affected first by their condition and second by each treatment option. Knowing this key information will help tailor the care they will receive to best suit their needs.

Because musculoskeletal conditions affect bones, joints, muscles, tendons, and ligaments, the majority of orthopaedic injuries and conditions inhibit motion and limit activity. First understand your patients’ level of activity prior to the onset of their condition. Are they a high-performance athlete competing in marathons, competitive biking, or daily surfing? Are they a dedicated gym goer, yoga enthusiast, or martial arts student? How many miles do they run, jog, walk, bike, or swim on a weekly basis? What is the average level of intensity that they incorporate into their weight training routine? Are they sedentary, with little expectation beyond return to activities of daily living? In addition to setting patient expectations, this information may also help you diagnose their condition. Was the patient running five miles daily at a 10 minutes/mile pace but recently increased their routine to eight miles daily at a 9 minutes per mile pace? Increasing duration and intensity of activity abruptly may be the mechanism of injury in the development for a stress fracture for instance.

Not all patients will be high-performance athletes, but understanding their activity level is still significant to their treatment and recovery. Does your patient walk to work daily? If so, how many city blocks? Do they have to navigate stairs or a crowded area such as railway stations, bus stops, or subways? Would they be able to travel safely with a controlled ankle motion boot, cast, or sling in place, or while utilizing crutches, a knee walker, or a wheelchair? If the patient is not using public transportation, do they drive to work? Any time a patient is taking narcotic pain medication, muscle relaxants, or barbiturates, they must be advised against operating any moving vehicles or heavy machinery because of such side effects as sedation, drowsiness, muscle weakness, lightheadedness, and dizziness.

Other factors to consider regarding ability to drive include weight-bearing status, laterality of injury, injury-induced pain and/or postoperative pain, peripheral neuropathy, and joint stiffness. Further discussion with the patient is advised when lower extremity or spinal arthrodesis surgery is recommended because the loss of range of motion of the foot and ankle may impair ability to apply force to the brake pedal or accelerator, and the loss of range of motion at the level of the cervical spine can inhibit peripheral visibility while driving. One recommendation for all patients returning to driving is to start with a short drive in a traffic-free area and to be accompanied by another licensed driver. A companion is recommended in the event that driving exacerbates injury pain and the patient is not able to safely return home. Understand there is no “clearance” for driving. It is important to remember each patient has individual factors that will affect this recommendation and must be evaluated on a case-by-case basis. Table 2-1 provides general guidelines for return to driving after orthopaedic injury. Lower extremity impairment was evaluated as time required to perform an emergency stop. The above return to driving recommendations represent when braking function returned to normal. Upper extremity recommendations are based on ability to maneuver the wheel of the vehicle appropriately in situations where an abrupt swerve or sharp turn is necessary.

Although there are no state or federal laws restricting the operation of a motorized vehicle while wearing an immobilization device or during the postoperative period for an orthopaedic patient, the National Highway Traffic Safety Administration has published guidelines recommending the patient does not drive.³ You may educate your patient that in the event of accident or injury, they may be considered liable if their disability prevented them from operating the vehicle efficiently. If the patient is diagnosed with a permanent disability, they can be referred to a driver rehabilitation
specialist to determine if vehicle modifications can be made to allow safe driving. For those with temporary disability, physical and occupational therapists will be instrumental in rehabilitating the patient to safe driving function.

Now that you understand the patients’ ability to navigate their world, determine what other activities of daily living will be affected by their injury. Do they reside in an apartment, condominium, or house? Are these dwellings multilevel? Do they live independently without assistance from friends or family members? Patients may also navigate stairs by sitting on the bottom or top stair, lifting their body up off the ground by pushing up off the ground, and navigating up or down to the next stair by pushing off with their uninjured lower extremity.

Does the patient shop for and prepare their own food? Will they be able to continue to prepare their own meals with their injury? If not, are take-out services available in their area and affordable to the patient? If the answer to these questions is not yes, the patient will require a home care assistance or visiting nurse services. Please refer to Chapter 9 section I for further information regarding home care services.

Inquire about hobbies and extracurricular activities the patient engages in often. Once you understand a patient’s prior activity level, have a discussion regarding both their clinical and nonclinical goals following competition of treatment. This demonstrates your investment in their future and will help you set realistic expectations for treatment outcomes.

Hygiene: Do they bathe in a shower or a bathtub? Is there a handheld showerhead available? Postoperative patients should refrain from submerging and soaking incisions for 2 or more weeks following surgery to prevent wound maceration and dehiscence. Depending on the size and location of the incision, it may be acceptable to get the surgical area wet in the shower. Patients may wash with warm water and soap and blot or pat the incision dry following the shower. They should avoid scrubbing, rubbing, or abrading a healing wound. Likewise, they should avoid environments
with high humidity and excessive sweating, whereas their incision is healing to prevent superficial soft-tissue infections.

If a cast or a splint is in place, patients must make a strong effort to keep the construct dry. Moisture will weaken the plaster or fiberglass material, therefore providing less support and stability to the healing bone or soft tissue. Padding that becomes damp may irritate skin and initiate soft-tissue infections. Several chain pharmacy stores stock waterproof cast covers or they can be purchased online (Figure 2-1). Patients often experiment with homemade versions, including plastic bags, trash bags, cellophane wrap, and tape. Do advise they apply several layers because a hole the size of a pin head will cause a leak significant enough to affect the cast or splint material.