ORTHO 3 EXAM done printed Flashcards
Intro to an Ortho examination
• Similar format to what was done in UQ/LQ Screen
• However now the PT is
more focused on a specific joint
Introduction
• At this point in time, the PT has already conducted ahistory, a medical screening, and an UQ and/or LQ scan
• PT has already r/o non somatic causes of pain
• During the UQ or LQ scan, a joint should have been positive for orthopedic dysfunction.
• Either a limitation in motion or pain
• The PT now does a more thorough examination of all the affected joint(s)
.
What are the components of an Ortho Examination?
• Observe
• Edema, color changes, asymmetries
• Palpation
• For Hypertonicity, myofascial assessment, temperature
changes, pain
• AROM/PROM
• Already done in UQ/LQ Screen, but focus on other mo-tions that may not been tested
• Note ROM and pain
• MMT
• Noting for strength and pain. Cause of weakness
• Accessory Motion
• Assessing for joint motion (not covered in this class)
• Special Tests
How does a PT interpret the Results?
- Beyond the scope of this class
- Instead will focus on three musculoskeletalphenomenon
- Fractures
- Sprains
- Strains
- Other diagnoses may be discussed as well
Fractures
• Three common causes
• Sudden impact (most common)
• Stress fracture – associated with repetitiveactivities
• Pathologic fracture – associated with dis-
ease, such as cancer
Sign and sx’s of a Fracture
- Pain and local tenderness
- Deformity
- Immediate Edema
- Ecchymosis
- Pain with WB
- Pain with vibration
- Ultrasound
- Tuning fork (256 Hz)
- Painful weakness with MMT
Fractures associated with OP
• Those with OP, will get fx will less impacted trauma• OP don’t always apply to post menopausal
women
• Those who are at great risk are:
• Smokers, alcohol abuse
• Low vitamin D intake
• 5F’s = Female, Fifty, Fair skin, Fair haired, Frail
• Prolong corticosteroid and anti coagulant use
• Bed ridden
Muscle Strain is?
- Disruption of the muscle fibers
- Due to a fall, a sudden twist, or a pull-ing a ms tendon.
- Due to overstressing the ms or doing an improper technique
Sign and sx’s of a strain
- Pain to injured area
- Tender to touch
- Swelling
- Bruising
- Inflammation
- Cramping
- Pain with stretch, I say stretched at full range, that the muscle is fully stretched.
- Weakness
- Loss of the ability to move joint
Sprain is?
- Disruption of the ligaments
- Due to
- Sudden motion
- Long sustained motion
A strain must have muscle weakness?
Yes
A strain must have pain with stretch?
No
When will there be the most muscle weakness at a strain?
Third degree
When will there be the least pain at a strain?
Third degree
When will there be the least weakness for strain
First degree
Is there alway decreased range of motion for strain?
No, by thirdd egree it may increase.
What do we always look for to make sure that there is a strain?
Muscle weakness.
Sign and sx’s of a sprain
- Pain to injured area
- Swelling
- Bruising
- Pain with stretch
- Weakness, due to poor stabilization and/orpain
- Loss of the ability to move joint
For weakness when will the ligament look like a strain?
At first degree
For sprain, must it always have devreased ROM?
No, at third degree it may increase.
Are there a lot of similarities between strains and sprains?
Yes
Where do we a difference between strains and sprains?
At stage 2&3. That by sprain it is min to moderate weakness still but the strain it is min to mod and mod to severe.
Where can we be more sure to differentiate between the strains and sprains?
Pain with isometric contraction. Sprain will never have pain with isometric contraction because the ligaments are not being stretched.
What is the vertebral Artery?
• There are 2 vertebral arteries
• Ascends thru the transverse foramina of the cervi-cal vertebrae
• Turns sharply along the posterior arch of atlas
• Then pierces the AO membrane and enters the
subarachnoid space
• They join each other and form the basillar artery
• Gives off a branch called the posterior inferior
cerebellar artery to the cerebellum
• Supplies blood to the brain stem
• Which houses the cranial nerves
What are s & S which may indicate dysfunction to thevertebral-Basilar Artery (VBA)?
Which we must be aware of so that we can know if we are to go and perform any cervocal PT of increased aggressiveness.
• More than the 5 D’s. Don’t memorize, but understand that theVBA supplies the CN’s
• Dizziness/vertigo/light headedness
• Nausea (often with vomiting)
• Numbness—most often unilateral facial
• Ataxia/unsteadiness of gait is the most common
• Diplopia
• Ipsilateral Horners syndrome
• Ipsilateral limb ataxia
• Ipsilateral sensory abnormalities of face (CN V); most com-
monly a loss of pain and temperature (dissociated sensory
loss); can get diminished/absent ipsilateral corneal reflex
• Ipsilateral cranial nerve IX–XII abnormalities
• Nystagmus; cerebellar or vestibular in origin
• Possible ipsilateral cranial nerve VII deficit
Alot of constituitional issues and alot of CN issues, because the vertebral arteries do supply blood to the brain so vestibular and cerebellar and CN issues are primary to be looked at.
What is the most common VA dysfunction?
• VBA dissection
• Vessel wall weakness, causing the a pieceof the artery to come loose
• This broken piece can travel up into the
vessels of the brain and cause a stroke or death
What motions Narrow the Vertebral Artery?
• Controversial
• However it appears that the majority of articles agree
• Extension (anterior circulation), rotation (past
45 degrees assess post circulation) and traction will occlude the contralateral VA
• Will be compensated by ipsilateral carotid ar-
tery
Look up and turn, it will occlude the artery.
Vertebral artery testing (VAT) is called what?
DeKleyn’s test
How does one perform the deklyn’s test?
Well the head needs to become declined, that they are lying supine and their head is extendeda nd rotated, just the two motions apthat we did just say are prime for occlusion, and so if they do complain of cerebellar, taxic, CN, or vestibular issues, then it is a positive finding.
VAT is extremely controversial
Pros and cons
For it • Screen for assessing VBA • Offers medico-legal protection • Against it • Putting pt at risk if they do have VBA dys-function • Not a common motion done during PT • Puts more stretch than a typical PT proce- dure • Poor sensitivity
Hautant’s Test
Test for
-Used to differentiate dizziness/ vertigo from a articular problem origin or due to vascular dysfunction
To see if the problem is due to the joint or it is due to occlusion of the vasculature.
Patient Position/action of the Hautant’s
- 2 part testing. Pt sitting
- Flexes both shoulders
- then close eyes. If arms move, it is non vascular. If not, have the pt do the next step
- Pt rotate or extend the head, and
then closes their eyes
- Held for 10 – 30 seconds
Since if the vessels are for sure not occluded, because the neck is neither extended not rotated, so why are they presenting with any of the sign of VBA? Rather it is cervical and not vascular.
But if they are okay at closing their eyes, so we need to go and ask them to actually extend and rotate their own head, and then close their eyes and then it will let us know if it is vascular.
Chair rotation test
If negative now, when before with the deklyen’s it was positive, it may be due to vestibular issues.
If the chair rotation test is positive then this might mean…
That they are getting signsa nd symptoms without provoking their vestibular system, so it is more likey the vascular system.
If the chair rotation test is positive, then what will be do next?
The hautant’s.
Because it is positive, it incpdicates vascular, so we perform a less aggressive deklyn’s tests, namely, the hautants.
Why would the hautant’s be able to tell you that it is VBA and not cervicogenic?
Because the hautant’s is a light enough TOM that it will not evoke musculature pain but it is aggressive enough to cause occlusion.
So if the patient is bothered after the hautant’s then it is clear that it is a VBA issue.
Why by the chair rotation test we are not sure if it is VBA ir musculature?
By the CTT it is occluding and it is aggressive enough to cause musculature pain.
So which is it, vascular or musculature?
So we go and do the hautant’s that is aggressive enough for occlusion and not enough for musculature.
So how would you know if it is musculature?
If the hautant’s come out negative, then we know that the CTT did cause a pain, and now we only go and do that which will occlude, and if we see that the person is not getting aches, then we are clear that it is the musculature.
When is the canadian c spine rule made use of?
When there is a GCS of 15 or there is stable trauma.
When is the Canadian C spine rule not used?
Non-trauma • GCS<15 • Hemodynamically unstable • Age <16 • Acute paralysis, previous spinal disease or surgery.
If ANY High Risk factor present – then
Get an x-ray
What are some of these high risks for the cervical which one is to get an x-ray for?
- Age >65 year
- Dangerous mechanism
- fall from elevation ≥ 3 feet / 5 stairs
- axial load to head, e.g. diving
- MVC high speed (>100km/hr), rollover, ejection• motorized recreational vehicles
- bicycle struck or collision
- Paresthesia in extremities
If ANY Low-Risk factor present – then assess
clinically with ROM testing
(If the answer to any of these is NO then get an x-ray)
1.
Simple rear-end MVC which DOES NOT include the fol-lowing
• ! pushed into oncoming traffic
• ! hit by bus / large truck
• ! rollover
• ! hit by high speed vehicle
2. Delayed onset of neck pain
3. Absence midline c-spine tenderness
Able to actively rotate neck?
45 Degree Left and Right? If able then NO x-ray needed. If un-able, get an x-ray.
When do you imeediately get an x-ray?
When the cause of the injury was a high risk.
When do you not immediately get an x-ray?
When it is not a high risk.
Do you never get an x-ray when it is a non-high risk?
No, there are still tomes where you can require a x-ray even though it is not a high risk mechanism.
When will you require an x-ray when the cause of the injury was not a high-risk?
(If the answer to any of these is NO then get an x-ray)
1.
Simple rear-end MVC which DOES NOT include the fol-lowing
• ! pushed into oncoming traffic
• ! hit by bus / large truck
• ! rollover
• ! hit by high speed vehicle
2. Delayed onset of neck pain
3. Absence midline c-spine tenderness
These are not high risk, but they are not calm enough to have us at ease, so we will require an x-ray.
Lets say that there was no high risk and the way that the person was injured did not make it that it would have had them being with pain immediately, meaning that it is calm but not too csalm tonnot require an x ray?
Meaning that it was rougher than usual, and so maybe the fact that they are with pain now is really not because of that event, so would they require a x ray?
It depends if they can or they cannot rotate their rpheads to forty five degrees to each side. If they can,mthen it will not require a x ray, but if they cannot, then yes, they will require an immediate x ray.
When we say that they will require an immediate x ray, what do we mean by that?
That we are not allowed to go and perform treatments on them.
Cervical AA Instability is a danger because…
The ligament that will hold the atlas neutral, by grabbing onto the odontoid of the axis, is lax, and so the head will roll forward, and it will cause the odontoid to go and press against the sojnal cord. So the person will display neural issue.
How do you make sure that it is indeed a cervical AA laxity?
Sharp purser test.
Where the patient is siting and the therapists stabilizes the axis, and then pushes back in the forehead, the therapist might hear a clunk, that the atlas has been put back in the correct spot, or the patient has less pain.
A patient comes in with c/o of tingling to their right
hand.
What are all the possible
causes?
From most severe to least severe • Brain Pathology • Brain Tumor • Multiple Sclerosis • Cervical myelopathy, which may be due to:• AA Instability • Cancer • Cervical Radiculopathy • Carpal Tunnel Syndrome
Brain Tumor will present with
- Headache N & V
- Speech deficits
- Sensory abnormalities • Visual changes
- AMS
- Seizures
- Ataxia
It would really depend on where in the brain, that some places this and some places that.
CPR for Unilateral Cerebral Le-sions
• Combination of 3 tests
- Pronator drift
- Finger tap
- DTR’s
- All three positive SP of 97% and SN of76%
What is the pronator drift test?
The patient is asking to keep their arms out snd suppinated, and then we see if they drift into pronation, their sensory system is nit working well, and so they drift away into pronation, if you ask them to close their eyes they will may do worse, st means, go into pronation faster, because the visual is out.
Multiple sclerosis affect young or old people?
Young, infact for those who are older, it is rare, I guess, for the onset to start.
Subjective for CM?
Q = Poor balance, loss of manual dexter-ity
R = Paresthesia
(B) usually warrants an MRI
Objective
Observation - atrophy of hands intrinsics • UE and/or LE Weakness
Special test for CM?
• UMN Tests: Babinksi, Clonus, Hoff- man’s Reflex, Inverted supinator sign • Hoffman: May be false positive, more significant if it is unilateral (Ep-stein, 2001) • Reflex Changes: • Biceps/brachioradialis attempt --> Finger flexion • Triceps attempt --> elbow flexion Pectoral Reflex • Hit deltopectoral groove, (+) ADD and IR of shoulder
Cervical Radiculopathyntroduction
• Compression of the nerve root at the…
intervertebral level,therefore this is a PNS lesion
A PNS legion is not a _____ and will _____ on the _____ test?
LMN
Negative
UMN
Special test for LMN?
Spurling test.
What is the sequence of the spurling test?
Extension then SB and then compression.
•Upper limb tension testing.
How many do we have and for which nerves?
3
Ulnar, median, and radial.
Why is the ulnar nerve to have flexion of the elbow?
Because the merve goes posteriorly and it will stretch the most like that.
Why is the median nerve stretch at suppination?
Because since the median is center, so then you need to go and stretch it more than at what it is if it is neutral, so it will be to require pronation.
But the radial and the ulna are pronation because the radial will need to be stretch with pronation. And the ulnar will also get stretched at pronation.
All are pronation except the median that is different.
Name me four tests for the CR.
The upper limb tension test.
The distraction.
Spurling
And if the cervical rotation is less 60 degrees.
These are peripheral nerve compression test, and now UMN.
What is carpal tun-nel syndrome (CTS)?
• Median nerve compression syndrome at the level of the carpal tunnel
What else does the median nerve innervate?
- Innervates the thenar ms, severe nerve compressioncan cause atrophy to the thenar muscles
- Any compression of the median nerve in the tunnelwill cause pain t/o its distribution
Besides repetative motion what else can cause CTS?
Pregnancy, Extra fluid
Hypothyroidism, Makes the connective tissueto be more fluidy
Diabetes
Liver Disease,The nitrates that have not broken down, they will hang out.
CTS Special Tests
Tap over the ventral distal wrist
-instruct pt to hold this position for 1 minute, both wrists in flexion against each other.
And if they result in: -Parathesia and tingling into thumb, index finger, middle finger, and lateral half of ring finger, then they are positive for CTS.
CTS CPR• Five tests
• Shaking hands for symptom relief, is the person has pain so they will shake the hand as if to relieve the pain.
• Wrist-ratio index greater than .67
• Age greater than 45. They are older.
• Diminished sensation in median sensation to thumb, this is the median nerve distribution.
Symptom Severity Scale (SSS) score greater than 1.9, it really does hurt them
Load and shift test is a
Test for ?
-test for atraumatic instability of theGH joint
Load and shift test is does in what position?
-pt sitting in good posture
if slouched, it will cause head of thehumerus go anteriorly
Load and shift is done how?
-stabilize the clavicle and scapula with one hand -other hand grasps the head of thehumerus and load it to the joint -and then move anteriorly and posteriorly
What is a positive repsonse for the load ans shift?
-reproduction of sx’s -more than 25% movement.
Apprehension (crank) test/Relocation test Test for?
- for traumatic instability of the GHjoint
- high spec,99
Apprehension (crank) test/Relocation test is do e is which position?
Supine
How is the Apprehension (crank) test/Relocation test done?
The patient lies down supine and the shoulder is abduction to 90 and the elbow is flexed to 90 and the shoulder is slowly ER
Apprehension (crank) test/Relocation test is positive how?
- pain or look of apprehension on pt’s face
- pain decreases with posterior force on the shoulder (this is the relocation test)
Valgus and varus, explain.
Valgus is when the the medial aspect of the elbow os more medial than it should be, and it is stressed by placing force on the lateral part of the elbow and if it moves more than it should it is positive or if there is pain.
and varus is when the medial aspect is more lateral and you press on the lateral aspect of the elbow towards the medial part and see if there excess movement or if there is pain..
Sciatic nerve divides into the
tibialnerve and common peroneal n
Common peroneal divides into the
superficial and deep peroneal nerve
Tibial nerve divides into the
medialand lateral plantar nerve
Dural Test of dural system especially
L4-S2 & Sci-atic tract
How do you do the dura test?
Its very similar tot he straight leg raise.
That you have the patient ins upine and you have their knee is in extension and you just flex the hip, while keeping the knee extended
Howndo you rule out hamstring with the SLR?
Have them dorsiflex and see if that causes pain, and if yes, then ask them to flex their nexk, and see if that causes pain, and spif yes then it is the dura.
Pain to the dura can be because of the following reasons…
• Herniated disc
Tumor
• Adhesion
With the SLR how would you stress the tibial nerve?
Now we need to stretch it to stress it. So we know that our tibia is medial, so we will dorsiflex and we will evert the foot
How do you stress the sural bpnerve?
We know that we have already stressed the tibial neve with dorsiflexion and with eversion, so lets go and try something else, lets go and dorsiflex and invert.
How do you stress the common peroneal nerve?
You know that the peroneal nerve, the fibula nerve, is lateral, so you want to push into media, nut we are not dealing witht he tibial ie the sural, so here, by the peroneal, we will want to go and plantar flex, but we also want to go and IR the hip.
What about if a SLR causes a contralateral pain in their leg?
This bpcan indicate a hige herniated disc, which if they have B&B issue, it might be indications for surgery.
Tests for lumbar instability
Implies that during movement
the pt loses theability to control the movement for a brief period of time(milliseconds)
• May be structurally unstable
• The brief loss of control results in an instabilityjog or sudden shift of movement in part of the
ROM
H and I Test is a test for?
Lumbar instability and muscle spasm
Patient Position/action for H&I test?
- pt standing
- H portion – SB first then does flex and ext- I portion – Flex/ext first then SB
Positive Response for the H& I test.
Discrepancy between the H and I portions
- A negative response may indicate hypomobility
Segmental instability test vs. H&I test. One choose one over the other?
The HI test is for general screen of the instability, but where is that specific joint that is instable? Of course we will not look for the details if the general screen comes out that there is no issue, also why would we just look at the specifics if we have not done a general screen to see if there is any issues or not. Just like by when we go and do the squat to see if there is an issue at the hip or at the knee or at the ankle.
