examination of orthopedic and athletic injuries, 3rd edition copyright © 2010. f.a. davis company...

Examination of Orthopedic and Athletic Injuries, 3rd EditionExamination of Orthopedic and Athletic Injuries, 3rd Edition

Copyright © 2010. F.A. Davis Company

The Injury Examination ProcessThe Injury Examination Process

Chapter 1



Systematic Examination TechniqueSystematic Examination Technique Objective data

Baseline measures Re-evaluations Rehabilitation and treatment protocols

Documentation Medical records

Legally required Communication tool



Table 1.1. Role of the Noninjured Limb in the Examination Process

Table 1.1. Role of the Noninjured Limb in the Examination Process

Evaluation Strategies

1. Perform each task on uninjured limb first.

2. Perform each task on injured limb first.

Increase or decrease apprehension and muscle guarding?



Clinical AssessmentClinical Assessment Clinical assessment vs. acute evaluations

What are the differences? Special considerations

Discretion Religious considerations Informed consent

Signed written statement Verbal Emergency medical care



HistoryHistory Identifies

Mechanism of injury Past medical history Underlying pathology Impact injury may have on patient’s life

Communication skills Open-ended questions

Avoid “yes” or “no” questions unless critical



Past Medical History Past Medical History Past medical history

Non-acute examinations (physicals) Health conditions Previous injuries Predisposing factors NCAA Guideline 1B: Medical

Evaluations, Immunizations, and Records (Box 1-3)

Previous history questions

Is there a history of injury to the body area? On either side? Describe and compare

current injury Do the current symptoms

duplicate the old symptoms?

Are there any possible sources of weakness from a previous injury?



Past Medical HealthPast Medical Health General medical health

Current health status? Comorbidities present?

Relevant illness and lab work Note during exam if they may

affect injury management or the healing process.

Medications What medications are they

currently taking? What interactions or effect

may they have on healing, treatments, etc.?

Smoking Decrease exercise tolerance Increased risk for CV disease May delay fracture and

wound healing



History of Present ConditionHistory of Present Condition Mechanism of injury

(MOI) How did the injury

occur? Macrotrauma Microtrauma

Identifies structures involved

Relevant sounds or sensations

Onset and duration of symptoms Acute Chronic



History of Present ConditionHistory of Present Condition Pain

Location Type Referred Radicular Daily pain patterns Provocation and

alleviation patterns

Other symptoms Treatment to date Affective traits Disability/limitations



Physical ExaminationPhysical Examination Goals

Rule out differential diagnosis Determine clinical diagnosis Identify impairments and functional limitations

Standard precautions against bloodborne pathogens (Box 1-5)



InspectionInspectionImmediate observations

Physical examination observations (bilateral) Deformity

Subtle or gross? Swelling

Hemarthrosis Edema

Girth measurements (Special Test 1-1)

Skin Redness Ecchymosis

Infection signs

As soon as patient enters facility observe Gait Posture Function Guarding Splinting



InspectionInspection Functional assessment

Perform functional tasks that were identified as problematic.

Impairments should be identified and measured.



PalpationPalpation Bilaterally performed in specific sequence Sequencing strategy #1

Bones Ligaments Muscles and tendons

Sequencing strategy #2 Palpate all structures Begin away from pain site and progress toward

suspected injury.



PalpationPalpation Point tenderness Trigger points Change in tissue density Crepitus Tissue temperature



Perform bilaterally Involves

Active range of motion (AROM) Manual muscle testing (MMT) Passive range of motion (PROM) Joint stability tests Stress testing Joint play

Joint and Muscle Function Joint and Muscle Function AssessmentAssessmentJoint and Muscle Function Joint and Muscle Function AssessmentAssessment



Active ROMActive ROM Joint motion produced by the patient

contracting the muscles Evaluated first (unless contraindicated) Note

Ease of movement Range of motion achieved

Painful arc Compensation



Manual Muscle TestingManual Muscle Testing Assesses strength and provocation of pain by

relatively isolating the muscle Resisted range of motion (RROM) assesses

strength throughout the muscle’s entire ROM Procedure

Stabilize limb proximally Apply resistance distal to muscle attachment, not

joint Grade accordingly (Table 1-6)



Manual Muscle TestingManual Muscle Testing



Passive ROMPassive ROM Clinician moves the joint through the ROM Identifies the available movement and pain

patterns Apply over-pressure to determine end-feel Findings

PROM > AROM — suspect muscular weakness or tissue lesion

PROM = AROM and are deficient — suspect capsular adhesions or joint tightness



Joint Stability TestsJoint Stability Tests Procedure

Apply specific stress to non-contractile tissue

Hypermobile — more laxity than normal

Hypomobile — below normal laxity

Laxity — clinical sign of the amount of “give” within a joint; identified by stress testing

Instability — joint’s inability to function under the stresses of function activity



Stress TestingStress Testing



Joint PlayJoint Play Accessory/arthrokinematic motion

Rolling Spinning Gliding

Procedure Patient relaxed in loose-pack position Gliding or distracting stress is applied Degree of movement assessed Compare bilaterally



Special TestsSpecial Tests Specific procedures applied to selected tissues Unique to each structure Results are compared

Side to side Cause provocation Cause alleviation

Reported as positive (+) or negative (-)



Neurologic ScreeningNeurologic Screening Upper and lower quarter

screen Evaluate

Sensation Motor function Deep tendon reflexes

Identify Nerve root impingement Peripheral nerve damage CNS trauma Disease

Indicated by Numbness Paresthesia Muscular weakness Pain of unexplained origin Injury to cervical or lumbar

spine



Neurological Screening 1-1.Neurological Screening 1-1.Lower Quarter ScreenLower Quarter ScreenNeurological Screening 1-1.Neurological Screening 1-1.Lower Quarter ScreenLower Quarter Screen



Neurological Screening 1-2.Neurological Screening 1-2.Upper Quarter ScreenUpper Quarter ScreenNeurological Screening 1-2.Neurological Screening 1-2.Upper Quarter ScreenUpper Quarter Screen



Sensory TestingSensory Testing Dermatome — area of skin innervated by a

spinal nerve root Bilaterally performed Patient position

Eyes closed and head turned away Discrimination tests

Light touch discrimination Sharp and dull discrimination Two-point discrimination



Motor TestingMotor Testing If muscle weakness is noted during

neurological screening, test another muscle innervated by the same nerve root. If one muscle is weak, suspect muscle pathology

or peripheral nerve patholgy. If both muscles are weak, suspect nerve root or

peripheral nerve pathology.



Reflex TestingReflex Testing Increased response upper motor

neuron lesion Decreased response lower motor

neuron lesion Deep tendon reflex (DTR)

Muscle stretched and relaxed Patient should look away Strike tendon with reflex hammer Jendrassik maneuver for difficult patients



Table 1–10. Deep Tendon Table 1–10. Deep Tendon Reflex Grading Reflex Grading Table 1–10. Deep Tendon Table 1–10. Deep Tendon Reflex Grading Reflex Grading



Vascular ScreeningVascular ScreeningGross assessment of blood flow to and from the extremities Capillary refill

Nail beds Pulses

Lower extremity Femoral Posterior tibial Dorsal pedal

Upper extremity Brachial Radial Ulnar

Systemic Carotid



Results from the history and functional assessment can reduce the number of tests to be performed. Example

Symptoms: Gradual onset No need to perform acute fracture special tests

Use best evidence Efficient

Eliminate time wasted performing unnecessary special tests Makes examine more accurate

Eliminate false positives

The Role of Evidence in the The Role of Evidence in the Examination ProcessExamination ProcessThe Role of Evidence in the The Role of Evidence in the Examination ProcessExamination Process

examination of orthopedic and athletic injuries, 3rd edition copyright © 2010. f.a. davis company...

Documents

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athletic injuries

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current injury