Transcription

1 Musculoskeletal Exams and Injections Knee Ankle Shoulder Wrist Back

2 Learning Objectives 1-Knee exam for effusion and tears of menisci and ligaments 2-Ankle exam to differentiate between fractures and sprains 3-Shoulder exam for impingement syndrome and tendonitis 4-Lower back exam for disc herniation 5-Aspirate and inject knee, ankle, foot, shoulder, wrist and hand

3 Case #1 CC: left knee pain HPI: 17 yo female adolescent presents to your clinic ~12 hours after twisting her left knee while playing soccer. She reports experiencing a sharp pain to the inner part of her knee immediately following the injury and states she has been unable to completely straighten her left leg. PE: Moderate joint effusion. Medial joint line tenderness to palpation. Pain with passive flexion and audible click demonstrated upon external rotation of the tibia.

4 Questions What is the most likely diagnosis? What are some clues from the history that would lead you to the diagnosis?

5 Knee Exam Guided by history Mechanism of injury Location of pain Exam Inspection Palpation Maneuvers Acute problems Fractures Meniscus tear Ligamentus tear Chronic problems Osteoarthritis Patellofemoral arthralgia

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8 History Rotational injury Knee joint locks or gives Pain is medial or lateral Exam Effusion often present Tenderness over joint line McMurray s test flexion/external rotation flexion/internal rotation positive w/audible, palpable pop Meniscus Injury

9 McMurray s Test (A) Medial Meniscus (Lat. Rotation of Tibia) (B) Lateral Meniscus (Med. Rotation of Tibia)

10 McMurray Exam Externally rotate the tibia Extend the knee University of Washington

11 Collateral ligaments History Valgus or Varus stress Pain at/above joint line Bear some weight Exam Swelling, ecchymosis, effusion Tender at/above joint line Stability testing at 0 & 30 *MCL often has meniscus tear

12 Assessment of collateral ligament stability. The knee should be stressed in full extension and at 30 degrees of flexion. The amount of opening compared with the opposite knee indicates severity of injury.

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14 ACL Maneuvers Lachman s knee flexed to 30 degrees femur held in place tibia brought forward NO ENDPOINT Anterior drawer knee flexed to 90 proximal tibia held w/both hands, pulled forward NO ENDPOINT

15 Anterior Drawer With the knee flexed to approximately 80 verification of complete relaxation of the hamstrings is achieved by hamstring palpation. With the foot stabilized and in neutral rotation, a firm, but gentle, grip on the proximal tibia is achieved. An anterior force is then applied to the proximal tibia with a gentle to-and-fro motion to assess for increased translation compared to the normal contralateral knee.

16 Lachman s Test One hand secures and stabilizes the distal femur while the other firmly grasps the proximal tibia. A gentle anterior translation force is applied to the proximal tibia.

17 Demonstrate Knee exam 1. Observe standing - valgus, varus, pronation of feet 2. Observe Gait 3. Sitting - palpate joint margin and lateral collateral ligament 4. Lying on back a. ROM b. Effusion palpable ballot patella, fluid wave c. Palpate along joint line, tendons, ligaments, bursa 5. Ligamentous stability a. 0 and 30 degrees b. 0 and 30 degrees c. Lachman 20 0 Anterior 90 0 d. Posterior drawer 6. Menisci- McMurray test

18 Case #2 CC: left ankle pain HPI: 34 yo female homemaker presents with pain and swelling to left ankle after accidentally tripping over one of her child s toys last night. States she been able to walk without assistance but only very slowly. PE: Swelling and ecchymosis over the lateral malleolus of left ankle. Moderate tenderness to palpation along area just anterior to the malleolus. However, no bony tenderness. Likewise, there is no tenderness to palpation over the navicular nor the base of the 5 th metatarsal. Stability assessment reveals a negative anterior drawer.

19 Questions Are radiographic studies indicated for further evaluation? Which ligament is most likely involved in this particular case?

20 The Ankle Bones tibia, fibula, talus Tendons Achilles' (posterior) ant tibialis/extensors (anterior)

21 Lateral Collateral Ligament

22 Medial Deltoid Ligament

23 Ankle Injuries History Inversion Eversion, forced plantar/dorsiflexion Exam Inspection Effusion, edema, ecchymosis Palpation Ligaments Bony Structures

24 Grading of Ankle Sprains First degree Minimal swelling Second degree Greater swelling, ecchymosis Third degree Unstable, positive anterior drawer

25 Ankle Injuries 90% rule 90% sprains 90% lateral ATF, CFL, PTF, Deltoid Injured in order Heal in reverse

26 The Ankle Exam Anterior drawer stabilize tibia pull foot forward in linear fashion while holding calcaneus Talar Tilt passive inversion 0 & 30 degrees PF

27 Anterior Drawer Test (A) Method 1- Drawing the foot forward. (B) Method 2- Pushing the leg back.

28 Drawer Test Tilt Test

29 Ottawa Ankle Rules Inability to bear weight Point tenderness BMJ 2003;326:417

30 Fractures

31 Demonstrate Ankle exam 1. Can the patient bear weight for 4 steps? Observe. 2. Inspection - Swelling, Ecchymosis 3. Palpation Bony Ligaments - anterior talofibular calcaneofibular posterior talofibular deltoid a. Bone tenderness at the posterior edge or tip of either malleolus? b. Bone tenderness at the navicular or the base of the fifth metatarsal? 4. Anterior drawer, Talar tilt

32 Case #3 CC: right shoulder pain HPI: 51 yo active male presents with aching pain to his right shoulder. Denies any specific injury but mentions he plays tennis at the local country club 5 days/week and has noticed considerable pain when he attempts to serve. Also has symptoms when combing his hair or taking off his shirt. PE: No swelling or ecchymosis. ROM is full in all planes but discomfort is noted at the end ranges of flexion and abduction. Strength is 4/5 upon resisted abduction vs 5/5 on the left. Pt winces when you place the shoulder in 90 degrees of flexion and then internally rotate. The remainder of the musculoskeletal exam in normal.

33 Questions What is the most likely diagnosis? What is the most likely muscle involved in this injury? What are some predisposing factors for this type of musculoskeletal problem?

34 Shoulder Anatomy Bony structures Sternum Clavicle Humerus Scapula Glenoid Acromion

35 Shoulder: 4 joints Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic

36 Anatomy Muscles Rotator cuff Supraspinatus Infraspinatus/ teres minor Subscapularis Deltoid Pectoralis major/minor Serratus anterior Latissimus dorsi Trapezius Biceps/triceps

37 Shoulder Exam Guided by history Mechanism of injury Location of pain Exam Inspection Palpation Maneuvers Acute problems Shoulder dislocation AC separation Chronic problems Shoulder impingement Bicipital tendonitis

38 Spurling's Test Spurling's test for cervical root disorder: The neck is extended and rotated toward the affected shoulder while an axial load is placed on the spine.

39 ROM

40 Painful Arc

41 Apley Scratch Test The patient attempts to touch the opposite scapula to test range of motion of the shoulder. (Left) Testing abduction and external rotation. (Right) Testing adduction and internal rotation.

42 AC Separation History Fall on outstretched hand Lateral direct trauma Exam Tender AC joint Visible gap

43 Anterior Shoulder Dislocation History Fall Collision abducted/ externally rotated Shoulder popped out Exam Hollow under acromion Anterior bulge Check for humeral neck fracture

44 Shoulder Impingement History Swimming, throwing Vague, deep pain Pain with abduction above 90 Exam Normal appearance Limited ROM Scratch test Empty can test

45 Supraspinatus Examination ( Empty Can" Test) The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.

46 Neer's Test Neer's test for impingement of the rotator cuff tendons under the coracoacromial arch: The arm is fully pronated and placed in forced flexion.

47 Infraspinatus/ Teres Minor Examination The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees

48 Bicipital Tendonitis History Overuse Pain inferior to acromion Exam Tender at bicipital tendon insertion (Speed s and Yergason s test)

49 Demonstrate Shoulder Exam 1) Inspection - symmetry, erythema, swelling 2) Bony palpation 3) Soft tissue palpation rotator cuff - with shoulder extension biceps tendon - long head in bicipital groove with shoulder externally rotated 4) ROM Apley "Scratch" test - Active ROM 5) Muscle strength testing in all 6 cardinal movements of the shoulder while noting which tests cause patient pain.

50 Work with 4 joint models 1. Knee: joint, suprapatellar pouch, pes anserine and ITB bursa 2. Ankle and foot: tibiotalar, Morton s neuroma and plantar fasciitis, 1 st MTP 3. Shoulder: subacromial bursa, AC joint, SC joint, biceps tendon 4. Wrist: first metacarpal joint, radioulnar joint, carpal tunnel syndrome, trigger finger, De Quervain s tenosynovitis

51 Indications for Diagnostic and Therapeutic Injection Soft Tissue Bursitis Tendonitis or tendinosis Trigger points Ganglion cysts Neuromas Entrapment syndromes Fasciitis Joint Effusion of unknown origin or suspected infection (only diagnostic) Crystalloid arthropathies Synovitis Inflammatory arthritis Advanced osteoarthritis

52 Absolute Contraindications Local cellulitis Septic arthritis Acute fracture Bacteremia Joint prosthesis Achilles or patella tendinopathies History of allergy or anaphylaxis to injectable pharmaceuticals or constituents

53 Knee Aspirations and Injections

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55 Knee Aspirations

56 Ankle and Foot Injections

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59 Shoulder injections

60 Posterior Approach

61 Bicipital Tendon Injection

62 AC Joint Injection

63 Hand/Wrist Injections

64 Carpal Tunnel Syndrome

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66 Am Fam Physician 2003:68:265-72,

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69 Method of injecting directly into the carpal tunnel hand is positioned on a rolled towel injected at the distal wrist crease (or 1 cm proximal to it) Injection occurs along the ulnar side of the palmaris longus tendon have the patient pinch the thumb and fifth fingers together while slightly flexing the wrist needle is angled downward at a 45-degree angle toward the tip of the middle finger and advanced 1 to 2 cm as it traverses the flexor retinaculum. Discomfort in the fingers should prompt repositioning of the needle. Am Fam Physician 2003:68:265-72,

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71 Method of injecting proximal to the carpal tunnel Using a 3-cm-long, 0.7-mm needle introduced at a 10- to 20-degree angle, a mixture of 10 mg of lidocaine (Xylocaine) and 40 mg of methylprednisolone is injected at the distal wrist crease between the tendons of the palmaris longus and flexor carpi radialis muscles. The mixture is introduced as a bolus and massaged toward the carpal tunnel. The needle should be advanced slowly and repositioned if resistance is encountered or the patient reports pain or paresthesias in the fingers

72 Am Fam Physician 2003;67:

73 Wrist Joint Am Fam Physician 2003;67:

74 De Quervain's Tenosynovitis

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76 Practice with Joint Models HAVE FUN!!

77 Back Anatomy: Muscles

78 Back Anatomy

79 Low Back Exam History Mechanism Red Flags Exam Inspection ROM LE neuro exam Radiographs? Acute problems Lumbar strain Disc herniation Vertebral fracture Chronic problems Osteoarthritis Spinal stenosis

80 Acute Low Back Pain History Sudden onset Less than 4 weeks Red Flags for: Fracture Infection Tumor Red flags: Age over 50 Fever Trauma Cancer history Unexplained weight loss Drugs (IVDA) Immunosuppression

81 Lumbar strain History Pain off midline Aching, not radicular Exam Muscular tenderness or spasm ROM generally intact Normal neuro exam

82 Acute Disc Herniation Exam Pain or paresthesias of specific nerve root Pain reproduced on straight leg raise Corresponding muscle weakness L4 Knee jerk absent L5 Dorsiflex foot and great toe Sensory dorsal foot S1 Plantarflex foot Sensory lateral foot, posterior calf Ankle reflex

83 Because of the way the nerve roots exit, L4-L5 disc pathology usually affects the L5 root

84 (A) Herniation of the disc between L4 and L5 compresses the fifth lumbar root. (B) Large herniation of the L%-S! disc compromises not only the nerve root crossing it (First sacral) but also Fifth lumbar nerve root. (C) Massive central sequestration, involves all the nerve roots in the cauda equina and may result in bowel and bladder paralysis

85 Straight Leg Raising (SLR)

86 Dynamics of SLR

87 Estimated Accuracy for Lumbar Disc Herniation Test Ipsilateral SLR Contralateral SLR Sensitivity 80% 25% Specificity 40% 90%

88 Vertebral Fracture History Older patients Risks for osteoporosis No trauma needed Exam Tenderness over spine Normal neuro Radiographs if suspected

89 Osteoarthritis History Older patient Worse with movement Morning stiffness Exam Decreased ROM Can have nerve compression

90 Demonstrate Back Exam 1. Gait - normal, on toes, on heels toe lifts (on one foot) if suspect Sl radiculopathy 2. Range of motion of back while standing 3. Palpation of back (sitting) - palpate paraspinal muscles, vertebrae - spinous process 4. Neuro exam - sitting - reflexes, motor, sensory if absent ankle jerk - retest patient in kneeling position 5. Straight Leg Raising (SLR) - supine, ipsilateral and contralateral 6. Abdominal, rectal, pelvic exams - as needed

91 References Physical Examination of the Spine and Extremities. Stanley Hoppenfeld Orthopedic Physical Assessment, David J. Magee The CIBA collection of Medical Illustrations, MS system, Frank H. Netter The Painful Shoulder: Part I. Clinical Evaluation. Thomas W. Woodward, Thomas M. Best The Injured Ankle. Randell K. Wexler Acute Knee Injuries. Howard B. Tandeter, Pesach Shvartzman, Max A. Stevens