1. ORTHOPAEDIC &
TRAUMA UPDATE:
PROTOCOLS AND BEST PRACTICE
J. Peter Tooley, SPT
George Washington University
10/3/13

2. Objectives
• To Review protocols for commonly seen injuries on
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•
•
•
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

3. PROTOCOLS AT
FOR ELECTIVE JOINT PROCEDURES
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4. 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!

5. General THA Protocol
ANTERIOR PRECAUTIONS???
• DO NOT
• Cross Legs
• Twist at the waist
• Go past 90° of hip flexion
• Move leg actively into
abduction
http://www.munosconggolf.com/wp-content/uploads/2011/07/golf-swing.jpg
POSTERIOR PRECAUTIONS
• DO NOT
• Cross Legs
• Twist at the waist
• Go past 90° of hip flexion

6. General THA Protocol
• Exercise Program 2x/day
• Up in Chair ~45min
• Ambulate POD#1
• Stairs POD#2
http://www.scottsdalejointcenter.com/_images/walking-after-hip-replacement.jpg

7. 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

8. 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

9. Dr. Jabara & Dr. Ringler
THA- Ringler
TKA
• Performs Rarely
• Standard TKA Exercise
• Post Precautions
Program
• Precautions:
• WBAT
• 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**
http://www.springerimages.com/img/Images/Springer/PUB=Springer-Verlag-Berlin-Heidelberg/JOU=00167/VOL=2008.16/ISU=2/ART=2007_447/MediaObjects/MEDIUM_167_2007_447_Fig1_HTML.jpg

10. 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°
http://media.ottobock.com/orthotics/_general/images/knee-cpm_16_9_teaser_onecolumn.jpg

11. 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
http://www.mchonline.org/wp-content/uploads/2011/11/spine.jpg

12. 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)
http://www.bonappetit.com/wp-content/uploads/2013/06/blt-set-free-overlay-bg.jpg

13. 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
http://spinerevolution.com/wp-content/uploads/2011/09/home-pettine-surgery.jpg

14. 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)
http://www.spinesport.com/images/nerves.jpg

15. PROTOCOLS AT
FOR ORTHOPEDIC TRAUMA INJURIES
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16. General Trauma Considerations
• Rescheduling d/t Surgery?
• BID for Isolated LE fractures
• Coordination of care
• Rib fractures – SupineSit??
• 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)!

17. 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

18. 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

19. 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
Femoral Shaft Fx.
• Paterno MV, Archdeacon MT Is there a standard rehabilitation protocol
after femoral intermedullary nailing? J Orthop Trauma. 2009;23(5):S3946.
• Hip abduction weakness, knee extensor weakness, anterior knee pain, gait
abnormalities.

20. Amputations
• Positioning
• Avoiding contractures
• Kiwi Brace
• Transfers
• Balance, strength, A/D
• Exercise
• Proximally
• Prep for prosthesis
• Skin protection
http://www.libertyhospital.org/_FileLibrary/Content/263/PostAmputation_titlebar.jpg http://1.bp.blogspot.com/-Z7Kvr1Ja1HM/Ucd141vq_PI/AAAAAAAAS74/DzwVEyEI_ws/s1600/20130623_130409.jpg

21. 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?

22. 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

23. 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

24. 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

25. 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

26. Dr. Cliff Jones
Hip Fx
Tib Plateau/ Distal
Femur
• Wt. Bearing per fixation
• CPM POD #0 – Home
type
• Typically WBAT
orders
• Hinged knee brace –
Partial ROM

27. Dr. Cliff Jones
Spine
Pelvis
• 23hr/day bracing (TLSO)
• MOBILIZE ONLY!
• In chair or out of bed
• Out of bed & Out of Chair
3x/day
• Exercise:
• Ankle Pumps
• AVOID:
• Hip/Abdominal/Back
Exercises
• No Quad Sets or Hamstring
sets
• MOBILIZE ONLY!
3x/day
• Weight Bearing Status:
• Non-op/ Elderly=WBAT
• Younger/ Operative=NWB
• Ankle Pumps

28. EVIDENCE BASED
PRACTICE

29. 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. PreOp 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.

30. 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

31. THA/TKA
• Chow TP et al. 2010. - RCT
• AROM vs. PROM vs. PNF
• Significant increase of flexion ROM
• No significant change b/t groups

32. Some complications of Othro/Trauma
procedures.
• Compartment Syndrome
• Fat Embolism Syndrome
• Deep Vein Thrombosis
http://compulsiveeatingdiet.com/wp-content/uploads/2013/02/Bulimia-Complications.jpg

33. 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‡

34. Fat Embolism Syndrome
Parisi DM, et al 2002. & OzyurtY 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

35. Well’s
Clinical
Prediction
Rule for
DVT
http://acupaday.org/2013/06/25/know-your-wells-clinical-prediction-rules-in-pt/

36. 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%

37. 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

38. Wells Clinical Prediction Rule
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

39. What does this mean?
• Risk score
• Stop activity
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
• Seek out doppler or
d-dimer.
• Resume activity per
throbolytic treatment
• Well's CPR Calculator
• Diagnosis Flow Chart

40. • 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.

41. 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.

42. 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:

43. Well’s CPR for PE
Wells 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 risk
2-6 points: Moderate risk
<2 points: Low risk

44. Questions?
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45. References
• Spectrum Health Rehabilitation and Sports Medicine Services – Physical
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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, 17951798
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):54855.
Paterno MV, Archdeacon MT Is there a standard rehabilitation protocol
after femoral intermedullary nailing? J Orthop Trauma. 2009;23(5):S3946.

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

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