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jessiekate22
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Exam
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2012-06-11 19:56:43
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Fourth Week
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2020
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  1. The knee osseous componenets
    • - distal end of the femur
    • - proximal tibia
    • - patella
  2. Soft tissue components
    • Capsule- envelops the knee jt from above the intercondylar fossa of the femur to below the tibial condyles
    • Menisci-lie on the periphery of the tibial plateaus, following the basic outlines of the plateaus
    • - function is one of shock absorption and spreading stress over the jt surface and decreasing cartilage wear
    • Ligaments- MCL- medial capsular lig, tibial collateral lig. LCL- lateral capsular lig, fibular collateral lig. Ant cruciate lig, post cruciate lig
  3. Tibiofemoral biomechanics
    • - biaxial
    • - flexes and ext around an axis that is horizontally oriented
    • - rotates around a verticle axis
  4. Knee flexion- ext
    • - polycentric
    • - total range of knee flex- ext in a normal 5- 10*
    • - hyperext to 140-150* flexion
  5. Knee flexion- ext
    • - flexion is limited by soft tissue approimation of the calf and posterior thigh
    • - ext is terminated by locking the jt in closed pack position
  6. What happens with the knee jt when it is flex- ext
    • the menisci act to reduce jt incongruity by moving and conforming to the shape if the femoral jt surface
    • - as the knee ext and the contacting radius of the femoral condyle increases, the ant aspects of the menisci glide forward
    • - as knee flexes, the ant aspect of menisci recede to conform to the smaller radius of the contactingfemoral condyles
  7. What happens with knee flexion- ext
    - rolling and gliding always occur in the same direction; ant during ext and posterior during flexion
  8. What happens when doing transverse rotation at the knee?
    • - undergoes rotation in the transverse plane
    • - most easily felt when the knee is flexed
    • - useful for attenuating the rotatory forces acting in the knee during normal function
    • - there is also a rotation of the knee that accompanies flex and ext of the jt
    • - ext rot of the tibia on the femur during final 15-20* of ext approx 40*
    • - int rot during the initial 15-20* of flex approx 25*
  9. What is the transverse rotation due to?
    • - the shape and orientation of the medial femoral condyle
    • - articular surface of the medial femoral condyle is also longer in an AP plane than the lateral condyle
    • - medial side of the tibia continues forward along the curved medial femoral condyle while the lateral surface undergoes a lateral spin
    • - cruciate ligaments also contribute to rotation
  10. Patellofemoral Biomechanics
    • - the normal function of the patella is the trochlear groove in a rhythmic pattern which increases the leverage of the quads mm
    • - to do this, the patella mst withstand shear and compressive forces placed on the articular surfaces
    • - the patella is pulled distally during flex into the trochlear groove
    • - during ext the patella moves proximally
  11. What is the closed- packed position of the knee
    • - most stable position of a jt
    • - tension on the jt capsule and lig is maximal and causes the jt surface to become fully approximated
    • - for the knee; the closed packed position is full ext with ext rot
  12. What is the loose- packed position of the knee
    • - the position in which the jt capsule is most lax
    • - this occurs at about 25* of knee flexion
  13. What is the capsular pattern of the knee
    • - cap patterns are expressed as a proportional loss of range
    • - both flex and ext are lost
    • - some authors state flexion is lost in a greater proportion
  14. extrinsic disorders that can refer pain?
    • - Lsp
    • - hip
    • - spinal nerve compression
  15. What are the intrinsic disorders that can cause knee pain
    • - osteoarthritis
    • - meniscal injury
    • - MCL injury
    • - Ant cruciate lig injury
    • - patellofemoral pain
  16. Osteoarthritis of the knee
    • - adbnormal knee mechanics may cause secondary changes in the articular cartilage, subchondral bone and supportive structures
    • - knee is a common site of OA, tibiofemoral and patellofemoral
    • - previous fractures of the jt surfaces, ligamentous instability or tears of the meniscus may all result in subsequent degenerative change
    • - usually begins in the medial or lateral tibiofemoral compartment
  17. How would pts present in OA?
    • - pain
    • - morning stiffness, relieved after motion but returns after theweight bearing tolerance of the jt is exceeded by proonged standing or walking
    • - a fixed flexion contracture may develop
    • - Quads atrophy
    • - prepatellar tenderness
    • - retropatellar pain and crepitus
  18. How do you manage OA?
    • - anti inflam
    • - relative rest
    • - weight loss
    • - modalities for pain control
    • - strengthening of mm, quad
    • - gait re-education
    • - mobs technique aid in reducing joint pain and stiffness, esp small amplitud movements at end range
  19. Meniscal injury
    • - in the young, injury is most often associated with a traumatic event
    • - most common mechanism of injury is a flexed knee with foot anchored on the ground. While the tibia rotates to the femur, the medial meniscus is most vulnerable
    • - int rot of the tibia renders the lateral meniscus susceptible to injruy
    • - the medial meniscus often tears in the post !/3. In young people, a longitudinal tear is most common and is frequently associated with major lig damage such as an ACL rupture
    • - the lateral men is oftern damages in the middle 1/3. Lngitudinal tears occur in association with lig damage, but radial and flap tears are more common
    • - with age the menisci become more brittle
    • - injury may occur following a period of hyperflexion which increase the pressure on the posterior horns
    • - horizontal cleavage tears are the most common degenerative tears and occur in either meniscus
  20. Common physical assessment findings of the meniscus tear
    • - swelling occurs several hours after the injury, gradually resoves with rest and returns after activity
    • - locking: a fragment of the meniscus becomes displaced and traped between the tibial and femoral condyles, preventing full ext. The knee will often unlock with a clunk
    • - pain at end range flexion/ ext
    • - pain on squatting
    • - flaps tears can produce catching or clinking
    • - knee may give way- reflex inhibition of the quads mm due to pain
    • - pseudocyst on the lateral jts line when the knee is flexed to 45* if a radial tear of the lateral men
    • - mcmurrays test positive
    • - localised jt line tenderness on palpation
  21. What are the two treatments
    • - limit aggravating acitivites
    • - anti- inflammatories
    • - ice
    • - interferential to relieve pain
    • - quads and hamstring exercises aimed at gaining mm strength and control. This will increase jt stability
    • - gradual return to activity

    • Surgery:
    • - the goal of meniscal surgery is to preserve as much of the tisue as possible
  22. MCL injury
    • - a valgus force will cause the deep fibres to tear due to their up/ down orientation
    • - an ext rot force will tear more the superficial fibres due to their oblique orientation
    • - tears are classified according to the degree of injury
  23. 1st degree MCL injury
    • - medial knee pain
    • - unable to straighten
    • - no effusion
    • - possible hamstring spasm
    • - tenderness over the proximal medial condyle
    • - pain on valgus stress testing
    • - no laxity
  24. 2nd degree MCL injury
    • - larfer ext rot or valgus force
    • - possible effusion, esp tear of deeper fibres
    • - pain on valgus stress testing
    • - increased laxity with end feel
  25. 3rd degree MCL injury
    • - usually associated with ACL injury
    • -tenderness
    • - gross effusion or no effusion (capsular tear)
    • - stress testing produces no or little pain, no end feel and massive opening
    • - if no avulsion on x-ray, brace 30* to 90* for 3-4 weeks
  26. Ant cruciate lig injury mechanism of injury
    • - classic injury will involve a twisting mechanism follwed by sudden pain, giving way and possibly an audible pop or crack
    • - can also be caused by a direct ext force on femur
  27. ACL injury
    • - immediate effusion occur 5 min to 1 hr post injury
    • - haemarthrosis is boggy and slow o move
    • - knee can lock if the ACL bundles up into the intecondylar notch
    • - typically has MCL and medial meniscus injury occuring as well
    • - tested by lachmans ant drawer
    • - management
  28. Patellofemoral pain
    • - occurs 1in 4 people
    • - characterised by a diffuse ache
    • - increase with stairs, squatting, prolonged sitting with flexion
  29. How does patellofemoral pain present onexamination
    • - increased Q angle (13-15*)
    • - tight ITB and hamstings
    • - VMO insufficiency
    • - excessive pronation
    • - pain on resisted ext through range
  30. How do you manage Patellofemoral pain?
    • - taping
    • - quads VMO exercise
    • - emphasis on close chain co activation
    • - stretching of tight mm
    • - orthotics if indicated
  31. Sports injury- what you need to manage these
    • - sound technical physio skills
    • -sports specifics skills
    • - anatomy
    • - sub/objective- clinical tests
    • - acute on field assessment
    • -sports psychologogy
    • - sports pharmacology
    • - communication skills
    • - clinical reasoning
    • Sports specific skills- familiar with chosen sport, understand biomechanics and physical demand of sport, common injuries, exercise physiology of given sport, common training programs, language used in given sport
  32. Clinical reasoning needed to be a sports traininer?
    • -fundamental requirement
    • - cannot be applied effectively in a given sport without both skills set
    • - work with sports/teams and life long learning to develop both skill sets
  33. How do you prevent injury
    • -pre-season screening- no your athletes- medical and physical
    • - protective equipment
    • - ent safety
    • -prophylatic taping
    • - maintaining adequate flex and strength- understand ur sport
    • - apporpriate training/prep
  34. How do u prepare?
    • - onsite- emergency management plan
    • - personnel- who will beon the field, and what is each person's role
    • - equipment- what will be on the field and what is nearby
    • - procedue for emergencies
    • - phones-who ring 000
    • - access for ambulance
    • - location of gates
    • - pre-season meeting to discuss and implement emergency plan and procedures
    • - know ur athletes, conditions and med. Know legislation, prohibited drugs and dietary requirements
  35. On field management
    • - D- danger
    • - R- response
    • - S- send for help
    • - A- airways check
    • - B- breathing check
    • - C- CPR
    • - D- defibrillate ASAP
  36. Secondary survey to injury on field
    • - identify serious med or skeletal injury
    • - consciousness
    • - assessment of injury- spinal, CPR (put pt on spine board), splint limb, manual conveyance, ambulatory aid
  37. Concussion
    • - Grades
    • 1- no LOC, if assymp. after can RTP
    • 2- brief LOC, symp > 15 min, no RTP that day
    • 3- LOC
    • - Red flags
    • vomit
    • blood/ fluid visible in ear or nose
    • double vision
    • nystagmus
    • LOC
    • - Risks of RTP
    • secondary impact syndrome
    • epidural or subdural hematoma
    • post- concussive syndrome
  38. Spinal cord injury
    • - trauma injury- C/S- rugby
    • - brachial plexus neurapraxia (burner)- tackling
    • - if unsure treat as a spinal injury
  39. Shock
    • Signs of shock
    • - moist, pale, cool clammy skin
    • - agitated
    • - thirsty
    • - weak and rapid pulse
    • -shallow breathing, increase RR
    • - decrease BP
    • More likely with blood loss, fractures or internal bleeding
    • Can occur as a psycholgical reaction to injury
  40. Heat/ cold illness
    • - hyperthermia
    • rapid pulse
    • increase respiratory rate/ shallow breathing
    • increased temp (>39)

    • -Hypothermia
    • decreased HR, RR, BP, Temp (<33), nerve conduction
  41. Musculoskeletal injuries
    • - #
    • - mm strains or tears
    • - ligament tears or ruptures
    • -jt dislocation
    • - contusions
    • - abrasions
  42. Assessment
    • - STOP (stop, talk, observe, play on?)
    • - TOTAPS (talk, observe, touch, active, passive, skills)
  43. Management of acute injuries
    • - RICER
    • - ankle sprain
    • - ACL, MCL
    • - hamstring/ quad mm strain
    • - shoulder sublux/ dislocation
    • - finger dislocation
    • - mose bleeds
    • -eye injury
    • - dental injuries
    • - ear injuries
    • - sudden death syndrome
    • - hyperventilation
  44. Over use injuries
    • - stress #
    • - tendinopathy
    • - chondromalacia/ PFP
    • - jt instability
    • - compartment syndrome
    • - neuroma
    • - skin lesions and blisters
    • - overtraining/ staleness
  45. Special conditions
    • - asthma
    • - diabetes
    • - epilepsy
    • - iron- deficiency anaemia
    • - disabled atheletes
    • - children
  46. Rehad
    • - sports specific rehad
    • - need to be progresse to a higher level
    • - requires thorough understanding of the demands of the sport
    • - input into appropriate progression back to lay
    • - sound knowledge of requirements of the sport
    • - good working relationship with the athlete and coach
    • - know sport = credibility
    • - credibility = trust
  47. Psycholgical response to injury
    • - Athlete may experience the stages of loss
    • Denial
    • Anger
    • Bargaining
    • depression
    • acceptance
    • - athlete may try to manipulate practitioners in the health care system
    • - athlete may have increased fear of injury upon return to play after full recovery
    • - be mindful of these responses/issues when working with athletes
  48. What is a fracture?
    - a break of a bone that can be complete or incomplete
  49. What is a jt dislocation
    when the jt surfaces are completely displaced and the articular surfaces are no longer in contact. WIth severe trauma, a # and dislocation can occur at the same time. This commonly occurs at the ankle
  50. What is a subluxation of a jt?
    - a lesser degree of a dislocation such that the articular surfaces are still partly apposed
  51. What types of # are there?
    • - traumatic
    • - pathological
    • - stress
    • - avulsion
  52. What are the different # classifications?
    • - location
    • - degree of displacement
    • - open or closed
    • - shape or line of #
    • - intra- articular or extra- articular
    • - impacted
    • - compresion
  53. Location of #s
    • - vertebral # are classified acording to the vertebra involved eg #l3
    • - in a long bone, a # is described as proximal, mid shaft or distal
  54. Degree of displacement
    - displaced # = where the # segments override each other, are lateral to each other or extremely distracted from each other
  55. Open or closed #
    • - open is where the #, or force causing the #, has resulted in the skin being breached
    • - closed # is where the skin remains intact
  56. Shape of the #
    • - transverse
    • - oblique
    • - spiral
    • - comminuted
    • - greenstick
  57. What is an intra/extra- articular #
    • - intra- articular- the # line extends into a jt surface
    • - extra- articular- the # line does not involve the jt surface
  58. What is an impacted #
    - the bone ends are pushed into each other
  59. Compression #
    bone that has been crushed and is most commonly used to describe a collapsed vertebra
  60. Fracture healing
    • - resorption of # and infiltration of the area by a fibrinous inflam exudate
    • - a bridge of callos forms around the # bone ends
    • - callous is replaced by a network of woven bone
    • - remodelling
  61. What are the factors affecting # healing?
    • - age
    • - fracture site
    • - fracture shape
    • - blood supply to the fragments
    • - amount of displacement of the fractures
    • - health and fitness
    • - type of bone
  62. # NOF
    • - major public health issue
    • - lifetime risj for hip # in women 17%, men 6%
    • - incidence of hip # rises a great deal after the age of 55
    • - majority of these occur in the elderly, after low velocity falls or by less traumatic means such as catching the foot while walking, twisting the foot in WB and efemoral neck breaks due to rot force
    • - degree of break at the neck is how it is classified
  63. How do you treat NOF
    • - depends on site, nature of the fracture, age of pt
    • - displaced subcapital # are associated with higher incidence of AVN and non-union than undisplaced fractures
  64. What are teh complications of a #NOF
    • - deep vein thrombosis
    • - respiratory probelms
    • - urinary retenion
    • - avascular necrosis of femoral head
  65. # NOF physiotherapy management
    • - cardiorespiratory complcations- breathing exercises should begin on the first day of pst surgery, but can stop when physio is happthat the chest is clear and pt is mobilising well
    • - DVT and pulmonary embolism- DVT- serious complication of ortho trauma and jt replacement. Incidnce 10-80%, depending on the metho of detection and associated risk
    • - EXercise- following hip surgery, the most important mm to reh are the hip abductors and ext, as well as the kne ext (static gluteal contractions, active assisted or active hip flex, active or assisted hip abd, inner range stat quads, bridging, hip abd and ext in standing
    • - gait and mobility
    • - education
  66. What are the clinical features of DVT?
    • - cramp like pain in calf or behind the knee
    • - tenderness on deep palpation
    • - swelling of the lower limb
    • - increased pain in the calf on passive DF of the foot (Homan's sign)
  67. DVT- prophylactic measures
    • - compression stockings
    • - bed exercises (simple foot and ankle)
    • - early mobilisation
  68. Total hip replacement
    • - a total hip is an artifical jt where both the femoral and acetbular sides of the hip jt are replaced.
    • - thefemoral component is placed into medullary canal of the femur, and proximally hasa small diameter head that articulates with a corresponding socket that is fixed into the acetabulum
  69. What are indications for a total hip replacement
    - pts that are candidates for elective replacementare those with disabling pain and functional limiation of the hip despite an adequate trial of conservative therapy (medication, physio)
  70. THR post op management
    • - pts may be nursed in be with abduction pillow
    • - post- op exercises begin on day 1
    • - mobilisation with assistance of an appropriate walking aid
    • - when moving the pt or getting them out of bed, care must be taken to ensure the leg does not get adducted or slexed beyond 90 degrees (esp following a posterior approach) where the risk of dislocation is increased
  71. Complications post THR
    • - the most frequent complication post THR are;
    • Dislocation. Flexion > 90*, adduction past midline and int rotation should be avoided
    • - sciatic nerve damage
    • - leg length inequality
  72. Total knee replacement
    the femoral and tibial jt surfaces are re-surfaces with metal components and a polyethylene insert fits between. The patella may or may not be resurfaced
  73. Indication of a total knee replacement
    • - osteoarthritis of the knee, primary or secondary
    • - rheumatoid arthritis
    • - post traumatic arthritis
    • - avascular necrosis
  74. TKR post op management
    • - routine post- operative care is necessary
    • - ice or cryocuff
    • - early mobilisation
    • - exercise
    • - gait education and progression
  75. What are the TKR complications?
    • - wound healing
    • - neurovascular injury
    • - infection
    • - stiffness
  76. Dislocation of the patella and management
    • - when the knee is flexed and the quadmm are relaxed, the patella can be forced laterally by direct violence, slipping over the lateral femoral condyle to the outerside of the knee
    • - patella is generally easily reduced
    • - the knee is held straight and is usually immobilised in a Zimmer extension splint for a period of 3 weeks
    • - quads exercses begin immediately in the splint
    • - as soon as the pt can straight leg raise, walking is allowed
    • - once the splint is removed, felxion is usually quickly regained. The patella may be taped at theis stage to facilitate tracking and prevent lateral subluxation
  77. Complications of a patela dislocation
    • - re-dislocating
    • - stellate fracture of the condral undersurface of the patella
  78. Fractures of the distal fib
    • - most common around the ankle region
    • Management depends on loaction of fracture
    • - fracture at the tip of the lateral malleolus may be treate as ankle sprains
    • - fracture above the tip of the malleolus but bellow the syndesmosis will be immobilised in plaster for approx 6 weeks
    • - fractures at the level of the syndemosis will be internally fixated, then immobilised in plater
  79. Physiotherapy management of the # of distal fib
    • - intial application of plaster cast
    • - treatment of post immobilistation stiffness following removal of cast
    • - skin care
    • - pt edu
    • - xercises to restore range of ankle movement strength and balance
    • - passive mobilisation techniques
    • - gait training

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