The Injury Examination Process

Examination of Orthopedic and Athletic Injuries, 3rd Edition

The Injury Examination Process

Chapter 1

Copyright © 2010. F.A. Davis Company


Systematic Examination Technique

 Objective data

 Baseline measures

 Re-evaluations

 Rehabilitation and treatment protocols

 Documentation

 Medical records

 Legally required

 Communication tool



Table 1.1. Role of the

Noninjured Limb in the

Examination Process

Evaluation Strategies

1.

Perform each task on uninjured limb first.

2.

Perform each task on injured limb first.

Increase or decrease apprehension and muscle guarding?



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



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



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)

 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?



Past Medical Health





General medical health





Current health status?

Comorbidities present?

Relevant illness and lab work

 Note during exam if they may affect injury management or the healing process.





Medications





What medications are they currently taking?

What interactions or effect may they have on healing, treatments, etc.?

Smoking







Decrease exercise tolerance

Increased risk for CV disease

May delay fracture and wound healing



History of Present Condition

 Mechanism of injury

(MOI)

 How did the injury occur?

 Macrotrauma

 Microtrauma

 Identifies structures involved

 Relevant sounds or sensations

 Onset and duration of symptoms

 Acute

 Chronic



History of Present Condition

 Pain

 Location

 Type

 Referred

 Radicular

 Daily pain patterns

 Provocation and alleviation patterns

 Other symptoms

 Treatment to date

 Affective traits

 Disability/limitations



Physical Examination

 Goals

 Rule out differential diagnosis

 Determine clinical diagnosis

 Identify impairments and functional limitations

 Standard precautions against bloodborne pathogens (Box 1-5)



Inspection

Immediate observations

 As soon as patient enters facility observe











Gait

Posture

Function

Guarding

Splinting

Physical examination observations (bilateral)

 Deformity

 Subtle or gross?

 Swelling





Hemarthrosis

Edema

 Girth measurements

(Special Test 1-1)

 Skin





Redness

Ecchymosis

 Infection signs



Inspection

 Functional assessment

 Perform functional tasks that were identified as problematic.

 Impairments should be identified and measured.



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.



Palpation

 Point tenderness

 Trigger points

 Change in tissue density

 Crepitus

 Tissue temperature



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



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



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)



Manual Muscle Testing



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



Joint Stability Tests

 Procedure

 Apply specific stress to non-contractile tissue

 Hypermobile — more laxity than normal

 Hypomobile — below normal laxity

 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



Stress

Testing



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



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 (-)



Neurologic Screening

 Upper and lower quarter screen





Evaluate

 Sensation

 Motor function

 Deep tendon reflexes

Identify

 Nerve root impingement

 Peripheral nerve damage

 CNS trauma

 Disease

 Indicated by

 Numbness

 Paresthesia

 Muscular weakness

 Pain of unexplained origin

 Injury to cervical or lumbar spine



Neurological Screening 1-1.

Lower Quarter Screen



Neurological Screening 1-2.

Upper Quarter Screen



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



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.



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



Table 1 –10. Deep Tendon

Reflex Grading



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



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


The Injury Examination Process

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