F2 Teaching

Joint Examination

Sept 15th 2009

Andy Higgins

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

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

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

Shoulder Assessment

Observation (Look): Deformity Muscle wasting Swelling Structure alignment Palpation (Feel): Heat Pulses Sensation Palpation for site of lesion

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

Broad Arm Sling

Knee Anatomy - Anterior

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.

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

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

Mechanisms of Injury - LCL

Can be produced by:

Varus forces

Much less common than MCL injuries

Quadriceps Tendon Rupture

History

Significant injury

Palpate on each assessment to confirm integrity

Straight leg raise – be suspicious if unable

Knee Assessment

Observation (look): Deformity Muscle wasting Swelling Structure alignment Palpation: Heat Swelling – sweep tests Pulses Palpation for site of lesion OTTAWA RULE

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

Special Tests

Valgus MCL

Varus LCL

PCL Posterior Sag, Gravity

test, Pencil test

ACL Anterior Drawer,

Lachmans

Menisci McMurrays

PCL INJURIES

The Pencil Test

Anterior Drawer

Lachman’s Test

Medial Stress test

Lateral Stress Test

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

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

OTTAWA ANKLE RULE

Foot

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!