Joint Assessment. Sherry Mace- Addair MS, FNPc. May 16 th 2012

Transcription

1 Joint Assessment Sherry Mace- Addair MS, FNPc May 16 th 2012 An orthopedic assessment should be performed in a consistent manner every time. This will get one accustomed to a routine and help prevent an incomplete exam. A good physical exam is necessary even if one does not know the entire anatomy. A good reference book can help decipher the exam findings later. I recommend the Atlas of Human Anatomy, by Frank H. Netter, MD. I also recommend Essentials of Musculoskeletal Care published by the American Academy of Orthopedic Surgeons. Essentials in Musculoskeletal Care by AAOS- ISBN # Netter s Exam book- ISBN # History- Let the patient talk! Usually pain, deformity or weakness brings them in. Acute vs. Chronic Mechanism- with anatomic location of symptoms Nerve Root Irritation- dermatomal numbness/tingling Night Pain- RTC, arthritis, neoplasm Constitutional symptoms- wt loss, fevers, night sweats, night pain Instability- hx dislocation? Motion- restricted? Weakness? Functional Status Pain- sharp, ache, nerve, worse in am (RA), worse with activity (DJD), radiates anywhere? Swelling after? Deformity- when noticed? Injury? Getting worse? Weakness- Big muscle groups = proximal, loss of bowel bladder? Basic Exam On every patient, in every clinic setting and for every musculoskeletal complaint, the following basic components of the exam should be addressed and documented. Always include side to side comparison. Always remove clothing with modesty in mind. Inspection General presentation (distress, grimacing, alert, crying, happy) 1

2 Gait (antalgic, wheelchair, cane, rotation of leg, try to watch them walk into exam room) Skin (intact, bruising, swelling, deformity, atrophy) Palpation (crepitance, tenderness, deformity) Range of Motion (if unsure of what it is called, measure every way you can move the joint and look up later) Strength (5/5 scale, painful areas) Special exams (joint specific) Neurologic (2 point discrimination, reflexes, gross sensation) Vascular (pulses, skin temp, edema, hair growth) Shoulder Inspection & Palpation Anterior view- examine skin and bony structure Poster view- Look for symmetry and muscle atrophy. AC joint- Palpate the end of clavicle and acromion for tenderness or spurs. Locate the AC joint and X it with the marker Subacromial bursa- palpate the anterolateral portion of acromion, moving down toward deltoid until you feel the acromiohumeral sulcus. Tenderness here is related to bursitis or rotator cuff tear. Long head biceps tendon- Palpate over humeral head, find the groove anteriorly, internally and externally rotate humerus. Shoulder Range of Motion Forward flexion- from starting position to overhead. Normal External rotation with arm at side. Normal to about 90 (limited in arthritis) External rotation with arm abducted 90 - Normal about 90 (limited in athletes and reconstruction) Internal rotation- highest midline spinous process by hitchhiking thumb. (limited in arthritis) Shoulder Muscle Testing Deltoid- arm in 90 of abduction and push down. Doesn t completely isolate deltoid, RTC involved Supraspinatus- 90 abduction, 30 forward flexion, internal rotation. Push down as pt resists 2

3 Infraspinatus & teres minor- apply resistance with the arm at side, elbow at 90, and externally rotated 30 Subscapularis- Flat hand against lower back, lift off and resist Shoulder Special Tests Neer Impingement sign- depress scapula with one hand, elevate are with other hand. Compresses the greater tuberosity against the anterior acromion and elicits discomfort in patients with rotator cuff tear or impingement syndrome. Hawkins impingement sign- Reinforces a positive Neer. Elevate shoulder to 90, flex elbow to 90, place forearm in neutral rotation. Support arm and internally rotate the humerus. Pain elicited with this test is indicative of rotator cuff tear or impingement syndrome. Cross-body adduction- elevate shoulder 90, adduct arm across body in horizontal plane, pain over AC suggests arthritis of the joint. Apprehension sign- Arm in 90 of abduction, elbow at 90 and then maximal external rotation. Patients with anterior instability may report apprehension and a sense of impending dislocation. Pain is less specific. Sulcus sign- traction in an inferior direction with arm relaxed at patient s side. Inferior shoulder laxity will cause a widening of the sulcus. Jerk Test- 90 flexion and max internal rotation with elbow at 90. Adduct arm across body in horizontal plane while pushing humerus in posterior direction. Positive of posterior subluxation or dislocation occurs. Knee Inspection & Palpation Anterior view- valgus or varus deformities, asymmetry of alignment, thigh atrophy Posterior view- atrophy of thigh and calf, swelling in popliteal fossa Gait Knee effusion- suprapatellar region is where it will be visible. Milking helps see it, feel for ballottement Patella- locate patellar and quadriceps tendons. Displace patella laterally and medially. Watch for apprehension/pain Fairbanks. Palpate the tibial tuberosity Patellar tracking-palpate patella as knee flexes and extends. Crepitus is noted with pf arthritis although doesn t correlate with severity. Infrapatellar bursa- below patella on either side of patellar tendon, check for swelling. Will be dumbbelllike 3

4 Joint line tenderness- flex knee and identify joint line (soft spot). Tenderness can be associated with meniscal tear. Find the medial joint line and mark an X with the pen. Knee Range of Motion- flexion extension. Normal to 145 Knee Muscle Testing- Quadriceps, hamstrings Knee Special Tests Patellar instability apprehension sign Perkins - Patient seated, knee extended, displace patella laterally and then flex knee to 30. With instability, this maneuver displaces the patella to an abnormal position on the lateral femoral condyle. Patient often perceives pain and becomes apprehensive. Meniscal tear McMurray circumduction test - Flex knee to max pain free position. Hold that position while externally rotating the foot then gradually extend the knee while maintaining the tibia in external rotation. This maneuver stresses the medial meniscus and often elicits a localized medial compartment click and/or pain in patients with a tear. The same maneuver performed while rotating the foot internally will stress the lateral meniscus. Pain free flexion beyond 90 is necessary for this test to be useful. MCL- Valgus stress test- Knee extended then flexed at 25. Apply stress at the lateral side of knee. If opens up in full extension, severe injury. LCL- Varus stress test- Knee extended and then flexed at 25. Reverse the stress pattern used for the MCL. If opens up in full extension, severe injury. Anterior and posterior drawer- knee flexed at 90, stabilize the leg by sitting on the foot. Grasp proximal tibia with both hands. Palpate hamstring tendons to ensure that they are relaxed. Slide tibia anteriorly for an anterior drawer and posteriorly for a posterior drawer. Compare with uninjured knee. Be careful! PCL thumb sign- flex knee at 90. Normally, anterior tibia sits 1 cm anterior to fem condyle. Place thumbs on the anterior plateaus. If the PCL is injured, the proximal tibia falls back and the area available to place your thumbs decreases. When the tibial plateaus are flush with the fem condyles, there is 10mm or more or posterior laxity, consistent with a complete tear of the PCL. Hip Inspection & Palpation Anterior view- atrophy of thigh muscles and overall alignment of hip, knee and ankle Posterior view- atrophy of buttock and post thigh. Note iliac crest symmetry Gait- look for limp Anterior palpation- masses, adenopathy, tenderness over ASIS, greater trochanter. Lateral palpation- trochanter bursa palpation, palpate proximal and posterior margin of trochanter for tendonitis (gluteus medius, external rotator) 4

5 Hip Range of Motion Zero starting position; flex opposite leg enough to flatten the lumbar spine. Normal hip flexion to 110 to 130 Abduction-once pelvis begins to tilt, stop. Normal is 35 to 50 Adduction- stop when pelvis starts to rotate. Normal is 23 to 35 Internal and external rotation- check with hip and knee flexed at 90. Think about what the femoral head is doing. Measure how far the foot goes. Don t do in children. Hip Muscle Testing Hip flexors- patient seated, ask to flex hip against resistance Hip extensors- prone position, knee in 90 flexion, ask patient to extend hip as you resist Hip abductors- patient on side. Abduct thigh as you resist Hip adductors- patient supine, place hand on medial thigh and ask patient to adduct. Resist the effort. Hip Special Tests Trendelenberg- ask patient to stand on one leg. With normal strength, the pelvis will stay level. If hip abductor strength is inadequate on the stance limb side, the pelvis will drop with the iliac crest becoming lower on the opposite side Faber Figure of 4 test - Flexion/abduction/external rotation maneuver to detect hip and SI joint pathology. With patient supine, place the affected hip in flexion, abduction and external rotation and then press the hip back into extension by placing the foot of the opposite tibia. If the maneuver is painful, the n the hip or SI region may be affected. Baby- Developmental Dysplasia of the Hip Ortolani- newborns Barlow-newborns Galeazzi-toddlers Nice clip on you tube to show technique Ottawa Ankle Rules Ankle sprains graded I-III I- Stretching Tender to palp; mild swelling; normal function II- Partial Tearing Tender to palp; mod swelling & ecchymosis, some instability, wt bear 5

6 III- Complete Rupture Pain; marked ecchymosis/edema; gross instability; no wt bear Usually don t need x-rays for grades I & II. Per Ottawa rules, x-rays are necessary for the patient who: 1. Is unable to bear weight initially after injury or when examined 2. Has tenderness over the posterior edge of the distal 6cm or distal tip of the medial or lateral malleolus 3. Has tenderness over the fifth metatarsal or tarsal navicular 6