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Telemedicine for Orthopaedic assessment in

Primary care NHS Grampian

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CONTENTS

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1. SETUP...... 5

1.1 SHOULDER…………………………………………………… 6 1.2 RED FLAGS…………………………………………………… 6 1.3 EXAMINATION……………………………………………….. 6 1.4 SPECIAL TESTS……………………………………………...10 1.5 NHSG GUIDANCE…………………………………………….11

2. HIP………………………………………………………………12 2.1 RED FLAGS…………………………………………………… 12 2.2 EXAMINATION………………………………………………...12 2.3 NHSG GUIDANCE…………………………………………….15

3. KNEE…...…………………………………………………...... 16 3.1 RED FLAGS……………………………………………………16 3.2 EXAMINATION………………………………………………...16 3.3 SPECIAL TESTS………………………………………………18 3.4 NHSG GUIDANCE…………………………………………….20

4. HAND………………………...…………………………………21 4.1 DUPUYTREN’S DISEASE……………………………………21 4.2 TRIGGER FINGER…………………………………………....22 4.3 DE QUERVAINS TENOSYNOVITIS………………………...22 4.4 BASE OF THUMB OA…………………………………...... 24 4.5 CARPAL TUNNEL SYNDROME……………...... 26

5. SURGICAL REFERRAL……………………………………….28

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THIS IS AN EXCITING TIME FOR ALL OF US TO BE PART OF A TOTALLY NEW ASSESSMENT APPROACH IN PRIMARY CARE. Telemedicine surged in to everyday clinical use as a necessity for safe remote assessment during the COVID 19 pandemic and now has an increasing, evolving role in routine clinical assessment.

Currently there is little evidence based guidance for GP’s to perform telemedicine assessments for common MSK problems. This guide has been developed to aid these examinations in this developing field and we aim to expand it in the future in conjunction with Grampian Guidance resources.

Telemedicine assessment is not always a complete replacement for face to face consultation. Clinicians exercise judgement as to when telemedicine assessment is appropriate and when a patient must be seen face to face. This guide is a suggested practical framework for remote assessment of common hip, knee and shoulder pathologies but telemedicine alone will not always be suitable for more complex or unusual presentations. It’s useful to try out these short examinations in advance to practice adapting visual or auditory cues.

This examination guide has been developed as a distilled version of examination necessary to make a reasonable assumption of the most likely differential diagnosis and provide valuable content if referral is required. More than ever, the diagnostic process starts with a detailed history resulting in a “list” of differentials. Examination is of course then used to exclude or support differentials and narrow down the most probable diagnosis.

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In combination, these will then help clarify the outcome of the appointment, such as:

 Self-care advice  Physiotherapy/First Contact Practitioner  Email input from the GPwER team  Referral to secondary care (physio, ortho, xray)  Urgent assessment via ED or ortho on call

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SETTING UP THE ASSESSMENT WELL CAN MAKE THE CONSULTATION MORE EFFECTIVE:

• Adequate IT facilities – It is important to ensure that both the clinician and the patient have adequate IT facilities and know how to use them. In time this will improve but some patients may require additional time or support in setting up a telemedicine call.

• Placement – patients and clinicians should consider whether the location and background setting is suitable and quiet to aid conducting a telemedicine assessment. Bright lighting behind someone can make it difficult to see them so lights or windows should be behind the camera. The patient may also need adequate space around them to move limbs freely and additional equipment needed such as a chair. Try to avoid “clutter” of objects on camera as this can distract from the assessment for both patient and clinician.

• Positioning – Ideally the camera should be static but at adequate distance away to allow full visualisation of the examination. The camera may be best located approx. 2- 3ft off the ground and 6ft from the patient. Consider also the joint being examined and the need for any additional furniture such as a chair or sofa to lie flat on. We’ve found SHOWING the patient where to stand/what to do can be easier and our photos represent camera positions we have found helpful.

• Clothing – Advise the patient in advance of the clothing best worn for the specific examination e.g. shorts and/or t shirt.

• Communication – Speak clearly in short simple instructions particularly when asking patients to perform specific movements. It is also helpful to clearly demonstrate a movement and ask the patient to copy. Allow the patient time to reply or and ask questions to avoid speaking over each other.

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SHOULDER

RED FLAGS (URGENT REFERRAL)

¥ Mass/deformity/swelling – SUGGESTION OF POSSIBLE MALIGNANCY

¥ Red skin/Fever/Systemic upset – INFECTION

¥ Inability to lift arm after trauma – FULL THICKNESS CUFF TEAR

¥ Unusual motor or sensory deficit

¥ Dislocation – REFER TO EMERGENCY DEPT

POSITION Standing in front of the camera approx. 6ft away with space to fully outstretch arms in all directions. The sequence below is intended to allow for a structured, fluid assessment.

ASSESS THE NECK 1. Observe the shoulder and posture and for any swelling/deformity. Ideally view anterior and posteriorly. Ask patient to locate and point to where the pain arises and radiates. 2. Can you move your neck for me? – look up to the ceiling, chin on chest, turn to look round to the right and then to the left Does this reproduce the presenting pain? - If yes, consider neck as a cause

ASSESS THE SUB ACROMIAL REGION - ABDUCTION

3. With hands by their side and thumbs point forward ask patient to abduct both arms fully to see comparison of abduction. Make particular note of site of painful arc, and/or weakness and pain relaxing the arm back to the side of the body.

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Painful arc around 90°: likely rotator cuff related pain-see later for further assessment. Around 120°: consider AC joint. 4. If there is high arc pain ask the patient to press firmly on the AC joint: Is it tender to press on the top of the shoulder (AC joint marked X below)?

5. If so ask the patient to cross their arm over their chest to the opposite shoulder (SCARF test). This may provoke AC joint pain.

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If there are positive findings of 3, 4 and 5 consider AC joint pathology – RICE/ physiotherapy/injection – refer with X-ray if fails.

ASSESS THE SHOULDER GLENOHUMERAL JOINT - EXTERNAL ROTATION 6. Ask the patient with upper arm abducted and elbows flexed to 90° to externally rotate hands to the side as far as possible

If there is asymmetric range of external rotation then consider glenohumeral pathology – adhesive capsulitis/OA – x-ray may be needed to differentiate.

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REMAINING ROM

7. Check remaining ROM for deficit

• Elevation – Please lift both hands forwards together • Internal rotation – With the good arm reach up into your back as high as possible and turn around (clinician take note of the spinous level achieved)

• Now relax and do the same with the painful arm (clinician can see any difference in spinous level achieved between the symptomatic and asymptomatic limbs)

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FURTHER ROTATOR CUFF ASSESSMENT/SPECIAL TESTS

Rotator cuff strength screening could be considered by asking the patient to elevate arms whilst holding a weight gripped in hands outstretched – a tin of beans or soup weighs approx. 0.4-0.5kg. Then we can then ask the patient with outstretched hands to pretend to tip out and empty the tins on the floor asking for reproduction in pain or weakness.

If the reproduces pain or there is pain in high arc in the absence of AC joint pain or SCARF positive then then this may suggest sub acromial pathology/ rotator cuff pathology. Checking power by asking the patient to oppose all these movements using their unaffected hand is very helpful - weakness may be very suggestive of a rotator cuff defect.

Modified Hawkins testing can also be performed via telemedicine: pain indicates evidence suggestive of sub-acromial pathology.

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HIP

RED FLAGS ¥ Mass/deformity/swelling – SUGGESTION OF POSSIBLE MALIGNANCY ¥ Red skin/Fever/Systemic upset – INFECTION DISCUSS WITH ON CALL ORTHO ¥ Acute severe hip pain with

- High energy impact trauma or - Low energy trauma in known osteoporosis - Shortening of leg - External Rotation of leg - Sudden limitation of mobility - Inability to weight bear CONSIDER REFERRAL TO EMERGENCY DEPARTMENT

POSITION Initially standing but probably best lying side on to the camera approx. 6ft away with space to fully outstretch lower limb and lie flat.

OBSERVATION

1. Observe the patients gait. Note use of stick or antalgic (limping gait) or Trendelenburg gait (weakness of hip abductors causing pelvic tilt/droop on the opposite side).

2. Ask then to point to where they feel most of the pain and where it radiates.

Make particular note of where the pain originates. Pain over the lateral aspect or greater trochanter is more likely to be greater trochanteric pain syndrome or referred from the back. Hip pathology can give rise to groin pain radiating to the knee and beyond.

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STRAIGHT LEG RAISE 3. Lying flat, ask the patient to SLR the unaffected limb and then the affected limb. Reduced SLR may be due to hip OA but also suggest back pathology. It is useful to check if neuropathic pain is experienced.

HIP FLEXION 4. In a lying position as the patient to bring their knee up into their chest as far as possible. Compare to the unaffected side and look for pain or restriction.

HIP ROTATION

5. In a lying position ask them to make a “figure of 4” with the affected limb. If restricted due to pain or stiffness in the groin may suggest OA of the hip which can radiate pain to the knee. Compare to unaffected limb

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6. Internal rotation can also be assessed in a sitting position with knee flexed at 90 degrees. With hands on lap to stabilise the pelvis and internally rotating the hip as below is a useful way to identify pain or stiffness originating in the hip joint itself.

CONSIDER THE LUMBAR SPINE

7. Particularly if the pain is a radiating pain and does not involve the groin, consider evaluating the lumbar spine by asking the patient to gently flex and extend the lumbar spine by bending forward to touch their toes and then leaning back to look up at the ceiling. Further examination and questioning may be needed.

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KNEE

RED FLAGS

¥ Mass/deformity/swelling – SUGGESTION OF POSSIBLE MALIGNANCY

¥ Red skin/Fever/Systemic upset – INFECTION

DISCUSS WITH ON CALL ORTHO

¥ Injury with need to exclude fracture

- Rapid swelling/effusion - Loss of ability to extend knee - Feeling of pop or snap

REFER TO EMERGENCY DEPT

POSITION Sitting or Standing in front of the camera approx. 6ft away with space to fully outstretch lower limb and lie flat. A chair may be useful for those with poor mobility or balance

OBSERVATION 1. Observe the patients gait. Ask them to stand facing and note any swelling/erythema or valgus/varus deformity.

2. Ask then to point to where they feel most of the pain and where is radiates.

RANGE OF MOVEMENT

3. Observe and note full extension of the knee and compare to the opposite side.

4. Ask the patient to flex the knee and bring the heel to their bottom and compare to the opposite side. Inability to flex to at least 90° should certainly be noted and considered restricted.

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130°

0°

Alternatively ask the patient to squat down and assess if fully flexing the knee equally to the other side. Completing the squat movement is a very reassuring sign as many patients with significant knee problems will not achieve this.

CHECK HIP ROTATION

5. In sitting position - with knee flexed at 90° ask them to internally and externally rotate the hip. Painless motion is reassuring in excluding hip as the cause of knee pain.

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CHECK THE KNEE EXTENSOR MECHANISM

6. Can the patient straight leg raise the affected limb? If so, this can help to exclude injury to those soft tissues.

MENISCAL ASSESSMENT

7. Thessaly testing can be modified over telemedicine as a method of evaluating for meniscal injuries. Ask the patient to stand on one leg with knee flexed at 20°. Then ask them to rotate their pelvis on the flexed knee fully to the left and the right. A positive result is demonstrated by pain and/or clicking on the affected side supporting clinical suspicion of meniscal pathology.

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Its use in clinical application is varied so bear in mind the clinical history and remaining examination findings.

¥ For example a 22 year old who twisted their knee 6 months ago playing football but is still bothered with locking and medial knee pain has a positive Thessaly test reproducing clicking and pain medial may well have a stronger case to support a medial meniscal injury. ¥ In comparison a 64 year old who twisted their knee 6 months ago with valgus deformity and knee pain and complains of giving way and clicking may also have a positive Thessaly test with medial and lateral knee pain. They may also have meniscal damage but it is more likely to be degenerative and in combination with osteoarthritis which may be more likely the cause for symptoms.

LIGAMENT ASSESSMENT

8. Ligament stability is difficult to assess remotely and if there is clinical suspicion of significant ligament injury then face to face assessment should be considered.

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HAND

Remote assessment of the hand could be considered but is unlikely to be appropriate for complex or trauma cases. Even a simple hand injury needs full and thorough assessment to exclude underlying tendon or other injury. Some of the more straight forward Primary Care conditions can probably be assessed as below.

DUPUYTREN’S DISEASE

POSITION Sitting or Standing in front of the camera approx. 2-3ft away. Best with a stationary camera such as laptop. A table or desk in front of the camera will be needed.

OBSERVATION

1. Ask the patient to hold both hands out with palms facing the camera. Observe for nodules/cords/contracture.

2. Ask the patient to place the palm of their hand flat on the table.

3. If the patient is unable to put their hand flat and there is fixed deformity or significant functional impairment then referral shoulder be considered.

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TRIGGER FINGER

POSITION Sitting or Standing in front of the camera approx. 2-3ft away. Best with a stationary camera such as laptop.

OBSERVATION Ask the patient to demonstrate the trigger/click that occurs when they get symptoms. Significant triggering needing injection/intervention will usually be easily reproducible by the patient as it will have occurred a number of times.

It is important to note that trigger finger will produce a convincing sudden click/release as the tendon nodule “pop” through the pulley. If the symptoms are more in keeping with stiffness then alternate diagnosis should be considered.

DE QUERVAIN’S TENOSYNOVITIS

POSITION Sitting or Standing in front of the camera approx. 2-3ft away. Best with a stationary camera such as laptop.

OBSERVATION

1. Ask the patient to point to where they are getting pain. Look for any changes that may suggest alternative diagnosis e.g. finger joint swelling suggestive of synovitis, evidence of osteoarthritis (Heberden or Bouchard nodes) or Z deformity of the thumb.

2. Ask them to palpate around the thumb base and snuff box to see if there may be any other cause such as base of thumb OA (you may need to demonstrate this first).

3. Check the ROM in the thumb and fingers – can you make a fist and then put your hand flat on the table?

4. Demonstrate and ask the patient to perform Finkelstein’s Test (see below).

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FINKELSTEIN’S TEST

This is the main diagnostic test for De Quervain’s. Ask the patient to make a fist wrapping their fingers over their thumb. Then ask them to move the wrist in an ulnar direction. Applying force using the other hand may help.

A positive test will reproduce pain very quickly. This can be uncomfortable in an asymptomatic patient, so it is important to compare both sides to see if there is a disproportionate pain response.

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BASE OF THUMB OSTEOARTHRITIS

POSITION Sitting or Standing in front of the camera approx. 2-3ft away. Best with a stationary camera such as laptop.

OBSERVATION 1. Ask the patient to point to where they are getting pain. Look for any changes that may suggest alternative diagnosis e.g. finger joint swelling suggestive of synovitis, evidence of osteoarthritis (Heberden or Bouchard nodes) or Z deformity of the thumb.

2. Ask them to palpate around the thumb base to and assess if this reproduce the pain (you may need to demonstrate this – see below).

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3. Check the ROM in the thumb and fingers – can you make a fist and then put your hand flat on the table?

THE LEVER TEST

4. This test can be performed by asking the patient to grasp the affected thumb over the first metacarpal just distal to the base of the thumb. Then the patient needs to “lever” the first metacarpal back and forth across the base of thumb joint. A positive test will reproduce pain.

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CARPAL TUNNEL SYNDROME

POSITION Sitting or Standing in front of the camera approx. 2-3ft away. Best with a stationary camera such as laptop

OBSERVATION 1. Ask the patient to describe the symptoms and point to where they get pain or sensory symptoms.

2. Observe for evidence of Thenar muscle wasting asking the patient to hold both hands palm side up to the camera.

TESTING ABDUCTOR POLLICIS BREVIS 3. Ask the patient to hold their hands with palms facing each other approximately 30cm a part. Then ask the patient to point their thumbs towards each other and hold them in that position. Keeping the thumb in this position ask them to one by one push the thumb into the opposite palm keeping the thumb out straight.

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SPECIAL TESTS

4. Tinel’s testing can be considered by ask the patient to ‘tap’ over the carpal tunnel with the opposite hand. It will be necessary to demonstrate this first and probably a good idea to time this so you can be sure an adequate test has been achieved (approx. 30 seconds). Then repeat this on the opposite side. A positive test will provoke sensory symptoms in median nerve distribution.

5. Phalen’s testing can also be achieved by asking the patient to hold the back of their hands together in palmar flexion again timing for 60-120 seconds. This again would be positive in reproducing sensory symptoms median nerve distribution.

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REFERRAL FOR JOINT REPLACEMENT SURGERY

When considering referral to Orthopaedics for joint replacement surgery there is the possibility to now make part of this assessment using telemedicine from secondary care. In order to progress the patient journey we require the following information:

 A history of symptoms and severity e.g. night pain, optimised analgesia etc.  Examination of the affected limb  Relatively recent imaging usually a plain film x-ray in the last 12 months  Recent BMI <40

If this information is available at time of referral and included in the SCI referral template then we will be able to vet them to a new patient near me appointment. From this we are potentially able to offer and list for surgery/image guided injection. Grampian Guidance is a valuable source of further information.

Please refer for an x-ray as appropriate - even if routine x-ray requests are not being undertaken they will still be processed by radiology and we will hold the referral until the x-ray is available to review.

We hope this information is helpful in contributing to the early stages of routine telemedicine. Please feel free to use this guide in any way that helps and we welcome any feedback to help improve future guides.

Dr Gavin Stephen and Dr Greig Nicol

GPwER Orthopaedics

NHS Grampian

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