8/7/2013

Physical Exam Skills and Office Procedures in Orthopaedics

Outline • • • •

Knee exam Knee aspiration and injection Shoulder exam Subacromial bursa injection

UCSF Essentials of Primary Care August 14, 2012 Carlin Senter, M.D.

Knee Anatomy

The quadriceps muscles extend the knee

http://thefitcoach.wordpress.com/2012/04/07/267/

http://scientia.wikispaces.com/Thigh+and +Leg+-+Lecture+Notes

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The quadriceps muscles merge to form the quadriceps tendon… patellar tendon

The hamstrings flex the knee

www.hep2go.com

Pes anserine bursa

There are 4 main ligaments in the knee

http://meded.ucsd.edu/clinicalmed/joints.htm

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Meniscus

Musculoskeletal work-up

• History • Inspection • Palpation • Range of motion • Other Tests

Knee exam

Common Causes of Knee Pain by Location of Symptoms • Anterior: - Patellofemoral syndrome - Quadriceps tendinitis - Patellar tendinitis

• Medial

• Lateral: - Lateral jointline: meniscus tear or OA - IT band syndrome - LCL sprain (rare) - Fibular head: fracture (rare)

• Posterior - Hamstring tendinitis - Gastrocnemius strain - OA, meniscus tears, effusion, popliteal cyst….

- Medial joint-line: meniscus tear or OA - MCL sprain - Pes anserine bursitis

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Inspection

http://doctorhoang.wordpress.com/20 10/09/06/valgus-knee-and-bunion/

http://meded.ucsd.edu/cl inicalmed/joints.htm

Palpation of patella - supine

Palpation of joint line seated or supine

http://www.rheumors.com/kneeexam/palpation.html

Palpation of patellar facet

Ballottement 4

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Knee range of motion • ROM: normal 0-135

Other Tests: Lachman to evaluate ACL Sensitivity 75-100% Specificity 95-100%

– Determine if knee is locking or if ROM is limited due to effusion – Locking: think bucket handle meniscus. • Urgent xrays, MRI • Urgent referral to sports surgeon for arthroscopy

Permission for use provided by Dr. Charles Goldberg, UCSD

PCL: Posterior Drawer

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

MCL and LCL

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Meniscus: McMurray

Meniscus: Thessaly

Sensitivity medial 65%, Specificity medial 93%

Magee, DJ. Orthopaedic Physical Assessment, 5th ed. 2008.

Meniscus: Squat

Knee exam practice • Standing: inspection – Varus or valgus

• Sitting: palpation – – – –

Joint line Femoral condyles Tibial plateau Fibular head

• Supine – – – –

Patellar facets Patellar grind ROM Special tests

Lachman Posterior drawer Varus 0 and 30 Valgus 0 and 30 McMurray medial and lateral • Thessaly • Squat • • • • •

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Intra-articular corticosteroid injections: do they work for knee OA?

• Good short-term pain relief

Knee aspiration and injection

– Effect size 0.72 at 2 and 3 weeks

• No significant effect on function – Effect size 0.06

• No evidence for long-term pain relief • Clinical effect independent of degree of inflammation present

– Don’t need to restrict injection just to those with effusion

• Frequency: general practice once every 3 months max – Concern for cartilage toxicity with more than 4/year

• AAOS: recommends for short-term pain relief (level II) Zhang W et al. OARSI recommendations for the management of hip and knee osteoarthritis: Osteoarthritis Cartilage. 2010 Apr;18(4):476-99.

Superolateral approach • Patient supine • Extend knee • Bump under knee so flexed 10-20 degrees • Superior border patella • Lateral border patella • 1cm below • Mark with syringe cover or tip of pen

Injection set-up bucket • • • • •

Betadine Ethyl chloride Alcohol swabs 4x4 guaze Bandaids

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Injection prep

Needles, syringes, meds

Corticosteroids

Why use local anesthetic with steroid injection?

• Dilute the steroid

– Decrease likelihood of steroid atrophy – Decrease irritant nature of steroid crystals causing post-injection flare

• Pain relief

– Diagnostic and therapeutic (subacromial more than knee)

• Floculation: combining steroid and local anesthetic can precipitate crystals. Carefully inspect for precipitate before injection.

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Why aspirate the effusion before injection?

Aspiration

• Clinically

– Decreased pain and stiffness because effusion gone – More effect of steroid because not diluted by effusion – Inspect fluid for inflammation/infection, send to lab if question – Confirms that injxn was intra-articular

• Significantly greater improvement in VAS for patients who had joint aspirated at time of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.) • Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.)

Post-injection patient instructions • Rest: no definitive evidence-based recommendation – Recommendations in literature vary

• No restrictions • Bed rest x 24 hours • Light activity x 7 days, no weight bearing exercise

• Avoid swimming, hot tub, bath x 24 hours – Let injection site heal

Contraindications to steroid injection Joint infection Fracture Prosthetic joint Hemarthrosis (theoretically higher risk of infection) • Soft tissue infection overlying joint • • • •

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Relative contraindications to steroid injection

• Corticosteroid injection within past 4 months • Coagulopathy (ok if on warfarin but check recent INR, make sure not >> 3) • Poorly controlled diabetes

Risks of steroid injection in the knee • Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days • Suppression of hypothalamic pituitary adrenal axis, mild – Lasts 1-3 days post-injection

• Facial flushing: 10% with Kenalog – 19-36 hours post-injection

• Skin or fat atrophy • Post-injection steroid flare: 1-10%

– Synovitis in response to injected crystals – Within hours - 48 hours post-injection – More common in soft tissue injections (20% of trigger points) than intraarticular injections

• Septic arthritis: 1/3000-1/50,000 – 1-2 days after injection

• Possible risk of chondrocyte toxicity with repeated injections Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2010.

My current knee injection steps 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Knee injection

Patient supine with bump under knee Mark injection site (superior lateral) Betadine x 3 Alcohol x 1 Ethyl chloride for skin anesthesia Alcohol again 22g needle attached to 10cc syringe containing 5cc of 1% lidocaine without epi Slowly advance and inject lidocaine, 1mm at a time Feel resistance give when in joint Aspirate, make sure fluid straw-colored and clear Keep needle in place, switch syringe Inject 1cc of 40mg kenalog

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Underlying Anatomy - Bones

Shoulder anatomy

Acromion

• Humerus • Scapula o Glenoid o Acromion o Coracoid o Scapular body • Clavicle • Sternum

Greater Tuberosity

Clavicle

Glenohumeral Joint

Lesser Tuberosity

The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa

Acromion

Spine of scapula is at the level of T3

Bottom of scapula is at level of T7

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Supraspinatus (Abduction)

The Rotator Cuff Muscles (SITS) The tendons of the rotator cuff muscles reinforce the capsule of the glenohumeral joint.

Greater Tubersosity

Posterior View

Lesser Tuberosity

Anterior View

Subscapularis (Internal Rotation)

The Biceps Muscle

Infraspinatus (External rotation))

Teres Minor (External rotation)

Shoulder exam

• #1 Supination of the elbow (screwing, twisting) • #2 Flexion of the elbow Long head

Short head

3 attachments: • Radial tuberosity (distal) • Glenoid (long head) • Coracoid (short head)

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Neck examination • • • •

Inspection Palpate CS FF and extension Spurlings

Cervical Spine Spurling’s Maneuver • Neck extended • Head rotated toward affected shoulder • Axial load placed on the cervical spine • Reproduction of patient’s shoulder/arm pain indicates possible nerve root compression

Shoulder examination

Shoulder examination

• Inspection

• Inspection

• Palpation • ROM • Strength

• ROM • Strength

• Palpation

– Patient in gown

– Supra – Infra and teres minor – Subscapularis

• Other tests

– Supraspinatus – Infraspinatus & Teres minor – Subscapularis

http://meded.ucsd.edu/clinicalmed/joints 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

http://meded.ucsd.edu/clinic almed/joints2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM

• Other tests

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Range of motion

Range of motion

Internal rotation

Abduction

External rotation

Flexion

Other tests

Supine shoulder PROM • • • • •

Rotator cuff strength Impingement tests Biceps Labrum AC joint

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Supraspinatus = abduction

Infraspinatus and teres minor = external rotation

Supraspinatus

Infraspinatus

Empty can Photos from Dr. Christina Allen

Subscapularis = internal rotation

Lift-Off

Subscapularis

Photos from Dr. Christina Allen

Teres minor

Photos from Dr. Christina Allen

Subscapularis = internal rotation

Belly press

Subscapularis

Photos from Dr. Christina Allen

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Impingement signs

Impingement syndrome • Inflammation of the subacromial space

Subacromial bursa

Supraspinatus

– The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid bursa

Hawkin’s Photos from Dr. Christina Allen

Biceps Tests: Speeds

Biceps Tests: Yergasons

Tests for biceps pathology (tendinitis, tendinopathy, tear)

Tests for biceps pathology (tendinitis, tendinopathy, tear)

Palms up, patient pushes up against resistance (resisted elbow flexion)

Patient supinates (twists out) against resistance

+Test is pain at proximal biceps tendon Sens = 54%, Spec = 81%

Neer’s

+Test is pain at proximal biceps tendon Sens = 41%, Spec = 79%

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O’Brien’s Test To r/o Labral Tear • Arm forward flexed to 90° • Elbow fully extended • Arm adducted 10°to 15°with thumb down • Downward pressure • Repeat with thumb up • Suggestive of labral tear if more pain with thumb down • Sens = 59-94%, Spec = 28-92%

• Tests for AC joint osteoarthritis or sprain • Can be done passively by patient or physician • +Test is pain at AC joint

Shoulder Exam Hands On Key Components of the Shoulder Exam: - Inspection - Palpation - Range of Motion: abduction, flexion, ER, IR - Strength - Neurovascular - Special tests

Testing the AC Joint: AC Crossover

Special Tests: • Spurling’s (cervical spine radiculopathy) • Job’s, aka Empty-can (supraspinatus) • Lift-off test (subscapularis) • Resisted external rotation (infraspinatus) • Hawkins (impingement sign) • Neers (impingement sign) • Speeds (biceps) • Yergason’s (biceps) • O’briens (SLAP tear) • AC crossover (AC joint OA or sprain)

Subacromial injection for impingement syndrome

http://www.youtube.com/watch?v=wr_FBVjHJY8

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Approach

Impingement syndrome • Inflammation of the subacromial space

Subacromial bursa

Supraspinatus

1. Posterior 2. Lateral

– The area under the acromion and above the glenohumeral joint – Structures in this space • Supraspinatus • Subacromial/subdeltoid bursa

Slide courtesy of Anthony Luke, M.D.

Subacromial Injection Posterior approach Landmarks • Posterior and lateral borders of acromion • Coracoid Technique • Insert needle at Posterior “soft spot” • Aim parallel to angle of lateral acromion to reach subacromial bursa • Direct needle towards opposite nipple

http://www.aafp.org/afp/2003/0315/p1271.html

Slide courtesy of Anthony Luke, M.D.

Subacromial Injection Lateral approach Landmarks • Lateral border of the acromion Technique • Inject 3 mm below lateral border of the acromion • Angle needle parallel to plane of the acromion Slide courtesy of Anthony Luke, M.D.

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Subacromial Injection

Subacromial injection palpation

• 5 – 8 mL combination of local anesthetic solutions • 1 – 2 mL steroid solution My preferred solution: • 5 mL 1% lidocaine with 1 mL 40 mg/mL triamcinolone

Subacromial injection

Thank you

Questions? [email protected]

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