User talk:Ssothere2

PRINCIPLES OF PHYSIOTHERAPY MANAGEMENTFOR PATIENTS ON TRACTION
PRINCIPLES OF PHYSIOTHERAPY MANAGEMENTFOR PATIENTS ON TRACTION

1.	Maintain normal movement and function of non-injured (unaffected) structures 2.	Restore normal movement and function ASAP to # (injured area)

IF PATIENT IS ON TRACTION:

1.	He is confined to bed

Have general problems i.e.: ↓ circulation ↓ Respiration (↑chest infection) ↑pressure (↓skin condition) ↓ Movement (↓ROM, ↓ muscle strength)

2.	Local problems (injured part):

Swelling Pain Weakness (↓muscle strength) ↓ Movement ↓ Function ↓ Skin condition

3.	Psychological implications

Treat whole person Concentrate on affected area/ areas Prepare for mobilization/discharge.

FORCES ACTING ON FRACTURE SITE

1.	Must know position of fracture site, so can : -protect fracture site -analyze forces acting on fracture site 2.	Unopposed muscle forces will pull fracture segments out of alignment. E.g: Subtrochanteric fracture of femur Until fracture site is stable, DO NOT contract Iliopsoas or Abductors or will increase deformity. If fracture site is stable, can do isolated contractions or co-contractions. If fracture site is unstable, try co-contractions or stabilize fracture site yourself. (Not always possible)

Traction position tries to eliminate unopposed muscle force → Good alignment.

	Assessment of patient on traction – patient cannot move limb. 	Describe position limb is held in (hip flexion= 45o, abduction = 10o) 	Static muscle contraction (can’t use Oxford scale) 	Co-contractions 	Passive/accessory movements. If muscle cannot move joint, cannot use Oxford scale 	Grade statistically (nil, poor, fair, good) Must know position of fracture site, so can work out forces acting on fracture site. Fracture site must be protected.

CONTRA-INDICATIONS

→ NO excessive movement at the fracture site →NO ↑ in P →DO NOT remove the support from fracture site (Need minimal movement at fracture site to stimulate healing)

ASSESSMENT OF PATIENT ON TRACTION

1.	Data Base :

-	X-rays -	Medical notes -	Patients details

2.	Subjective assessment :

-	Date of injury/admission -	Dates and types of procedures -	Future medical plans -	Patients main problem -	Previous medical problems -	Social history: accommodation, work, hobbies /sports etc… -	Psychological state.

DETERMINE CONTRAINDICATIONS AND MODIFY OBJECTIVE ASSESSMENT

3.	Objective assessment

•	Look: - General: -	Position of patient -	Face (expression and pallor) -	General wasting -	General bruising -	General swelling Decide which joints/area of body likely to be most affected – concentrate on this area first.

-Local:

-	contour -	Color -	Skin condition -	Conditions of muscles.

•	Feel :

-	Temperature -	(sensation) -	(painful structures) -	Muscle tone -	Soft tissue swelling/ bony contours.

•	Move:

-	Assess affected limb (active and passive movement and muscle strength as possible) -	Describe position joint is held in -	Check all uninvolved joints and muscle strength

N.B: No Oxford scale therefore grade statistically (Nil, poor, fair, good). Reflexes - contra-indications!!

Joint stability – contra-indicated in presence of unfixed fractures Joint crepitus – assess if possible e.g: P/F joint Limb measurement – inappropriate at this stage

Gait

Function – in bed e.g: washing, eating, sitting Special tests – contra-indications!

CARE OF PATIENTS IN TRACTION:

-	Fracture site must always be adequately supported. -	Check line of pull of traction is parallel to shaft of fracture bone -	Check pin sites for sepsis /oozing -	Check weights are hanging freely -	Check bed is elevated to provide counterattraction (if necessary). -	Check ropes are moving freely within traction system e.g: over pulleys -	Check position of patient relative to traction is correct i.e.: position of Braun frame etc… -	Check pressure areas -	Check daily when you Rx the patient.

ADVICE TOPATIENTS WITH POP:

-	Do NOT wet plaster (use plastic bag in bath etc…) -	Never poke objects done pop to scratch etc…as may break skin. -	Check if POP too loose or too tight (both need medical attention) -	Circulatory exercises + + and isometrics. -	Elevate limb as much as possible -	Check skin around edges on POP for chaffing etc… -	Do not walk on POP (use plaster shoe) -	If pop breaks, return to hospital immediately.

INTERPRETATION OF ORTHOPAEDIC X-RAYS

APLEY’S RULE OF TWO

1.	Two (or more) views = AP and lateral (oblique) 2.	Two sides = for comparison, especially with children, and where wrists and elbows are affected. 3.	Two joints = must visualize whole of bone, including joint above and below 4.	Two or more times = to monitor progress

Must be methodological when reading an X-ray or you will miss something. Need to: -	Stand back and overall impression of X-ray (general examination) -	Examine every cortex of every bone in every view, and every joint (detailed examination) Convenient approach / sequence to examination is:

PATIENT SOFT TISSUE BONE JOINT

1.	PATIENT

Check the following:

-	Name (same as patient ) -	Date (recent, serial) -	Side (right or left) -	Area or region shown -	Estimate age of patient -	Small size, absent 2o centres = infant Open epiphyseal plate = child Closed epiphyses = adult Calcified vessels, osteoporosis = elderly

2.	SOFT TISSUES

Look for variations in shape and intensity Check the following: -	X-ray penetration = hard or soft -	Shape : swelling or wasting of muscles planes e.g. polio, soft tissue mass or joint effusion if in region of joint -	Density= increased density can be due to calcification of a tendon, blood vessel, haematoma or abscess, or due to foreign body such as a bullet of needle. Decreased density of soft tissue is due to either fat or gas (compound fractures, gas gangrene)

3.	BONES

Look for variations in shape, density and bone architecture. = Shape:

-	The bone may be bent or widened (e.g. Paget’s disease) -	Malaligned (e.g. varus, valgus, recurvatum, flexion) -	Discontinuous (e.g. fracture, amputation)

= Density:

-	Generalized decreased density (e.g. osteopenia = osteoporosis, osteomalacia) or -	Localized decreased density (e.g. lytic lesions due to bone cysts, bone abscess, myeloma, tumors, dysplasia etc…) -	Irregular alterations of density are also known as altered architecture (e.g. marble bones) -	Generalized increased density (e.g. fluorosis, marble bones) and -	Localized increased density (sclerosis e.g osteoid osteoma, sequestrum and sclerotic metastases)

= Periosteum:

-	Look for a periosteal reaction (e.g. sunburst, onion peel, Codman’s triangle, osteitis, fractures)

= Cortex:

-	Thin cortex (e.g. osteogenesis imperfecta) -	Thickened cortex (e.g. Paget’s disease) or -	Breached cortex (e.g. fracture, post-surgery)

= Medulla:

-	Increased, decreased or absent.

4.	JOINT

Specific points relating to the reading of joints X-rays are: = Congruity of joint surfaces: Subluxation and dislocation, outline of joint surface (normal, smaller or bigger e.g hip dysplasia), abnormal shape (e.g. Perthe’s disease or OA)

= Joint space:

Cartilage is radiolucent so children have wider joint spaces than adults (cartilaginous epiphyses) Widened joint space in adults due to joint effusion, reduced joint spaces due to cartilage loss e.g. chronic arthritis Widened joint space in children due to Perthe’s disease (epiphysis collapses)

= Subarticular bone:

Eroded or osteoporotic bone due to rheumatoid arthritis while sclerotic bone indicates avascular necrosis (dead bone)

= Periarticular bone:

-	Osteophytes in osteoarthritis -	Cyst formation can occur in OA -	Deformity e.g.: malunion of old fractures or slipped upper femoral epiphysis can lead to deformed joints.

DESCRIPTION OF BONE LESION

1.	Situation = which bone, which side, where (: epiphysis, metaphysis, diaphysis) 2.	Size of lesion = 10 cent size coin etc… 3.	Single or multiple lesions = within bone or within body 4.	Contents: – empty = fluid cartilage - Not quite empty = fibrous tissue - Bone = osteoid osteoma - Trabecular pattern (soap bubble) = giant cell tumor etc… 5.	Margin = well define sclerotic border (usually benign) or absent/ ill defined (usually malignant). 6.	Extent = does lesion involve other tissues beside bone (usually malignant) 7.	Periosteal reaction = unusual in benign lesions, common trauma, infections and malignancy.

SPECIALIZED RADIOGRAPHIC TECHNIQUES

	Arthrography 	Myelography 	Tomography 	Computerized tomography (CT) 	Stress radiographs (stressed ligaments) 	Magnetic resonance imaging (NMR/MRI) 	Radio-isotope scanning. -	 E.g: techretium - 99m (osteoplastic activity) Gallium - 67 (taken up by proteins found in healing bone and tumors- indicates infection)

(See Dandy pg53 - 61, Appley pg15 - 18)

REFERENCES

1.	Essential orthopaedics and trauma – DJ Dandy, Churchill Livingstone, 2nd ed. , 1993 2.	Manual of orthopaedic surgery – RK Marks (editor), UCT Publishers, 2nd edition, 1990 3.	Apley’s system of orthopaedics and fractures – AG Apley, L Solomon, Butterworths, 6th ed., 1982 Compiled by: L J Hunter, physiotherapy department, wits.

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