ORTHOPAEDIC & TRAUMA UPDATE:PROTOCOLS AND BEST PRACTICE

J. Peter Tooley, SPT

George Washington University

10/3/13

Objectives• To Review protocols for commonly seen injuries on

orthopedic and trauma floors• To review specific orders given by each trauma and ortho

surgeon.• To review some evidence based best practices for ortho

and trauma rehab.• To review some complications that can occur with• Introduce and give brief overview Clinical Prediction rule

for DVT/PE

PROTOCOLS AT

FOR ELECTIVE JOINT PROCEDURES

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General TKA Protocol• Follow Supine Exercise and Seated Stretching Protocols

– 2x/day• CPM per Physician Orders (6-8hrs/day)• ROM Measured (flex seated; ext supine)• Ambulate POD1, Stairs POD2/3 as appropriate

• Pasquini SM, et al. FWW vs. Std. Walker

• Up in Chair 45 minutes• Goals:

• >/= 90° Passive flexion• </= (-10)° passive extension• Ambulate 150ft.

• In bed pt. should lay with legs extended – no pillows!

General THA Protocol

ANTERIOR PRECAUTIONS???

• DO NOT• Cross Legs• Twist at the waist• Go past 90° of hip flexion• Move leg actively into

abduction

POSTERIOR PRECAUTIONS

• DO NOT• Cross Legs• Twist at the waist• Go past 90° of hip flexion

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General THA Protocol• Exercise Program 2x/day• Up in Chair ~45min• Ambulate POD#1• Stairs POD#2

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Dr. James Bakeman

THA

• Standard Posterior Hip Program• Posterior Precautions• Abduction pillow in bed• BID Activity POD#1

• SCD until ambulate 100ft.

• Typically WBAT • D/C Day 2 with pain

controlled and pass PT

TKA

• Standard TKA Exercise Program • Precautions

• No kneeling on involved knee• Avoid running and jumping

• Continuous Passive Motion• During Hospital stay• 6-8hrs/day• As tolerated up to 120°• Poss. At home.

• SCD until ambulate 100ft.• D/C day 2 with pain controlled

and pass PT

Dr. David Bielema

THA

• Standard Anterior Hip Program• Anterior precautions• Anterior hip exercises

• Thigh High TEDS until 6wks post Op 23hrs/day

• SCD until D/C• 30lbs WB (no cement)

TKA

• Standard TKA Exercise Program

• Precautions:• No kneeling on involved limb• Avoid Running & Jumping

• Thigh High TEDS until 6wks post Op 23hrs/day

• No CPM• SCD until D/C• OP PT starts after 2wk f/u

Dr. Jabara & Dr. Ringler

THA- Ringler

• Performs Rarely• Post Precautions• WBAT

TKA

• Standard TKA Exercise Program

• Precautions:• No kneeling on involved limb• Avoid Running & Jumping

• Thigh High TEDS until 6wks post Op 23hrs/day (24hr)

• SCD until ambulate 100ft.• CPM per Request**

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Dr. Mark Asperheim

THA

• Standard Posterior Hip Program• Precautions & Exercises

TKA

• Standard TKA Exercise Program

• Precautions:• No kneeling on involved limb• Avoid Running & Jumping

• Thigh High TEDS until 6wks post Op 12hrs/day

• SCD until ambulating 100ft.• CPM in hospital

• Start at 50°. Progress 10°/day up to 120°

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General Spine Protocol• Mobility

• Log Roll• Brace on in Sitting or

Supine (Physician dependent)

• Sitting Limitation• No longer then 30

minutes at one time

• Assistance• No Trapeze

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There’s more.• Back (including Laminectomies)

• No BLT’s• Bending > 90°• Lifting > 10lbs• Twisting at the waist

• Say no to recliners**

• Cervical Spine• Do not reach overhead with both arms• Avoid flex, ext or twisting at neck• No lifting > 5lbs• Recliner sleeping if possible• Bracing (physician dependent)

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Spine Surgeons• Elective fusions and after traumatic fxs.• Pro-Exercises • Dr. Brown

• Bracing Fusions (sitting); Trauma see orders

• Dr. Easton• Brace in sitting (be sure to double check orders)

• Dr Russo• Almost always a TLSO• Brace in supine (per orders)

• Dr. Stubbart• Brace Sitting

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Spine Surgeons• Dr. Jason Squires

• Brace sitting; does not hold activity• Spinal cord stimulator = Laminectomy tx.

• Dr. Marilyn Gates• Elective fusions• No brace required (PRN)

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PROTOCOLS AT

FOR ORTHOPEDIC TRAUMA INJURIES

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General Trauma Considerations• Rescheduling d/t Surgery?• BID for Isolated LE fractures• Coordination of care• Rib fractures – SupineSit??• Remember Spine and Pelvic trauma = Log roll to

uninvolved side • Transfers – Slide Board vs. Stand Pivot• No Hemi Walker NWB 1 arm 1 leg (30lbs & Up)!

General Hip Fx Protocol• Things to consider

• Hip fx. Exercises (Isometrics, quad, HS, prox hip.)• Wt. Bearing Status

• Location of fx.• WBAT, 30lbs.

• Mobility• Diagonal Method for bed mobility vs. Log roll technique

General Tib/Fib fx Protocol• Assistive device selection

• Location of fracture• ie: wheeled walker vs. knee roll about for proximal tib/fib fxs.

• Wt. Bearing status• Level of function needed

• Exercises• Do not stretch ankle• Think proximal

Acetabular Fx.• Acetabular fx

• Commonly concurrent with post. hip dislocation• 60° Precautions• Wt. bearing• CPM? (Dr. Jones)• Transfers• Moed BR, et al. 2007. – complete recovery uncommon

• Paterno MV, Archdeacon MT Is there a standard rehabilitation protocol after femoral intermedullary nailing? J Orthop Trauma. 2009;23(5):S39-46.• Hip abduction weakness, knee extensor weakness, anterior knee pain, gait

abnormalities.

Femoral Shaft Fx.

Amputations• Positioning

• Avoiding contractures• Kiwi Brace

• Transfers• Balance, strength, A/D

• Exercise• Proximally• Prep for prosthesis

• Skin protection

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Exercise Considerations w/ these populations.

• Are they appropriate?• What does the physician prefer?• Where do we start?

• Isometrics• Proximal strengthening

• Core stabilizers?

• Uninvolved side.• Quads & Hamstrings after TKA

• Stevens-Lapsley, et al. 2010

• Evidence tells us Exercise is good. Any specific protocols?

Dr. Ringler• Isolated Fx. POD #0 Eval & D/C• Tibial Plateau or Distal Femur

• CPM POD#0 & Home• Hinged knee brace (ROM variable)

• Hip fractures• Usually WBAT – However Dependent on fixation

Dr. Bielema• Simple Iso fx Eval POD #0; D/C if possible• Tib Plateau or Distal femur fx

• No CPM• Knee immobilizer or hinged knee brace

• Ext or minimal mvmt

• Hip Fx.• Wt. Bearing depends on type of fixation

Dr. Agnew• New Surgeon (OAM)• Iso fx POD #0 Eval and possible D/C.• Tib Plateau & Distal Femur fxs.

• Braces w/ long post. leg splint w/ FAS extension• Has not ordered CPMs

Dr. Terry Endres• Simple Iso fx Eval POD #0; D/C if possible• Tib plateau or distal femur

• Will order in-house CPM (sometimes home orders)• Hinged brace w/ partial ROM• Quad sets, SAQs, SLRs

• Hip fx.• WBAT

Dr. Cliff Jones

Hip Fx

• Wt. Bearing per fixation type

• Typically WBAT

Tib Plateau/ Distal Femur

• CPM POD #0 – Home orders

• Hinged knee brace – Partial ROM

Dr. Cliff Jones

Spine

• 23hr/day bracing (TLSO)• In chair or out of bed

3x/day• Exercise:

• Ankle Pumps• AVOID:

• Hip/Abdominal/Back Exercises

• No Quad Sets or Hamstring sets

• MOBILIZE ONLY!

Pelvis

• MOBILIZE ONLY!• Out of bed & Out of Chair

3x/day• Weight Bearing Status:

• Non-op/ Elderly=WBAT• Younger/ Operative=NWB

• Ankle Pumps

EVIDENCE BASED PRACTICE

THA/TKA• Liu SS, et al. –Predicting Mod to Severe Pain

• 20% Rest; 33% Activity• Predictors Rest: Female, Younger, Inc. BMI, TKA vs THA, Inc. Pre-

Op pain @ incision site, Pre-Op Opioids, General Anesthesia• Predictors Activity: Pre-Op pain @ incision site, General

Anesthesia, Pre-Op anti-convulsants & anti-depressants, Prior surgery at surgical site

• Lenssen AF, et al. – Goniometric measurement • Fair Inter-rater reliability for flexion in supine and extension.

• Pellino TA, et al. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty.

THA/TKA• Seibens HC, et al. 2012

• Outcomes of weight bearing status during rehabilitation after THA• WBAT > likelihood for home discharge following therapy• Outcome similar to more restrictive approaches

• Milne S, et al. 2003 – CPM following TKA• Positive ST effects with combined PT

• Denis M, et al. 2006 – CPM effectiveness• No significant reduction in impairment or LOS

• Trzeciak T, et al. • CPM, Beneficial for Pain, stiffness, and functional ability

THA/TKA• Chow TP et al. 2010. - RCT

• AROM vs. PROM vs. PNF• Significant increase of flexion ROM• No significant change b/t groups

Some complications of Othro/Trauma procedures.

• Compartment Syndrome• Fat Embolism Syndrome• Deep Vein Thrombosis

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Compartment Syndrome

• Risk Factors• Blunt trauma• Circumferential Burns• Injection/Infiltration injury• Revascularization after

arterial anastomosis• Unconscious pt. with

compressed limb

• Assessment• Pain w/ passive stretch**• Pain out or proportion

related to injury• Poor capillary refill• Pallor• Paresthesias/Paralysis^

(n. distribution)• Distal Pulse

abnormality‡

Fat Embolism SyndromeParisi DM, et al 2002. & Ozyurt Y et al. 2006.

• Complication of skeletal trauma• Fat droplets into systemic circulation• Presentation

• Triad• Pulmonary distress• Mental status change• Petechial rash 24-48 hrs post pelvic/long bone fx.

• Difficult to recognize• No routine diagnostic tool

Well’s Clinical

Prediction Rule for

DVT

http://acupaday.org/2013/06/25/know-your-wells-clinical-prediction-rules-in-pt/

Applying this to patients

• Pt. presents with S/Sx of DVT• Swelling, discoloration, a cord in leg vein that can be felt, tachycardia, fever,

tissue temp increase, tenderness, pain in leg• Pt. with history of DVT.• Pt. with associated risk factors (stasis, venous damage,

hypercoagulability)• Strong: Fx, Joint arthroplasty, gen surg, trauma, SCI

• Pts. postoperatively THA & TKA• Pts. with active cancer• REMEMBER DVT/PE can be asymptomatic ~50%

Incidence in Ortho/Trauma population• Aldridge D, et al. 2004 – DVT Risk

• Hip replacement no prophylaxis 54%• Hip replacement with prophylaxis 16%• Knee replacement with prophylaxis 31%• Hip fracture with prophylaxis is 27%• Thromboembolic complications have been reported in 30-60% of

persons following stroke

Clinical Feature Points

Active cancer (treatment ongoing or within previous 6 months or palliative

1

Paralysis, paresis, or recent plaster immobilization of the lower extremities

1

Recently bedridden for more than 3 days or major surgery, within 4 weeks

1

Localized tenderness along the distribution of the deep venous system

1

Entire leg swollen 1

Unilateral calf swelling of greater than 3 cm (below tibial tuberosity) 1

Unilateral pitting edema 1

Collateral superficial veins 1

Previous Hx DVT 1

Alternative diagnosis as likely as or more likely than DVT -2

Total Points

Wells Clinical Prediction Rule

What does this mean?

• Risk score interpretation (probability of DVT):

• >/=3 points: high risk (75%);

• 1 to 2 points: moderate risk (17%);

• <1 point: low risk (3%).• All with 95%CI

• Stop activity• Seek out doppler or d-dimer.

• Resume activity per throbolytic treatment

• Well's CPR Calculator

• Diagnosis Flow Chart

• In patients with symptoms in both legs, the more symptomatic leg is used.

• Tenderness along the deep venous system is assessed by firm palpation in the center of the posterior calf, popliteal space, and along the femoral vein in the anterior thigh and groin.

• Calf swelling was measured 10 cm below the tibial tuberosity.

• The most common alternative diagnoses are: cellulitis, calf strain, and post-operative swelling. • If a clinician is unable to make a reasonably accurate estimate of the

likelihood of DVT relative to other disorders, the developers of the rule suggest assigning this item a 0. This may over-estimate a patient’s probability, but decreases the likelihood of missing a DVT.

Case Example• 64 y/o male s/p Right THA 2 days ago c/o pain in his right

calf muscle in bed and increases when he gets to ambulate. Pt. wears TEDs in bed with SCDs and received VTE prophylaxis Pt. has a history of prostate cancer – he recently finished chemotherapy 4 months ago, CAD, HTN. You notice his right LE is visibly larger then the left (measured 3.7cm circumferential difference between his legs 10cm below tibial tuberosity.). Pt. medical history shows DVT 20 years prior that did not end up in at PE.

Case Example• 64 y/o male s/p Right THA 2 days ago c/o pain in his right

calf muscle in bed and increases when he gets to ambulate. Pt. wears TEDs in bed with SCDs and received VTE prophylaxis Pt. has a history of prostate cancer – he recently finished chemotherapy 4 months ago, CAD, HTN. You notice his right LE is visibly larger then the left (measured 3.7cm circumferential difference between his legs 10cm below tibial tuberosity.). Pt. medical history shows DVT 20 years prior that did not end up in at PE.

• Score:

Well’s CPR for PEWells Clinical Prediction Rule for PE

Clinical Characteristic Score

Clinical s/sx of DVT (minimum of leg swelling and pain with palpation of deep veins

3

An alternative diagnosis is less likely than PE 3

HR greater then 100 beats/minute 1.5

Immobilization or surgery in the previous 4 weeks 1.5

Previous DVT/PE 1.5

Hemoptysis 1

Malignancy 1

Risk Score Interpretation>6 points: High risk2-6 points: Moderate risk<2 points: Low risk

Questions?

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References• Spectrum Health Rehabilitation and Sports Medicine Services – Physical

Therapy TKA &THA Protocol• Wells, P.S., Anderson, D.R., Bormanis, J., Guy,F., Mitchell,M., Gray, L., Clement, C.,

Robinson, K.S., and Lewandowski, B. (1997).Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet, 350, 1795-1798

• Dr. Steve Tepper, PT, PhD, Blood Vessel Diseases Lecture 8, Summer 2012. George Washington University.

• Dr. Ellen Costello, CardioPulmonary Diseases, Lecture Notes, Fall 2012, George Washington University.

• Liu SS, et al. Predictors for moderate to sever acute postoperative pain after total hip and knee replacement. Int Orthop. 2012;36(11):2261-7.

• Siebens HC, et al. Outcomes and weight-bearing status during rehabilitations after arthroplasty for hip fractures. P MR. 2012;4(8):548-55.

• Paterno MV, Archdeacon MT Is there a standard rehabilitation protocol after femoral intermedullary nailing? J Orthop Trauma. 2009;23(5):S39-46.

References• Parisi DM, Koval K, Egol K. Fat embolism syndrome. Am J Ortho.

2002;31(9):507-12.• Ozyurt Y, Erkal H, Ozay K, Arikan Z, Traumatic fat embolism syndrom: a

case report. Ulus Trauma Cerrahi Derg. 2006;12(3):254-7.• Pasquini SM, et al. The impact of assistive device prescription on gait

following total knee replacement. J Geriatric Phys Ther. 2012;33(2):64-70.

• Pellino TA, et al. Use of nonpharmacologic interventions for pain and anxiety after total hip and total knee arthroplasty. Orthop Nurs. 2005;24(3):182-90.

• Chen B, Zimmerman JR, Soulen L, DeLisa JA. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Med Rehabil. 2000;79(5):421-6.

• Lenssen AF, et al. Reproducibility of goniometric measurement of the knee in the in-hospital phase following total knee arthroplasty. BMC Musculoskelet Disord. 2007;17(8):83.

References• Milne S, et al. Continuous passive motion following total knee arthroplasty, Cochrane

Database Syst Rev. 2003;(2).• Denis M, et al. Effectiveness of continuous passive motion and conventional physical

therpay after total knee arthroplasty: a randomized control trial. Phys Ther. 2006;86(2):174-85.

• Trzeciak T, et al. Effectiveness of continuous passive motion after total knee replacement. Chir Narzadow Ruchu Ortop Pol. 2011;76(6):345-9.

• Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients prob ability of pulmonary embolism: Increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83(3):418.

• Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does This Patient Have Deep Vein Thrombosis? J Ame Med Assoc. 2006;295(2):199-207.

• Wilbur J, Shian B. Diagnosis of deep venous thrombosis and pulmonary embolism. Ame Fam Physician. 2012;86(10):913-919.

• Aldrich D, Hunt D. When can the patient with deep venous thrombosis begin to ambulate. Phys Ther 2004;84:268-273.

• Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. J Bone Joint Surg Am. 2007;89(6):1170-6.