Physio facts of the week: Orthopaedics (2/12/12)
Each patient is different and no two will be the same so you will need to clinically reason each choice. For the following questions consider your patient to be normal with no complications.
1.What mobility aid do patients usual require Day 1 total hip replacement?
- Patients will usually mobilise with a zimmer frame.
2.How long is the average length of stay for a patient following a total knee replacement?
- 5-7 days Total knee replacement
- 3-5 days Unilateral
3. You come to see a patient and need to check observations are normal before you get the patient out of bed. What are the normal ranges for blood pressure?
- 120/80 to 140/90. Remember the blood pressure is relative to the patient. They may have a normal higher or lower than the normal.
- Blood pressure can be increased by stress and pain and other medical reasons. Ask your self if you can change these variables? Can you help with stress ie reassurance.
- For example some people are anxious that they feel sick and wont be able to reach a sluice bowl. Therefore leave it within reach. Some may be anxious about getting out of bed. Explain the process and provide reassurance.
- Another reason for increased blood pressure is pain. Have they had pain relief? Time pain relief 30mins before treatment where possible. Educate the patient on taking pian relief regular as advised by nursing staff to maintain good pain relief and make exercises easier.
- Low blood pressure – High risk of fainting. If slightly on the low side ensure you give them adequate time to adjust. ie sit up in bed, sit on edge of bed, sit by side of bed. Advise them to sit if feeling faint. Have oxygen ready (care should be taken with oxygen if the patient has COPD), assistance and a method in place if the patient starts to feel faint. Watch the patient carefully, sweating, feeling clammy, feeling sick, dizziness and fainting are signs of low blood pressure. A patient shouldn’t faint if you see the signs early enough and act appropriately. Ask your senior more about this. All patients are different and you need to treat them accordingly.
4. Name four exercises which would be suitable for a Day 1 total knee replacement to begin providing they were a text book case with no complications?
- Static quad – Squeezing the knee down into the bed. This helps reduce the risk of DVT, get the quad firing and increases blood flow to the quad. Warning: The quad stabilises the knee and maintains an extended position for stance phase. If the patient is unable to contract the quad the knee is likely to give way. Some patients will have a femoral nerve block following a TKR so the leg may be numb for up to 12 hours post op.
- Inner range quad- Place the knee on a towel and extend the knee. Again this gets blood circulating in the leg and gets the quad firing.
- Straight leg raise- I would be expecting a patient to achieve this within the first few days.
- Knee flexion
- Principles of exercises DAY 1 TKR : Increase ROM, increase circulation, improve firing and strength of quads. Total knee replacements are often sore post op. Organise pain relief and push exercises to improve mobility.
5. Which leg should the patient place first to help offload the operated leg day 1 Right TKR when using a zimmer frame?
- We normally advise a ‘step to’ gait on the first day. The frame will be placed first then the operated leg, in this case right, and then left so that the toes are in line with each other.
6. What movement should be avoided Day 1 anterior cruciate ligament (ACL) reconstruction?
- The ACL prevents anterior translation of the tibia on the femur. In the first few days after surgery the quads may be inhibited due to pain and they may also be weak. To avoid pressure on the graft you should teach the patient how to get out of bed so that they do not lift their leg. They can do this by using their hands to lift the leg via clothing however another technique is used more frequently where the non operated leg slides under the operated leg to support it. This technique will be on Physiowizard soon however it is learnt best through demonstration by a senior.