5 - SCREENING FOR REFERRAL OF LL Flashcards
PROGNOSTIC PROFILING
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Screening for referral
SCREENING FOR REFERRAL
- Triage in PT not skill reserved only for PT who practice direct access &
who need to ensure treating patients’ safety
- Also necessary skill in cases where patient’s condition changes, during
PT treatment or simply between time, physician consulted & time PT
initiates treatment
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Early identification of serious spinal patho
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- Determine level of concern. Consider evidence to support red flags & individual profile of person’s health determinants to decide level of concern about presence of serious pathology
- Decide on your clinical action, based on level of concern determined in step 1
- Consider pathway for emergency / urgent referral. Know local referral pathways & pathways to access specialist care if indicated
Ankle fracture:
- description
- clinical decision rules
Ankle fracture
- Interruption of continuity of bone
- Subjective history
o Trauma, accident, fall from height, recent severe sprain
o F > M
- Risk factors: osteoporosis (greater in women > 50 y)
- Objective examination:
o Swelling, joint effusion & hemarthrosis
o Pulsating pain & during palpation
o Weight bearing avoidance
Clinical decision rules
- Clinical tool quantifying individual contributions that various components of history, physical examination & basic laboratory results make towards diagnosis, prognosis, or likely response to treatment in individual patient
- Clinical practice guidelines advocate for use of clinical decision rules to identify those at risk
of serious LL injuries
- Intent to guide diagnostic & treatment decision-making process
Different assessments / tests for ankle fracture
Ottawa ankle rules
Bernese ankle rules
Tuning fork test
Table
Knee fracture:
- history
- initial physical exam
- special tests
- x-ray
- specialized imaging
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Different tests / assessment for knee fracture
Ottawa knee rule
Pittsburgh decision rules
Table
Hip fracture:
- description
- tests
- Pathological hip fractures caused by minor trauma to skeletal segments weakened by other
patient’s ongoing pathology & age - Same trauma in healthy patients would not be sufficient to generate fracture
- Could be spontaneous structural failure
- Half of pathological fractures of proximal femur occur in neck region
- Early surgery in hip fracture patients linked with improved outcomes, operating within 48h of admission recommended
Patellar pubic percussion test
Fulcrum test
TABLE
Deep vein thrombosis:
- description
- medical history
- objective examination
- management
= formation of thrombus occluding vein
Medical history
- Age > 40y
- Recent surgery (high incidence in hospitalized patients)
- Immobilization > 3 days
- Long plane journeys in previous 4 weeks
- History of stroke, cancer, heart attack, previous DVT, fractures AAII
- Use of estrogen contraceptive, intravenous drugs
- Patient reports episodes of foot paleness & loss of pulse of dorsal artery of foot
Objective examination
- Warmth, oedema, pain on palpation of calf along course of veins
- Pain increasing with walking & standing, decreases with rest or with limb in unloading elevated position
- Only 50% of patients present pain
- Oedema is most specific symptom
- Homans sign (rapid ankle DF leading to cramp-like pain in calf). Present in less than, 1/3 of patients with confirmed DVT & present in 50% of patients without DVT (low accuracy)
Management
- Most vein thrombi dissolve completely without therapy
- Recommended anticoagulant therapy (heparin) & early loading with use of compressive
stockings
- Non weight bearing movement
Peripheral arterial disease (PAD):
- description
- medical history
- objective exam
= total or partial blockage of vessels that supply blood from heart to periphery
Medical history
- Smoking (80% of patients with PAD)
- Diabetes
- Obesity
- Hypertension
- Age > 50y
- M > F
- Sedentary lifestyle
Objective examination
- Pain during exertion
- Leg weakness
- Claudication intermittent: patient has pain, fatigue in calf while exerting, since demand for blood supply increases. It reduces with rest
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1) Femoral pulses palpation
2) Dorsalis pedis pulse palpation :
Found navicular go slightly away between MT1 & MT2
3) Popliteal pulses palpation
4) Posterior tibial pulses palpation: between medial
malleolus & ant side of Achilles’ tendon
Compartment syndrome:
- description
- acute vs chronic
- objective exam
- management
COMPARTMENT SYNDROME
= ischemia of tissue caused by increased pressure within compartment
- Reduce normal blood flow in that compartment (groups of muscles, nerves & vessels contained within non-elastic band), resulting in lack of oxygen in area
Acute compartment syndrome
=> Occurs after violent muscle contusions OR excessive compression of compartment by bandages or plaster
Chronic exertional compartment syndrome
- Overuse condition
- Myofibrillar damage caused by increased osmotic pressure & decreased blood flow
- Pain & cramping during or after exertion, relieved by rest
- Typical of athletes doing demanding activities (triathlon, marathon runners)
Objective examination
- Pain in leg, which increases with stretching
- Pain may be throbbing & defined as sharp during palpation
Management
- Surgical fasciotomy to decompress area & provide space to tissues (2 points to release pressure)
- While waiting for surgery, conservative treatment based on education: recommend not to
use tight shoes or brace, rest NSAIDs to reduce inflammation
