Download The Injury Examination Process

Examination of Orthopedic and Athletic Injuries, 3rd Edition
The Injury Examination Process
Chapter 1
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Systematic Examination Technique

Objective data

Baseline measures
 Re-evaluations
 Rehabilitation

and treatment protocols
Documentation

Medical records
 Legally
required
 Communication tool
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Table 1.1. Role of the
Noninjured Limb in the
Examination Process
Evaluation Strategies
1.
2.
Perform each task on
uninjured limb first.
Perform each task on injured
limb first.
Increase or decrease
apprehension and muscle
guarding?
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Clinical Assessment

Clinical assessment vs. acute evaluations


What are the differences?
Special considerations

Discretion
 Religious considerations
 Informed consent
 Signed
written statement
 Verbal
 Emergency
medical care
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
History

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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Past Medical History
Past medical history
Previous history questions


Non-acute examinations
(physicals)




Health conditions
Previous injuries
Predisposing factors
NCAA Guideline 1B: Medical
Evaluations, Immunizations,
and Records (Box 1-3)
Copyright © 2010. F.A. Davis Company
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?
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Past Medical Health

General medical health
Medications
Current health status?
Comorbidities present?

Relevant illness and lab
work






Note during exam if they may
affect injury management or
the healing process.

Smoking



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What medications are they
currently taking?
What interactions or effect
may they have on healing,
treatments, etc.?
Decrease exercise tolerance
Increased risk for CV disease
May delay fracture and
wound healing
Examination of Orthopedic and Athletic Injuries, 3rd Edition
History of Present Condition

Mechanism of injury
(MOI)

How did the injury
occur?



Macrotrauma
Microtrauma
Identifies structures
involved
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
Relevant sounds or
sensations
 Onset and duration of
symptoms


Acute
Chronic
Examination of Orthopedic and Athletic Injuries, 3rd Edition
History of Present Condition

Pain






Location
Type
Referred
Radicular
Daily pain patterns
Provocation and
alleviation patterns
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
Other symptoms
 Treatment to date
 Affective traits
 Disability/limitations
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Physical Examination

Goals

Rule out differential diagnosis
 Determine clinical diagnosis
 Identify impairments and functional limitations

Standard precautions against bloodborne
pathogens (Box 1-5)
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Inspection
Immediate observations

As soon as patient enters
facility observe





Gait
Posture
Function
Guarding
Splinting
Physical examination
observations (bilateral)

Deformity


Swelling




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Hemarthrosis
Edema
 Girth measurements
(Special Test 1-1)
Skin


Subtle or gross?
Redness
Ecchymosis
Infection signs
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Inspection

Functional assessment

Perform functional tasks that were identified as
problematic.
 Impairments should be identified and measured.
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Palpation

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.
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Palpation

Point tenderness
 Trigger points
 Change in tissue density
 Crepitus
 Tissue temperature
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Joint and Muscle Function
Assessment

Perform bilaterally
 Involves

Active range of motion (AROM)
 Manual muscle testing (MMT)
 Passive range of motion (PROM)
 Joint stability tests
 Stress testing
 Joint play
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Active 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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Manual 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)
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Manual Muscle Testing
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Examination of Orthopedic and Athletic Injuries, 3rd Edition
Passive 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

Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Joint Stability Tests

Procedure



Apply specific stress to
non-contractile tissue
Hypermobile — more
laxity than normal
Hypomobile — below
normal laxity
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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

Examination of Orthopedic and Athletic Injuries, 3rd Edition
Stress
Testing
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Joint 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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Special 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 (-)
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Neurologic Screening

Upper and lower quarter
screen


Evaluate
 Sensation
 Motor function
 Deep tendon reflexes
Identify
 Nerve root impingement
 Peripheral nerve damage
 CNS trauma
 Disease
Copyright © 2010. F.A. Davis Company

Indicated by





Numbness
Paresthesia
Muscular weakness
Pain of unexplained origin
Injury to cervical or lumbar
spine
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Neurological Screening 1-1.
Lower Quarter Screen
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Neurological Screening 1-2.
Upper Quarter Screen
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Sensory 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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Motor 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.
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Reflex 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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
Table 1–10. Deep Tendon
Reflex Grading
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Examination of Orthopedic and Athletic Injuries, 3rd Edition
Vascular Screening
Gross 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
Copyright © 2010. F.A. Davis Company
Examination of Orthopedic and Athletic Injuries, 3rd Edition
The Role of Evidence in the
Examination Process

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
Copyright © 2010. F.A. Davis Company