What is the most frequently sprained ligament with inversion ankle sprains? 1/30/2014

Transcription

1 What is the most frequently sprained ligament with inversion ankle sprains? A. Anterior Talofibular B. Anterior Tibiofibular C. Calcaniofibular D. Posterior Talofibular E. Deltoid Lateral ligaments of the ankle Are the anterior talofibular Ligament, calcaneofibular Ligament and the Posterior talofibular ligament. Ankle Drawer Test With foot in slight plantar flexion, Dr stabilizes tibia Posterior drawer Dr adds a posterior force on dorsum of foot Assesses posterior talofibular ligament Anterior drawer Dr adds an anterior force on the heel with foot in neutral position Assesses anterior talofibular ligament Considered positive for complete tear if there is increased laxity 1

2 1 st Degree Ligament integrity Conservative care 2 nd Degree Partial tearing (slight laxity) Usually no need for surgery 3 rd Degree Complete rupture Immobilization Surgery rarely indicated Ankle Sprains The Anatomy of an Ankle Sprain Traumatic Inversion strains the peroneus(fibularis) longus and brevis muscles. 2

3 The Anatomy of an Ankle Sprain Traumatic Inversion strains the peroneus longus and brevis muscles. Shortening of those muscles pulls the Fibula inferiorly and posteriorly. Anatomy of an Ankle Sprain The plantar attachment of the peroneus longus pulls the 1 st cuneiform metatarsal joint inferiorly stressing and flattening the medial arch. This is all compounded by the Sprain of the Lateral ankle ligaments to varying degrees leading to joint instability. 3

4 Assessment Inversion Ankle sprain(845.09) Lower Extremity Somatic Dysfunctions(739.6) 4

5 Treatment Osteopathic Manipulation. RICE. NSAIDS. Splint/Taping. Exercises. Fibular Head Somatic Dysfunction The head of the fibula is grasped between the thumb and index fingers and moved anterolaterally and posteromedially along its plane of motion Is there restriction in either direction? If the fibular head prefers anterior motion with restriction of posterior motion, it is termed anterior fibular head somatic dysfunction 5

6 Fibular Head Posterior: Sitting-Direct-Muscle Energy Patient seated, legs hanging Operator seated in front of patient Operator grasps fibular head with thumb and index finger and pulls anterior Other hand is used to externally rotate, dorsiflex and evert foot with ER of tibia (Pronate) Patient is instructed to internally rotate, invert and plantar flex(supinate) foot against operator counterforce. Repeat several times to free articulation Coding and Billing ICD-9 Inversion Ankle sprain(845.09) Lower Extremity Somatic Dysfunctions(739.6) E&M Procedure OMT 1 LowerExtremity 6

7 Case 3: 26 year old male presenting with complaint of left lateral elbow pain. The pain is worse after hitting golf balls at the range or trying to hit baseballs in the batting cages. Mechanism of injury? Pertinent Neuro and Ortho exams. Biomechanical Exam. Further history FOOSH injury on left side a month ago. He was playing soccer and was tripped, falling forwards on his left outstretched arm. No apparent injury, swelling or pain. 7

8 Physical Exam 120/68 HR 70 RR18 T 98.4 Cor: Regat 70, no murmur Pulm: CTA B/L no W/R/R. Orthopedic:NegTinnelsat elbow, Point tenderness at Left Lateral epicondyle Biomechanical: Pronation SD with Posterior Radial Head SD Mechanism of FOOSH Injuries There is reciprocal glide of the radial head in response to the direction of movement at the distal end of the radius. Figure 1 Figure 2 8

9 Somatic Dysfunction - Elbow Somatic dysfunction of the ulnohumeral joint is usually primary. Somatic dysfunction of the radioulnar joint is usually secondary. Radial head moves posterior during pronation& anterior during supination Radial head influenced by All forces through upper extremity. (esp. force to distal radius reciprocal motion) Position of forearm Muscles of pronation and supination Diagnoses Cervical(739.1), Thoracic(739.2), Upper Extremity(739.7) somatic dysfunctions Treatment XRay? PRICE? OMT A/P Somatic Dysfunction - Elbow Somatic dysfunction of the ulnohumeral joint is usually primary. Somatic dysfunction of the radioulnar joint is usually secondary. Radial head moves posterior during pronation& anterior during supination Radial head influenced by All forces through upper extremity. (esp. force to distal radius reciprocal motion) Position of forearm Muscles of pronation and supination 9

10 Diagnostic Approach Observe skin of the affected area Observe the carrying angle Evaluate active and passive motion Flexion, extension Pronation, supination Abduction, adduction Palpate for TTC Evaluate above and below (Shoulder girdle, thoracics, carpel bone dysfunction and treat respectivc SD) Dx of radial head SD With thumb and index finger grasp radial headmonitor for reciprocal motion during at end of pronation & supination (pronation= radial head posterior, supination= radial head anterior) (monitor) Dx of radial head SD With thumb and index finger grasp radial head, motion test Name somatic dysfunction for motion preference Compare both arms 10

11 Tx: direct ME Dx: radial head posterior Contact the posterior aspect of radial head with thumb Engage the barrier with supination & extension Patient attempts to pronate (Dr. resists and matches force) Pt relaxes, Engage new barrier Dr. s thumb, supination and pronator m. force cause radial head to move anterior Continue 2 more times as directed and reassess motion * supinate Coding and Billing ICD-9 Lateral Epicondylitis(726.32) Cervical(739.1), Thoracic(739.2), Upper Extremity(739.7) somatic dysfunctions E&M Procedure

12 "The philosophy of one century is the common sense of the next." -- Henry Ward Beecher Question Answer/ Wrap up. Current Procedural Terminology E&M Codes CPT Book OV codes NP Sick Established sick

13 OMT Codes 1-2 areas treated areas areas areas areas areas are Cranial, Cervical,Thoracic, Lumbar, Sacral, Innominate, Upper Extremity, Lower Extremity,Rib cage, Visceral. Modifiers.25 separate identifiable service on same day (Patient seen for Headache diagnosis muscle tension type HA, Cervical Somatic Dysfunction E&M ICD-9 codes ) ICD-9 codes Head/ Cranial Somatic dysfunction Cervical Somatic dysfunction Thoracic Somatic dysfuction Lumbar Somatic dysfunction Sacral Somatic dysfunction Innominate Somatic dysfunction Lower extremity Somatic dysfunction Upper extremity Somatic dysfunction Rib Somatic dysfunction Abdominal/ Visceral somatic Dysfunction 13