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TRANSCRIPT
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F2 Teaching
Joint Examination
Sept 15th 2009
Andy Higgins
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Ligamentous Injuries
Can be applied to most ligament injuries throughout the extremities.
Grade 1 – Pain No laxity
Grade 2 – pain with laxity/deformity – with End feel* .
Grade 3 – Pain – severe laxity/deformity – No end feel*
* Knee/ankle
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ACjt/SCjt Ligamentous injuries
Common Mechanisms of injury:
FOOSH
Direct blow
Grade according to pain and amount of disruption
Treatment:
Broad arm sling for both
Follow up if Grade 2 or above
Grade 3 May need surgical intervention
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Ligametous shoulder injuries
True dislocation of the shoulder joint will have caused significant ligamentous injury – look out for Bankhart lesions
Rotator cuff injury more of note
Efficient history taking with appropriate examination will give info as the integrity of the cuff
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Shoulder Assessment
Observation (Look): Deformity Muscle wasting Swelling Structure alignment Palpation (Feel): Heat Pulses Sensation Palpation for site of lesion
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Move
Active range of motion. Flexion/Extension/Abd/Add/Medial/lateral
Passive range of motion. Flexion/Extension/Abd/Add/Medial/lateral
Resisted muscle testing
Special tests – impingement tests / Cuff integrity tests
Check joint above and below
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Broad Arm Sling
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Knee Anatomy - Anterior
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Mechanisms of Injury –
Meniscal Lesions
Common in activities involving forced rotation on a weight-bearing leg.
Can be slow onset of effusion.
Localised ant/med knee jt pain - commonly.
If age>50yrs then consider degenerative meniscus if no history of trauma.
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Mechanisms of Injury - ACL
Can be produced by:
Pure Hyperextension
Combination of valgus force and external rotation of the tibia relative to the femur
Contact sports
Rapid onset Haemarhtrosis
Feeling of instability
Inability to bear weight
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Mechanisms of Injury - MCL
Can be produced by:
Valgus Force
With or without rotation
Proximal origin most effected
Can be combination injury due to multiple attachments
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Mechanisms of Injury - LCL
Can be produced by:
Varus forces
Much less common than MCL injuries
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Quadriceps Tendon Rupture
History
Significant injury
Palpate on each assessment to confirm integrity
Straight leg raise – be suspicious if unable
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Knee Assessment
Observation (look): Deformity Muscle wasting Swelling Structure alignment Palpation: Heat Swelling – sweep tests Pulses Palpation for site of lesion OTTAWA RULE
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Active range of motion. Flex/Ext
Passive range of motion. Flex/Ext/MR/LR
Resisted muscle testing. Flex/Ext/MR/LR
Special tests – Ligamentous tests
Straight leg raise.
Patella. Position. Tenderness
Palpation for site of lesion
Gait Analysis
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Special Tests
Valgus MCL
Varus LCL
PCL Posterior Sag, Gravity
test, Pencil test
ACL Anterior Drawer,
Lachmans
Menisci McMurrays
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PCL INJURIES
The Pencil Test
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Anterior Drawer
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Lachman’s Test
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Medial Stress test
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Lateral Stress Test
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OTTAWA KNEE RULE
For knee injuries – not insidious onset
Age 55 years or older
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90 degrees
Inability to walk four weight-bearing steps at once after the injury and in the emergency department
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Ligamentous ankle injury
Mechanism
Commonly combination of inversion/plantarflexion/ medial rotation
Eversion less common – be concerned!
Ability to weight bear immediately
Begin assessment at the knee
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OTTAWA ANKLE RULE
Foot
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Tubigrip
To apply or not?
Not much evidence that use will reduce patients pain, reduce swelling or aid recovery
?reduces proprioceptive input and recovery of muscle activity
Great placebo though!
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