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Outline Knee Anatomy 8/7/2013 Physical Exam Skills and Outline Office Procedures in Orthopaedics • Knee exam • Knee aspiration and injection • Shoulder exam • Subacromial bursa injection UCSF Essentials of Primary Care August 14, 2012 Carlin Senter, M.D. The quadriceps muscles extend the knee Knee Anatomy http://thefitcoach.wordpress.com/2012/04/07/267/ http://scientia.wikispaces.com/Thigh+and +Leg+-+Lecture+Notes 1 8/7/2013 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 2 8/7/2013 Meniscus Knee exam Common Causes of Knee Pain by Location of Musculoskeletal work-up Symptoms • Anterior: • Medial • History - Patellofemoral syndrome - Medial joint-line: meniscus tear or OA - Quadriceps tendinitis - MCL sprain • Inspection - Patellar tendinitis - Pes anserine bursitis P • Lateral: • Posterior • alpation - Lateral jointline: meniscus tear - Hamstring tendinitis or OA - Gastrocnemius strain - IT band syndrome • Range of motion - OA, meniscus tears, - LCL sprain (rare) effusion, popliteal cyst…. - Fibular head: fracture (rare) • Other Tests 3 8/7/2013 Palpation of joint line Inspection seated or supine http://www.rheumors.com/kneeexam/palpation.html http://doctorhoang.wordpress.com/20 http://meded.ucsd.edu/cl 10/09/06/valgus-knee-and-bunion/ inicalmed/joints.htm Palpation of patella - supine Palpation of patellar facet Ballottement 4 8/7/2013 Knee range of motion Other Tests: Lachman to evaluate ACL Sensitivity 75-100% Specificity 95-100% • ROM: normal 0-135 – 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 th Dr. Charles Goldberg, UCSD Magee, DJ. Orthopaedic Physical Assessment, 5 ed. 2008. PCL: Posterior Drawer MCL and LCL 5 8/7/2013 Meniscus: McMurray Meniscus: Thessaly Sensitivity medial 65%, Specificity medial 93% th Magee, DJ. Orthopaedic Physical Assessment, 5 ed. 2008. Meniscus: Squat Knee exam practice • Standing: inspection • Supine – Varus or valgus – Patellar facets • Sitting: palpation – Patellar grind – Joint line – ROM – Femoral condyles – Special tests • – Tibial plateau Lachman • Posterior drawer – Fibular head • Varus 0 and 30 • Valgus 0 and 30 • McMurray medial and lateral • Thessaly • Squat 6 8/7/2013 Intra-articular corticosteroid injections: do they work for knee OA? • Good short-term pain relief – Effect size 0.72 at 2 and 3 weeks • No significant effect on function Knee aspiration and injection – 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 Injection set-up bucket • Patient supine • Betadine • Extend knee • Ethyl chloride • Bump under knee so • Alcohol swabs flexed 10-20 degrees • 4x4 guaze • Superior border patella • Bandaids • Lateral border patella • 1cm below • Mark with syringe cover or tip of pen 7 8/7/2013 Injection prep Needles, syringes, meds Why use local anesthetic with steroid Corticosteroids 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. 8 8/7/2013 Why aspirate the effusion before Aspiration injection? • 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 Contraindications to steroid injection • Rest: no definitive evidence-based • Joint infection recommendation • Fracture – Recommendations in literature vary • Prosthetic joint • No restrictions • • Bed rest x 24 hours Hemarthrosis (theoretically higher risk of • Light activity x 7 days, no weight bearing exercise infection) • Avoid swimming, hot tub, bath x 24 hours • Soft tissue infection overlying joint – Let injection site heal 9 8/7/2013 Relative contraindications to steroid Risks of steroid injection in the knee injection • Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours • Corticosteroid injection within past 4 months after, lasting 5 days • Suppression of hypothalamic pituitary adrenal axis, mild • Coagulopathy (ok if on warfarin but check – Lasts 1-3 days post-injection • Facial flushing: 10% with Kenalog recent INR, make sure not >> 3) – 19-36 hours post-injection • • Skin or fat atrophy Poorly controlled diabetes • 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 intra- articular 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 Knee injection 1. Patient supine with bump under knee 2. Mark injection site (superior lateral) 3. Betadine x 3 4. Alcohol x 1 5. Ethyl chloride for skin anesthesia 6. Alcohol again 7. 22g needle attached to 10cc syringe containing 5cc of 1% lidocaine without epi 8. Slowly advance and inject lidocaine, 1mm at a time 9. Feel resistance give when in joint 10. Aspirate, make sure fluid straw-colored and clear 11. Keep needle in place, switch syringe 12. Inject 1cc of 40mg kenalog 10 8/7/2013 Underlying Anatomy - Bones Shoulder anatomy Acromion Greater Tuberosity • Humerus Clavicle • Scapula o Glenoid o Acromion o Coracoid o Scapular body • Clavicle • Sternum Glenohumeral Joint Lesser Tuberosity The LABRUM is a fibrocartilaginous ring of tissue that attaches to the glenoid rim & deepens the glenoid fossa Spine of Acromion scapula is at the level of T3 Bottom of scapula is at level of T7 11 8/7/2013 The Rotator Cuff Muscles (SITS) Supraspinatus (Abduction ) The tendons of the rotator cuff muscles reinforce the capsule of the glenohumeral Greater Tubersosity Posterior joint. View Lesser Tuberosity Infraspinatus Anterior (External rotation) ) View Teres Minor Subscapularis (External rotation) (Internal Rotation) The Biceps Muscle Shoulder exam • #1 Supination of the elbow (screwing, twisting) • #2 Flexion of the elbow Long head 3 attachments: • Radial tuberosity (distal) • Glenoid (long head) • Coracoid (short head) Short head 12 8/7/2013 Cervical Spine Neck examination Spurling’s Maneuver • Inspection • Neck extended • • Head rotated toward Palpate CS affected shoulder • FF and extension • Axial load placed on • Spurlings the cervical spine • Reproduction of patient’s shoulder/arm pain indicates possible nerve root compression Shoulder examination Shoulder examination • Inspection • Inspection – Patient in gown • Palpation • Palpation • ROM • ROM http://meded.ucsd.edu/clinic • Strength almed/joints2.htm , • Strength permission granted by Dr. – Supraspinatus Charles Goldberg, UCSD SOM – Supra – – Infra and teres Infraspinatus & minor Teres minor – Subscapularis – Subscapularis • Other tests http://meded.ucsd.edu/clinicalmed/joints • Other tests 2.htm, permission granted by Dr. Charles Goldberg, UCSD SOM 13 8/7/2013 Range of motion Range of motion Internal rotation Abduction External rotation Flexion Supine shoulder PROM Other tests • Rotator cuff strength • Impingement tests • Biceps • Labrum • AC joint 14 8/7/2013 Infraspinatus and teres minor = Supraspinatus = abduction external rotation Supraspinatus Infraspinatus Teres minor Empty can Photos from Dr. Christina Allen Photos from Dr. Christina Allen Subscapularis = internal rotation Subscapularis = internal rotation Subscapularis Subscapularis Lift-Off Belly press Photos from Dr. Christina Allen Photos from Dr. Christina Allen 15 8/7/2013 Impingement syndrome Impingement signs Subacromial bursa Supraspinatus • Inflammation of the subacromial space – 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 Neer’s Biceps Tests: Speeds Biceps Tests: Yergasons Tests for biceps pathology Tests for biceps pathology (tendinitis, tendinopathy, (tendinitis, tendinopathy, tear) tear) Palms up, patient pushes Patient supinates (twists up against resistance out) against resistance (resisted elbow flexion) +Test is pain at proximal +Test is pain at proximal biceps tendon biceps tendon Sens = 41%, Spec = 79% Sens = 54%, Spec = 81% 16 8/7/2013 O’Brien’s Test To r/o Labral Tear Testing the AC Joint: • Arm forward flexed to AC Crossover 90° • • Elbow
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