9.4 Orthopedic Conditions, Fractures & Joint Replacements

Orthopedic Conditions, Fractures & Joint Replacements

Orthopedic conditions, joint arthroplasties, fractures, and spinal surgeries represent a substantial volume of acute, subacute, and home health occupational therapy practice. The primary focus of the Certified Occupational Therapy Assistant (COTA) in orthopedic rehabilitation is restoring functional independence in self-care, mobility, and home management while strictly enforcing anatomical healing precautions and weight-bearing restrictions.

1. Total Hip Arthroplasty (THA): Surgical Approaches & Precautions

Total Hip Arthroplasty (THA) involves replacing the damaged femoral head with a metal/ceramic ball and the acetabulum with a prosthetic cup. The surgical approach dictates the specific post-operative movement precautions required to prevent prosthetic dislocation.

+-----------------------------------------------------------------------------+
|                 TOTAL HIP ARTHROPLASTY (THA) PRECAUTION MATRIX              |
|                                                                             |
|   [POSTERIOR / POSTEROLATERAL APPROACH]     [ANTERIOR / ANTEROLATERAL]      |
|   • Disruption: Posterior capsule & piriformis• Disruption: Anterior capsule|
|   • PRECAUTION 1: NO Hip Flexion > 90°      • PRECAUTION 1: NO Hyperextension|
|   • PRECAUTION 2: NO Adduction past midline • PRECAUTION 2: NO External Rot.|
|   • PRECAUTION 3: NO Internal Rotation      • PRECAUTION 3: NO Bridging/Extr|
|     ("No crossing legs, no pigeon toes")      Adduction (per surgeon)       |
|   • Duration: 6 to 12 weeks post-op         • Duration: 6 to 12 weeks       |
|                                                                             |
|   [GLOBAL PRECAUTIONS (Revision / High Risk)]                               |
|   • Strict combination of BOTH Posterior and Anterior Precautions!          |
+-----------------------------------------------------------------------------+

Comprehensive THA Approach Comparison & Functional Adaptations

2. Standardized Weight-Bearing Statuses

Orthopedic surgeons specify weight-bearing (WB) orders based on fracture stability, bone density, and prosthetic fixation type (cemented vs. non-cemented / biological ingrowth).

+-----------------------------------------------------------------------------+
|                   STANDARDIZED WEIGHT-BEARING TAXONOMY                      |
|                                                                             |
|   [NWB: NON-WEIGHT-BEARING] (0% Weight)                                     |
|   • Operative foot MUST NOT touch the ground under any circumstance.        |
|                                                                             |
|   [TTWB / TDWB: TOE-TOUCH / TOUCH-DOWN] (10%–15% Weight)                    |
|   • Foot touches ground for BALANCE ONLY. Imagine "egg under foot".         |
|                                                                             |
|   [PWB: PARTIAL WEIGHT-BEARING] (20%–50% Weight)                            |
|   • Allows a prescribed percentage of body weight (calibrated on scale).    |
|                                                                             |
|   [WBAT: WEIGHT-BEARING AS TOLERATED] (50%–100% Weight)                     |
|   • Client bears weight according to personal comfort and pain tolerance.   |
|                                                                             |
|   [FWB: FULL WEIGHT-BEARING] (100% Weight)                                  |
|   • Full body weight permitted without restriction.                         |
+-----------------------------------------------------------------------------+

Clinical Weight-Bearing Training Protocols for the COTA:

1. Scale Calibration: Use a standard bathroom scale under the operative limb in standing to provide real-time visual and proprioceptive feedback on exact poundage corresponding to 20%, 30%, or 50% PWB.
2. Tactile Biofeedback: Place the COTA's hand or an empty foam cup under the client's operative heel during TTWB gait to ensure only light balance contact occurs without heel strike.
3. Assistive Device Selection: NWB and TTWB require bilateral axillary crutches, a rigid standard walker, or a rolling walker; single-point canes are strictly insufficient for NWB/TTWB/PWB.

3. Upper Extremity Fractures & Rotator Cuff Repairs

Colles' Fracture vs. Smith's Fracture

+-----------------------------------------------------------------------------+
|                 DISTAL RADIUS FRACTURE COMPARISON                           |
|                                                                             |
|   [COLLES' FRACTURE]                         [SMITH'S FRACTURE]             |
|   • Mechanism: Fall On Outstretched Hand     • Mechanism: Fall onto flexed  |
|     (FOOSH) with wrist in EXTENSION.           wrist (hyperflexion).        |
|   • Displacement: DORSAL displacement of     • Displacement: VOLAR (palmar) |
|     distal radius fragment.                    displacement of fragment.    |
|   • Deformity: "Dinner Fork" deformity.      • Deformity: "Garden Spade".   |
|   • Splint: Volar wrist cock-up (neutral).   • Splint: Volar/neutral splint.|
+-----------------------------------------------------------------------------+

COTA Rehabilitation Protocol for Colles' Fracture:

1. Early Active ROM of Uninvolved Joints: Immediately initiate full AROM of fingers, thumb, elbow, and shoulder to prevent joint stiffness and dependent edema.
2. Edema Management: Retrograde massage, upper extremity elevation above the heart level, and light compression glove (Isotoner glove).
3. Median Nerve Monitoring: The median nerve passes through the carpal tunnel directly adjacent to the distal radius. The COTA must vigilantly screen for signs of Acute Carpal Tunnel Syndrome (numbness, paresthesias, or tingling in the thumb, index, and middle fingers; thenar muscle weakness). Report immediately to surgeon if symptoms appear.
4. CRPS Surveillance: Monitor for signs of Complex Regional Pain Syndrome (Type I / RSD): disproportionate burning pain, hyperhidrosis, shiny/taut skin, extreme temperature asymmetry, and allodynia.

Rotator Cuff Surgical Repair (SITS Musculature)

The rotator cuff comprises four dynamic stabilizing muscles: Supraspinatus (most frequently torn), Infraspinatus, Teres Minor, and Subscapularis (SITS).

+-----------------------------------------------------------------------------+
|              ROTATOR CUFF SURGICAL REHABILITATION PHASES                    |
|                                                                             |
|   [PHASE 1: PROTECTION (Weeks 0–6)]                                         |
|   • Immobilized 24/7 in abduction pillow sling.                             |
|   • STRICT PASSIVE ROM ONLY (Codman's pendulums, passive external rot).     |
|   • NO active shoulder motion! NO lifting or weight bearing!               |
|                                                                             |
|   [PHASE 2: AAROM to AROM (Weeks 6–12)]                                     |
|   • Wean from abduction sling.                                              |
|   • Active-Assisted ROM (pulleys, cane/wand) progressing to active AROM.    |
|   • Isometric rotator cuff stabilization.                                   |
|                                                                             |
|   [PHASE 3: STRENGTHENING (Weeks 12+)]                                      |
|   • Progressive isotonic resistance (TheraBand, light hand weights).        |
|   • Functional overhead task integration and work simulation.               |
+-----------------------------------------------------------------------------+

4. Spine Surgery Precautions (BLT) & Mobility Training

Spine surgeries (lumbar laminectomy, discectomy, anterior/posterior lumbar interbody fusion [ALIF/PLIF], cervical fusion) require strict post-operative movement precautions to protect spinal fusion hardware, prevent graft displacement, and permit neural decompression sites to heal.

+-----------------------------------------------------------------------------+
|                     SPINE SURGERY PRECAUTIONS (BLT)                         |
|                                                                             |
|   [B - NO BENDING]                                                          |
|   • Keep lumbar spine in neutral alignment.                                 |
|   • Never bend over from the waist to pick up objects or dress.             |
|   • Squat with hips/knees or use a long-handled reacher.                    |
|                                                                             |
|   [L - NO LIFTING]                                                          |
|   • Do not lift objects weighing > 5 to 10 pounds (e.g., a gallon of milk).  |
|   • Hold lifted items directly against the chest center of gravity.         |
|                                                                             |
|   [T - NO TWISTING]                                                         |
|   • Keep shoulders, chest, and pelvis rigidly aligned in the same plane.    |
|   • Pivot with feet when turning; do not rotate the torso.                  |
|   • ALWAYS use the LOG-ROLLING technique for bed mobility!                  |
+-----------------------------------------------------------------------------+

The Log-Rolling Bed Mobility Protocol:

1. Preparation: Client lies supine; knees are bent with feet flat on the bed; arms are crossed securely over the chest.
2. Synchronized Roll: The client rolls the shoulders, torso, and hips simultaneously as one solid, rigid unit onto their side, completely eliminating spinal torsion/twisting.
3. Sit-to-Stand Transition: From side-lying, the client drops both lower legs over the edge of the mattress while simultaneously pushing upward with the downward elbow and top hand to bring the trunk vertical into a seated position.

Cervical Spine Orthoses & Precautions:

• Rigid Cervical Collars (Miami J, Aspen, Philadelphia Collar): Limit cervical flexion, extension, and lateral rotation. The COTA trains the client in safe hygiene (shaving/washing one side of the neck at a time while maintaining neutral head alignment) and warns against overhead reaching.

5. Clinical Scenario: Orthopedic ADL Intervention

Clinical Case Vignette: A 71-year-old client who underwent a right Total Hip Arthroplasty (THA) via a posterolateral approach 2 days ago is evaluated in acute care. The client has orders for Weight-Bearing as Tolerated (WBAT) with strict posterior hip precautions. The client expresses severe anxiety about getting dressed and using the toilet without dislocating the new prosthetic hip.

COTA Treatment Implementation:

1. Lower Body Dressing Training:
   • The COTA introduces an adaptive dressing kit: a reacher, a sock aid, a dressing stick, and a long-handled shoehorn.
   • The client is seated on a firm chair with armrests. The COTA instructs the client to dress the operated (right) leg first by clamping pants with the reacher and pulling them over the foot without flexing the hip past 90°.
   • For socks, the client slides the sock over the sock aid, drops the device to the floor holding the cords, slides the right foot into the plastic trough, and pulls the cords upward without bending forward.
2. Toileting & Showering Setup:
   • The COTA trains the client on a raised toilet seat with armrests. When sitting down, the client extends the right operated leg forward, reaches back for the armrests, and lowers slowly, maintaining the hip at $<90^\circ$ flexion.
   • An abduction wedge pillow is placed between the legs to prevent adduction past midline during sleep and rolling.